Implant Therapy: Clinical Approaches and Evidence of Success, Second Edition

Library of Congress Cataloging-in-Publication Data

Names: Nevins, Myron, editor. | Wang, Hom-lay, 1958- editor.

Title: Implant therapy : clinical approaches and evidence of success / [edited by] Myron Nevins, Hom-Lay Wang.

Description: Second edition. | Batavia, IL : Quintessence Publishing Co Inc, 2019. | Includes bibliographical references and index.

Identifiers: LCCN 2019004076 | ISBN 9780867157987 (hardcover)

Subjects: | MESH: Dental Implants | Dental Implantation--methods | Periodontal Diseases--therapy

Classification: LCC RK667.I45 | NLM WU 640 | DDC 617.6/93--dc23

LC record available at https://lccn.loc.gov/2019004076

© 2019 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

411 N Raddant Road

Batavia, IL 60510

www.quintpub.com

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Bryn Grisham

Design: Sue Zubek

Production: Kaye Clemens

Printed in China

Dedications

Foreword

Preface

Contributors

1 A Clinical Decision: Save the Tooth or Place an Implant?

MYRON NEVINS • RICHARD I. HERMAN • YOSHIHIRO ONO

2 From Osseointegration to Predictable Long-Term Implant Stability: Clinicians’ Perspectives

2.1 THE DEVELOPMENT AND PREDICTABILITY OF OSSEOINTEGRATED IMPLANTS

MYRON NEVINS

2.2 LONG-TERM RESULTS OF IMPLANTS IN NATIVE AND REGENERATED BONE

MASSIMO SIMION

2.3 CONNECTIVE TISSUE ATTACHMENT TO A LASER-MICROTEXTURED SURFACE

CARY A. SHAPOFF

2.4 LONG-TERM IMPLANT SUCCESS: PART I

JEFFREY GANELES • FREDERIC J. NORKIN • LILIANA ARANGUREN • SAMUEL ZFAZ

2.5 LONG-TERM IMPLANT SUCCESS: PART II

DAVID M. KIM • WONBAE PARK

2.6 LONG-TERM IMPLANT SUCCESS: PART III

TAMSIN J. CRACKNELL • DEON FERREIRA • PETER HAWKER • ANDREW ACKERMANN

3 Introduction to Implant Surgery: Optimal Positioning of the Dental Implant

HOM-LAY WANG • JIA-HUI FU

4 Implant Placement for the Mandibular Posterior Quadrant

HSUN-LIANG CHAN • HOM-LAY WANG • MYRON NEVINS

5 An Introduction to the Success of Short Dental Implants

CRAIG M. MISCH

6 The Evolution of Imaging and Associated Applications for Implant Surgery

GEORGE A. MANDELARIS • BRADLEY S. DEGROOT

7 Decision Making for Implant Therapy in the Maxillary Esthetic Zone

SVEN MÜHLEMANN • DAVID SCHNEIDER • RONALD E. JUNG • CHRISTOPH H. F. HÄMMERLE

8 Management of the Extraction Site: Socket Grafting

GUSTAVO AVILA-ORTIZ • HOMAYOUN H. ZADEH

9 Placement of Dental Implants into Extraction Sockets

DAVID M. KIM • JERRY CHING-YI LIN • CHIA-YU (JENNIFER) CHEN

10 Seeking the Optimal Esthetic Result in the Maxillary Anterior

DANIELE CARDAROPOLI

11 Predictable Esthetic Anterior Maxillary Reconstruction with Dental Implants and Maxillary Tuberosity Grafts

JOSÉ CARLOS MARTINS DE ROSA • LUÍS ANTÔNIO VIOLIN PEREIRA

12 Immediate Loading of Implants in Edentulous and Partially Dentate Patients

TIZIANO TESTORI • FABIO GALLI • RICCARDO SCAINI • MATTEO DEFLORIAN • ANDREA PARENTI • HOM-LAY WANG • MASSIMO DEL FABBRO

13 Sinus Elevation in the Posterior Maxilla via the Lateral Window Approach

STEPHEN S. WALLACE • TIZIANO TESTORI

14 Maxillary Transcrestal Sinus Floor Elevation Procedures

HOM-LAY WANG • ANN DECKER • TIZIANO TESTORI

15 The Use of Zygomatic Implants for Maxillary Edentulous Patients

JAMES K. F. CHOW • GLEN LIDDELOW

16 Treatment of the Edentulous Patient Using All-on-Four and the Zygoma Implant

STEPHEN M. PAREL • PAULO MALÓ • MIGUEL DE ARAÚJO NOBRE

17 Horizontal Bone Augmentation Procedures: A GBR Approach

MARCO RONDA • MASSIMO SIMION • FORTUNATO ALFONSI

18 Vertical Bone Augmentation with Advanced Flap Design

ISTVAN URBAN

19 Growth Factors: Clinical Development for Periodontal and Implant Applications

MARC L. NEVINS • WILLIAM V. GIANNOBILE • YOUNG-DAN CHO • (JEFF) CHIN-WEI WANG

20 The Introduction of Tissue Engineering for Bone Regeneration

ROBERT E. MARX

21 Soft Tissue Management to Augment Implant Success

GIOVANNI ZUCCHELLI • MARTINA STEFANINI

22 Implant-Abutment Junction: A Crestal Bone and Soft Tissue Determinant

LUIGI CANULLO

23 Effective Application of Orthodontics with Implant Therapy for Periodontally Compromised Patients

YOSHIHIRO ONO • TAKESHI SASAKI • MITSUHIRO IWATA • SACHIKO MAEDA • TOKOU MATSUI • KIMIO NAKAMURA • KIYONOBU SABURI • SATOKO ONO RUBIN

24 The Interaction Between Implantology and Orthognathic Surgery

