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Ken Nicholson

Implant Dentistry in General

Practice Part 2: Treatment Planning
Abstract: This paper, the second of a series of two, provides an introduction to treatment planning in implant dentistry for the general
dental practitioner.
CPD/Clinical Relevance: Appropriate training has made implant placement and restoration a routine treatment option in general practice.
Dent Update 2016; 43: 522528

Good treatment planning can only occur Patient expectations patient is essential from the outset. The use
when based upon a thorough understanding Patient expectations must of educational models, clinical photographs
of the principles of implant dentistry in be identified early in the consultation and a diagnostic set-up are invaluable in
general practice. These include: process and compared with a detailed case conveying the appearance of the planned
The Faculty of General Dental assessment to determine if they can be restoration.
Practice UK/General Dental Councils met. Much implant company marketing
recommendations;1 literature gives a very positive aesthetic Treatment options
Patient expectations; outcome for implant-supported restorations,
Thorough case assessment. Even when the required
potentially setting the patients expectations criteria to provide a long-term successful
The clinician should begin with the beyond what may be readily achievable.
end result in view in terms of whole patient implant-supported restoration can be met,
It is not the implant components that alternative treatments must be considered
care, not limiting the treatment plan to the
determine the aesthetic outcome but the and discussed with the patient as part of the
replacement of missing or failing teeth and
time spent on case assessment in order to informed consent process. Priest suggests
their implant-supported restorations.
arrive at a correct diagnosis and treatment that the use of dental implants for the
plan.2 The question What can I do for you? replacement of a single missing tooth helps
Treatment planning should reveal their expectations. Implant preserve the adjacent teeth by sparing their
considerations restorations must provide both appropriate use as abutments for fixed and removable
Patient expectations; and achievable form and function. Providing partial dentures.4 He reports a 97.4% survival
Treatment options; function is a much more straightforward
rate over a 10-year period but also describes
Ancillary/complementary treatment; process than providing form.2,3
complications such as loss of implant
Occlusal requirements; Answers to the question What
crowns, screw loosening, broken screws,
Soft tissue and bone augmentation; can I do for you? are crucial:
cement washout, margin exposure and
The number of implants; 1. I cannot tolerate this denture
porcelain fracture. A review paper contrasts
Provisional restoration; reasonable;
implant success against implant survival
The definitive restoration; 2. This crown/bridge keeps falling out
where the implant survival rate may be
Treatment stages and overall timescale; reasonable;
100% vs 52% success in one study.5 The risks
Maintenance. 3. I would like this space filled reasonable;
and benefits of each treatment option must
4. I want to look ten years younger
be clearly described and discussed in terms
that the patient can understand.
Ken Nicholson, BDS, MSc(ImpDent), 5. I would like a Hollywood smile very
Faculty of Examiners RCS Edin, 91 unreasonable.
Answers 4 and 5 should be taken Ancillary and complementary
Newforge Road, Magheralin, Craigavon
( as warning signals. treatment
Clear communication with the In cases where there is
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inadequate space in the vertical or Occlusal requirements should ask is What are the benefits to the
horizontal planes to accommodate Unlike natural teeth that benefit patient?13 and are they achievable without
the implant restoration, orthodontic from the sensitive shock-absorbing features complications? It is essential that the
treatment may be indicated. On occasions, and mechanoreceptors of the periodontal GDP must be competent to carry out the
orthodontic extrusion prior to extraction ligament, osseointegrated implants are procedure.
has been suggested to improve the effectively ankylosed to the surrounding Retzepi and Donos14 reviewed
vertical position of the hard and soft bone. Without the protective features the biological principle and therapeutic
tissue margins. The repositioned margins of the periodontal ligament, implant applications of guided bone regeneration
then allow for implant placement in a restorations are more susceptible to occlusal (GBR) for the following:
position that will provide a better aesthetic overload that may lead to screw loosening, i. socket preservation;
outcome.6 component fracture, porcelain fracture, ii. alveolar ridge augmentation prior to
The following questions need bone loss and eventual implant loss. This implant placement;
to be asked: susceptibility is brought into perspective iii. immediate implant placement in fresh
Is the periodontal condition of the when patients describe a solid wooden extraction sockets;
remaining teeth acceptable? If not, sensation on biting and chewing.7 Wolffs iiii. width; and
implant treatment should not proceed. law8,9,10 basically states that bone growth v. height augmentation in combination with
In the horrendous example shown in and remodelling throughout life shows implant placement.
Figure 1, the patient was only interested adaptation to the mechanical environment. They concluded that GBR can
in having the cantilever bridges Restorations should be planned so that predictably lead to the regeneration of bone
replacing UL1 and UL2 replaced with they do not cause occlusal intolerance in each of these scenarios. An occlusive
implant-supported restorations as that exceeds the adaptive capacity of the membrane is used to avoid the ingress of
these were the most mobile teeth in his bone11 to avoid bone loss.12 The bone/ soft tissue into the bone graft material and
mouth. space must be maintained for augmentation
implant interface should be loaded within
Will your proposed treatment affect in the vertical or horizontal dimension or
the physiological tolerance of the patients
adjacent restorations? For example, both. Socket preservation with particulate
bone, for example by using a reduced
implant placement surgery may result graft material alone (ie without the use of an
occlusal table and low cusp angles. Extreme
in the margin of adjacent restorations occlusive membrane) may actually interfere
care is required to protect the bone implant
becoming exposed. If not identified with the normal bone healing process.
prior to treatment and avoided However, it is important to point out that
completely through a modified surgical complications with GBR techniques are
approach or discussed with the patient, Soft tissue and bone
the outcome can be costly for both augmentation
There may be a need to consider
patient and operator. If the presenting alveolar soft tissue augmentation before, during
Does the patient wish to have additional foundation will not allow a successful or after implant placement. The approach
cosmetic treatment? For example, what implant restorative outcome then that and material used will be determined by
if the operator arrives at the end of the foundation may have to be augmented the desired objective. A systematic review
restorative phase to find that the patient with soft tissue, hard tissue or both. If this is investigated the efficacy of soft tissue
has decided to have his or her teeth not feasible then an alternative treatment augmentation around dental implants and
bleached? plan must be followed. What the clinician in partially edentulous areas.15 It concluded
that the sub-epithelial connective tissue
graft is the treatment of choice for soft tissue
bulking in both the implant and partially
edentulous site. The authors highlighted
the lack of studies for gain in keratinized
mucosa and also that many of the studies
were company sponsored, introducing the
potential for bias.

