A CAfter clinical examination, radiographic imaging, and study casts, the next level of diagnosis can begin. For a case in which the needs are largely restorative, such as veneering

A COMPREHENSIVE APPROACH TOTREATMENT WITH AND WITHOUT

ENDOSSEOUS IMPLANTS

Neil L. Starr, DDS, PC

The incorporation of one single-tooth implant and

crown, together with a series of all-ceramic crowns or

veneers for the adjacent natural teeth, creates a great

challenge for the clinician and dental ceramist.

Endosseous implant placement requires careful

staging in accordance with the healing time frames

associated with tissue maturation.

[Au: Please approve the selection of this

principle for the opening page or select a

different one of your choice.]

IPPHILOSOPHY & BACKGROUND

Editor’s note: In this closing chapter, Dr Starr synthesizes the treatment-planning principles

relevant to a partially edentulous case. This article appeared in the Seattle Study Club Journal

over a decade ago, and yet the concepts are timeless. Dr Starr’s chapter convincingly demon-

strates that once understood, the principles of treatment planning transcend the cases pre-

sented in this book and readily become part of the clinician’s everyday armamentarium.

INTRODUCTION

Our ultimate therapeutic goal as dentists is to achieve maximum health, masticatory function,

speech, esthetics, and comfort for our patients. Generally, treatment can be divided into three

levels: (1) emergency care for relief of pain or sudden dysfunction; (2) removal of the causative

factors of the disease processes; and (3) removal of the effects of the disease or traumatic insult.

Level 1, emergency treatment, must be accomplished before any other level of therapy is insti-

tuted (Table 17-1).

The purpose of level 2 is to control inflammation. A basic tenet of periodontal therapy is the

mechanical debridement of all accretions adherent to the clinical crowns and roots of teeth or

restorative materials, both supragingivally and subgingivally. This is accomplished by scaling,

root planing, and curettage procedures in concert with plaque-control instruction. For dental

caries, it is evident that early placement of restorations prevents the need for more extensive

intervention later.

The focus of this article is level 3: attempting to correct alterations in form and function.

2

17 A COMPREHENSIVE APPROACH TO TREATMENT WITH AND WITHOUT ENDOSSEOUS IMPLANTS • Starr

TABLE 17-1 EMERGENCY DENTAL TREATMENTS

Problem Treatment category Treatment

Deep caries crowns Sedative restorations “Direct fillings” or temporary fillings

Symptomatic teeth/abscess Endodontic Drainage, antibiotics, conventional or surgical treatment

Occlusal trauma or Occlusal therapy Selective adjustment, appliance myofascial pain syndrome therapy, anti-inflammatory

medication

Large circumscribing periodontal/ Extraction of hopeless teeth Interim fixed or removable periapical lesions restoration as necessary

Broken appliances Prosthetic repair Re-establish masticatory function and esthetics

3

DIAGNOSTIC EVALUATION

DDIAGNOSTIC EVALUATION

Diagnosis, treatment planning, and treatment sequencing continue to be difficult and trouble-

some areas for dentists and dental specialists in the therapeutic approach to the partially eden-

tulous patient. A comprehensive dental-periodontal examination must be performed first.

This will ensure that all members of the treating team have addressed their problem areas and

have collated their respective treatments into the overall therapeutic scheme. The clinical eval-

uation consists of caries, periodontal, endodontic, orthodontic, orthognathic, occlusal/

temporomandibular joint (TMJ), and systemic examinations (Box 17-1). To facilitate this diag-

nostic evaluation, a full-mouth series of periapical radiographs of teeth and residual ridges

must be taken. A panoramic radiograph, possibly a cephalometric radiograph, and a dental

computed axial tomography (CAT) scan are suggested to help assess the bone quality and den-

sity and thereby supplement conventional dental radiography. CAT scan technology is often

enhanced today by the use of barium-impregnated surgical templates2 or with gutta percha

markers to more precisely analyze all available bone sites. Mounted study casts should also be

made. In most situations it is suggested that two sets of original casts be taken: one to be pre-

served diagnostically and the other to be worked on therapeutically.

After clinical examination, radiographic imaging, and study casts, the next level of diagnosis

can begin. For a case in which the needs are largely restorative, such as veneering or crowning one

BOX 17-1 DIAGNOSTIC EVALUATION

Caries• Supragingival• Subgingival• Insufficient clinical crown height

Endodontic considerations• Symptomatic teeth• Separated instruments• Dystrophic calcifications• Fractured roots• Apical and lateral zones of osseous destruction• Status of existing posts-cores

Esthetics• Smile analysis• Lip line analysis• Gingival topography assessment• Incisal plane assessment

Malocclusion• Loss of occlusal vertical dimension

Missing teeth• Without replacement• With delayed replacement

Occlusal trauma• Primary: bruxism, clenching, retrograde wear• Secondary• TMJ considerations

Orthodontics• Tooth shift or collapse

Periodontal disease1

• Degree of bone loss• Topography of alveolar defect (potential

impact of bone loss on adjacent teeth)• Classification of periodontal biotypes

Size and shape of residual deformed bony ridgeareas• The degree of resorption will influence the

surgical and restorative ventures

Medical status• Systemic disorders• Psychological concerns

Traumatic injury• Clinical crown deformity• Soft and hard tissue deformities• Facial deformity

Developmental/acquired deformities• Cleft palate, cleft lip• Amelogenesis Imperfecta, other deformities

Systemic influences• Systemic diseases (eg, diabetes, cirrhosis)• Osteoporosis, osteopenia, osteomalacia• Liver or kidney dysfunction• Anticonvulsants• Antidepressants• Vitamin D deficiency• Parathyroid hormone• Aging; estrogen deficiency• Gastrointestinal problems• Psychiatric/psychological considerations

4


E

or more teeth, gingival esthetic guidelines may be a large component of the treatment planning.

To establish a diagnosis in more compromised situations, it is important to ascertain the

patient’s tooth loss history. A variety of etiologic factors may have been responsible for tooth loss:

caries, subsequent endodontic complications, traumatic injuries to teeth (and/or alveolus), peri-

odontal disease (acute or refractory), trauma from occlusion, or iatrogenesis.

