c h a p te r

4 TREATMENT PLANNING

1 INDICATIONS AND CONTRAINDICATIONS

INDICATIONS Osseo integrated implant surgery is a treatment option available for any patient, regardless of sex or age. The exceptions for this treatment are patients with chronic, uncontrollable diseases, or abnormalities of mucosal membranes and/or jawbones. Osseointegrated implant treatment is ideal for patients unable to wear complete dentures and have adequate bone for insertion of fixtures. Indications for treatment are as follows (Albrektsson, et al., 1986; Blomberg, Lindquist, 1983; Laney, 1986; Laney, et al., 1986): 1. edentulous patient, 2. partially edentulous patient with history of difficulty in wearing removable partial dentures, 3. patient with missing dentition requiring long span fixed partial denture (bridge) treatment, 4. patient who refuses using a removable type prosthesis. Other indications have been described as follows (Adell, et ai., 1981; Blomberg, Linquist, 1983; Laney, et al., 1986; Zarb, et al., 1987): 1. any edentulous area or severe change in complete denture bearing tissues, 2. poor ora! muscular coordination, 3. low tissue tolerance, I.e. more alveolar mucosa instead of attached mucosa, 4. parafunctional habits that compromise prosthesis stability, 5. unrealistic patient expectations for complete dentures, 6. hyperactive gag reflex, 7. patient psychologically against removable prosthesis, 8. unfavorable number and location of potential natural tooth abutments, 9. single tooth loss; avoid preparation of sound teeth.

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of bone remodeling occurs within this time period. 6. Patients with a history of drug, alcohol, or tobacco abuse should be evaluated carefully. Patients with histories of habitual abuse usually have less resistance to infection. Thirty percent of infection resistance is lost in these types of patients and could result in delayed wound healing. After surgery for implant installation, all patients should abstain from alcohol or tobacco use a minimum of two weeks. 7. Irradiated patients need to have their medical histories evaluated. The history should reveal the disease prognosis and amounts of radiation used in therapy. Patients who have received less than 4,000 Rads of radiation therapy may experience delayed wound healing, a common occurence after radiation treatment. The second surgical procedure, abutment connection to supporting fixtures, should be postponed for at least twice the normal healing time. 8. Patients with chronic diseases such as diabetes or high blood pres sure, should be evaluated on an individual basis, and consultation with the primary physician is necessary.

2 DIAGNOSIS
It is very important that the general physical condition of a patient is checked accurately in order to obtain an overall health assessment. Initial data gathered on each patient should include medical history, dental history, radiographic study, study casts, and photographs, all essential in treatment planning (Laney, et al., 1986). Based on the data and a thorough clinical exam, a detailed treatment plan can be proposed including loca tions and directions for fixtures.

3 MEDICAL HISTORY
The medical history is one of the most important and revealing aspects of patient evaluation (Laney, 1986). The patient completes a detailed ques tionnaire with references to the following (Fig. 4-1): 1. Determine if the patient is currently under the care of a physician. If so, determine the nature of present illness and therapy. 2. Determine if the patient has a history of rheumatic or congenital heart disease, rheumatic fever, angina, myocardial infarction, or arrhyth mias which could be episodic, especially when the patient is in a stressful situation. 3. Determine if the patient has a history of diseases of the kidney, urinary tract, gastrointestinal system, respiratory system, endocrine system, and nervous system.

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Theory and Practice of Osseointegration

CONTRAINDICATIONS

Absolute contraindications to osseointegrated implant treatment are as follows: 1. high-dose irradiated patients, 2. patient with psychiatric problems such as psychoses, dysmorphophobia (Laney, et al., 1986), 3. hematologic systemic disorders; Relative contraindications are described as follows: 1. pathology of hard or soft tissues, 2. recent extraction sites, 3. patient with drug, alcohol, or chewing tobacco abuse, 4. low-dose irradiated patients. Other contraindications are discussed further: 1. Patients who have received radiation therapeutic doses of more than 5000 Rads should avoid having these procedures. The patients physician and radiotherapist should be consulted on dates of treat ment, dosages, and portals of entry. After large amounts of radiation therapy, the patient has a reduced wound healing capacity and may not achieve successful osseointegration. 2. Patients who exhibit problems such as dysmorphophobia, are not good candidates for this type of treatment. This treatment sometimes involves changes in appearances, either esthetics or facial contours, and these patients may have difficulty adjusting to their changed appearance. 3. Patients who have blood dyscrasias such as leukemia, hemophilia, and thrombocytopenic purpura should not have this type of treatment due to their overall general health conditions. 4. Existing pathology of hard or soft tissues, such as a benign tumor, should be evaluated on an individual basis. If a patient has a benign tumor present, the tumor should be removed prior to implant proce dures. After surgical procedures for tumor removal, the prognosis for the patient and the status of the surgical site determine whether or not the patient is a good candidate for osseointegrated implant treatment. Patients with soft tissue problems, such as collagen or connective tissue deficiency diseases, should be evaluated. Any active stage of disease must be managed before considering implant treatment. 5. Patients who have had recent extractions should be questioned to determine the dates of extraction. If the extraction has been pre formed within six months to one year, the surgeon should evaluate the site radiographically and decide if the bone has healed adequately for further procedures. There is no reason to postpone treatment greater than one year after an extraction since the greatest amount

