Essentials of Dental Implant Treatment Planning
Samia Hardan, DDS*
past 40 years, dental implants have evolved to where they are now considered to
be a reliable treatment with a one-year implant survival rate of 96.6% and a
five-year survival rate of 91.2%.1-4 As a result of continued
research in treatment planning, implant design, materials, and techniques,
predictable success is now a reality for the rehabilitation of many challenging
clinical situations.1 Many types of implants are now available for
application to different cases, and an increasing number of clinical practices
have become involved with this form of treatment.
Patient Selection and Treatment Planning
patient selection and suitable evidence from clinical and radiographic
examinations are essential when identifying patients for implant therapy.5
When evaluating patients for implant placement, a multidisciplinary approach is
necessary. A thorough medical history should be obtained to rule out any
immediate anesthetic, surgical, psychological, psychiatric, or medical risks to
long-term retention.6 At present, there are no reports of absolute
contraindications for the placement of dental implants; concurrent medical
diseases (eg, uncontrolled diabetes, hemophilia, granulocytopenia, organ
transplantation, osteoradionecrosis, alcoholism, heavy smoking, poor dental
hygiene), however, greatly influence the success rate and potential
complications for implants.7,8
In addition to a thorough medical
history, a comprehensive dental examination should be performed. Restorative
requirements, interarch space, jaw relationships, location of edentulous areas,
and the quantity and quality of available bone should be evaluated. Panoramic,
periapical, or occlusal x-rays or computed tomography scans should be taken
(Figure 1).7-9 Computerized and linear tomographic images provide
the unique advantage of cross-sectional views of anatomic structures not
available with other radiographic techniques (Figure 2).7-10 They may
also be needed to determine the position of dental implants relative to
critical structures (eg, the inferior alveolar canal, mental foramen, maxillary
sinus, nasal cavity, incisive foramen, anterior loop, adjacent teeth, buccal or
lingual cortical plates) (Figure 3).7-10 Variables that can affect
implant success (eg, bone type, dental arch, implant location, anatomical
variations, natural dentition) should be also assessed. These include bone
type, dental arch (maxilla versus mandible), implant location, anatomical
variations, and the presence of natural dentition.
quality and quantity are inadequate for the placement of implants, bone
augmentation procedures may be indicated. These include the use of either
bioabsorbable or nonabsorbable barrier membranes and bone grafts or bone
substitutes to enhance regeneration.11,12 For implant placement in
the posterior maxilla, sinus grafting is a highly predictable and effective
therapeutic modality to increase available bone height.13 The basic
approach to the sinus involves an osteotomy performed on the lateral maxillary
wall, elevation of the sinus membrane, and placement of bone graft material.
important guidelines have traditionally governed both submerged and
non-submerged endosseous dental implant systems.5 These are: 1)
minimize thermal trauma to bone; 2) permit osseointegration through a primary
healing period of variable duration; and 3) limit micromotion to less than 100 µm during the healing period.
Insertion of implants at the time of
extraction (ie, immediate placement) is viable if mechanical fixation can be
achieved (Figures 4-5-6).14,15 The efficacy of immediate implant
placement has been established and shown to be predictable.16 To
minimize the risk of implant failure, osseointegrated oral implants are
conventionally kept load-free during the healing period. Immediate and early
loaded implants are commonly used in mandibles possessing good bone quality.
While it is possible to successfully load oral implants immediately after their
placement in mandibles meeting specific criteria, it is yet unknown how
predictable this approach is.17,18
Implant Complications and Maintenance
implant has been described as one that is clinically mobile. In contrast, a
failing implant is one that shows progressive loss of supporting bone, but is
clinically immobile.5 Early failures occur during the
osseointegration period, usually within the first year following an implant
insertion. Late failures occur once the osseointegration process is complete
and implant function is established, usually about one year following implant
insertion.19 Complications limited to the soft tissues surrounding
implants and not involving the supporting bone have been defined as ailing
implants or biological complications and can have several possible causes
Patients should be on a regular
recall schedule to monitor the maintenance—including plaque control—of the
implant-supported prostheses. Maintenance programs should be designed on an
individual basis, as there is a lack of data detailing precise recall
intervals, methods of plaque and calculus removal, and appropriate
antimicrobial agents for maintenance around implants.20 Dental professionals should be aware that marginal
bone loss around the crestal portion of the implant often occurs during the
first year of occlusal loading (Figure 7).