Many teeth may serve as strong viable abutments. However, teeth substantially affected by

periodontal disease, caries, or endodontic problems must be identified early because they may

have minimal value as abutments for either individual crowns or splinted restorations. These

teeth may also represent a serious periodontal liability to adjacent teeth or bony ridges.

ESTHETIC TREATMENT APPROACH

Esthetics and osseointegration were developing on parallel paths during the mid-1980s to early

1990s. Each emphasized the importance of the integrated team approach to achieve the ulti-

mate periodontal and restorative result. Preserving the soft tissue architecture, and in particu-

lar the papillae, was a major concern. We know that maintaining the papilla between two teeth

is somewhat predictable,3 but between a tooth and an adjacent implant it is less predictable.4,5

Concern for the loss or reduction in height of the papilla between two adjacent implants has

created a new esthetic issue.3 Therefore, the concepts of selective extraction of teeth and sock-

et preservation and augmentation at the time of tooth extraction appear to be invaluable in the

restoration of form, function, and esthetics.6–11

Principle 1Esthetics plays a major role in our diagnostic and therapeutic endeavors. Howev-

er, long-term clinical assessments have shown that its real value will play out opti-

mally when it is achieved in concert with all of the functional needs of the dentition.

Tarnow12 and colleagues observed that in healthy mouths the gingival

papilla filled the space between the teeth 100% of the time when the distance

from the contact point of adjacent teeth to the crest of bone was 5 mm or

less. When the distance was 6 mm, the papilla did not fill the space com-

pletely in approximately 50% of the patients, and when it was 7 mm or more,

it did not fill the space in about 75% of the cases. The pronounced scalloped

periodontal biotype (because of its triangular-shaped tooth) usually has a

distance between 6 to 7 mm. Under normal conditions, this is the tissue type

that usually has some interproximal recession with the formation of “black

triangles.” Further clinical insults to the soft tissue, such as tooth prepara-

tion, excessively rapid orthodontic tooth movement, tooth extraction, scal-

ing, root planing, and injudicious retraction of soft tissue may increase the

gingival recession, thus further compromising the esthetic result (Fig 17-1).

The extraction of an anterior tooth usually results in resorption of bone

on the facial and interproximal surface. In addition, a decrease in the faci-

olingual dimension of the interproximal areas is not uncommon. These

findings are obvious in the scalloped type of periodontium and even more

Fig 17-1b All-ceramic crowns for maxillary anterior teeth,respecting the gingiva and harmonizing with the gingivaltopography.

Fig 17-1a Maxillary anterior teeth with facial margins ofcrowns exposed and failing composite restorations.

5

Fig 17-2c All-ceramic veneers on master stonecast.

Fig 17-2d Preoperative smile profile. Fig 17-2f Definitive ceramic veneers with smileprofile.

Fig 17-2e Definitive ceramic veneers for themaxillary teeth, with restored occlusal functionand improved dental and facial esthetics.

obvious in the pronounced scalloped type.13 This can create an esthetic dilemma for both the

patient and the dentist. Complicating the matter is that the root morphology of the anterior teeth

is usually more tapered, both faciolingually and mesiodistally, than those found in the flat type of

periodontium.14–16 The end result of extracting an anterior tooth with a scalloped type of periodon-

tium is (1) greater loss of interproximal hard and soft tissues; (2) a more palatal positioning of the

interproximal papillae; and (3) a wider mesiodistal dimension between the adjacent teeth (because

of the taper of their roots). The outcome is a large noticeable black triangle, which is often treated

by closing the space with a wider crown, with laminate17 placed on the adjacent teeth, or with the

use of pink porcelain to simulate the lost gingiva. Often these options are not satisfactory.

When a patient’s needs are primarily restoratively focused, such as veneering or crowning

one or more teeth, gingival esthetic guidelines (Figs 17-2 and 17-3) will be a significant compo-

nent of the overall effort.

Fig 17-2a Edge-to-edge maxillary incisor rela-tion, with crossbite at the mandibular right lat-eral incisor, canine, and first premolar,demonstrating marked incisal wear. The den-toskeletal Class III arrangement (with thin lipform) exaggerates the flat facial profile.

Fig 17-2b Following a diagnostic compositemock-up directed at creating anterior guidance,building out the teeth to enhance the facial pro-file, and improving the incisal edge relation tothe lower lip, the maxillary teeth were preparedfor ceramic veneers. The incisal edges of themandibular teeth were reshaped by odontoplas-ty to create the proper overbite-overjet relation.

Fig 17-3a Mottled enamel with marked discol-oration and recurrent caries.

Fig 17-3c Smile view with provisional acrylicrestorations, which create both gingival and incisalbalance with the patient’s lips and facial form.

Fig 17-3b Provisional acrylic restorations torestore form, function, and esthetics to theinvolved maxillary teeth.

6

The addition of bone and soft tissue at or after tooth extraction, or of tooth lengthening by

restorative and/or surgical measures to achieve esthetic outcomes, requires even greater inter-

disciplinary planning (Box 17-2).

Fig 17-4a Frontal view of preoperative worndentition.

Fig 17-4c Composite mock-up of lip line smile.Fig 17-4b Frontal view of composite mock-up.

To properly address the esthetic requirements of the patient, it is necessary to envision the

desired outcome before performing the procedure.18

Esthetics is fundamentally about tooth form, and it is most predictably realized with the

assistance of an intraoral diagnostic mock-up to improve incisal form, lip line esthetics, and

gingival topography. (Fig 17-4) The outcome is the development of an intraoral esthetic blue-

print. This results in dentist verification, improved laboratory communication, and patient

affirmation. Molds of the improved intraoral anatomic form of the teeth should be poured in

stone and then enhanced further in the dental laboratory with the application of wax. Silicone

impressions are fabricated by the laboratory, then returned to the clinician to be used to verify

proper tooth reduction.18

Principle 2The incorporation of one single-tooth implant and crown, together with a series of all-ceramiccrowns or veneers for the adjacent natural teeth, creates a great challenge for the clinician anddental ceramist.6 Endosseous implant placement requires careful staging in accordance withthe healing time frames associated with tissue maturation.

