In a two-part article, Jamie Kerr discusses the first stage of dental implant treatment – planning.
Due to the ever-increasing ageing population, and heightened social media focus on dental aesthetics, the past two decades have seen dental implants becoming a popular method of replacing missing teeth.
Although the traditional removable partial denture still has its place in restorative dentistry, increased awareness into alternative treatment options has resulted in higher demand for fixed prostheses such as fixed bridgework or implants, to improve aesthetics and function. Dental implants are an important treatment option available to patients when use of their adjacent teeth is contraindicated or unjustified, and a long-term aesthetic replacement for the missing tooth or teeth in question is desired (Norton, 2001).
As implants themselves have changed through the years, the methods to restore them have also changed, with a variety of options available to the clinician, depending on the clinical scenario. Full arch dental implant treatment is now commonplace in dentistry, but the complexity of such treatment plans should not be underestimated. No matter the complexity of the proposed treatment, thorough case assessment and treatment planning is essential for success (Nicholson, 2016). It is important to point out that whether clinicians are simply restoring implants or performing the surgical stages as well, they must complete appropriate formal training in implant dentistry to gain the knowledge and skills required.
This two-part article will focus on the treatment stages required in order to ensure that a functional and aesthetic single-tooth implant-retained restoration can be achieved, and how it is maintained long term.
History and clinical examination
Clinical evaluation of the patient is one of the most important aspects of any dental treatment and implants are no different. There are several clinical guides available that cover the full patient assessment in detail, therefore I will summarise what I feel are the most important points to investigate and evaluate.
- Medical history – detailed medical history is essential. Special precautions required for conditions/medications that increase failure rates such as:
- Diabetes (uncontrolled)
- Bisphosphonates – 20% risk of BRONJ (bishosphonate-related osteonecrosis of the jaw) in patients treated with IV bisphosphonates, 0.34-4% risk of BRONJ with oral bisphosphonates – patients on IV bisphosphonates should be treated in a hospital setting (Nicholson, 2016)
- Smoking – light/moderate smokers (<15/day) = 10.1% failure risk, heavy smokers (>15/day) = 31% failure risk (non-smokers = 1.4% failure risk) (Nicholson, 2016)
- Dental history – regular attendance previously is important but not essential, although the patient must be advised that routine maintenance after implants are placed is essential
- Expectations – realistic? ‘Hollywood Smile’ = refer!
- Time restraints – unrealistic time restraints? Never guarantee you will meet a deadline as complications can occur
- Extraoral – assessment of TMJ/symmetry/lymph nodes as part of routine exam
- Smile-line assessment: high = complex
- Lip support: flanged partial denture? Volume of hard and soft tissue lost? Complex
- Oral hygiene – is patient able to remove plaque adequately? OHI required?
- Periodontal status
- BPE assessment – pockets >3mm? = full periodontal exam
- Active periodontal disease – stabilisation required prior to implant placement
- Soft tissues
- Biotype: type one = thin (increased chance of recession), type two = thick (Sethi, 2009)
- Keratinised tissue: adequate volume or soft tissue graft required?
- Hard tissues
- Bone loss due to resorption? When were teeth lost?
- Bone augmentation (grafting) required?
- Ideal Implant position = 1.5mm apical of ACJ (of adjacent teeth) (Nicholson, 2016)
- Adjacent teeth – prognosis? Restorations required?
- Space – at least 7mm of mesio-distal space is required for a single implant restoration (Nicholson, 2016a)
- Tooth wear – active bruxism habit?
- Adequate posterior support?
- Occlusal overload – failed post-crown? Don’t replicate!
- Over-eruption? Inadequate restorative space?
- Guidance – keep away from pontics.
The use of extraoral and intraoral photography is essential for assessment and planning and should be routinely carried out as part of a full case assessment for implant patients. In addition to this, impressions or intraoral scans should be taken to provide mounted study models/wax-ups, which will allow for full planning to be completed.
Radiographic examination and imaging
A combination of imaging techniques can be used in order to aid assessment and planning. Appropriate radiographs in the form of periapicals and/or an OPT can be used depending on the clinical scenario.
Cone beam computed tomography (CBCT) is used in the majority of implant treatment plans now and I, for one, would not be comfortable placing an implant without a CBCT image being available to me. Intraoral scanning is also becoming popular and can be used as part of the record taking process or to combine with CBCT to plan the restorative aspects prior to performing the surgery. Provisional restorations and surgical guides can be designed using the combined CBCT and intraoral scans.
After collating all the information gathered at the case assessment, diagnoses can be reached, and treatment options can be discussed. As I alluded to earlier, three main options of replacing teeth exist; denture, bridge or implant.
It is important to gain informed consent for any treatment proposed and therefore any available and appropriate options must be discussed with the patient. No treatment is also always a viable option and the patient has the right to opt for this if he/she chooses, but they must also understand the associated risks of no treatment.