LEANDRO G. VELASCO

25 Etiology and Management of Post-Loading Complications: Implant Loss or Failure and Peri-implantitis

STUART J. FROUM • PARNWARD HENGJEERAJARAS • KUAN-YOU LIU • PANPICHA MAKETONE • YE SHI

26 Regenerative Protocol to Treat Peri-implantitis

STEFANO PARMA-BENFENATI • CARLO TINTI • MARISA RONCATI

27 The Importance of Dedicated Maintenance Therapy for Long-Term Success

MARISA RONCATI

28 Peri-implant Maintenance Therapy for Long-Term Success

ALBERTO MONJE • HOM-LAY WANG

29 Implant Complications: A Reality Requiring Prevention

MARK E. LUDLOW • LYNDON F. COOPER

Index

Dedications

I dedicate this effort to my wife, Marcy. She has remained the wind beneath my wings, even when I was preoccupied with the editing process. She is my best friend and soulmate and encourages my commitment to education.

—Myron Nevins

I dedicate this book to my lovely family, my research collaborators, my friends, my former and current students, my chairs, and the University of Michigan for their continued support of my career. Without their sacrifices and support, this journey would be impossible.

—Hom-Lay Wang

Foreword

Oral implant therapy is recognized as one of the most significant innovations of dentistry in the 20th century. The reconstruction of edentulous or partially edentulous patients with osseointegrated dental implants has been revolutionary to improve esthetics, phonetics, and function for our patients. In this comprehensive book, Drs Myron Nevins and Hom-Lay Wang—leaders in regenerative and reconstructive dentistry—have assembled a text that will be a tremendous benefit to students, clinical scholars, and practicing clinicians alike. Given the strong adoption of dental implant therapy into clinical practice, it has become increasingly important for clinicians to have the proper guidance in both the identification of suitable patients and the clinical scenarios for the placement of dental implants for oral rehabilitation. No longer is it sufficient for a dental implant simply to survive: To be successful, implants must be placed optimally to provide the proper esthetics and function that last predictably over time. Thus, the appropriate training and treatment planning is critical to implant success to avoid biologic and/or technical complications that have increasingly plagued implant therapeutic outcomes over the years.

In this text, Drs Nevins and Wang have brought together chapters from leaders in implant dentistry. First, they work to improve the understanding about clinical decision making over the dilemma of tooth preservation versus extraction. However, if extraction of a hopeless tooth is required, how do we appropriately treatment plan? The plan must be designed for the good of the patient to facilitate the coordination of the team of surgeons, restorative dentists, and auxiliaries needed to deliver functional implant reconstructions for the lifetime of the patient. The first several chapters of the book focus significantly on treatment planning, including the use of 3D imaging and patient and implant-site risk assessment to determine the potential for implant installation and clinical success. If there are insufficient soft and hard tissues present, how does a surgeon augment deficient alveolar bone ridges for single or multi-implant placements? The book provides expert step-by-step guidance on local bone augmentation situations by region (anterior, posterior, mandibular, and maxillary areas) and the unique clinical challenges posed by each area. The cases and illustrations wonderfully depict the clinical scenarios and treatment protocols to emphasize the principles so well portrayed in the book. There are valuable chapters on managing the maxillary sinus or when insufficient vertical and/or lateral alveolar bone is available. Treatment alternatives using sinus floor augmentation, vertical bone augmentation, or the use of short dental implants play into these alternatives prepared by leaders in the field. The use of cutting edge therapies for hard and soft tissue reconstruction using tissue engineering methodologies (growth factor biologics, novel scaffolding technologies, or bone graft substitutes) have improved the repertoire of regenerative options for rehabilitation for the partially or fully edentulous patient.