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Part I

Theory and Practice of Osseointegration

Please check or write:

1. is your health good? YES NO 34. As a child, did you have growing pains or twitching of the limbs? 35. Have you had painfui or swollen joints? 36. Have you been told by a physician that you have a heart murmur? 37. Do you now have or. have you ever had any heart trouble? 38.. Do you have high biood pressure? 39. Do you bleed for-a long time when you cut yourself? 40. Do you bruise easiiv? 41. Do you have any blood disorder such as anemia (thin blood)?. 42. Do you have any chest pain on exertion? 43. Are you short of breath on mild exertion? 44. Do you ankles ever swell0 45. Do you have a persistent cough7 46. Do you have asthma? 47. Do you have hay fever? 48. Do you have any altergies (to food, cat's fur. dusL etc.}? 49. Do you have hives or skin rash? YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 50 Have you ever expenenced an unusual reaction to any of the following drugs: A. Penicillin YES NO NO NO D. Iodine E. Suffa drugs F Other medicines YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES. NO YES NO YES NO YS NO YES NO YES NO YES NO YES: NO YES NO YES NO . YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES. NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO 2. When was your last check up? _________ ;_________________1 _______ _________ 3. Are you currently being seen by a physician? 4. Do you have allergies to medications7 5. Have you ever had a major disease? (Heart, Liver, Kidney) 6. Are you taking any medications? 7. How long since your last visit to a dentist? 8. What wcrk was done at that time? 9. Have you noticed your bite changing? 10. Do you clench or grind your teeth? T t . Have you ever had your bite adjusted? 12. Do you have difficulty in opening your mouth wide? 13. Do you have pain in or near your ears? 14 Have you ever been told that you had gum trouble?
15. Have you ever been treated for periodontal disease (Pyorrhea)7

YES YES YES YES . . . - : -

NO NO NO NO .

________________ ________ :__________ YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO

16. Have you ever had orthodontic treatment (braces)? 17. Have you had any complication associated with any previous dental treatment? 18. Do you now or have you ever had sinus trouble? 19. Have you ever had any injury to your face or jaws? 20. Have you been examined by your physician within the last year7 21. Are you being treated for any condition by a physician now? 22 Have you been taking any medicines within the past year? 23. Has there been any charge in your general health in the past year? 24. Have you lost or gained weight in recent months9 25. Have you ever been seriously ill? 26. Have you ever been hospitalized? 27. Have you ever had surgery? 28. Have you ever had a blood transfusion 29. Have you ever had x-ray or surgery treatment for a tumor growth or other conditions about your head, mouth, or on your lips? 30 Have you ever been treated for a growth or tumor in any other part of your body7 31. Are you frequently ill? 32. Do you often feel exhausted or fatigued? 33. Have you ever had any of the following diseases or conditions: A. Jaundice (yeiiow skin & eyes) B, Hepatitis . C. Tuberculosis :D. Venereal disease E. Heart attack f ; Stroke Q Ulcers H. Epilepsy I. Diabetes (sugar disease) J. Measles YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO K. Chicken, pox L Mumps

B. Barbiturates (sleeping pills) YES C Aspirin YES

51. Have you ever experienced an unusual reaction to a dental anesthetic ("Novocaine injection)? 52. Do you often have to get up at night to urinate7 53. During the day. do you usually have to urirate frequently? 54. Are you thirsty much of the time7 55. Has anyone in your family ever had diabetes7 56 Has a doctor ever said you had kidney or bladder disease or infection? 57. Has a doctor ever said you had liver disease? 58. Do you have any numbness or tingling in any part of your body? 59. Has any oart of your body ever been paralyzed7 60. Do you ever have fits or convulsions'7 61. Do you have a tendency to faint? 62. Do you have frequent severe headaches7 63 Do you consider yourself to be a nervous person?

YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO

64. Do you suffer from severe nervous exhaustion? 65. Do you often feel unhappy and depressed? 66. Do you often cry? 67. Are you easily upset or irritated? 68.. W omen Are you taking female hormones (oral contraceptives, etc.)? 69 W omen Are you pregnant at the present time? 70./W o m e n Are. you in o r have you passed through menopause (change o f life)? 71. W omen Have you had a hysterectomy or ovarectomy?

M Polio N. Rheumatic fever O. Scarlet fever P Glaucoma Q Prostate Disorders R. AIDS-related complex

Please inform the doctor if your health changes in any way.

Signature

' ' .

_______

... /

____________ Date

Fig. 4-1

Patient medical history questionnaire

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4. Determine if the patient has a history of abnormal bleeding tendencies, such as prolonged bleeding and/or any other abnormal findings. If so, consider consultation with a hemotologist prior to further treatment. 5. Determine if the patient has a history of allergies, such as sensitivity to certain drugs and/or dental materials. 6. Determine if the patient is abusing drugs, alcohol, or chemical sub stances. This could be difficult to assess during preliminary visits and may be difficult to confirm without additional tests. Use of chewing tobacco may be easier to confirm. 7. Determine if the patient is under care for psychological problems. The basic premise for evaluating the medical history is to identify potential medical problems that could prohibit a patient from receiving implant treatment. If a problem exists, immediate consultation with the patients primary care physician and/or specialist should be done. A thorough explanation of proposed treatment is outlined for the physician and final decision for treatment is made after joint consultation.

4 DENTAL HISTORY
Dental history is an important part in evaluation for implant treatment. In the dental history, extraction dates should be verified to determine if they were performed within the minimum six-month period of time; this could be a relative contraindication. Also, determine reasons for previous extrac tions. Cental history includes information gathered during the oral examina tion. Evaluate soft tissue condition for health of periodontium, pathology, location of alveolar and attached mucosa, and redundancies. Evaluate remaining teeth condition for caries, relative positions, mobility, plaque index, and presence of calculus. Evaluate edentulous areas for undercuts, pathology, and size and shape of residual bone. Evaluate present occlusion for interferences, occlusal wear, prematurities, associated muscle tender ness, limited range of mandibular motion, and evaluate for temporo mandibular disorders. Evaluate parafunctional habits such as bruxism, which can have detrimental long-term effects.

5 ORAL EXAMINATION
A thorough oral examination should include evaluation of soft tissue conditions, oral hygiene, and periodontal health (Laney, 1986). Associated structures should be checked, especially in patients with severe bone resorption; note the position of mental foramina and neurovascular bundles

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Theory and Practice of Osseointegration

which may be palpable. Information gathered during the oral examination, dental history, and medical history, help determine potential for successful treatment. Other factors requiring further treatment, such as systemic illnesses or medical consultations, should be completed prior to performing any implant procedure. If a patient is selected as a candidate for implant treatment, further examination is done. Patients with natural dentition present, should have a treatment plan that includes periodontal management as well as prosthetic treatment for the remaining dentition within the plan for oral rehabilitation. From a periodontal aspect, attached gingiva management problems should be addressed (see Chapter 12). If periodontal problems exist adjacent to the proposed fixture installation site, the problems should be treated and hope less teeth should be extracted prior to implant surgery.

6 STUDY CASTS
Study casts, a facebow transfer, and occlusal registration are essential for treatment planning. The study casts are important for studying the remaining dentition and residual bone, and for analyzing the maxillo mandibular relationship (Desjardins, 1988; Laney, 1986). The mounted study casts can be helpful to the surgeon for fixture placement. Angle Class II or in situations are more easily evaluated from a centric relation record on the articulator. The directions for mandibular fixture placement can be estimated. In the Angle Class II or III situation, the fixture is angled toward the maxillary teeth or residual ridge; this helps prevent prosthodontic problems when fabricating the prosthesis for proper esthetics and function. A diagnostic wax-up can be done on the study casts or duplicate study casts. Proposed fixture installation sites can be checked on the study casts for proper alignment, direction, location, and relation to the remaining denti tion. A diagnostic wax-up helps to determine the esthetic placement of teeth and potential functional speech disturbances. After adjustments are completed and the diagnostic wax-up is finished, a resin template can be made from the study casts. : ..... Also, a complete preoperative photographic series is helpful in diag nosis. Frontal, profile, and intraoral series can be done both at preoperative and post-operative appointments for comparison (Laney, 1986).