For simplicity reasons, I will not discuss the advantages and disadvantages of alternative treatments but encourage the reader to research these appropriately in order to discuss these with your patients.
Implants have several advantages over other treatment options and the main ones are listed below:
- Long-term success – 97.4% survival over 10 years (single tooth implant) compared to conventional cantilever bridge (69%) (Nicholson, 2016a)
- No damage to adjacent teeth
- Fixed restoration – no need to remove
- Reduces rate of bone resorption in edentulous space.
Unfortunately implant treatment also has several disadvantages such as; increased cost, need for surgical procedures and chance of surgical and prosthetic complications.
These must be explained to our patients in detail. The patient must be made aware of what is involved in implant surgery, the timescales involved and the risks of implant failure and surgical complications occurring, as well as the routine post-op surgical issues with discomfort, swelling and bruising. They must also be informed of all costs associated.
When planning implant restorations, it is important to plan with the final prosthesis in mind (Nicholson, 2016). Occasionally, additional treatment is required prior to implant treatment in order to provide a successful outcome. Stabilisation of periodontal disease or removal of poor prognosis teeth may be required to avoid overloading implants or changing occlusion in future. Orthodontics may be required to create adequate spacing for the implant restoration. Discussions must also be made with the patient to confirm if further cosmetic treatment is desired, such as adjacent teeth being whitened or veneered to lighten the shade, as this will need to be performed in conjunction with the restorative stages for the implant. Occlusal considerations for implants are also essential as they do not facilitate the natural characteristics of the PDL and therefore are more prone to over-loading if not planned appropriately. This can lead to screw-loosening, restoration fracture, abutment fracture, bone loss and eventual implant loss.
If inadequate hard or soft tissue has been diagnosed, then again, additional treatments may be required before the implant can be placed, in order to allow the implant to be placed in the ideal 3D position, for the best restorative outcome. Hard and soft tissue augmentation is a complex treatment need and therefore will not be discussed in this article.
Discussions about method of temporisation are essential for missing anterior teeth, and even for posterior teeth if the patient wishes to have a provisional to fill the space during the implant treatment stages. A flangeless removable partial denture is commonly used but the patient may wish to avoid dentures and therefore Essix retainers or Rochette resin-bonded bridges can be offered to the patient. Discussion on what type of definitive restoration that you plan to use must also be discussed, and the patient can be shown diagnostic wax ups or digital mock-ups of what the planned outcome is. Advantages of screw- and cement-retained restorations can be advised. A discussion on advantages of fixed versus removable is also essential for larger cases.
An approximate timescale of the proposed treatment plan is important to discuss with your patient as they will likely want their implant restoration as soon as possible. Educating your patient in what stages are involved and why they have required healing periods is important to avoid your patient feeling like they are getting nowhere with their treatment and not knowing why. In majority of cases, a staged protocol is used, and this will be discussed in the surgical and restorative stages shortly. In some cases, simultaneous extraction of the required tooth and immediate implant placement can be performed. When appropriate, provisional restorations can be also, on occasion, be placed at the same time as the implants are placed, although proper planning for these cases must be completed. It is important your patient knows their treatment stages and the timescale involved.
The treatment plan must be outlined in a written consent form, which the patient must be given. This allows adequate time to read, understand and ample opportunity to ask any questions about it prior to commencing treatment.
In summary, the important points to cover during discussion on the treatment plan, and to include in your consent document are:
- Treatment options and associated advantages/disadvantages and costs
- Treatment option chosen – outline any additional treatments required
- Number of implants being placed and where
- Risks of implant placement – including surgical risks, success rates, postop complications
- Method of temporisation – fixed versus removable
- Approximate timescale and number of visits required – immediate placement/loading?
- Planned definitive restoration type/material – screw- or cement-retained?
- Maintenance plan
Part two of the article will cover the surgical and restorative stages of implant treatment, together with important maintenance protocols.
Nicholson K (2016) Implant dentistry in general practice part 1: introduction. Dent Update 43(5): 410–6
Nicholson K (2016a) Implant dentistry in general practice part 2: treatment planning. Dent Update 43(6): 522–8
Norton MR (2001) Single-tooth Implant-supported Restorations. Planning for an Aesthetic and Functional Solution. Dent Update 28(May): 170–5
Sethi S (2009) A Single Implant with Tissue Training in the Aesthetic Zone. Dent Update 36(6): 366–72
For referrals – Dentistry On The Square, 12 Niddrie Square, Glasgow G42 8QE.
Alternative email: Jamiekerr@dentistryonthesquare.co.uk.
Course details – upcoming courses on ‘Restoring implants in general practice’ to be confirmed for May and September 2019.
If interested please contact firstname.lastname@example.org for more details.