Drs Nevins and Wang also bring together critical aspects in interdisciplinary clinical care in highly complex clinical situations, when tooth preservation is often coupled with implant therapy as well as with orthodontics and/or orthognathic surgery. Loading protocols for immediate- or delayed-implant placement are presented to consider the most appropriate applications of these treatment guidelines. How these reconstructions are planned, delivered, and maintained both provisionally and long-term are presented in fine detail.

With the long-term maintenance of dental implants, a key biologic complication following therapy is the initiation and progression of peri-implantitis. This difficult-to-manage clinical situation is addressed using a variety of approaches, ranging from nonsurgical care to resection, regenerative therapy, or implant removal and augmentation of the residual bony defect. Finally, specific protocols are presented for appropriate dental implant maintenance therapy in collaboration with restorative dentists, surgeons, and dental hygienists to promote the long-term preservation, stability, and clinical success of osseointegrated dental implants.

In summary, I anticipate that this text will be a valuable asset to the student and clinician who have the highest standards of clinical care. Please enjoy the book and implement the principles presented here for the optimal rehabilitation of the dental implant patient.

William V. Giannobile, dds, ms, dmedsc

Preface

Every text is a reflection of its era. We saw the need in this era for an extraordinary textbook that would present to contemporary readers the long-term patient benefits of implant therapy. It was immediately evident that it would cover the scope from diagnosis and treatment planning through various treatment modalities and conclude with the maintenance of the result, because we are very mindful of the many complications in implant treatment that require thoughtful management. It was necessary for us to seek contributions from leaders and role models for each phase and modality. The response from contributors was positive, and the excellence of their chapters reveals their enthusiasm for the topic.

For many years, osseointegrated implants have demonstrated successful tooth replacement, much to the satisfaction of the dental profession. The initial research results emerging from P-I Brånemark and associates captured the attention of dentistry. It is worth noting that their research took place over a considerable period of time, without marketing a product until many unknowns were resolved. The dental community was intrigued with the scientific studies that were brought to their attention, and research and innovation continued.

The early emphasis was centered on the edentulous patient, but implant treatment is routinely used today as an alternative to fixed restorative dentistry. The periodontist or surgeon was a prisoner of the size and form of the jaw, but changes in treatment planning were initiated in 1989 with the first reports of simultaneous delivery of an implant into an extraction wound. Then came recovery of implant fenestrations or dehiscences with regenerative protocols as well as the development of guided tissue regeneration, which expanded the population of implant candidates with the regeneration of bone surface deformities. Reports of implant treatment in the maxillary and mandibular posterior regions surfaced as a result. Three-dimensional radiography provided information to help avoid or alter anatomical obstacles. Grafting of the floor of the maxillary sinus, bone augmentation, and eventually, vertical growth of bone all provided corrections that were previously thought impossible. To quote Sir Anthony Eden, “Every succeeding scientific discovery makes greater nonsense of oldtime conceptions of sovereignty.”

All educational institutions include osseointegrated implants in their curricula. This is because of the overwhelming improvement in treatment demonstrated by the leaders of surgical innovation, and the prosthetic community has participated in a similar fashion to produce excellent results through implant treatment. Dentistry not only offers a remarkable base of evidence that supports many well-established concepts but also continues to push for intellectual advancements. We must continue our investigation of new therapies to improve dentistry. An old Chinese proverb states, “Learning without thought is deceptive; thought without learning is perilous.”

Unfortunately, the challenge of peri-implantitis has threatened long-term implant survival. This has awakened the profession to the need for strict oversight with well-constructed maintenance programs to provide early diagnosis and appropriate correction. Our patients are not immune to biologic complications, with or without implants. The main issue today is the fundamental clinical question: Can we or should we preserve the remaining natural dentition, or do implants offer a more predictable prognosis?

This text addresses the challenge of decision making with specific solutions for each area of the dentition. It uses the evidence that is now available for both paths of treatment and directs the well-informed clinician toward resolution. We expect to affect the thinking process of the discriminating dentist who is willing to invest time in the decision-making process to arrive at the optimal result for the patient’s benefit.