BOX 17-2 MAPPING THE COURSE OF ESTHETIC DENTAL TREATMENT WITH CERAMIC RESTORATIONS

7


I. Emergency treatment• Restore anatomic/clinical crowns

A. Fabrication of provisional acrylic restorations, orB. Application of composite bonding to restore form

• Endodontic treatmentA. Fractured teethB. Pulpal involvementC. Periapical infection

II. Initial therapy• Debridement of plaque and calculus deposits adherent to the clinical crowns and roots of teeth or

restorative materials both supra- and subgingivally• Oral hygiene instruction

III. Intraoral digital imaging and diagnostic mock-up18

Enables the clinician, patient, and laboratory technician to evaluate:• The three-dimensional appearance, form, and function of teeth• The actual size, shape, and form of teeth• Incisal length and incisal plane relative to lip profile19

• Location and form of the gingival topography to complement tooth form relative to smile profile

IV. Anticipation of endosseous implant placement• Placement into recently or immediately extracted tooth root(s)• Augmentation of bone and soft tissue volume before placing the implant

V. Restorative tooth lengthening• Fabrication of post-cores for teeth with insufficient tooth length/retention

VI. Surgical tooth lengthening• To improve the tooth’s biomechanical profile• To enhance retention and resistance form• To improve esthetic profile and length of tooth form

VII. Placement of endosseous implants• To create an individual clinical crown• After tissue healing associated with clinical tooth lengthening • Use of surgical template to provide correct implant location and angulation• At time of tooth extraction, with immediate provisional restoration (without opposing tooth contact)

VIII. Uncovering of endosseous implant(s): Two-stage protocol• Mucogingival therapy as needed

IX. Fabrication of implant-supported provisional restoration

X. Tooth preparation and impression• Performed using an index of the form of the teeth.• On the basis of the diagnostic mock-up, the preparation of the teeth can be accurately performed• Followed by a master impression technique that is predictable for the clinician

XI. Fabrication of interim provisional restoration• From bis-GMA or acrylic materials• To restore tooth form, function, and esthetics on an interim basis

XII. Try-in/Insert of ceramic restorations• Check the individual and collective fit of the restorations• Adjust the contact point or contact areas• Use radiographic verification of seating of the restorations, to help ensure successful luting, long-

term function, and maintenance

XIII. Adjustment and installation of an occlusal guard or bite platform appliance• When deemed necessary

8


Dental therapeutics without implantsWhen sophisticated dental therapy will be managed without the use of endosseous implants, the

approach to treatment can be subdivided into periodontal, orthodontic/orthognathic, occlusal,

and restorative phases. These phases are interdependent even if one initially takes precedence over

another, or if two or more of the phases are concurrent (Box 17-3).

BOX 17-3 MAPPING THE COURSE OF DENTAL THERAPY—WITHOUT IMPLANTS

I. Emergency treatments (Table 17-I)

II. Scaling, root planing, curettage, oral hygiene instruction• Closed or open flap debridement

A. Mechanical debridement of calcareous plaque deposits adherent to clinical crowns and roots ofteeth or restorative materials both supra- and subgingivally

B. Removal of all chronic granulation tissue

III. Operative dentistry• Restoration and conservative control of dental caries

IV. Orthodontic treatment (partial or full)• Level and align teeth• Erupt fractured or impacted teeth• Extrude teeth to level infrabony defects and/or augment the bone and soft tissue topography• Support orthognathic correction

V. Fabrication of interim provisional restoration• Guidelines

A. Replace missing and/or recently extracted teethB. Maintain or improve inter- and intra-arch harmonyC. Assess adequacy of tooth reductionD. Determine the clinical crown profilesE. Develop therapeutic occlusal schemeF. Control occlusal forces and assess function

VI. Periodontal surgery• Osseous therapy

A. Regeneration/augmentation1. Regeneration of attachment apparatus of teeth2. Regeneration and augmentation of ridge deformities

B. Ostectomy/osteoplasty1. Improve alveolar topography2. Achieve minimal sulcus depth

C. Mucogingival therapy1. Enhance the gingival complex around teeth and implants2. Grafting procedures (eg, subepithelial connective tissue grafts, allogeneic dermal grafts, etc)

VII. Re-evaluation• Establish prognosis of the remaining teeth

A. Function and estheticsB. OcclusionC. PhoneticsD. Mucogingival considerationsE. Emergence profiles

VIII. Prosthetic phase• Fixed prosthesis• Fixed-removable prostheses• Fabrication of an occlusal appliance after installation of the final prosthesis, when deemed necessary

IX. Maintenance

9

AHEAD

The objective of periodontal therapy is alveolar repair and restoration of normal anatomic

form (gingival health). Treatment is directed at decreasing the inflammatory response by

improving the osseous topography and the relationship of the overlying soft tissue, to decrease

probing depth. Amsterdam20,21 has noted that this is most predictably accomplished for teeth

of normal anatomic root lengths with probing depths not exceeding 4 to 7 mm [Au: Changeto 7 mm, which already exceeds 4 mm?] measured from the cementoenamel junction (CEJ)

(Fig 17-5). The advantage of this osseous surgical approach is an increase in the clinical crown

length, and hence a final crown design with sufficient biomechanical retention-resistance.

Figs 17-5a to 17-5c Radiographic evidence of subgingival calculus accumulations and inconsistent bony margins. Resulting increase in crown-to-root ratiosof maxillary anterior group of teeth.

Fig 17-5d Poorly adapted composite veneers formaxillary anterior teeth, with marked gingivalinflammation and generalized probing depth inthe 5- to 6-mm range.

Figs 17-5e and 17-5f Splinted ceramo-gold-metal restorations, after healing from apically positionedmucoperiosteal flap surgery to eliminate the periodontal disease and create normal topographic form,with minimal probing depth throughout. (Periodontal therapy by Dr Garry Miller. [Au: Please providecity and state.])

a b c

10


Experimental and clinical research over the last decade has shifted the focus of periodontics

toward increased use of guided tissue membrane techniques. These approaches seek to regen-

erate desired attachment apparatus circumscribing the periodontally compromised root.

