Decision Making in Implant Dentistry

Failing
to
plan
is

planning
to
fail
T.V.Narayan

tv_narayan@yahoo.com

General
risk
assessment
10

Treatment Planning
•Chief Complaint?
•History, Medication
Assessment:
•Clinical Examination  
 
 
•Radiographs
•Photographs
•Casts in the articulator  
with corrected face-bow
•Diagnostic wax-up
•Cone beam, CT-scan
•Surgical guide
1. Periodontal
2. Biomechanical
3. Function/Occlusion
4. Esthetics
5. Medical Precaution

Diabetes
• Diabetes
is
currently
considered
a
relative

contraindication
to
implant
placement

• Possible
alteration
in
bone
healing
mechanisms

• Reviewing
the
literature
published
in
the
last
10

years,
the
survival
rate
for
implants
in
diabetic

patients
ranges
between
88.8%
and
97.3%
one
year

after
placement,
and
85.6%
to
94.6%
in
functional

terms
one
year
after
the
prosthesis
was
inserted

Recommendations
for
risk
reduction
in

diabetics

• Interventions
for
replacing
missing
teeth:

antibiotics
at
dental
implant
placement
to
prevent

complications

Esposito
M,
Worthington
HV,
Loli
V,
Coulthard
P,
Grusovin
MG
Cochrane
Database
of
Systematic
Reviews

2010,
Issue
7.
Art.
No.:
CD004152.
DOI:
10.1002/14651858.CD004152.pub3

Authors'
conclusions

There
is
some
evidence
suggesting
that
2
g
of
amoxicillin
given
orally

1
hour
preoperatively
significantly
reduce
failures
of
dental
implants

placed
in
ordinary
conditions.
No
significant
adverse
events
were

reported.
It
might
be
sensible
to
suggest
the
use
of
a
single
dose
of
2

g
prophylactic
amoxicillin
prior
to
dental
implant
placement.
It
is
still

unknown
whether
postoperative
antibiotics
are
beneficial,
and

which
is
the
most
effective
antibiotic.

DENTAL
EVALUATION
1.Dental
history

2.Clinical
examination

3.Radiographic
examination

4.Study
models

5.Photographs

Clinical
Examination
1. Mouth opening: at least 3 fingers
2. Quality & quantity of attached gingiva &
muscular attachment
3. Jaw relationship -- severe class II & III
4. Jaw movement – parafunctional habit
5. Condition of adjacent teeth
6. Interocclusal clearance-minimum 7 mm
for cemented restorations

Inter-occlusal clearance
Condition of residual ridge Width of alveolar ridge

Abnormal frenum
Condition of attached gingiva
Condition of alveolar ridge
Bony Torus

LOW MED HIGH
Periodontal

Biomechanical

Function/Occlusion

TMD

Dentofacial/Esthetics

Medical
Precautions
Risk Assessment
John Kois

Additional
risks
and
modifiers
Status
of
neighboring
teeth-‐Endodontic
and
restorative

Timing
of
implant
placement

THE
SAC
CLASSIFICATION

AND
TOOL

Classification
Determinants
Esthetic
Vs
Non
–Esthetic
sites

Complexity
of
the
process

Risk
of
complications

Areas
of
Potential
risk
Biological
factors-‐
Hard
&
Soft
tissue
volume,
infection,

occlusion
etc

Technical
factors-‐
Restoration
design
&
lab
issues

Esthetic
factors-‐Risk
assessment,
need
to
replace
lost
soft

tissue

Patient
factors-‐Esthetic
needs
or
expectations
exceeding

what
can
be
achieved,
commitment
&
compliance

Process
factors-‐No.
of
steps
involved
&
Complexity,
co-‐
ordination
&
scheduling