7 ANATOMICAL LIMITS FOR FIXTURE PLACEMENT

MAXILLARY ANTERIOR REGION The maxillary anterior region has less bone quality and lower bone quantity when compared to the mandibular anterior region. Bone quantity

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C Fig. 4-2 Anatomical limits in the maxilla: A) Fixture length selection in the maxilla is limited to position of nasal cavities, sinuses, incisive canal, and palatal sutures. B) Direction of fixture placem ent is limited to the positions of the nasal cavities since there is minimal bone height in the central incisor regions. C) The canine eminence area has the m ost bone available between the nasal cavity wall and the adjacent sinus wall.

and quality influence success rates; maxillary success rates are lower due to the bone quality. In many patients, there are anatomical limitations in the maxilla. The nasal cavity and maxillary sinuses usually interfere with fix ture site selection, especially In a patient with severe bone resorption (Branemark, et at., 1984). Bone resorption in the maxilla gradually continues after tooth ex tractions, resulting in diminishing height and width. As the bone height decreases, the remaining bone narrows to close approximation with the nasal cavity, maxillary sinuses, and incisive canal nerve bundle. When the bone resorption is severe, bone availability may be limited to oanine eminence areas, lateral wall of the nasal cavity, and medial wall of the sinus (Desjardins, 1988). This area may accomodate longer fixtures, as long as 15 millimeters, when positioned to the right and left sides of the nasal cavity. When only two fixtures can be placed, the patient can receive over denture treatment. With an adequate amount of bone, six fixtures can be placed to

Part 1

Theory and Practice of Osseointegration

support a fully bone anchored prosthesis. The main limitation for fixture placement in this region is the mid-palatine suture. A fixture in this area may create forces separating adjacent bone structures and possibly caus ing damage to the incisive canal nerve and associated blood vessels (Fig. 4-2). MAXILLARY POSTERIOR REGION Due to the resorption pattern, proximity of sinuses, and quality of bone, fixtures are rarely placed in the maxillary molar areas. In the premolar areas of the maxilla, the bone is usually thick and spongy. The premolar area usually has adequate bone height compared to the molar areas and may accomodate fixtures between the lateral and inferior walls of adjacent sinuses. Edentulous patients show a similar pattern for maxillary resorption, from the buccal towards the palatal; the residual ridge appears to constrict palatally with continued resorp&oi1 ? . If a patient presents with a deep palatal vault and some resorption, remaining bone height may still be adequate. If a patient presents with a low palatal vault, resorption of the alveolar ridge creates the appearance of flattened maxillary bones. The combination of severe bone resorption and a low palatal vault creates a difficult situation for implant procedures (Fig. 4-3). MANDIBULAR ANTERIOR REGION The mandibular anterior region between mental foramina usually has adequate bone for placement of four to six fixtures (Desjardins, 1988). A minimum of 7 millimeters from the inferior border of the mandible to the crestal ridge is needed in this region for adequate fixture length (Laney, 1986). During surgical procedures, careful dissection of the mental foramina and associated structures is necessary. Normally, the mandibular canal extends five millimeters anterior to the mental foramen within the body of the mandible. The pathway of the nerve bundle can curve mesially and posteriorly to exit near the apex of the second premolar. The mental foramen is the opening for the inferior alveolar nerve and artery bundle which exits as the mental nerve, distributing through the chin and lower lip area. If damage were to occur to this nerve, parasthesia may result. The mental foramen can be detected by radiographic analysis but the actual location and size does change with age and resorption, so dis section is essential during surgery. In patients with severe bone resorption, the mental foramen position may be located on top of the residua! alveolar ridge. Occasionally no foramen is found but rather the nerve is iocated in the soft tissue above the bone. Edentulous patients show a similar resorp tion pattern in the mandible, from the facial toward the lingual with a decrease in height. After years of continued mandibular resorption, fixtures can still be placed directly into soiid cortical bone (Fig. 4-4). MANDIBULAR POSTERIOR REGION In the mandibular posterior region, fixture installation can be difficult due to the presence of the inferior alveolar canal. To insure a margin of