Contributors

Andrew Ackermann, bchd, mchd

Private Practice Limited to Prosthodontics

Sandton, South Africa

Fortunato Alfonsi, DDS

Private Practice

Genova and Domodossola, Italy

Liliana Aranguren, DDS, MDSc

Private Practice Limited to Periodontics and Implant Dentistry

Boca Raton, Florida

Gustavo Avila-Ortiz, DDS, PhD, MS

Professor and Chair

Department of Periodontics

University of Iowa College of Dentistry

Iowa City, Iowa

Luigi Canullo, DDS, PhD

Private Practice Limited to Surgery and Implant-Supported Prosthetic Rehabilitation

Rome, Italy

Daniele Cardaropoli, DDS

Scientific Director

Institute for Professional Education in Dentistry

Private Practice

Turin, Italy

Hsun-Liang Chan, DDS, MS

Clinical Associate Professor

Department of Periodontics and Oral Medicine

University of Michigan School of Dentistry

Ann Arbor, Michigan

Chia-Yu (Jennifer) Chen, DMD

Research Fellow

Division of Periodontology

Harvard School of Dental Medicine

Boston, Massachusetts

Young-Dan Cho, DDS, PhD

Osteology Foundation Scholar

Department of Periodontology

School of Dentistry

Seoul National University

Seoul, Korea

James K. F. Chow, MDS, MBBS

Honorary Clinical Associate Professor

Oral and Maxillofacial Surgery

Faculty of Dentistry

The University of Hong Kong

Hong Kong, China

Lyndon F. Cooper, DDS, PhD

Associate Dean of Research and Head

Department of Oral Biology

College of Dentistry

University of Illinois at Chicago

Private Practice

Chicago, Illinois

Tamsin J. Cracknell, B eng (Mech), MSc (Clin Epi)

Research Engineer

Southern Implants

Irene, South Africa

Miguel de Araújo Nobre, RDH, MSc Epi

Director

Department of Research and Development

Department of Oral Hygiene

Malo Clinic

Lisbon, Portugal

Ann Decker, DMD

Doctoral Student

Department of Periodontics and Oral Medicine

University of Michigan School of Dentistry

Ann Arbor, Michigan

Matteo Deflorian, DDS

Section of Implantology and Oral Rehabilitation

Dental Clinic

Department of Biomedical, Surgical, and Dental Sciences

Institute for Scientific Clinical Research and Treatment (IRCCS)

Galeazzi Orthopedic Institute

University of Milan

Milan, Italy

Bradley S. DeGroot, DDS, MS

Private Practice Limited to Periodontics and Dental Implant Surgery

Chicago, Illinois

Massimo Del Fabbro, MSc, PhD

Department of Biomedical, Surgical, and Dental Sciences

Institute for Scientific Clinical Research and Treatment (IRCCS)

Galeazzi Orthopedic Institute

University of Milan

Milan, Italy

Deon Ferreira, BChD (Hons), MDent

Private Practice Limited to Prosthodontics

Lyttelton, South Africa

Stuart J. Froum, DDS

Adjunct Clinical Professor and Director of Clinical Research

Department of Periodontology and Implant Dentistry

New York University College of Dentistry

Private Practice

New York, New York

Jia-Hui Fu, BDS, MSc

Assistant Professor

Department of Periodontics

Faculty of Dentistry

National University of Singapore

Singapore

Fabio Galli, MD

Head of Prosthodontics

Department of Implantology and Oral Rehabilitation

Institute for Scientific Clinical Research and Treatment (IRCCS)