Although there is some clinical unpredictability associated with this therapeutic approach, it

represents a step in the direction of augmentation/regeneration versus resection.22 This new

era of regeneration therapeutics constitutes a positive shift in treatment strategy.22

Secondary occlusal traumatism, represented by moderate-to-severe loss of alveolar support

and significant clinical mobility, results in a need to splint two or more teeth to recreate collec-

tive stability and functionality. This was and continues to be predictably achieved with the use

of partial- or full-coverage crowns.

Where bite collapse has occurred, the restoration is more difficult. In this case, a provision-

al restoration is used to replace the extracted teeth, to restore lost occlusal vertical dimension,

and to establish or re-establish anterior guidance, allowing for disarticulation of posterior

teeth during excursive movements (Fig 17-6).

When teeth require subgingival preparation in conjunction with full-coverage restorations, it

is important to evaluate the mucogingival environment and determine the value of recreating or

enhancing the masticatory mucosa. Autogenous gingival grafts, subepithelial connective tissue

grafts, and repositioning of an existing gingival complex are commonly used approaches.

The orthodontic phase seeks to improve tooth alignment, erupt fractured or impacted teeth,

or facilitate the extrusion of teeth with infrabony defects.23 If the gingival zone on the facial,

lingual, or palatal surface is deficient, it is prudent to consider a mucogingival procedure

before tooth movement. This minimizes the concern about recession if the tooth must assume

a position not directly over its basal support.

When indicated, orthodontic intervention generally precedes the provisional restorative

phase. If the protocol is reversed, the clinical team may be required to make significant addi-

tional repairs and recementations. Cement washout places teeth at greater risk of developing

caries, and the patient may require a new provisional restoration before the impression phase

of therapy.

After the provisional restorations are fabricated and tooth stability is achieved, the restora-

tions can be removed to allow better access to the surgical field for correction of any residual

hard and soft tissue inconsistencies. After the tissue has matured and the prognosis is estab-

lished for all remaining teeth on both an individual and collective basis, subgingival prepara-

tion can be finalized and the provisional restorations relined, followed by completion of the

fixed or fixed-removable prosthesis.

11

Fig 17-6a Pretreatment view of 55-year-old male withmissing teeth (partial denture replacement), severe peri-odontitis, and complete bite collapse.

Figs 17-6c to 17-6e Pretreatment radiographic and clinical views showing periodontal and periapical pathology, a Class III mal-occlusion, and primary and secondary occlusal traumatism.

Fig 17-6b Posttreatment: Metal-ceramic fixed splintedrestorations.

Figs 17-6f to 17-6h Provisional acrylic restorations (before periodontal surgical correction). Immediate replacement of extracted teeth. Lat-eral excursive movement demonstrating re-establishment of anterior guidance.

Figs 17-6i to 17-6k Definitive metal-ceramic fixed restorations. Prosthesis continues to function at 12 years follow-up. (Periodontal therapyby Dr M. Stiglitz, Washington, DC.)

c

d e

f

g h

k

i

j

12


Dental therapeutics with implants

Based on longitudinal studies of the viability24–31 of endosseous implantology, implants used

as an integral part of periodontal prosthesis now offer the patient and dentist a more stable

and predictable restoration. Their relative immobility and load-bearing capacity, when secured

in a qualitatively adequate bony housing, may allow for fabrication of a fixed prosthesis resist-

ant to displacement. The damage pattern of primary and secondary occlusal trauma attendant

many teeth may be reversed. Even teeth that appear to have a hopeless prognosis may be able

to assume a useful prosthetic role (Box 17-4).

In periodontal disease, as with dental caries, we may find permanent scars that complicate ther-

apy more than the active disease process itself. In many circumstances, anatomic deformities such

as an altered residual ridge form32,33 or close proximity of the sinus wall34,35 represent propagating

factors that require additional surgical correction. These difficulties may necessitate a staged

approach of augmentation, regeneration32,36 or onlay grafting first,33 followed by a second surgical

phase of implant placement and healing.

During the past decade, implant restorations were reasonably acceptable from an esthetic per-

spective. However, in cases of advanced periodontal disease, the resorption of alveolar bone creates

a significant challenge to achieve an esthetic, functional restoration. Placing implants in resorbed

bone often results in long, unesthetic teeth with an adverse crown-to-implant ratio. Implant posi-

tioning is critical from faciolingual, mesiodistal, and incisoapical perspectives. It was quickly deter-

mined that the type of periodontium, whether thick-flat or thin-scalloped, significantly affects the

esthetic outcome. The thin-scalloped type, with its friable gingival and osseous morphology, often

results in tissue recession, ultimately exposing metal at the gingival crown margins.

From a diagnostic standpoint, the dental team must try to anticipate the size and shape of

the deformity that would be created by removing the involved teeth. These judgments will play

heavily in the restorative design.

From a periodontal-prosthetic perspective, we know that many severely compromised teeth can

still offer the patient short-term function. For this reason, the restorative dentist may strategically

retain some of these teeth to facilitate an interim fixed provisional prosthesis rather than rely on a

removable design.36 This decreases the risk of prematurely loading the implant body, and induc-

ing micromotion during initial stages of interfacial bony healing.37 A well designed and construct-

ed interim provisional restoration is most important now that osseointegration technology38–46

and osseous regenerative technology47,48 have significantly changed the sequencing and length-

ened the timing of prosthetic treatment for the partially edentulous case (see Box 17-3). The weak

remaining teeth may be removed at a later stage in favor of additional endosseous implant sup-

port, as dictated by the biomechanical needs of the final restoration.

Periodontal surgical therapy is performed for all teeth that have a favorable prognosis.

Either regenerative approaches23 or pocket reduction49–51 and clinical crown exposure proce-

dures should be rendered before endosseous implant placement.

When orthodontic treatment is involved, it may require early tooth positioning to create

adequate space prior to implant placement. In some situations, such as a flared maxillary ante-

rior segment with few or no posterior teeth, implants may be placed first and employed as the

anchorage mechanism to retract and align the remaining teeth. In these situations, we are lim-

ited only by the treatment-planning creativity of the dental team. One must not minimize the

value of orthodontic mechanotherapy to move teeth through a healthy bony environment.