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63

(
Fig. 4-3 Fixture placement is lim ited in the posterior areas du e to the sinus location A) The first and second prom olar areas have the m ost bono available. B) There is less bone available in the area distal to the second prem olar C) After bone resorption, there is reduced bone height since the crest is in close proxim ity to the floor of the sinus in
tho m o lfir nrtxui

safety, there should be a minimum of one millimeter clearance between the fixture apex and the inferior alveolar canal. The canal has a diameter of approximately two to three millimeters and Its pathway can curve slightly. The canal extends from the ramus into the body of the mandible at an angie of 150 degrees forward and downward. The canal then curves anteriorly and is approximately six millimeters below the second molar apex, travers ing one-third the body of the mandible. The final pathway continues and curves between the first and second premolar area, opening below the second premolar apex as the mental foramen. The pattern of bone resorption is almost the same an both the buccal and lingual side such that the alveolar bone crest does not appear to change toward the buccal or lingual direction. However, the pattern of resorption in the crestal region can create a variety of shapes, from a sharp edge to flat and wide. When fixtures are installed into a sharp edge-shaped alveolar crest, first remove the sharp edge with the bone trimmer. Selection of a shorter fixture might be necessary after bone trimming since the

64

Part 1

Theory and Practice of Osseointegration

.1
,-r

if
'M l 'W i
*

Fig. 4-4 Anatom ical limits in the mandible: A) There are no anatomical limits in the anterior region between mental foram ena, therefore long fixtures can be placed to contact the infracortical bone. B) Due to the inferior alveolar canal, the m andibular posterior area has lim ited bone height available. C) Use only shorter fixtures in the molar areas to avoid dam age to the inferior alveolar canal.

original length was selected on radiographic examination before bone trim ming. The inferior alveolar canal position can differ slightly from patient to patient, so fixture installation above the canal is done carefully to prevent perforation into the canal (Fig. 4-4).

8 RADIOGRAPHIC EXAMINATION
Radiographs help determine the quantity and quality of residual bone. Necessary radiographs include periapicals, occlusals, orthopantograph, and a cephalometric radiograph (Laney, 1986). The jawbone anatomy and bone tissue abnormalities can be seen with radiographs and aid in circum venting potential problems. Since a radiograph is two-dimensional, the surgeon must visualize surgical sites in three-dimensions. Computer tomography scanning has been proposed for use but is not available to all practitioners (Andersson, Svartz, 1988; McGivney, et at., 1986; Schwarz, et

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al , 1987; Wishan, et al., 1988). Panoramic radiographs are reliable and useful for determining location and direction of fixtures. The morphological outlines of both the maxilla and mandible can be seen in an orthopantograph. In a radiograph of the mandi ble, the inferior alveolar canal and mental foramina positions are located to determine available bone height. In the maxilla, lateral and inferior walls of maxillary sinuses and the floor of the nasal cavities can be seen (Fig. 4-5). A major disadvantage of the orthopantograph is distortion; this dis advantage accounts for 50-70% distortion horizontally, and 10-32% distor tion vertically. When considering the distortion disadvantage, the use of a transparent plastic template is not recommended for measuring bone directly on the radiograph to determine fixture lengths. To obtain the actual lengths and heights of bone from an orthopantograph, a special resin splint can be made prior to radiographic procedures.

9 FABRICATION OF RADIOGRAPHIC SPLINT

A resin splint can serve dual purposes as both a radiograph measuring device and a surgical guide splint. A surgical guide splint is useful for deter mining the location and direction for fixture installation and is used during the second surgical procedure to identify positions of buried fixtures. This splint is important for safe fixture placement. The splint aids the surgeon in positioning fixtures as ideally as possible, in relation to remaining natural dentition and residual alveolar ridges (Blustein, et a!., 1986; Edge, 1987). There are two methods for fabrication of a resin splint (Fig. 4-618). One method involves duplication of the patients present prosthesis, such as a complete denture, and using the duplicate as both a radiographic and surgical splint. The other method involves fabrication of a resin denture from the study casts (Watanabe, et at., 1988). Duplication of the patients complete denture can involve use of different kinds of dental materials. One

Fig. 4-5 An orthopantograph is distorted and fixture lengths should not be selected directly from orthopantograph m easurements.