Treatment planning for implants/fixed orthodontics courses

Treatment planning for
implant restorations
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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ContentsContents
 IntroductionIntroduction
 Available bone and implantAvailable bone and implant
 Classification and treatment plans forClassification and treatment plans for
partially and completely edentulouspartially and completely edentulous
 Treatment options for mandibular implantTreatment options for mandibular implant
over denturesover dentures
 ConclusionConclusion
 ReferencesReferences

INTRODUCTIONINTRODUCTION
The treatment plan should begin withThe treatment plan should begin with
a clear idea of the end result which shoulda clear idea of the end result which should
fulfill the functional and aesthetic needs offulfill the functional and aesthetic needs of
the patient. It is important that these goalsthe patient. It is important that these goals
are realistic, predictable and readilyare realistic, predictable and readily
maintainable.maintainable.

Available BoneAvailable Bone
 Available bone is that portion of a partiallyAvailable bone is that portion of a partially
or totally edentulous alveolar ridge thator totally edentulous alveolar ridge that
can be used to insert an endostealcan be used to insert an endosteal
implant, or basal bone that can be used toimplant, or basal bone that can be used to
support a subperiosteal implant.support a subperiosteal implant. (Charles(Charles
M.M. Weiss)Weiss)

ATWOODS CLASSIFICATION
 Order I:Order I: pre-extraction.pre-extraction.
 Order II:Order II: post extraction.post extraction.
 Order III:Order III: high, wellhigh, well
rounded.rounded.
 Order IV:Order IV: knife edge.knife edge.
 Order V:Order V: low, well rounded.low, well rounded.
 Order VI:Order VI: depressed.depressed.

 CLASSIFICATION ACCORDING TO THE AMERICANCLASSIFICATION ACCORDING TO THE AMERICAN
COLLEGE OF PROSTHODONTISTS:COLLEGE OF PROSTHODONTISTS:
 Based on bone height (mandible only) that isBased on bone height (mandible only) that is
measured at least vertical height of the mandiblemeasured at least vertical height of the mandible
 Type I:Type I: Residual bone height of 21mm or greater.Residual bone height of 21mm or greater.
 Type II:Type II: Residual bone height of 16-20mm.Residual bone height of 16-20mm.
 Type III:Type III: Residual alveolar bone height of 11-15mm.Residual alveolar bone height of 11-15mm.
 Type IV:Type IV: Residual alveolar bone height of 10mm or less.Residual alveolar bone height of 10mm or less.

AVAILABLE BONEAVAILABLE BONE
Available bone describes the amount of bone in the
edentulous area considered for implantation and is
measured in: Height.
Width.
Length
Angulation.
Crown-Implant body ratio.

AVAILABLE BONE HEIGHTAVAILABLE BONE HEIGHT

The minimum height of the available bone
for endosteal implants is related to the density of
the bone.
The minimum bone height for a predictable long-
term endosteal implant survival is 10mm.

 The height of the implant also affects its totalThe height of the implant also affects its total
surface areasurface area..
 An implant 3 mm longer provides more than 10%An implant 3 mm longer provides more than 10%
increase in surface area.increase in surface area.
 The advantage of increased height helps inThe advantage of increased height helps in initialinitial
stability, the overall amount of bone-implantstability, the overall amount of bone-implant
interface, and long term resistance to momentinterface, and long term resistance to moment
forcesforces..

 The root form implants ofThe root form implants of
4.0 mm4.0 mm crestal diametercrestal diameter
usually require more thanusually require more than
5.0 mm5.0 mm of bone width toof bone width to
ensure sufficient boneensure sufficient bone
thickness and blood supplythickness and blood supply
around the implant foraround the implant for
predictable survival. Thesepredictable survival. These
dimensions provide moredimensions provide more
thanthan 0.5 mm0.5 mm bone on eachbone on each
side of the implant.side of the implant.
AVAILABLE BONE WIDTHAVAILABLE BONE WIDTH

 Each 1mm increase in diameter corresponds to aEach 1mm increase in diameter corresponds to a
surface area increase of approximately 20% tosurface area increase of approximately 20% to
30%.30%.
 StressStress equals force / functional area over which it isequals force / functional area over which it is
applied, theapplied, the greater diameter decreases thegreater diameter decreases the
amount of stress at the crestal bone-implantamount of stress at the crestal bone-implant
interface.interface.