This can reduce and modify the size and shape of angular osseous defects, often through erup-

tion or extrusion.52–54 The improvement in hard and soft tissue topography allows the newly

regenerated bone to successfully receive endosseous implants.

Forced eruption of hopeless teeth is used to alter the soft and hard tissues before placing

implants. In addition, orthodontic extrusion is used to re-create lost interproximal papillae.

13


BOX 17-4 MAPPING THE COURSE OF DENTAL THERAPY—WITHOUT IMPLANTS

I. Emergency treatments (Table 17-I)

II. Scaling, root planing, curettage, oral hygiene instruction• Closed- or open-flap procedures

A. Mechanical debridement of calcareous plaque deposits adherent to clinical crowns and roots ofteeth or restorative materials both supra- and subgingivally

B. Removal of all chronic granulation tissue

III. Operative dentistry• Conservative control of dental caries

IV. Orthodontic treatment (partial or full)• Level and align teeth to improve position• Erupt fractured or impacted teeth to rebuild/reposition bony complex• Extrude teeth to correct infrabony defects and augment soft and hard tissue topography• Support orthognathic correction.

V. Fabrication of interim provisional restoration• Guidelines

A. Allow for extraction of hopeless teethB. Maintain or re-establish inter- and intra-arch harmonyC. Assess adequacy of tooth reductionD. Determine the clinical crown profilesE. Develop therapeutic occlusal arrangementF. Control occlusal forces and assess functionG. Allow for fabrication of “diagnostic template” with markers for radiographic analysis

VI. Periodontal surgery• Osseous therapy

A. Regeneration/augmentation1. Regeneration of the attachment apparatus of teeth2. Bone augmentation of deformed alveolar ridges

B. Ostectomy/osteoplasty1. Improve bone morphology2. Reduce pocket depth

• Mucogingival therapyA. Enhance the gingival complex around teeth and implantsB. Grafting procedures (eg, subepithelial connective tissue grafts, allogeneic dermal grafts, etc)

VII. Bone grafting, sinus bone augmentation procedures• Dictated by the need to most ideally locate and place implants

VIII. Fabrication of surgical template• Guide implant placement (based on clinical and radiographic interpretation)

IX. Implant placement• In existing alveolar bone sites or healed extraction sites• In bone augmentation sites (eg, sinus, alveolar ridges)• In fresh extraction sites

X. Interim maintenance to facilitate healing• For surgical sites, control the exposure of occlusive membranes and/or loose cover screws• For interim provisional prosthesis

A. Repair broken acrylic jointsB. Replace soft reline materials

• Maintain and monitor transitional implants

XI. Transitional implant-assisted/-supported restoration• Preservation or augmentation of gingival complex• Placement of transepithelial healing components for second-stage implants• Allow for soft tissue maturation• Selection of implant abutments• Conversion of existing provisional to implant-assisted/-supported restoration• Fabrication of new implant-/implant- and tooth-assisted provisional restoration

14


OOUTCOME-BASED PLANNING:INTERIM PROVISIONAL RESTORATIONS

The interim restoration may be designed in several different ways. One approach is to modify

an existing denture or splint, reline the crowns on selected natural teeth, and convert other

crowns to pontics as necessary. With a dearth of strong, well-distributed natural teeth, the

existing rigid metal framework can better resist normal occlusal forces and help prevent pros-

thesis fracture.

The removable interim prosthesis is the least desirable measure for preserving masticatory

function. Unfortunately, it must be used when the support provided by the remaining teeth is

too compromised and the number and distribution of teeth is insufficient to allow for the use

of a fixed prosthesis. In this situation it is imperative that the restorative dentist inspect the

edentulous areas at regular clinical intervals and replace the soft liner material of the denture

base when it becomes hard or brittle, or elicits a pressure ulceration in the soft tissue.

Currently, there are “temporary” or transitional dental implant systems that preclude the use of

the removable appliance. They allow the clinician to use a fixed “mini-implant” or conventional

endosseous implant–supported restoration throughout the plase of implant osteointegration.55–60

Ideally, a new fixed provisional restoration, with or without a rigid metal reinforcement, should

be made from a diagnostic wax-up, incorporating all of the esthetic, functional, and phonetic char-

acteristics being considered in the case. Any pre-existing limitations should be removed. This will

serve as a blueprint of the final prosthetic outcome. It can be used as a guide and will allow the den-

tal team to plan the case construction from the desired end point in reverse order (Fig 17-7).

In advanced periodontal disease, the maxilla generally resorbs apically and palatally; there-

fore, the mandible appears to be much larger than the maxilla. When all of the maxillary teeth

are eventually lost and the edentulous cast is mounted on an articulator, it appears as if the

patient has a prognathic relationship. However, this is not a true prognathic arch profile, but

rather a result of the bone resorption of the maxilla. And if the patient desires implants and a

fixed restoration, this case61 becomes a surgical and restorative challenge. The clinician(s) must

know before the implants are placed how this occlusal disparity will be corrected in the defin-

BOX 17-4 MAPPING THE COURSE OF DENTAL THERAPY—WITHOUT IMPLANTS (CONT)

XII. Re-evaluation• Stability of implants and remaining teeth• Occlusal vertical dimension• Esthetics• Phonetics• Proper emergence profiles of crowns for teeth and implants

XIII. Prosthetic phase• Implant-assisted

A. Fixed prosthesisB. Fixed-removable prosthesis

• Implant-supportedA. Fixed prosthesisB. Fixed-removable prosthesis

• Fabrication of occlusal appliance after final prosthesis is inserted if necessary

XIV. Maintenance

15

Fig 17-7a Pretreatment Class II, division 1 malocclusion with fail-ing crown and bridgework [Au: splint?]—a result of caries, post-core failures, and periodontitis.

Figs 17-7b to 17-7d Pretreatment radiographs.

Fig 17-7e Fabrication of acrylic provisional restorations. Note themarked anterior platform created to provide both centric holdingarea and necessary anterior guidance. (Socket preservation by DrKarl A. Rose [Au: Please provide city and state].)

Fig 17-7f to 17-7h Radiographs of tooth preparations after fabrication of provisional restorations.

Fig 17-7j Final ceramo-gold implant- and tooth-sup-ported restoration.

Fig 17-7i Final radiographic appearanceof completed maxillary restoration.

