Diagnosis and Treatment Planning for Implant Placement

Eight years ago, Dr. Gordon Christensen told me, If you can do molar endodontics or third molar extractions, then you should be placing and restoring implants‚ I believed what he said enough to begin a wonderful journey in my practice, learning to place and restore dental implants. Up to that point in my career I rarely even discussed implants as a treatment option. After all, I could do some really exotic crown and bridge restorations such as long-span bridges and cantilevered bridges, or I could provide my patients with removable partial dentures or full dentures. But the real issue was that I didn't have any understanding of implant components or procedures. When it came to diagnosis and treatment planning, my view of the world was limited by my lack of knowledge. I didn't have enough education or experience to feel comfortable restoring or maintaining the implants that my patients presented with. My fees were inadequate because I wasn't aware of the extra laboratory costs or tools needed to restore implants. I could not even properly communicate with the specialist placing the implants or the laboratory technician making the restorations. I guess I didn't see the value of implants until I obtained some education and experience.

So, I took a number of implant courses, and when I felt I had the proper education, I started placing and restoring implants. I placed 20 implants in my first year, more than 80 implants a year later, and almost 200 in my third year! My practice grew by leaps and bounds, and my skills in treatment planning and diagnosis grew as well. Best of all, my enjoyment in giving my patients a higher quality of dentistry has increased each year. This is an ideal time to enter the field of implant dentistry because the technology and engineering of endosseous implants have created one of the most successful treatments available for replacing missing teeth.

This article will discuss how I find implant patients in my practice, how I assess good candidates for implant therapy, and the criteria I use to define a well-placed and therefore easily restored implant.

PATIENT SELECTION

Let's begin by asking this question: What do patients want when it comes to dental treatment? Answer: They want what you want the best functioning, longest lasting, health promoting, aesthetically pleasing, and most comfortable treatment possible. I assume that every patient I see with one or more missing teeth will want implants. Every patient gets the treatment option of implants, and if they are interested, complete records are taken. This includes a panorex and study models at a minimum. We then perform a thorough health history as we look for a history of immune disorders or diabetes and habits such as smoking and chewing tobacco. We then perform a dental exam and we educate the patient about periodontal health, occlusion, and all tooth-related issues.

Each case is decided on its individual merits and goes something like this: if the patient has no serious health concerns and no bad habits but does have good oral hygiene habits, then this patient is an ideal candidate for implant therapy. If the patient smokes or chews tobacco, that is a reason to slow down, educate, and encourage him or her to stop or at least reduce the frequency of the habit. If the patient has an immune disorder or diabetes or is undergoing chemotherapy or treatment for a serious illness, we counsel him or her that when the health issue is under control, he or she will still be a candidate for implant therapy, although there is an increased risk of failure. If the patient doesn't exhibit good home care, he or she is educated and encouraged regarding the benefits of good periodontal health. Those who make an effort to improve are still considered good candidates, but those who do not put any effort into improving are discouraged from undergoing implant therapy.

Figure 1. Tooth No. 24 Steri-Oss 3.25 x 14-mm implant placed and restored with a porcelain-fused-to-gold crown in 1997 (89-year-old patient). Since then, teeth Nos. 19 and 29 have been restored with implants and crowns.

Next, we assess the age of the patient. We never place implants in males younger than 20 or in females younger than 18 years of age. Instead, we place treatment partials or temporary appliances to allow completion of growth before implant therapy is considered. However, there is no limit to the upside of age. One of my favorite patients was 89 years young when we placed her first implant to replace a lower central incisor. At 90, she returned asking for another implant-supported crown to replace tooth No. 19. At 92, she reported with tooth No. 29 broken to the gumline. When we offered a root canal, post buildup, and crown, she refused and instead asked to have the root removed and another implant placed. She knew she could depend on that treatment (the implant) working. She is 95 now and doing wonderfully (Figure 1).

So, we never take it seriously when the patient begins a conversation by saying, At my age, is it really worth it? For adults at any age, implants provide the stability, support, and function to provide a high quality of life. Therefore, any adult patient who presents with edentulous spaces, failed endodontically treated teeth, or teeth lost due to trauma, failed bridges, ill-fitting removable partial and complete dentures, horizontal and vertical fractures in teeth, malpostioned teeth, and hopeless teeth could be an implant candidate.

CLINICAL EXAMINATION

Figure 2. Inadequate ridge thickness for implant therapy. In this scenario, grafting more bone to gain bucco-lingual thickness must be done prior to placing an implant. Figure 3. Ridge of adequate thickness for a 3.5 x 13-mm Nobel Perfect implant that was placed moments after this picture was taken.