Caring for patients with dental
implants requires a dynamic and an individualized approach for the maintenance
and early recognition of implant-related complications. The clinical
supervision of a patient’s implant condition, with a good recall program,
should continue indefinitely. It is of great importance to implement a strategy
for the prevention of detrimental local conditions (eg, poor oral hygiene,
advanced periodontal disease, occlusal interferences).19
dental implants have revolutionized the fields of implants and periodontics. As
dental implants become a more accepted treatment modality, there is a need for
all dental professionals involved to be familiar with various treatment-planning
issues. Though the success can be highly rewarding, failure to forecast
treatment-planning issues can result in an increase of surgical needs, cost,
and case failure.
Department of Periodontology and Oral Implantology, Temple
School of Dentistry, Philadelphia, Pennsylvania.
- Misch CE.
Contemporary Implant Dentistry. 3rd ed. St.
Louis, MO: Elsevier
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- Iqbal MK, Kim S. A review of factors influencing treatment
planning decisions of single-tooth implants versus preserving natural teeth
with non-surgical endodontic therapy. J Endod 2008;34(5):519-529.
- Attard NJ, Zarb GA. Immediate and early implant loading
protocols: A literature review of clinical studies. J Prosthet Dent
- Dodson TB. Predictors of dental implant survival. J Mass
Dent Soc 2006;54(4):34-38.
- Watson RM, Forman GH, Welfare RD. Essentials of case
planning for osseointegrated implants. Br Dent J 1988;164(10):313-338.
- Matukas VJ. Medical risks associated with dental implants. J
Dent Educ 1988;52(12):745-747.
- Iacono VJ. AAP position paper. Dental implants in
periodontal therapy. J Periodontol 2000;71(12):1934-1942.
- Adell R, Lekholm U, Rockler B, et al. Marginal tissue
reactions at osseointegrated titanium fixtures (I). A 3-year longitudinal
prospective study. Int J Oral Maxillofac Surg 1986;15(1):39-52.
- Garg AK, Vicari A. Radiographic modalities for diagnosis and
treatment planning in implant dentistry. Implant Soc 1995;5(5):7-11.
- Gher ME, Richardson AC. The accuracy of dental radiographic
techniques used for evaluation of implants fixture placement. Int J Periodont
Rest Dent 1995;15(3):268-283.
- Hermann IS, Buser D. Guided bone regeneration for dental
implants. Current Openion Periodontol 1996;3:168-177.
- Hämmerle CH, Karring T. Guided bone regeneration at oral
implant sites. Periodontol 2000 1998;17:151-175.
- Kaufman E. Maxillary sinus elevation surgery: An overview. J
Esthet Rest Dent 2003;15(5):272-282.
- Gelb DA. Immediate implant surgery: Three-year retrospective
evaluation of 50 consecutive cases. Int J Oral Maxillofac Impl
- Rosenquist B, Grenthe B. Immediate placement of implants into
extraction sockets: Implant survival. J Oral Maxillofac Impl
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surgical steps for successful outcomes. Br Dent J 2006;201(4):199-205.
- Misch CE, Wang H, Misch CM, et al. Rationale for the
application of immediate load in implant dentistry: Part I. Impl Dent 2004;13(3):207-217.
- Lazzara RJ, Testori T, Meltzer A, et al. Immediate Occlusal
Loading (IOL) of dental implants: Predictable results through DIEM guidelines.
Pract Proced Aesthet Dent 2004;16(4):3-15.
- Tolstunov L. Dental implant success-failure analysis: A
concept of implant vulnerability. Impl Dent 2006;15(4):341-346.
- Guidelines for Periodontal Therapy. The American Academy
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- Suzuki JB. Maintenance of dental implants: Implant quality of
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Table 1: Evaluation of the Etiology for Implant Failures
Causes of Early Implant Failures
Causes of Late Implant Failures
Poor quality and quantity of bone and soft tissue:
- Severe alveolar bone
- Lack of keratinized gingival
- Collagen disorders
Occlusal overload/excessive stress:
not diagnosed or treated
Peri-implantitis and poor oral hygiene:
- Patient’s lack of desire for
- Patient’s lack of dexterity
because of handicap
- Hygienically difficult and
inaccessible prosthetic design
- Inadequate supervision of
patient’s oral hygiene
Unfavorable patient habits:
- Heavy long-term smoking
- Poor oral hygiene
- Plaque accumulation
Improper design, construction, and fit of
- Deficiency at any
restorative and laboratory stage leading to dynamic failures and fractures of
- Defective implant components
- Fatigue of implant
Inadequate prosthetic analysis and technique:
- Suboptimal insertion
- Lack of primary implant
- Poor three-dimensional
Inadequate surgical analysis and technique:
- Improper choice of the
- Suboptimal prosthetic design
- Suboptimal occlusal scheme
- Excessive load
Suboptimal implant design and surface