Fig 17-7k Final radiographic appear-ance of completed maxillary restoration.

b c d

f g h

16


D

itive prosthesis. The volume of available bone is significant to the long-term survival of

implants in this situation because of the exaggerated anterior-posterior discrepancy.

It is wise and judicious to fabricate a temporary appliance simulating the final restoration

before surgical procedures. This is essential when the clinician is contemplating a change in the

occlusal vertical dimension. This alteration will change the faciopalatal relationships of the

mandible to the maxilla.

The lip line esthetic diagnosis, as well as the lip support, will influence the decision to fabri-

cate a fixed or removable prosthesis. A simple and effective way to make a reasonable esthetic

appraisal of the final prosthesis is to evaluate the appearance of the patient’s existing prosthe-

sis. Assuming that it is acceptable to the patient and to the dentist, it is wise to duplicate the

existing prosthesis and evaluate the patient’s profile. If the appearance is the same as the orig-

inal restoration, it can be assumed that the teeth are supporting the lip. In this situation, it is

likely that an acceptable fixed restoration can be made. Conversely, if the lip “collapses in,” the

final prosthesis will likely require some form of labial support, often necessitating a removable

prosthesis. A fixed restoration would likely be unsatisfactory.

DIAGNOSTIC AND SURGICAL TEMPLATES

Like the surgical template, a diagnostic template with radiographic markers can be fabricated

to help both surgeon and restorative dentist in analyzing available bone sites via panoramic or

CT scan radiography prior to the surgical phase.62

The surgical template, a guide to surgical implant placement, is fabricated from either a

diagnostic wax-up or, preferably, a stone cast of the functioning provisional restoration.

After the provisional restoration is placed intraorally, impressions are taken of both the

prosthesis and the underlying edentulous ridges and tooth preparations. Stone casts are made

and an acrylic shell of the restoration is cured on a cast of the remaining prepared and/or

unprepared teeth. Access locations and axial alignments are carefully planned with the surgeon

and are carved into the acrylic form to anticipate all future implant placements.

While a lingual or palatal approach is commonly used to design the surgical guide, a facial

approach may also be considered. This will provide the surgeon with an accurate visualization

of the ideal implant sites, the desired path of abutment emergence, and the axis relation to the

final prosthesis.

The ability to perform surgical procedures demands excellent access, which is provided by

temporary removal of the provisional interim restoration. The surgeon will then orient the sur-

gical template by securing it to the prepared and/or unprepared teeth and penetrate into the

bone so as to bring about proper positioning of the implants.

Significant progress in biotechnology, radiology, and computer technology have allowed for

accurate diagnosis and treatment planning. This has recently resulted in the construction of

three-dimensional bone models, stereolithography63 (Fig 17-8), and navigational surgery to

position endosseous implants with greater precision.

Principle 3The trends that have brought dentistry to its current level of esthetic sophistication require theclinician to predict the outcome before implants are placed. If the esthetic evaluation is inaccu-rate, the final result will be less than desirable to the patient and the dentist.

17

Figs 17-8c and 17-8d Simulation of endosseous implant placement into four anterior maxillary sites, as determined by evidence of boneon the CT scan images.

Fig 17-8a Premaxilla after Le Fort I osteotomy. Soft tis-sue graft increased ridge height by 7 mm.

Fig 17-8b Diagnostic template using gutta percha mark-ers and barium sulfate to locate endosseous implants inanterior maxillary region.

Fig 17-8e Surgical template with titanium cylinders tolocate the implant sites with surgical precision.

Fig 17-8f Surgical endosseous implant placement basedon CT scan technology and stereolithography.

Fig 17-8g Provisional acrylic implant-supported transitional restoration.

18


SSURGICAL CONSIDERATIONS

The well-designed treatment plan may require one of a host of scenarios to deal with the installa-

tion of endosseous implants into bony sites that either still house teeth, or have ridge deformities.

Where implant placement is anticipated, the most common approach is to extract teeth at

the time of provisional restoration. Full maturation of the bony socket may then take anywhere

from 3 to 6 months. The newly formed bone in these recent extraction sites has proven to be

an excellent reservoir of pluripotential cells to promote successful osseointegration.

Another treatment approach may considerably shorten the duration of

treatment. Here the effort is made to place the implant at the time of tooth

extraction (Fig 17-9). The implant should be submerged several millimeters

below the bony crest to reduce the risk of dehiscence formation. In these situ-

ations, the ability to achieve primary flap closure will decrease the risk of post-

operative complications, especially if a cell-occlusive membrane is indicated.

In an effort to more precisely determine the quality of the bony housing for

possible immediate implant placement and to minimize the overall maturation

phase, the teeth may be sectioned horizontally at their gingival margins or at the

height of the alveolus.64 The pulp should be extirpated, the canal medicated and

sealed, and provisional restorations fabricated, leaving these tooth roots for the

surgeon to extract at the time of implant placement. This approach avoids inter-

ference with early socket healing and precludes the risk of additional crestal

bone resorption of the healing socket.65 The surgeon will decide whether to

extract and immediately place an implant into the socket. In some cases, the sur-

geon may prefer to extract the tooth, place a bone graft and membrane, and

allow the area to heal for 3 to 4 months before placing an implant.

When an edentulous ridge has a modest defect and the site has been

planned for implant placement, the surgeon may elect to position the

implants at an angle that corresponds to the ideal final restoration. Any pos-

sible fenestration over the implant may be corrected by placement of a phys-

ical membrane barrier (based on the principles of guided bone

regeneration).66 Here adequate space must be achieved to promote complete

reformation of the bone complex.

Dental implant placement in the atrophic or deformed alveolar ridge can be

a surgical challenge. Alveolar augmentation is currently accomplished with guided bone regenera-

tion techniques,47,67,68 sinus bone augmentation,69 bone grafting,70–72 and alveolar distraction

osteogenesis.73 Two or more surgical interventions are frequently required to correct a major ridge

deformity. First, the ridge must be reconstructed to a more normal anatomic shape and size,62 fol-

lowed by implant placement and soft tissue augmentation (Fig 17-10).74,75

Fig 17-9b Second-stage uncovering of implants. Notebone formation to crest of both sites. (Surgery by Dr G.Miller, Washington, DC.)