Now that we have a potential list of patients, when we identify a patient interested in implants we do a thorough clinical exam. Intraorally, we assess the following: the condition of existing teeth and their restorations; the periodontal status; tipped, torqued, or supererupted teeth; occlusion; and evidence of TMJ problems, bruxism, or clenching patterns. At the implant site, we look for an adequate bony foundation (Figures 2 and 3). We also assess tissue quality. Keratinized tissue in an amount sufficient to surround the resulting implant-crown complex is the gold standard. Sometimes a tissue graft might be part of the treatment plan when insufficient tissue is present.

Figures 4a and 4b. Preoperative model with same model after a wax-up.
 
Figure 5. The 2-mm twist drill (also known as a pilot drill) is positioned in the osteotomy site with the help of a surgical stent.


By taking upper and lower study models and a bite registration, we can create an ideal wax-up (Figures 4a and 4b) of the future restoration. Also, this allows us to fabricate a surgical stent (Figure 5) that helps us by guiding our surgical entry in terms of position and angulation. This is a very important step that has been slighted far too much in the past. According to Dr. Christensen, 29% of all implants are placed in the wrong position and 48% have poor angulation. We can correct these problems by educating general dentists and specialists alike to use pretreatment wax-ups and surgical stents. Unfortunately, what seems to happen all too often is that we ask the laboratory technician to accomplish some miraculous piece of work in order to cover up our poor implant placement. Perhaps we should consider removing poorly placed implants, regrafting the site, and placing a new implant (all at no charge) rather than restoring poorly placed implants.

Figure 6. A 5 x 13-mm Nobel Perfect implant immediately placed following the extraction of tooth No. 8.

Finally, good quality radiographs are essential. A panorex film gives us a wide field of view and a means of measuring the vertical height of bone. It also helps us identify the location of the mental foramen, the inferior alveolar canal, the nasopalatine duct, and the sinus cavity. For the measurements to be accurate, we simply need to know the magnification factor for the particular brand of machine. Since a panorex is only 2-dimensional, sometimes other views are desirable. Some practitioners use CAT scans or tomography to obtain a cross-sectional view of anatomic structures. In my office, we use a Soredex spiral tomography unit that also takes panorex films, TMJ films, and cephalometric films. Realis-tically, however, we only take tomograms about 10% of the time; we determine the need for this based on clinical judgment. Periapical films simply do not provide a broad enough view to see all the necessary information prior to placing implants. I also recommend postsurgical films (Figure 6) to verify the implant placement results.

DEFINING TREATMENT SUCCESS

Figures 7 and 8. Patients before-and-after photos of natural teeth and implant supported crowns (all single crowns).
 

Success in implants is defined by function, longevity, and in some cases aesthetics. We achieve function by restoring the ability to masticate food and to enhance speech. We preserve teeth that would otherwise be prepared for bridge abutments. We preserve bone from resorption through the physiologic pressure that stimulates and preserves the bone around implants. We provide appliances on implants that are easily tolerated and that don't stimulate the gag response. We improve the patients psychological state by restoring a missing part. In fact, when looking at the before-and-after treatment of the patient shown in Figures 7 and 8, it is interesting to note that no instructions were given to the patient other than please show your teeth in a smile. Look at the transformation in his clothing, grooming of facial hair, haircut, and the size of his smile. Having real teeth again truly has a profound effect upon a patients self-image.

Figure 9. This implant is ready to be restored and is clearly in the center of the ridge mesiodistally and bucco-lingually.

We gain longevity by placing the implant in the right position and providing maintenance over the long term. The final crown and implant should be in alignment and in a position that is vertical to the forces of occlusion. The biggest reason that implants fail is because of forces in a lateral direction or forces not directed down the long axis of the implant. Ideally, the implant should be centered in the ridge in a bucco-lingual direction and mesiodistally in the space available (Figure 9). This should position the resulting crown as close to the center of the opposing occlusal force as possible. Also, the occlusion should be as light as possible in centric occlusion (much lighter than the surrounding teeth). Other teeth will compress into their sockets when clenched by virtue of the periodontal ligament. Implants will not compress as they have no periodontal ligament and are integrated directly into the bone. The implant-supported crown should not be in contact in any excursive movements if at all possible. Keep in mind that teeth don't occlude when chewing food they only contact during swallowing or in pathological habits such as clenching and bruxism. We recommend night guards to most of our implant patients for that reason.

