The successful outcome of dental implant treatment is dependent on careful patient selection and risk assessment. This involves a detailed assessment of the patient complaints, their treatment needs and expectations and whether treatment with dental implants will address these. This assessment is even more crucial as the clinical envelop for tooth replacement with dental implants has grown extensively with the focus being on replacing the teeth with implants immediately or within six weeks of extracting the teeth to minimise the extent of bone resorption. Careful case selection and planning is thus the crux of achieving the published success rates with a clear understanding of the limitations of the implant treatment for any specific patient balanced against their expectations. Missing and failing teeth both have a negative impact on the patients quality of life and social well-being; however, this impact is even greater when implants fail with greater consequences on the patients psychological well-being.
The main reasons for tooth replacement are to improve function, aesthetics and psychological well-being as well as maintaining biological structures (e.g. bone and soft tissues) (Figure 4.1). Other lesser reasons may be to help establish other functions, for example, facilitate instrument playing where the front teeth are critical to support the instrument.
Conventional forms of treatment with dentures and bridges provide successful outcomes; however, these are not teeth ‘like their own’ especially dentures. Thus, whilst any missing tooth can theoretically be replaced with a dental implant, its appropriateness will be dependent on key factors, listed below, that are usually identified during the case assessment.
- Number of missing teeth or teeth to be lost
- The quantity and quality of the soft tissue and bone where the teeth are missing or going to be lost
- The reasons for the tooth loss
- The prognosis of the remaining teeth
- The condition of the rest of the mouth
- The impact of the proposed replacement option on the remaining dentition and oral health
The process of taking the patient through the journey of tooth replacement enables the clinician to select the patient and their appropriateness to the proposed treatment option. This journey usually incorporates a structured pathway which starts with an assessment of the patients presenting complaints, clinical evaluation and investigations followed by a treatment plan aimed at executing the agreed treatment focussed on addressing the patients’ concerns. This journey is critical when dental implants are the preferred treatment option as it will help establish the patients’ expectations alongside their compliance to the proposed treatment. It should also take into consideration the clinicians awareness of the dental implant system to be used.
A. Treatment Planning
During this process, the clinician tailors, to the best extent possible, the application of available treatment options and resources to each patient’s individual goals and needs. It also includes information about a patient’s reasons for seeking implant treatment, their expectations, the goal of treatment, the options for the intervention and possible risks along with the expected length of treatment and factors that could potentially compromise the predictability, long-term success and future maintenance. It should also include information about the costs of the immediate treatment and the long-term follow up and maintenance care that is essential to maintain the outcome after the treatment has been completed.
Treatment planning for an implant patient is undertaken in two phases: the generic phase aimed at primary disease stabilisation and site-specific phase which focuses on the planning for the provision of the implant treatment and includes an evaluation of the site-specific factors (Table 4.1).
Table 4.1 Principles of Treatment Planning for the Implant Patient.
|Generic Principles||Site-Specific Principles|
|Presenting Complaint and History||Revisit the presenting complaint|
|Medical and Social History||Soft tissues|
|Extraoral Examination: Smile Line||Periodontal health|
Plaque control and periodontal health
Dentition and state of the teeth; caries;
Bone volume and height
|Investigations (Radiographs)||Investigations: wax ups, guides, scans|
|Diagnosis and Preliminary Treatment Plan||Initial plan – discussion with patient|
|Primary Disease Management||Finalise the plan|
|Patient Compliance and Expectations||Treatment outcome|
- Generic Planning:
The aim of this phase is to establish stability in the mouth and provide the clinician with an opportunity of getting to know the patient and establishing their compliance to advice and guidance given. It is the precursor to the site-specific planning and involves the following steps:
This enables the framework around which the treatment will be planned and includes four steps:
- – Presenting complaint:
Establishes why the patient is seeking treatment and the reasons for the tooth loss.
- – Medical history:
Identifies key issues that may influence the provision of the implant treatment. There are no absolute medical contraindications to implant treatment; however, there are certain conditions that will influence the provision of implant treatment and also affect the long-term outcome to the implant treatment. These include a history of uncontrolled diabetes and hypertension, immunosuppression, oral mucosal disorders and bisphosphonate treatment. Bisphosphonates irreversibly alter the metabolism of the osteoclasts, so there is little or no bone resorption, even if the blood supply is good resulting in osteonecrosis also known as avascular necrosis of the bone or osteochondritis dissecans (the death of bone resulting in the collapse of the bone’s structural architecture). This leads to bone pain, loss of bone function and bone destruction. Thus, whilst not contraindicated, the surgical placement of implants may lead to bone necrosis and can also become a long-term complication with symptoms similar to toothache, exposed bone, swelling and altered sensation with recurrent soft-tissue infection. Intravenous bisphosphonate treatment has a greater risk than oral bisphosphonate treatment. A systematic review by Gelazius (2018) reported that patients treated with intravenous bisphosphonates seemed to have a higher chance of developing implant-related osteonecrosis of the jaw; however, the orally treated patient group appeared to have more successful results and thus implant placement in patients treated orally could be considered safe with precautions. Other antihypertensive drugs such as calcium channel blockers will also affect the gingival tissue overgrowth similar to that seen around teeth in the presence of poor plaque control. Table 4.2 gives an indication of the conditions that can affect implant treatment.
Table 4.2 Medical conditions that can affect implant treatment.
Moderate to severe neutropenia Atypical facial pain Poorly controlled diabetes Myofascial pain dysfunction syndrome Long-term corticosteroids Smoking Intravenous bisphosphonates Parafunction Psychological instability Cluster phenomenon Malignancy/terminal illness
- – Social history:
Highlights the risk factors that affect and influence the outcome to treatment both in the short term and the long term. These include the patients smoking history and status and their compliance. Chranovic et al. (2015) have reported that the insertion of implants in smokers significantly affected the failure rates, the risk of postoperative infections as well as the marginal bone loss. Additionally, maintenance of oral hygiene around implants and the risk of peri-implantitis is adversely affected by smoking. Alongside this, stress levels and habits such as parafunction will be established during this step especially as the latter is strongly linked with peri-implant disease.
- – Dental history:
Establishes the patients’ attitude to dental treatment and their compliance to protracted courses of treatment.
- – Presenting complaint:
Throughout these four steps, the clinician will be able to determine the patients expectations and how this aligns with the anticipated treatment with dental implants. It is an important part of the patient management. These four steps are also crucial after the implant treatment when the patient is in the maintenance phase.
- Clinical Assessment
This is undertaken in two steps: the extraoral and intraoral examination.
- – Extraoral Examination
Provides an overview of the features that may influence the aesthetic outcome. These include the facial asymmetry and deviation as well as the profile. The latter will be influenced by the type of implant-retained prosthesis that is being planned. Patients with a history of denture wearing may have lost a lot of bone and replacing a denture with a fixed prosthesis may have a profound influence on the patients’ appearance by affecting the lip support. The smile line at rest and high smile is also assessed to show the amount to tooth on display and how this will affect the end result (Figure 4.2a, b).
- – Intraoral Examination
A sequential approach is needed to ensure that factors that could influence the provision of treatment are captured and include the following
- – Intraoral Examination