1 mm1 mm – Bone remaining after implant– Bone remaining after implant
placement to anatomical structuresplacement to anatomical structures
2 mm2 mm – Tooth to implant– Tooth to implant
3 mm3 mm – Implant to implant– Implant to implant
7 mm7 mm - Implant to implant in over denture- Implant to implant in over denture

AVAILABLE BONE LENGTHAVAILABLE BONE LENGTH
The mesio-distal length of available bone in
an edentulous area is often limited by adjacent
teeth or implants. The length of available bone
necessary for endosteal implant survival depends
on the width of the bone.

AVAILABLE BONE ANGULATIONAVAILABLE BONE ANGULATION
Ideally the bone angulation is aligned with
the forces of occlusion and is parallel to the long
axis of the Prosthodontic restoration.

 TheThe limiting factor of angulationlimiting factor of angulation of force betweenof force between
the body and the abutment of an implant isthe body and the abutment of an implant is
correlated to the width of bone.correlated to the width of bone.
 In edentulous areas with aIn edentulous areas with a wide ridgewide ridge, wider root, wider root
form implants may be used. Such implants allowform implants may be used. Such implants allow
modifications up tomodifications up to 30 degrees divergence30 degrees divergence
 Narrow yet adequate width ridgeNarrow yet adequate width ridge often requires aoften requires a
narrower design root form implant. This limits thenarrower design root form implant. This limits the
acceptable angulation of bone toacceptable angulation of bone to 2020 degreesdegrees

CROWN-IMPLANT BODY RATIOCROWN-IMPLANT BODY RATIO
The crown height is measured from the
occlusal or incisal plane to the crest of the ridge
and the endosteal implant height from the crest
of the ridge to its apex.

 The greater the crown height, the greater theThe greater the crown height, the greater the
lever arm with any lateral force.lever arm with any lateral force.
 As theAs the crown-implant ratio increasescrown-implant ratio increases, the, the
number of implants and/or wider implantsnumber of implants and/or wider implants shouldshould
be inserted to counteract the increase in stressbe inserted to counteract the increase in stress

DIVISIONSDIVISIONS
OFOF
AVAILABLE BONEAVAILABLE BONE
 Division A (Abundant Bone)
 Division B (Barely Sufficient Bone)
 Division C (Compromised Bone)
 Division D (Deficient Bone)

Division ADivision A
(Abundant Bone)(Abundant Bone)
 >5mm width>5mm width
 >12 mm height>12 mm height
 >7mm mesio-distal>7mm mesio-distal
lengthlength
 <30 degrees<30 degrees
angulationangulation
 <15 mm crown height<15 mm crown height
 C/I ratio <1C/I ratio <1

 Division A is mostDivision A is most
often restored withoften restored with
Division A root formDivision A root form
implant.implant.
 Root form implantsRoot form implants
presents severalpresents several
advantages to otheradvantages to other
endosteal designs asendosteal designs as
the plate form orthe plate form or
transosteal implants.transosteal implants.

DIVISION A ROOT FORM IMPLANTDIVISION A ROOT FORM IMPLANT
ADVANTAGESADVANTAGES
 Greatest surface areaGreatest surface area
 Improved stress distributionImproved stress distribution
 Less fracture of implant and componentsLess fracture of implant and components
 Designed for variable bone densityDesigned for variable bone density
 More esthetic conditionsMore esthetic conditions

Division B (Barely sufficientDivision B (Barely sufficient
bone)bone)
 As the bone resorbs, the width of available boneAs the bone resorbs, the width of available bone
first decreases at the expense of the facialfirst decreases at the expense of the facial
cortical plate.cortical plate.
 There is 25% decrease in bone width the firstThere is 25% decrease in bone width the first
year, and 40% decrease in bone width within theyear, and 40% decrease in bone width within the
first 1 to 3 years after tooth extraction.first 1 to 3 years after tooth extraction.
 Once this Division B bone volume is reached, itOnce this Division B bone volume is reached, it
may remain for more than 20 years.may remain for more than 20 years.