ASSUMPTIONS
Appropriately
equipped
treatment
facility,
asepsis

Adequate
clinical
&
Lab
support

Recommended
protocols
are
followed

Patient
is
medically
fit

Patient
expectations
are
realistic

The
implant
no.,dimensions
and
type
is
appropriate
for
the

site

Implants
are
correctly
positioned

Restorative
materials
are
appropriate
to
the
task

Classification
of
Surgical
&
Restorative

cases
S-‐STRAIGHT
FORWARD

A-‐ADVANCED

C-‐COMPLEX

The
SAC
assessment
tool
is
an
online
tool
that
helps
categorize

surgical
and
restorative
cases
on
the
above
basis

iti.org

Periodontal
risk
assessment
50

ABSTRACT
Results: Experimental and clinical studies have identified various diagnostic criteria including probing parameters,
radiographic assessment and peri-implant crevicular fluid and saliva analyses. Cross-sectional analyses have
investigated potential risk indicators for peri-implant disease including poor oral hygiene, smoking, history of
periodontitis, diabetes, genetic traits, alcohol consumption and implant surface. There is evidence that probing using
a light force (0.25 N) does not damage the peri-implant tissues and that bleeding on probing (BOP) indicates
presence of inflammation in the peri-implant mucosa. The probing depth, the presence of BOP, and suppuration
should be assessed regularly for the diagnosis of peri-implant diseases. Radiographs are required to evaluate
supporting bone levels around implants.
The review identified strong evidence that
- poor oral hygiene  
- history of periodontitis  
- cigarette smoking  
are risk indicators for peri-implant disease.
Future prospective studies are required to confirm these factors as true risk factors.

The
interleukin-‐1
polymorphism,
smoking,
and
the
risk
of
periodontal
disease
in

the
population-‐based
SHIP
study.

Meisel
P,
Siegemund
A,
Grimm
R,
Herrmann
FH,
John
U,
Schwahn
C,
Kocher

T.Department
of
Pharmacology,
Ernst
Moritz

Abstract

Several
studies
have
shown
a
role
for
interleukin-‐1
gene
cluster
polymorphisms
in

the
risk
assessment
for
periodontal
diseases.
In
the
Study
of
Health
in
Pomerania

(SHIP),
3148
subjects
were
randomly
selected
from
the
population
and
assessed
for
a

broad
range
of
diseases
and
environmental/behavioral
risk
factors.
From
the

complete
study
group
in
the
age
40
to
60
years,
N
=
1085
subjects
were
genotyped
for

the
interleukin-‐1
genotype
composite
polymorphism
in
relation
to
periodontal

parameters.
The
study
objective
was
to
elucidate
the
gene-‐environment
interaction

between
the
risk
factors
smoking
and
IL-‐1
polymorphism.
An
increased
risk
of

periodontal
disease
was
found
for
IL-‐1
genotype-‐positive
smokers:
odds
ratio

adjusted
for
age,
sex,
education,
and
plaque
OR
=
2.50
(95%
C.I.
1.21
to
5.13;
p
=
0.013).

This
was
not
the
case
with
subjects
who
never
smoked:
OR
=
1.09
(0.73-‐1.62;
p
=

0.676).
These
results
support
the
hypothesis
of
gene-‐environmental
interaction
in

periodontitis.

Periodontal
therapy
Vs
Implants
#Periodontally
compromised
teeth
treated
and
maintained

regularly-‐

Survival
rates
of
92-‐93%
over
10
years

Oral
implants
-‐82-‐94%

Holm
Pederson
P,Lang
NP,Muller
F
Clin
Oral
Implant
Res,
2007;18:15-‐19

Do
implants
have
a
better
prognosis
than
teeth
with

reduced
marginal
bone
support?
–Consensus
conference
on

Teeth
Vs
Implants

Conclusion-‐Survival
rates
of
teeth
in
periodontally
well

maintained
patients
were
generally
higher
than
implants

Gotfredsen
K
,Carlsson
G.E
et
al,J
Oral
Rehab
2008;35
:2-‐8

Periodontal
risk
assessment
Criteria
for
decision
making
on
Periodontally
compromised

teeth

Tooth
stability
(SVI
value)