Fig 17-9a Extraction of the maxillary lateral incisorand first premolar with immediate implant placement.

19

Figs 17-10a and 17-10b Views of block bone graft with fixation in the anterior maxilla. (Surgery by Dr Jeffrey Posnick[Au: Please provide city and state].)

Fig 17-10e Definitive ceramic-gold implant- and tooth-supportedrestoration.

Fig 17-10c Preparation of block graft site to place endosseousimplants. First, the surgical template is installed. Measurementstaken relative to the template will locate the implants vertically in theblock-grafted bone relative to the cementoenamel junction of theadjacent teeth. Implants were placed to the proper mesiodistal, buc-copalatal, and vertical positions. (Surgery by Dr Garry Miller, Wash-ington, DC.)

Fig 17-10d Soft tissue topography demonstrating modest rise andfall of gingival topography. [Au: Is edit okay?]

Fig 17-10f Radiographic images of definitive maxillaryrestoration.

a b

20

Depending on the extent of the original ridge deformity, the surgical bone augmentation pro-

cedure can be relatively successful at restoring the bony contour to the following levels: Class I, 1

to 2 mm apical to the CEJ level of the adjacent teeth; Class II, 3 to 4 mm apical to the CEJ level of

the adjacent teeth; Class III, 5 mm or more apical to the CEJ level of the adjacent teeth.62

In reconstructing the deformed ridge to a Class I bone level, a normal overlaying soft tissue

profile will often be created. For the Class II bone level, where there is still some horizontal and

vertical depression, soft tissue augmentation by means of connective tissue grafts,74,75 autoge-

nous grafts (free or pedicle), or repositioning of the gingival complex, may mask the bony defi-

ciency and create a normal topographic appearance.62

For the Class III level, prosthetic materials are frequently required to restore the hard tissue

and soft tissue deformities and simulate the Class I reconstructed profile, which otherwise may

be compromised in both height and width (Fig 17-11).62

After the bony ridge has been reconstructed and endosseous implants placed, a sufficient

healing period must be observed to ensure a satisfactory “take.” Bone remodeling adjacent to

implant fixtures occurs over a period of at least a year, leading to a more mature bone (lamel-

lar compacta) within which the implant can better tolerate the forces of occlusion.77

Fig 17-11a Preoperative cast of residual ridge extending from formertooth site #17 - #26 inclusive, the result of removal of a squamouscell carcinoma.

Fig 17-11b Implant-supported fixed, ceramic-gold restorationsreplacing the anatomic crown, root, and gingiva—the Misch FPIII109classification for fixed implant prostheses. [Au: Please provide refer-ence.] (Implant placement by Dr Karl A. Rose, [Au: Please providecity and state.)

Principle 4The essential criteria for alveolar ridge reconstruction for successful implant placement are as fol-lows: (1) appropriate quantity of horizontal and vertical bone and adequate quality of bone; (2)sufficient keratinized tissue overlying the bony crest; and (3) adequate distance betweenimplants.3

T

21

Figs 17-12d to 17-12f Provisional restoration secured with set screw retention.

Fig 17-12a Maxillary dentition of 24-year-oldmale with partial anodontia.

Fig 17-12b Master cast of implant locationswith temporary crown cylinders.

Fig 17-12c Fabrication of heat-processed provi-sional acrylic restorations.

TRANSITIONAL IMPLANT-ASSISTEDRESTORATIONS

It is extremely important to coordinate the schedules of the surgeon and restorative dentist to

begin the process of restoring the implants after an established healing period.

The surgeon will perform a small gingival punch procedure or a more extensive mucope-

riosteal flap procedure, repositioning the gingival complex around the implants. A transepithe-

lial healing component is then fastened to each implant body. After soft tissue and periosteal

maturation, a high- or low-profile transepithelial abutment may be selected and a provisional

restoration can be made to restore form and function (see Fig 17-4). For one-stage implants,

the restorative dentist may begin the provisional restoration process directly.

When multiple implants are exposed and angulation concerns are anticipated, it is valuable

to make an impression that records the orientation of the fixture heads after early soft tissue

healing. A new provisional restoration may be fabricated in the laboratory (Fig 17-12) with tita-

nium temporary cylinders that are designed to mate directly with the implant body or to a

selection of available abutment heads.78

d e f

22


F

Frequently at the second stage, the existing interim provisional prosthesis must be modified

by shortening the undersurface of the pontics to provide room for the healing components.

Later, these components are removed; abutments of proper height are screwed into position,

and temporary crown cylinders are seated, shortened to contact the opposing occlusion, and

incorporated into the existing provisional restoration.

If there is any doubt as to the feasibility of accomplishing functional and esthetic alignment

of the implant abutment, temporary crown cylinders can be secured directly to the implant

body. It is noteworthy that these metal cylinders are available from most implant manufactur-

ers. They ensure intimate fit to the titanium abutment or implant head and allow the clinician

to start developing the anticipated contours. Of course, should the form need to be modified,

the acrylic itself offers ample opportunity without jeopardizing any accuracy of fit.

A transepithelial collar of minimal height, shallow sulcular depth, and a circumscribed border

of bound-down keratinized tissue are essential ingredients in allowing for conventional plaque-

control measures.

Chiche et al79 have pointed out that as a result of “surgical and anatomic limitations,”

implant placement may not correspond to the initial expectation set at the presurgical

phase, and over-contouring the final restoration could create esthetic and functional liabil-

ities. The path of emergence of the fastening screw through the prosthesis may compromise

part of the facial or occlusal morphology, especially if it passes through a primary centric

occlusal contact, an interproximal embrasure [or the facial veneer.] Even minor discrepan-

cies between an implant and crown axis may result in eccentric screws, since such deviations

are magnified at the level of the occlusion.

Here the transitional prosthesis is invaluable in diagnosing these prosthetic limitations. With

this early awareness, we can better anticipate and plan for the fabrication of an auxiliary sub-

structure to facilitate the prosthetic result in the dental laboratory.