Galeazzi Orthopedic Institute

University of Milan

Milan, Italy

Private Practice

Monza, Italy

Jeffrey Ganeles, DMD

Adjunct Associate Professor

Department of Periodontology

Nova Southeastern University

Fort Lauderdale, Florida

Clinical Associate Professor

Goldman School of Dental Medicine

Boston University

Boston, Massachusetts

Private Practice Limited to Periodontics and Implant Dentistry

Boca Raton, Florida

William V. Giannobile, DDS, MS, DMedSc

Professor and Chair

Department of Periodontics and Oral Medicine

University of Michigan School of Dentistry

Professor of Biomedical Engineering

Department of Biomedical Engineering

College of Engineering

University of Michigan

Ann Arbor, Michigan

Christoph H. F. Hämmerle, Prof Dr med dent

Chair

Clinic of Fixed and Removable Prosthodontics

Center of Dental Medicine at the University of Zürich

Zürich, Switzerland

Peter Hawker, BDS, MSc

Private Practice Limited to Prosthodontics

Adelaide, South Australia

Parnward Hengjeerajaras, DDS

Resident

Advance Program in Implant Dentistry

New York University College of Dentistry

New York, New York

Richard I. Herman, DDS

Adjunct Clinical Professor

Department of Postgraduate Endodontics

Nova Southeastern University

Fort Lauderdale, Florida

Mitsuhiro Iwata, DDS, PhD

Private Practice

Okayama City, Japan

Ronald E. Jung, Prof Dr med dent, Phd

Head and Vice Chair

Division of Implantology

Clinic for Fixed and Removable Prosthodontics and Material Science

Center of Dental Medicine at the University of Zürich

Zürich, Switzerland

David M. Kim, DDS, DMSc

Associate Professor

Department of Oral Medicine, Infection, and Immunity

Director, Postgraduate Program in Periodontology and Continuing Education

Harvard School of Dental Medicine

Boston, Massachusetts

Glen Liddelow, BDSc, MScD, DClinDent

Clinical Associate Professor

Department of Health and Medical Sciences

School of Dentistry

University of Western Australia

Nedlands, Australia

Jerry Ching-Yi Lin, DDS, DMSc

Lecturer

Division of Oral Medicine, Infection, and Immunity

Harvard School of Dental Medicine

Boston, Massachusetts

Kuan-You Liu, DDS

Doctoral Student

Department of Periodontology and Implant Dentistry

New York University College of Dentistry

New York, New York

Mark E. Ludlow, DMD, MS

Assistant Professor and Division Director of Implant Prosthodontics

Department of Oral Rehabilitation

College of Dental Medicine

Medical University of South Carolina

Charleston, South Carolina

Sachiko Maeda, DDS, Phd

Private Practice

Osaka, Japan

Panpicha Maketone, DDS

Doctoral Student

Department of Periodontology and Implant Dentistry

New York University College of Dentistry

New York, New York

Paulo Maló, DDS, Phd

Clinical Director

Malo Clinic

Lisbon, Portugal

George A. Mandelaris, DDS, MS

Adjunct Clinical Assistant Professor

Department of Graduate Periodontics

College of Dentistry

University of Illinois at Chicago

Private Practice Limited to Periodontics and Dental Implant Surgery

Chicago, Illinois

José Carlos Martins da Rosa, DDS, MSc, Phd

Private Practice

Caxias do Sul, Brazil

Robert E. Marx, DDS

Professor of Surgery and Chief

Division of Oral and Maxillofacial Surgery

Miller School of Medicine

University of Miami

Miami, Florida

Tokuo Matsui, DDS

Private Practice

Tokyo and Osaka, Japan

Craig M. Misch, DDS, MDS

Clinical Associate Professor

Department of Periodontics/Prosthodontics

School of Dental Medicine

University of Florida

Gainesville, Florida

Private Practice Limited to Oral and Maxillofacial Surgery and Prosthodontics

Sarasota, Florida

Alberto Monje, DDS, MS

Director, Division of Periodontology

Clínica CICOM

Badajoz, Spain

Associate Professor

Department of Periodontology

International University of Catalonia

Barcelona, Spain

Sven Mühlemann, Dr med dent

Center of Dental Medicine

Clinic of Fixed and Removable Prosthodontics and Dental Material Science

University of Zürich

Zürich, Switzerland

Kimio Nakamura, DDS, Phd

Private Practice

Osaka, Japan

Marc L. Nevins, DMD, MMSc

Assistant Professor

Department of Oral Medicine, Infection, and Immunity

Harvard School of Dental Medicine

Private Practice

Boston, Massachusetts

Myron Nevins, DDS

Associate Professor

Department of Oral Medicine, Infection, and Immunity

Harvard School of Dental Medicine

Boston, Massachusetts

Frederic J. Norkin, DMD

Private Practice Limited to Periodontics and Implant Dentistry

Boca Raton, Florida

Yoshihiro Ono, DDS

Director

The Japan Institute for Advanced Dental Studies

Osaka, Japan

Satoko Ono Rubin, DMD, MDSc

Clinical Assistant Faculty

Division of Periodontology

Department of Oral Health and Diagnostic Sciences

University of Connecticut Health Center

Private Practice

West Hartford, Connecticut

Stephen M. Parel, DDS

Private Practice Limited to Prosthodontics and Implant Dentistry

Dallas, Texas

Andrea Parenti, DDS

Lecturer

Department of Implantology and Oral Rehabilitation

Institute for Scientific Clinical Research and Treatment (IRCCS)