Type
of
osseous
defect

Decontamination
of
the
root
surface

Giano
Ricci
et
al,IJPRD,Vol
31,No.1,Pg29-‐37

Thomas
MV&
Beagle
JR,DCNA
2006;50:451-‐461

Implant
Survival
in
Periodontally
Compromised
Patients-‐
Vibeke
Baelum

Methods:
A
total
of
258
conventional
implants,
57
two-‐stage
and
201
one-‐stage

implants,
which
were
inserted
in
32
and
108
patients,
respectively,
between
June

1988
and
June
2002
were
followed
with
respect
to
their
survival,
as
well
as
the

periodontal
parameters
bone
loss,
probing
depth,
and
bleeding
on
probing.
All

patients
were
periodontally
compromised
who
had
undergone
periodontal

surgery
and
were
considered
able
to
maintain
a
high
standard
of
oral
hygiene.

Results:
The
5-‐year
survival
rates
were
97%
and
94%,
respectively,
for
the
two-‐

and
the
one-‐stage
implants.
The
10-‐year
survival
rate
remained
high
at
97%
for

the
two-‐stage
implants,
but
had
dropped
to
78%
for
the
onestage
implants.

Smoking,
short
implant
length,
and
insertion
during
the
later
period
(1995-‐2002)

were
found
to
be
associated
with
an
increased
failure
rate.

Conclusions:
Implants
placed
in
patients
with
a
history
of
periodontitis
have
a
5-‐
year
survival
similar
to
that
observed
for
implants
installed
in
non-‐diseased

persons.
Although
the
10-‐year
survival
of
the
one-‐stage
implants
was
somewhat

lower
than
has
been
observed
for
non-‐diseased
patients,
implant
placement

remains
a
good
treatment
alternative
also
for
periodontally
compromised

patients.

J
Periodontol
2004;75:1404-‐1412.

THE
NEED
FOR
ATTACHED/KERATINIZED
GINGIVA

NEED
FOR
ATTACHED
PERI-‐IMPLANT

SOFT
TISSUE
Many
investigators

have
concluded
that
so-‐called
attached

peri-‐implant
soft
tissue
doesn’t
provide
any
long
term

advantage
over
alveolar
mucosa

Zarb
&
Schmill,JPD1990;64:185-‐94

Mericske
–Stern,IJOMI1990;5:375-‐383

Wennstrom,Bengazi
&Lekholm,Clin
oral
implants
res

1994;5:1-‐8

A
growing
number
of
researchers
extol
its
virtue,
correlating
it

with
improved
soft
tissue
health,
greater
patient
satisfaction
and

fewer
complications

Schroeder
et
al,JOMS
1981;9:15-‐25

Bauman
et
al,Int
JOMI
1993;8:273-‐280

Siverstein,Lefkove
&
Garnick,JOI1994;20:36-‐40

Silverstein
&
Lefkove,
JOI1994;20:135-‐138

Chung
et
al
JP
2006

CLINICAL
RATIONALE
FOR
ATTACHED

PERI-‐IMPLANT
SOFT
TISSUE
Provides
a
prosthetic
friendly
environment

Facilitates
precise
prosthetic
procedures

Facilitates
oral
hygiene
maintenance

Resist
recession

Enhance
esthetic
blending

Width
of
attached
/keratinized
gingiva

Place
incision
about
1.5mm
buccal
to
the
lingual
mucogingival

junction

Move
the
tissue
buccally

Place
an
appropriate
healing

abutment
and
suture
leaving
a

zone
of
1
mm
open
healing

Secondary
healing

promotes
scar
tissue

formation,which
is

tightly
bound
down

to
the
bone

The
Apically
displaced
flap

Free
Gingival
Graft
81

Take
home
Periodontitis
is
a
risk
factor
for
implant
success
and
periimplantitis

Periodontally
compromised
teeth
which
satisfy
the
SVI
principles

and
are
adequately
treated
and
maintained
can
perform
as
well
as

implants

Implant
therapy
is
a
viable
treatment
option
in
patients
with

advanced
periodontal
disease,
provided
the
periodontitis
is

adequately
treated
and
maintained.

