3 General Principles for the Pre-Treatment Assessment of and Planning for Partially Dentate Patients Receiving Dental Implants
D. Morton, W.C. Martin, D. Buser
Treatment planning for partially dentate patients is critical to achieving optimum outcomes considered satisfactory by both patients and clinicians. Many factors should routinely be considered during the planning process in an effort to improve the predictability of treatment. Treatment regulators are the major factors that influence the presence or absence of risk to successful treatment outcomes. Each regulator is characterized by factors capable of reducing the quality of the treatment, and as such should be objectively evaluated for each treatment indication.
The following table summarizes the risk factors associated with the treatment of partially dentate patients (Table 1). Based on a detailed preoperative analysis, the individual risk profile of each patient can be established.
|Degree of Risk|
|Treatment Regulator||Risk Factor||Low||Medium||High|
|Clinician||Skill and education||Experienced clinician with formal postgraduate training or high levels of implant-specific continuing education||Experienced clinician with moderate levels of implant-specific continuing education||Inexperienced clinician with limited implant-specific continuing education|
|Experience||Extensive implant-specific clinical experience||Moderate implant-specific clinical experience||Limited implant-specific clinical experience|
|Patient||Medical risk factors||Absence of medical risk factors||Medical conditions present though controlled||Medical conditions that retard or diminish implant integration and smoking|
|Dental risk factors||Absence of periodontal or occlusal disease, high levels of hygiene and compliance||History of controlled periodontal or occlusal disease, questionable oral hygiene or compliance||Active periodontal or occlusal disease, poor levels of hygiene and compliance|
|Anatomic risk factors||Type 1 and 2 bone, adequate interocclusal space, favorable opposing dentition||Type 3 bone, questionable interocclusal space, less than ideal opposing dentition||Type 4 bone, inadequate interocclusal space, unfavorable malocclusion|
|Esthetic risk factors||Low esthetic risk based on esthetic risk profile||Moderate esthetic risk profile based on esthetic risk profile||High esthetic risk based on esthetic risk profile|
|Surgical approach||Documentation and evidence||Type 3 and 4 implant placement when implants with a micro-roughened surface are used||Type 2 implant placement when implants with a micro-roughened surface are used||Type 1 (immediate) placement when implants with a micro-roughened surface are used|
The most critical regulator capable of determining the quality of the treatment is the clinician. The clinician’s skill, ability to pay meticulous attention to detail, and experience must not be underestimated. Clinicians with advanced training in oral surgery, periodontology and/or prosthodontics or with high levels of implant-specific continuing education are often better prepared to provide treatment for patients whose treatment presents medium or high risk.
Clinicians with moderate levels of clinical experience and continuing education in implant and comprehensive dentistry should be encouraged to manage the rehabilitation of patients with low and medium risk to outcomes. These clinicians are more likely to recognize the need for specialty involvement and will most likely embrace accepted protocols, including a team approach to treatment and restoration-based implant treatment philosophies.
Inexperienced clinicians with only limited exposure to implant-specific continuing education should limit treatments to low-risk patients. These clinicians should seek access to experienced mentors and further education if they desire to increase levels of treatment difficulty.
A team approach to patient planning and treatment should be encouraged where at all possible in order to improve the opportunity for clinicians to gather experience and education with no concurrent risk to patients and their treatment success.
Another critical treatment regulator is the patient. The medical status of the patient should always be evaluated as part of the pre-treatment analysis. Because the loading of dental implants transfers stress to the supporting structures, particular emphasis should be placed on systemic disorders capable of reducing this capacity. Such factors may include diabetes, immune diseases, bone diseases, and smoking.
The dental status of the patient is a primary concern. The presence or absence of periodontal disease (both past and present) and the patient’s response to therapy should be noted. The patient’s occlusal classification and the presence or absence of occlusal disease is also important. The capacity to distribute occlusal loads appropriately through the stomatognathic system with the planned definitive restoration or restorations should be routinely evaluated.
The patients’ level of hygiene and motivation towards their dental health also influences treatment risk. Those patients with less than ideal oral hygiene and low motivation should have behavioral modification prior to the commencement of implant-based care. This risk factor is important to the health and integrity of the entire dentition, not only to the planned implants and restorations.
Lastly, the local anatomy of the site is an important consideration when evaluating the restorative phase of treatment. Patients characterized by type 1 and 2 bone, where high levels of implant survival are routinely observed, can be treated with a variety of loading options at a relatively low risk (Table 2). Risk to implant survival, particularly in the early stages of healing, increases as the quality of the supporting bone diminishes. Most implant failures continue to be recorded prior to, or shortly after, restorative loading, and are often associated with reduced bone quality or regions characterized by such. Emphasis should be placed on the combination of implant surface area and bone quality as short implants in type 3 and 4 bone can result in higher treatment risk for some implant systems, particularly when combined with accelerated treatment protocols (Table 2). More mature bone may be recommended in such circumstances.
|Compact Bone||Trabecular Bone||Type (Bone Density/Quality)|
|Homogenous compact bone throughout the entire jaw||Small amount of dense trabecular bone||1|
|Thick layer of compact bone||Core of dense trabecular bone||2|
|Thin rim of cortical bone||Core of dense trabecular bone||3|
|Thin rim of cortical bone||Core of low-density trabecular bone||4|