Galeazzi Orthopedic Institute

University of Milan

Milan, Italy

Private Practice

Piacenza, Italy

Wonbae Park, DDS, MS

Private Practice

Seoul, Republic of Korea

Stefano Parma-Benfenati, MD, DDS, MSc

Assistant Professor

Master Degree in Periodontology

School of Dental Medicine

Turin University

Turin, Italy

Private Practice Limited to Periodontology and Implantology

Ferrara, Italy

Luís Antônio Violin Pereira, MD, MSc, Phd

Professor

Department of Biochemistry and Tissue Biology of the Institute of Biology

University of Campinas

Campinas (SP), Brazil

Marisa Roncati, rdh, DDS

Assistant Professor

Alma Mater Studiorum

Bologna University

Bologna, Italy

Marco Ronda, MD, DDS

Private Practice

Genova, Italy

Kiyonobu Saburi, DDS, Phd

Private Practice

Osaka, Japan

Takeshi Sasaki, DDS

Private Practice

Tokyo, Japan

Riccardo Scaini, DDS

Section of Implant Dentistry and Oral Rehabilitation

Dental Clinic

Department of Biomedical, Surgical, and Dental Sciences

Institute for Scientific Clinical Research and Treatment (IRCCS)

Galazzi Orthopedic Institute

University of Milan

Milan, Italy

David Schneider,PD Dr med, Dr med dent

Lecturer

Center for Dental, Oral, and Maxillofacial Surgery

University of Zürich

Private Practice

Zürich, Switzerland

Cary A. Shapoff, DDS

Private Practice Limited to Periodontics and Dental Implant Surgery

Fairfield, Connecticut

Ye Shi, DDS

Doctoral Student

Department of Periodontology and Implant Dentistry

New York University College of Dentistry

New York, New York

Massimo Simion, MD, DDS

Professor and Chairman

Department of Periodontology and Implant Restoration

School of Dental Medicine

University of Milan

Milan, Italy

Martina Stefanini, DDS, Phd

Researcher

Department of Biomedical and Neuromotor Sciences

Alma Mater Studiorum

Bologna University

Bologna, Italy

Tiziano Testori, MD, DDS

Head of Section of Implantology and Oral Rehabilitation

Department of Biomedical, Surgical, and Dental Sciences

Institute for Scientific Clinical Research and Treatment (IRCCS)

Galeazzi Orthopedic Institute

University of Milan

Milan, Italy

Private Practice Limited to Implantology and Periodontology

Como, Italy

Carlo Tinti, MD, DDS

Assistant Professor

Turin University

Turin, Italy

Private Practice Limited to Periodontology and Implantology

Flero, Italy

Istvan Urban, DMD, MD, Phd

Assistant Professor

Department of Restorative Dentistry

School of Dentistry

Loma Linda University

Loma Linda, California

Private Practice

Budapest, Hungary

Leandro G. Velasco, DDS, MSc, Phd

Chief of Oral and Maxillofacial Surgery

Clínica Eleve

Hospital da Face

São Paulo, Brazil

Stephen S. Wallace, DDS

Clinical Associate Professor

Department of Periodontics

Columbia University College of Dental Medicine

New York, New York

Private Practice Limited to Periodontics

Waterbury, Connecticut

(Jeff) Chin-Wei Wang, DDS, DMSc

Clinical Assistant Professor and Director of Predoctoral Periodontics

Department of Periodontics and Oral Medicine

University of Michigan School of Dentistry

Ann Arbor, Michigan

Hom-Lay Wang, DDS, MSD, Phd

Collegiate Professor of Periodontics

Professor and Director of Graduate Periodontics

Department of Periodontics and Oral Medicine

University of Michigan School of Dentistry

Ann Arbor, Michigan

Homayoun H. Zadeh, DDS, Phd

Associate Professor

Director, Postdoctoral Periodontology Program

Herman Ostrow School of Dentistry

University of Southern California

Los Angeles, California

Samuel Zfaz, DDS

Private Practice Limited to Periodontics and Implant Dentistry

Aventura, Florida

Giovanni Zucchelli, DDS, MSc, Phd

Professor

Department of Biomedical and Neuromotor Sciences

University of Bologna

Bologna, Italy

The contemporary hallmark of a superior clinician is the ability to select therapies that are predictable and have long-lasting results. The question of whether to save a tooth or replace it with a dental implant is multifaceted, and the assessment requires a multidisciplinary approach to dental care. Giannobile and Lang have reported a trend over the past two decades toward a reduced emphasis in clinical practice to save compromised teeth.1 They suggest that clinicians should revisit the long and successful history of tooth maintenance, preserving the natural dentition without the rush to extract teeth and replace them with implants. Dental practitioners do a disservice to their patients and themselves when they fail to carefully weigh the advantages and disadvantages of such options in providing optimal oral health care delivery to patients.