Although
timelines
are
unclear,
a
minimum
period
of
3
months

following
extractions
and
periodontal
therapy
prior
to
implant

placement
seems
to
be
judicious

Implants
in
Patients
with
advanced
periodontal
disease
can

survive
as
well
as
in
those
without
,provided
a
strict
recall
for

maintenance
is
observed

Endodontics
and
implants
Endodontic
implantitis
and
Implant
endodontitis

In
1993
Sussman
and
Moss
presented
a
case
in
which
a

single
implant
was
placed
in
a
mandibular
incisor

extraction
socket
and
appeared
to
cause
an
adjacent
lateral

incisor
to
develop
periapical
pathosis
within
2
weeks.
The

radiolucency
communicated
with
the
im-‐
plant,
and,

despite
endodontic
intervention,
an
extensive
osteomyelitis

developed
around
the
implant
causing
the
implant
to
be

lost.
SussmanHI,MossSS.Localizedosteomyelitisse
condarytoendodontic-‐implantpa-‐
thosis.
A

case
report.
J
Periodontol
1993;64:306
–10.

In
1998,
Sussman

named
the
problem
endodontic
implant

pathology
(EIP)
and
described
two
types.

Type
1
is
implant-‐to-‐tooth
EIP,
which
occurs
when
a
tooth
with
a

vital
pulp
adjacent
to
an
implant
becomes
devitalized
after

implant
placement.
The
etiology
is
probably
direct
trauma
during

osteotomy
preparation.
Timely
endodontic
therapy
for
type
1

cases
could
theoretically
prevent
progression
into
type
2

involvement
(tooth-‐to-‐implant
EIP).

Type
2
occurs
shortly
after
implant
placement
when
there
is
an

exacerbation
of
a
preexisting
apical
lesion
associated
with
an

adjacent
tooth.
The
inflammation/infection
spreads
to
the

implant
and
prevents
osseointegration
during
stage
1
healing.

SussmanHI.Periapicalimplantpathology.JOralImplantol1998;24:13
3–8.

In
2001,
Brisman
et
al.

reported
four
type
2
cases
in
which

implant
infections
occurred
secondary
to
periradicular

infection
from
adjacent
teeth
with
previous
endodontic

treatment
that
appeared
to
be
successful,
one
involving
a

mandibular
anterior
tooth
and
three
involving
mandibular

posterior
teeth

BrismanDS,
BrismanAS,
MosesMS.
Implantfailures

associated
with
asymptomatic
endodontically
treated
teeth.

J
Am
Dent
Assoc
2001;132;191–5.

Incidence
of
Endodontic
Implantitis
and
Implant
Endodontitis

Occurring
with
Single-‐tooth
Implants:
A
Retrospective
Study
Bradley

S.
Laird,

Michael
S.
Hermsen,

Tom
G.
Gound,

Fahd
Al
Salleeh,

Matthew
R.
Byarlay,
DDS,
Merlyn
Vogt,
DDS,
David
B.
Marx,
 
JOE
—
Volume
34,
Number
11,
November
2008
233
single-‐tooth
implants
placed
in
116
subjects

Three
groups
were
analyzed:

group
A,
implants
with
no
adjacent
teeth
(n
︎
90);

group
B,
implants
with
non-‐
endodontically
treated

adjacent
teeth
(n
︎
123);

group
C,
implants
with
endodontically
treated
adjacent

teeth
(n
︎
20).

Conclusions

The
results
of
the

study
agreed
with

previous
research,
which
suggests
that

endodontically
treated
teeth
adjacent
to

single-‐tooth
implants
are
usually

successful
and
should
be
maintained.

Endodontic
treatment
of
teeth
induces
retrograde
peri-‐implantitis.
 
Zhou
W,
Han
C,
Li
D,
Li
Y,
Song
Y,
Zhao
Y.
 
Clin
Oral
Implants
Res,2009 
128
patients
of
ages
ranging
from
of
24-‐61
years

A
total
of
128

implants
with
adjacent
teeth
that
had

received
endodontic
treatment
at
least
1
week
prior
to

surgery
were
placed

The
date
of
endodontic
therapy
and
the
pulp
status
of
the

adjacent
tooth
before
endodontic
therapy
were
recorded.

