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Essentials of Dental Implant Treatment Planning

During the 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

Careful 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.

 

Site Preparation

If bone 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.

 

Implant Placement

Three 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

A failed 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 (Table).

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

Conclusion

Endosseous 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.

*Resident, Department of Periodontology and Oral Implantology, Temple University Kornberg School of Dentistry, Philadelphia, Pennsylvania.

 

References

  1. Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Elsevier Health Sciences, 2007.
  2. 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.
  3. Attard NJ, Zarb GA. Immediate and early implant loading protocols: A literature review of clinical studies. J Prosthet Dent 2005;94(3):242-258.
  4. Dodson TB. Predictors of dental implant survival. J Mass Dent Soc 2006;54(4):34-38.
  5. Watson RM, Forman GH, Welfare RD. Essentials of case planning for osseointegrated implants. Br Dent J 1988;164(10):313-338.
  6. Matukas VJ. Medical risks associated with dental implants. J Dent Educ 1988;52(12):745-747.
  7. Iacono VJ. AAP position paper. Dental implants in periodontal therapy. J Periodontol 2000;71(12):1934-1942.
  8. 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.
  9. Garg AK, Vicari A. Radiographic modalities for diagnosis and treatment planning in implant dentistry. Implant Soc 1995;5(5):7-11.
  10. 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.
  11. Hermann IS, Buser D. Guided bone regeneration for dental implants. Current Openion Periodontol 1996;3:168-177.
  12. Hämmerle CH, Karring T. Guided bone regeneration at oral implant sites. Periodontol 2000 1998;17:151-175.
  13. Kaufman E. Maxillary sinus elevation surgery: An overview. J Esthet Rest Dent 2003;15(5):272-282.
  14. Gelb DA. Immediate implant surgery: Three-year retrospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Impl 1993;8(4):388-399.
  15. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets: Implant survival. J Oral Maxillofac Impl 1996;11(2):205-209.
  16. Becker W. Immediate implant placement: Treatment planning and surgical steps for successful outcomes. Br Dent J 2006;201(4):199-205.
  17. 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.
  18. 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.
  19. Tolstunov L. Dental implant success-failure analysis: A concept of implant vulnerability. Impl Dent 2006;15(4):341-346.
  20. Guidelines for Periodontal Therapy. The American Academy of Periodontology. J Periodontol 1998;69(3):405-408.
  21. Suzuki JB. Maintenance of dental implants: Implant quality of health scale.  In: Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Elsevier Health Sciences; 2007:1073-1085.

Tables

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:

  1. Severe alveolar bone resorption
  2. Lack of keratinized gingival tissues
  3. Collagen disorders
  4. Malnutrition
 

Occlusal overload/excessive stress:

 1- Excessive loading

 2- Poor occlusal design

 3- Bruxism not diagnosed or treated

Peri-implantitis and poor oral hygiene:

  1. Patient’s lack of desire for proper hygiene
  2. Patient’s lack of dexterity because of handicap
  3. Hygienically difficult and inaccessible prosthetic design
  4. Inadequate supervision of patient’s oral hygiene
 

Unfavorable patient habits:

  1. Bruxism
  2. Heavy long-term smoking
  3. Poor oral hygiene
  4. Plaque accumulation
 

Improper design, construction, and fit of prosthesis:

  1. Deficiency at any restorative and laboratory stage leading to dynamic failures and fractures of implant components
  2. Defective implant components
  3. Fatigue of implant components

 

Inadequate prosthetic analysis and technique:

  1. Suboptimal insertion technique
  2. Lack of primary implant stability
  3. Poor three-dimensional implant position
 

Unknown factors

Inadequate surgical analysis and technique:

  1. Improper choice of the prosthesis
  2. Suboptimal prosthetic design
  3. Suboptimal occlusal scheme
  4. Excessive load
 

 

Suboptimal implant design and surface characteristics

 

Unknown factors

 

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