Figure 10. Healthy tissue around implant crown, tooth No. 10.

Aesthetics is always desirable and, with more experience, can be predictable. This begins with an adequate amount of bone into which the implant is placed. Next, having a healthy zone of keratinized tissue is absolutely a top priority. The depth of the implant into the bone, the vertical height from the crest of bone to the interproximal contact, the angulation and buccal-lingual position of the implant, and the oral hygiene of the patient all have an effect on the appearance of the finished restoration. It is possible today to make implant crowns that are beautiful and natural in appearance (Figure 10) with healthy gingival contours.

THE ROLE OF GENERAL DENTISTS

I feel that general dentists have an extremely important role in promoting and providing implant therapy to their patients. It is my opinion that when educated about implants via radio, newspaper, magazine, television, and the Internet, the public will approach family dentists seeking the benefits that implants offer. Also, as existing satisfied patients grow in numbers, they will by word of mouth refer family and friends for implant therapy. This growing number of interested people will seek our professional advice, our ability to treat, and our competent referrals to others. As general dentists, we see these patients for their routine care and maintenance (including maintenance of implants), and we develop trusting relationships with a majority of the people in our practices. We understand occlusion, as we will typically be restoring these implants with crowns, bridges, and appliances that require occlusal harmony. We are ethically responsible to diagnose and treat appropriately or refer to specialists for treatment.

If we choose to refer patients to specialists, we must coordinate the treatment program and pilot the care with all parties involved. This requires an understanding of dental implant therapy and an appreciation for the high value that implants can provide. Consider this: fixed prosthetics on natural teeth are 75% successful at 10 years, but fixed prosthetics on implants are 97.5% successful at 10 years. Add to this that well over 100 million people in this country are missing one or more teeth, and we are currently extracting 40 to 50 million teeth each year!

For us to be able to provide this high-quality care for our patients, it is important to educate and prepare ourselves first. Then we can see what the possibilities really are. My experience in education in dentistry leads me to believe that as a whole, dentists need to improve their skills in diagnosis and treatment planning, to see beyond the tooth to the entire mouth, and to see beyond the mouth to the whole person. If we will do comprehensive exams and offer treatment options to the patient that include the highest value dentistry, then the patient can make an informed decision. Informed, the patient can direct us regarding his or her dental care. The art and science in implantology today is reducing the time of treatment, reducing the trauma to the patient, and increasing the aesthetic result and the overall success rate.

Figures 11, 12, and 13. Flapless-sutureless placement of implant in less than 20 minutes.
 
 

 

Figures 14, 15, and 16. Immediate extraction series.
 
 

 

Can we enthusiastically offer this service to our patients? If we learn that some implants can be placed in as little as 20 minutes without suturing (Figures 11 through 13), with such little trauma that the patient can immediately return to normal activities that very day, would that promote our interest and enthusiasm? If we could remove a tooth in the aesthetic zone and immediately place an implant and a temporary crown in one appointment with great aesthetic results (Figures 14 through 16), would that stimulate our professional interest? (And how much would the patient appreciate it?) Finally, if we created stable lower dentures that fit securely, eliminated sore spots, and returned the patient to 100% of the function of normal teeth in their ability to masticate food by simply attaching the dentures to implants, wouldn't that be exciting to dentists as well as their patients?

From my own experience, I can honestly tell you that these things are being done today. Patients are excited and willing to receive this type of care. Patients want implants because they work and they offer good, long-term value. General dentists should learn to do implant therapy for the same reasons, and in doing so, this type of treatment will stimulate our professional growth and development. However, we need education on a continuing basis. We need experience, and we don't get experience by sitting on the sidelines. We get experience by doing the work. We need cooperation and communication among the different branches of dentistry. We need to find mentors to help us become comfortable in this area, and then we should become mentors to those who need our help.

I keep in touch with a growing number of dentists who are just beginning this journey, and one sentiment is repeated over and over: doing implant dentistry has stimulated their enjoyment of dentistry and has challenged them to learn more and provide a better standard of care in their practices. Doctors enjoy doing implant dentistry in their practices. Patients undergoing implant therapy appreciate the value and become very grateful patients.



Dr. Julian is a member of the American Dental Association, Kansas Dental Association, Dental Organization for Conscious Sedation, Academy of Laser Dentistry, and International College of Oral Implantologists. He is an educator for the Dick Barnes Group and is an educator for Nobel Biocare. He has maintained a private practice in McPherson, Kan, for 25 years. He can be reached at (620) 241-5000.



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