The
stability
of
all
implants
was
tested
by
OSSTELL
and

recorded
at
implant
placement,
after
4
and
12
weeks.

RESULTS:
The
incidence
of
retrograde
peri-‐implantitis
was

7.8%.
The
duration
from
endodontic-‐treated
adjacent
teeth

to
implant
placement
was
12.15+/-‐10.1
weeks,
and
the

distance
between
the
implant
and
the
adjacent
teeth
was

2.99+/-‐1.4
mm.
Distance
and
time
were
found
to
be
related

to
retrograde
peri-‐implantitis
(P<0.05).
The
stability
of

implants
with
retrograde
peri-‐implantitis
was
less
than
that

of
the
normal
implants,
but
the
difference
was
not

significant
(P>0.0

CONCLUSIONS:
The
incidence
of
retrograde
peri-‐
implantitis
may
reduce
by
increasing
the
distance
between

the
implant
and
adjacent
tooth,
and/or
the
duration
from

endodontically
treated
adjacent
tooth-‐to-‐implant

placement.

Although
preliminary,
these
data
might
orient
the

practitioner
to
avoid
retrograde
peri-‐implantitis.

Take
home
There
seems
to
be
conflicting
data
on
implant
survival

adjacent
to
endodontically
treated
teeth

Though
there
is
no
consensus
yet,
it
seems
prudent
to
place

implants
as
far
away
from
endodontically
treated
teeth
as

possible
and
as
late
after
endodontic
treatment
as
possible

(min
3mm
and
4
weeks)

Function,Occlusion
&
TMD

Bio
-‐Mechanics
Bite
forces-‐Masseteric
hypertrophy

Parafunction-‐Clenching
,
bruxism,
tongue
thrust

*Implant
angulations

Occlusion,Function
and
TMD

Rehabilitation
50
year
old
female

H/O
implant
therapy
in
the
Maxilla
about
8
years
ago
with
another
dentist

Repeated
failures
of
multiple

cemented
implant
prostheses
in
the
first
couple

of
years,
then
ignored
till
present
condition

Existing
implants
well
osseo-‐integrated

Medically
fit

Moderate
expectations

Initial
presentation
17/12/2010

Note
the
height
of
the
prepared

abutments

Rx
plan
1) Facebow
transfer
and
centric
records

2) Wax
mock
up
on
articulator
and
provisionalise

3) Crowns
on
12-‐22,
crown
on
14

4) Use
existing
implants
for17-‐16
and
cantilever
a
small
15

5) Install
implant
in
13
position

6) 23-‐25,
use
existing
implants

Extract
36,37,46,47

Install
implants
in
46,45,34,36

Screw
retained
implant
crowns
in
the
Mandible

Mandibular
anteriors
–composite
BU

35-‐RCT
&
crown

Transfers
to
the
articulator

Protemp
provs
in
Maxilla

Abutments
attached
to
maxillary

implants
and
milled

Heat
cured
acrylic
provs

Provs
in
place
and
Mandibular
anteriors

built
up
in
Light
cure
composite

Articulation
in
protrusive

Immediate
post
cementation
maxillary
Oct
17,2011
Had
to
use

electrosurgery
on
the
Centrals&
Laterals
prior
to
bonding

Take
home
A
careful
assessment
of
existing
occlusion
and
function
and

parafunction
is
essential
to
successful
implant
therapy

especially
where
multiple
implants
are
involved.

Developing
the
right
occlusal
scheme
in
cases
where

multiple
implants
are
being
used.

Mutually
protected
is
ideal

with
a
shallow
incisal
guidance

though
group
function
is
widely
accepted
when
implants

against
natural
teeth

Bilateral
balanced
for
implant
supported
dentures

`
Implants
are
a
treatment
option
and
should
be
treated
as

just
that-‐
not
as
a
separate
discipline

Good
implant
therapy
results
from
a
sound
understanding

of
Periodontics,
Endodontics
,
Occlusion
and
Restorative

procedures
apart
from
mere
surgical
skills

Decision Making in Implant Dentistry

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