TREATMENT PLANNING CONSIDERATIONS

Decisions made in treatment planning often determine the value of the result for the patient. Contemporary dentistry has benefited from the predictability of osseointegration,2–10 periodontal regeneration,11–29 successful endodontics,30 and prosthodontics, four compelling areas in which the clinician must be knowledgeable in order to make an informed decision regarding when to save the tooth or place an implant.

Nearly every patient asks the same questions during consultations. They are the following:

• How much discomfort will I endure?

• How many visits will be required?

• What will be the total treatment time?

• How will this affect my appearance?

• What is the financial commitment?

• What is the expected longevity of the treatment outcome?

There is minimal information available in evidence-based dentistry to assist in making many clinical decisions because of the number of variables that challenge the recruitment of populations for randomized controlled trials. As a result, when considering the prospect of replacing a maxillary first premolar with two roots, for example, clinicians eventually resort to their own clinical experience or case report publications. Considerations that must be made include the following:

• What is the distance from the apex of the tooth to an anatomical obstacle, and will it be necessary to augment the bone in the floor of the sinus (Figs 1-1a and 1-1b)?

• What is the position of the roots of the tooth relative to each other and to the neighboring teeth?

• Is the tooth vital, and how intact is the tooth structure and the occlusal level of bone (Figs 1-1c and 1-1d)?

• What type of lip line and dental display does the patient have, and how will it affect the esthetics?

• Could the tooth be treated endodontically? (A 2009 report by Morris et al31 concluded that implants require more postoperative treatment than endodontically treated teeth, possibly a result of contemporary advancements. In addition, many endodontic complications, with the exception of fractured teeth, are resolvable.)

Implant patients fall into two general categories. The first includes individuals with teeth that are congenitally missing or damaged by trauma or root resorption (Fig 1-2). The second group has demonstrated susceptibility to inflammation that is evidenced by radiographic bone loss (Fig 1-3). Those in the first category require only tooth structure correction or replacement, whereas the second group presents the additional challenge of preventing or minimizing recurrent inflammation. The primary factor dictating decision making becomes the length of the clinical root, ie, that portion of the tooth that resides in the alveolar process (see Figs 1-1c and 1-1d). With a susceptible patient, it is advisable to eliminate the periodontal disease and provide a carefully constructed periodic maintenance program to reduce the risk of active inflammatory disease.32 The therapeutic result has to provide an environment that the patient and dental hygienist can maintain (see Fig 1-3).

It is of paramount importance to recognize at the outset that it is possible, and in some instances preferable, to use the time-honored therapeutic approaches of conventional restorative dentistry. Although there is a lack of controlled studies in the discipline of periodontal prostheses, there is a paucity of significant randomized controlled human studies to support the clinical application of many periodontal and prosthetic approaches. There is, however, overwhelmingly positive clinical evidence gathered through the observation of treated patients to be considered. Periodontally compromised patients with mobile, drifting, or missing teeth have been successfully rehabilitated with or without implants (Figs 1-3 to 1-5). Such patients require a treatment plan that provides predictability over an extended time frame.

In patients with few missing teeth or those with obvious periodontal disease, total extraction of the dentition and replacement with implants is frequently unnecessary (Figs 1-6 and 1-7). There are many examples of positive long-term results with maintenance of the dentition, while at the same time there are increasing complications with implants. It is unfortunate that the dental profession frequently is unaware of the positive results of traditional periodontal, endodontic, and prosthetic care.10,33,34

TREATING PERIODONTALLY COMPROMISED TEETH

Favorable results can be accomplished when implants are placed in patients with a chronic history of periodontal disease. There are many publications that have demonstrated long-term healthy and functional implants in place after the loss of periodontally compromised teeth.9,10,35–39 It has been recognized that two very important factors are the elimination of periodontal disease before implants are placed and the availability of oral hygiene programs.32,40

Implants have provided an opportunity to greatly reduce the necessity for periodontal heroics by taking advantage of osseointegration. However, there is overwhelming evidence that periodontally compromised teeth can survive indefinitely.41–43 Esthetics and masticatory function may become compromised over time for some patients, but this is not usually the case. Osseointegrated implants have been one of the most significant improvements of the 20th century, and when appropriate, provide solutions heretofore unavailable. It is important that the dentist weigh the success of saving a tooth using the capabilities of contemporary periodontal regeneration and/or endodontics against the success of an implant. This presents a significant conflict for the knowledgeable dentist, while practitioners with minimal knowledge of the success of periodontics and endodontics generally find it easier to place an implant. The most important question for the dentist is, “What would I do if this problem were in the mouth of a friend or loved one?”