Division BDivision B
(Barely Sufficient Bone)(Barely Sufficient Bone)
2.5-5mm width2.5-5mm width
>12 mm height>12 mm height
>6 mm mesio-distal>6 mm mesio-distal
lengthlength
<20 degree angulation<20 degree angulation
between implant bodybetween implant body
and occlusal planeand occlusal plane
Crown/Implant ratio <1Crown/Implant ratio <1

Treatment options available for theTreatment options available for the
Division B edentulous ridgeDivision B edentulous ridge
 Insert division B implantsInsert division B implants
 OSTEOPLASTYOSTEOPLASTY
Converts to division A when greater than 12Converts to division A when greater than 12
mm bone height resultsmm bone height results
Converts to division C-H when less than 12 mmConverts to division C-H when less than 12 mm
bone height resultsbone height results

DISADVANTAGES OF DIVISION B ROOTDISADVANTAGES OF DIVISION B ROOT
FORMSFORMS
 Almost twice the stress is concentrated at the top crestalAlmost twice the stress is concentrated at the top crestal
region around the implantregion around the implant
 Lateral loads on the implant result in almost 3 timesLateral loads on the implant result in almost 3 times
greater stress than division A root formsgreater stress than division A root forms
 Fatigue fractures of the abutment post are increased.Fatigue fractures of the abutment post are increased.
 The crown emergence profile is less estheticThe crown emergence profile is less esthetic
 Implant costs are not related to diameter, so an increaseImplant costs are not related to diameter, so an increase
in implant number results in greater cost to the doctorin implant number results in greater cost to the doctor
and patientand patient

Division CDivision C
(Compromised Bone)(Compromised Bone)
Unfavorable in: WidthUnfavorable in: Width
(C-w)(C-w)
Height (C-h)Height (C-h)
Angulation (C-a)Angulation (C-a)
C/I ratio >1C/I ratio >1

 The resorption of the available bone occurs first inThe resorption of the available bone occurs first in
bone width, and then in height.bone width, and then in height.
 As a result, Division B ridge continues to resorb inAs a result, Division B ridge continues to resorb in
width although height of bone is still present, untilwidth although height of bone is still present, until
it becomes inadequate for any design ofit becomes inadequate for any design of
endosteal implants. This bone category is calledendosteal implants. This bone category is called
Division C-wDivision C-w..
 This resorption process continues, and theThis resorption process continues, and the
available bone is then reduced in height andavailable bone is then reduced in height and
calledcalled Division C-hDivision C-h

Division C edentulous ridgeDivision C edentulous ridge
(1) Osteoplasty(1) Osteoplasty
(2) Augmentation procedures(2) Augmentation procedures
(3) Root form implants(3) Root form implants
(4) Subperiosteal implants(4) Subperiosteal implants
(5) Ramus frame implants(5) Ramus frame implants
(6) Transosteal implants(6) Transosteal implants

Division DDivision D
(Deficient Bone)(Deficient Bone)
Severe atrophySevere atrophy
Basal bone lossBasal bone loss
Flat maxillaFlat maxilla
pencil thin mandiblepencil thin mandible

Division D edentulous ridgeDivision D edentulous ridge
 The completely edentulous Division D patient is mostThe completely edentulous Division D patient is most
difficult to treat in implant dentistry.difficult to treat in implant dentistry.
 The choice to render treatment is the doctor’s, notThe choice to render treatment is the doctor’s, not
the patient’sthe patient’s
 Benefits must carefully be weighed against the risksBenefits must carefully be weighed against the risks

 If implant failure occurs, the patient may become aIf implant failure occurs, the patient may become a
dental cripple, unable to wear any prosthesis.dental cripple, unable to wear any prosthesis.
 Therefore autogenous bone grafts to upgrade theTherefore autogenous bone grafts to upgrade the
division are strongly recommended before anydivision are strongly recommended before any
implant treatment is attemptedimplant treatment is attempted
 Once autogenous grafts are in place and allowedOnce autogenous grafts are in place and allowed
to heal for 5 or more months, endosteal orto heal for 5 or more months, endosteal or
subperiosteal implants may be inserted,subperiosteal implants may be inserted,
depending on the division of bone obtaineddepending on the division of bone obtained..