Number of implants
Useful information can be
obtained from the existing restoration,
and in the partially dentate situation
measuring the space available for the
implant-supported restoration. The
Figure 1. The patient requested that the cantilever bridges replacing UL1 and UL2 were replaced with number of implants required will partly be
implant-supported restorations.
determined by the type of restoration, fixed
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Figure 2. Inter-implant and tooth implant distance based on the work of Figure 3. Implant distance to adjacent structures. (Courtesy of Nobel Biocare,
Tarnow et al.16 (Courtesy of Nobel Biocare, Kloten, Switzerland.) Kloten, Switzerland.)

or removable, the location of the restoration restoration, the implant clinician works hand units be linked or separate. The restoration
and the space available. The inter-implant in hand with a laboratory/dental technician may be screw-retained or cement-retained.
distance should be at least 3 mm if crestal knowledgeable, skilled and experienced in The screw-retained restoration favours
bone and the inter-implant papilla are to be implant dentistry. retrievability but may compromise
maintained between the implants16 (Figure The provisional restoration may aesthetics. The cement-retained restoration
2). A recent study showed that the use of a be fixed or removable or, in some cases, can favour aesthetics but may compromise
platform-switched implant design (that is not required, for example if the restoration long-term survival of the restoration due
the diameter of the abutment is less than the is outside of the aesthetic zone. It may be to lack of detection and removal of excess
diameter of the implant at the level of the tooth-supported (eg adhesive bridge or cement when the restoration is fitted.
implant abutment interface) allows for the a modified Essix appliance), soft tissue- Failure to remove excess cement has
inter-implant distance to be less than supported or supported with temporary been implicated as a major cause of peri-
3 mm while still maintaining the inter- implants. Where the patient has an implantitis.20,21 The deeper the position of the
implant crestal bone level.17 The platform- existing partial denture, this may serve as a crown margin, the greater is the likelihood
switched implant design has been shown provisional restoration, although care needs of excess cement being undetected and only
to help maintain crestal bone levels and to be taken to ensure that the denture does when the crown margin is supragingival can
support the overlying soft tissue contour18,19 not apply pressure to the underlying implant all excess cement be assured of removal,
A dilemma arises when and/or graft material. which paradoxically may compromise
the interproximal space in the partially When starting with the end aesthetics.22
dentate situation does not readily allow for point in view, the diagnostic set-up may be The implant-supported cantilever
these spacing criteria to be applied. The used for the provisional restoration and will restoration remains a controversial issue.
practitioner must then consider the use of help determine the ideal position of the Misch recommends that, if a cantilever
ancillary treatment, eg the creation of space implant(s) from the restorative perspective design is to be used, the cantilever should
by orthodontic treatment, the use of larger rather than simply placing the implant(s) in be extended mesially and cantilevers based
or smaller diameter implants bearing in mind the region of the greatest volume of bone. upon two implants should be avoided.23
the loading of the implant(s), the emergence In general terms the Spoon denture design Others conclude that the presence of a
profile of the restoration, distance to should be avoided as it has the potential to cantilever has no impact on marginal bone
adjacent structures (Figure 3) and the option apply damaging pressure to the underlying loss, with the exception of the posterior
to use a cantilever design restoration. tissue/implant. When the final restoration is mandible.24 However, the presence of a
to be of a fixed design, buccal/labial flanges cantilever is associated with significantly
more technical problems at the implant
Provisional restoration on removable partial denture prostheses
should also be avoided as these can lead to
This is a most important The connection of implants to
wound breakdown after implant placement
component of treatment planning, since teeth also remains a controversial issue. It
and also give the patient a false impression
a poorly designed or ill-fitting provisional is generally accepted that this should be
of lip support when compared with the final
restoration has the potential to undo the avoided though, if required, the implant
work of the most skilful clinician, whereas should be linked to a tooth distal to it owing
a well-designed and well-fitting provisional to the inherent movement of teeth within
restoration has the potential to sculpt the The definitive restoration their sockets; the more posterior the tooth
tissues and contribute to a positive aesthetic This may be fixed or removable, the less is its movement.23 However, some
outcome. It is also of paramount importance and may comprise single or multiple units, studies suggest that linking natural teeth
that, for both the provisional and definitive in which case the question arises should the to implants can be successful with careful
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placement, in other words a single or two- documents/implant%20training%20

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