Some have conjectured that the implant-assisted provisional restoration may provide a

shock-dampening effect that may be beneficial during the first year of bone maturation adja-

cent to the implants. Of possibly greater value is the role of the provisional restoration in estab-

lishing the esthetic, phonetic, and functional needs for the final prosthetic design.

At this stage, a radiographic and clinical evaluation of the stability of the implant fixtures is

made. The weak teeth that were held strategically to support the interim prosthesis are extract-

ed at this time.37 Some of the natural teeth may be removed in favor of additional implants or

retained as indirect retainers in situations where fewer implants are used in the overall support

of the prosthesis. If a new transitional prosthesis has recently been fabricated, there may have

been a change in the occlusal vertical dimension or the esthetic form, both of which would

require further modification. Additionally, it may be necessary to consider mucogingival treat-

ment to enhance the complex of masticatory mucosa around selected teeth or implants.79

FINAL PROSTHETIC PHASE OF TREATMENT

When the final prognosis for all teeth and implants has been established, the restorative dentist

can employ crown and bridge techniques to construct the fixed or fixed-removable prosthesis. The

dentist may proceed with final impressions of the natural teeth, relate them to the proper position

23

of the implants or abutments, and fabricate a master mold. To initiate the laboratory procedures,

the case is carefully mounted on an appropriate articulator by a series of occlusal registrations.

On the master cast, a soft tissue marginal profile should be constructed around each natural

tooth die and implant analogue to simulate the gingival condition in the oral cavity. This allows for

predictable abutment head selection based on height, angulation, and emergence profile.

Technical choices are now made concerning case design, case construction, the use of tele-

scopic copings on retained natural teeth, or the use of precision dovetail slide attachments to

interlock sections of teeth and implants, when indicated.

The primary substructure is fabricated and tried in, the fit of the copings is tested individually

then collectively soldered, and the definitive metal-ceramic restoration is completed (Fig 17-13).

Today it is possible for the computer to be used as a complementary technique or an alter-

native to conventional impressions. Photogrammetry with digitized images, and laser/optical

scanners can support computer-aided design/computer-assisted manufacturing (CAD/CAM)

and computer-milling techniques in the fabrication of titanium-implant frameworks and

ceramic and zirconium-oxide implant frameworks.80

Upon delivery of the final case, a strong cement is used to secure the telescopic copings on the

remaining teeth. The implant-assisted dental reconstruction is then seated with a temporary

cement to create a hermetic seal at the interface of the abutment and superstructure. Retention

and resistance to displacement are provided by securing the prosthesis with set screws.81 Using

carefully machined/milled abutments, the practitioner may choose to cement the prosthesis in lieu

of screw retention.82

Fig 17-13b Ceramic-gold implant crowns and their relation to theimplant abutments.

Fig 17-13c Definitive gold implant abutments replacing maxillary leftlateral incisor, canine, and first premolar.

Fig 17-13d The implant crowns have been created with a ceramicroot form to address the loss of residual ridge height. The definitiveprosthetic replacement of both the anatomic crown and anatomicroot is classified by Misch as the FPII109 prosthesis. [Au: Please pro-vide reference.]

Fig 17-13a Definitive gold implant abutments replacing the maxillaryright premolars.

L

24


A

LONG-TERM PROFESSIONAL MAINTENANCE

Implant prostheses and their supporting components and adjacent tooth-supported prosthe-

ses are carefully monitored on a hygiene-recall maintenance program, alternating visitations

between the surgeon and the restorative dentist. Any tissue changes or prosthetic mechanical

problems83–85 can thereby be detected early and addressed accordingly. Although conventional

periodontal indices such as Plaque Index, sulcus bleeding, and probing depth are not directly

related to the success or failure of implant osseointegration, they may be appropriate for assess-

ing and monitoring the health of the peri-implant tissues. Periapical and panoramic radi-

ographs are taken at 12- to 18-month intervals to ascertain any changes that may take place in

the osseous configuration around implants or natural teeth.

Mechanical failures (such as breakage of porcelain, solder joints, components, and implants)

may occur long after the placement of the prosthesis, sometimes between 5 and 10 years.86 The cli-

nician who deals with these types of prostheses must be committed to servicing them in the future.

According to Wiskott and colleagues,85 fatigue failure is a “result of the development of microscop-

ic cracks in areas of stress concentration.” Continual loadings result in the cracks fusing to an ever-

growing fissure that insidiously weakens the restoration. Eventually, catastrophic failure results

from a final loading cycle that exceeds the mechanical capacity of the remaining sound portion of

the material.85 Based on the occlusal indicators, there may be great value in fitting the patient’s

dentition with an occlusal appliance as part of the long-term preservation of the prosthesis.

ACKNOWLEDGMENTS

Most of this chapter was originally published in the inaugural issue of the Seattle Study Club

Journal 1995;1: 21-34. It has been updated for use in this textbook. Portions of this chapter are

adapted from Weisgold AS, Starr NL. Restoration of the periodontally compromised dentition.

In: Periodontics: Medicine, Surgery, and Implants, Rose LF, Mealey BL, Genco RJ, Cohen DW

(eds). Philadelphia: Elsevier, 2004: chapter 27, 677–717. Used with permission.

I would like to express my thanks to Dr Arnold Weisgold for allowing me to reformat and

reprint this article from our original articles: Starr NL, Weisgold AS. Implant prosthodontics–An

adjunct in periodontal prosthesis, Part I and Part II. Alpha Omegan Scientific 1992:85(4)29–40.

I also thank the Alpha Omegan and its editor for the right to republish these articles in their new

form.

I would like to give a special thanks to my dear, trusted dental support team: Petra Nikolow, the

best dental assistant in the world; Jose Lara, a master technician whose quality is second to none;

Sylvie Rupple-Bozilov, our gifted and super-knowledgeable dental administrator; Cathrine Dagdag,

our graphic and technical information expert; Joan Meyer, the scheduling coordinator; and Som-

chay Moukdarath, an excellent dental hygienist possessing a strong combination of clinical and

people skills.

An additional expression of appreciation goes to Sylvie Rupple-Bozilov for her technical

assistance in the preparation of this manuscript.

25

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A CAfter clinical examination, radiographic imaging, and study casts, the next level of diagnosis can begin. For a case in which the needs are largely restorative, such as veneering

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