Before peri-implantitis was encountered, it was believed that implant success would exceed 90%.2–4,11 Several studies have demonstrated the error of thinking that implants always have a better long-term prognosis than teeth with treatable problems.44 Recent studies show that peri-implantitis and mucositis are frequent complications that challenge the future health of an implant.45,46 Therefore, the decision has to be carefully considered before treatable teeth are removed.

Conversely, there are routine treatment plan objectives for which tooth replacement with implants offers a better prognosis. When teeth are mobile because of significant loss of bone, esthetics may be greatly affected, even in a posterior quadrant. If there is horizontal bone loss beyond 50%, the bone level of adjacent teeth will contribute to vertical bone reconstruction, allowing implant placement to be favorable and providing a more acceptable result than resorting to pocket elimination surgery (see Fig 1-3).

THE ENDODONTIC TREATMENT OPTION

Recent literature demonstrates that endodontics and single-tooth implant therapy have similar success rates. Hannahan and Eleazer found that 95% to 97% of teeth with treated root canals were retained after a period of 8 years compared with implant retention rates of 85% to 90% over a similar time span.47 Postoperative intervention, an indication of treatment failure, was noted for 12.4% of implants compared with 1.3% of endodontically treated teeth. A more recent report studied the 10-year success rate of 1,175 endodontically treated teeth.48 The life-table analysis demonstrated that 93% of the teeth survived 10 years after endodontic treatment. However, it is critical to determine the criteria for success used when discussing implants.

Endodontic procedures are best performed under the surgical operating microscope, as it enhances the clinician’s ability to locate and navigate canals.49 It has been shown that with the microscope the ability to locate second mesiobuccal canals has increased from 53% to 93%.50,51 The success rates of periapical surgery have also demonstrated significant improvement (Figs 1-8 to 1-10). In such procedures, it is imperative to prepare the crypt and the canals as well as place the retroseal.52

The introduction of nickel titanium instrumentation allows the clinician to shape the canal, which increases the ability of the irrigation protocol to clean the complex anatomy of the root canal system. In addition, new advancements in material science related to obturation have developed. It is now possible to have a biocompatible sealer that bonds to dentin, as well as gutta-percha, which provides a fluid yet impermeable and tight seal.52

However, this should not be perceived as a competition between endodontics and implant treatment; rather, they should complement each other. On the basis of survival rates, it appears more than 95% of single-tooth implants and teeth that have undergone endodontic treatment remain functional over time50 (see Figs 1-8 to 1-10).

TREATING PATIENTS WITH SOUND PERIODONTIUM AND A LOCALIZED PROBLEM

There are frequently situations in which a tooth in the esthetic region can be saved, but the patient would benefit from its replacement with an implant. When both conventional and surgical endodontics have failed, extraction and site reconstruction allow the clinician to place an implant or a three-unit fixed partial denture. It is then possible to consider the length of the restoration and predict the likelihood of interproximal black triangles. It is also an advantage to replace one tooth without altering adjacent teeth (Fig 1-11).

PERIODONTAL REGENERATION

Not every tooth with reduced alveolar support is a candidate for extraction, especially if it would result in loss of continuity of the natural dental arch.53–56 These defects may be identified in patients with either a localized problem or advanced generalized periodontal disease. Variables such as age, medical history, esthetic expectations, and finances may influence the selection of treatment, but it is appropriate for practitioners to consider what they would do if this was their own mouth.

Treatment may include barrier membranes, autografts, allografts, xenografts, and alloplasts17–23 (Fig 1-12). The introduction of recombinant human platelet-derived growth factor BB (rhPDGF-BB) together with any of the previously mentioned materials has significantly improved the ability to achieve a successful outcome.23–29 Once again, it is necessary to consider the stability of the tooth and the morphology of the defect. The containment of the defect provided by remaining osseous structure provides the protection of the blood clot while it becomes organized and provides space maintenance for regeneration to containednoncontained22–28