Treatment planning forTreatment planning for
implant restorations inimplant restorations in
partially edentulouspartially edentulous
archesarches

 The implant dentistry bone volumeThe implant dentistry bone volume
classification developed byclassification developed by Misch and JudyMisch and Judy
builds on the four classes of partialbuilds on the four classes of partial
edentulism described in the Kennedy-edentulism described in the Kennedy-
Applegate system.Applegate system.

Class IClass I

Class IIClass II

CLASS IIICLASS III

CLASS IVCLASS IV

Class I - Division AClass I - Division A
Bone height > 10 mm
Length > 7 mm
Angulation < 30 degrees
Crown height < 15 mm
Removable prosthesis
Root form implants

Class I division BClass I division B
Bone width 2.5-5
mm
Bone height > 10
mm
Angulation < 20
degrees
Crown height < 15
mm
Osteoplasty
Small implants
augmentation

CLASS I – Division CCLASS I – Division C
Inadequate
available bone
height, Length
,Angulation.
Crown height > 15
mm
 Augmentation and
Sub periosteal
implants
Nerve repositioning

CLASS I Division DCLASS I Division D
Inadequate available bone
due to Severly resorbed
ridge involving basal bone
Crown height more than
20 mm
Augmentation

CLASS II Division A, BCLASS II Division A, B
Endostel implants with min
osteoplasty are common
modality.
Extrusion of opposing and
tipping of adjacent teeth
will cause excessive forces

CLASS II Division CCLASS II Division C
Conventional prosthesis
and small diameter
implants after ridge
augmentation with onlay
grafts

CLASS IIICLASS III
DIVISION A DIVISION C

 Single tooth implants are treatment ofSingle tooth implants are treatment of
choice when the soft and hard tissues arechoice when the soft and hard tissues are
in normal range.in normal range.

CLASS IVCLASS IV
•Traditional fpd is treatment of
choice when canines are
present
•Bone grafts should be placed
before placement of implants

TREATMENT PLANSTREATMENT PLANS
FOR COMPLETELYFOR COMPLETELY
EDENTULOUS ARCHESEDENTULOUS ARCHES

Classification of completelyClassification of completely
edentulous arches is also basededentulous arches is also based
on bone volume and locationon bone volume and location
present given bypresent given by Kent andKent and
Lousiana Dental schoolLousiana Dental school
 Edentulous jaw is divided into 3Edentulous jaw is divided into 3
regions:regions:

TYPE ITYPE I

TYPE IITYPE II

TYPE IIITYPE III

IMPLANTIMPLANT
OVERDENTURESOVERDENTURES

Many edentulous patients experience problems withMany edentulous patients experience problems with
their dentures, especially lack of stability andtheir dentures, especially lack of stability and
retention, together with a decrease of chewing ability.retention, together with a decrease of chewing ability.
one possibilty of solving this problem is the use ofone possibilty of solving this problem is the use of
endosseous implants to which an overdenture can beendosseous implants to which an overdenture can be
attached.attached.

Implant Overdenture AdvantagesImplant Overdenture Advantages
1.1. Minimum anterior bone loss; prevents boneMinimum anterior bone loss; prevents bone
lossloss
2.2. Improved estheticsImproved esthetics
3.3. Improved stability (reduces or eliminatesImproved stability (reduces or eliminates
prosthesis movement)prosthesis movement)
4.4. Decrease in soft tissue abrasionsDecrease in soft tissue abrasions
5.5. Improved chewing efficiency - 20 %Improved chewing efficiency - 20 %

6. Improved retention6. Improved retention
7. Improved support7. Improved support
8.Improved speech8.Improved speech
9. Reduced prosthesis size (eliminates palate9. Reduced prosthesis size (eliminates palate
flanges)flanges)
10. improved10. improved maxillofacial prosthesesmaxillofacial prostheses

Implant overdenture advantages versus fixedImplant overdenture advantages versus fixed
prosthesisprosthesis
 Fewer implantsFewer implants
less bone graftless bone graft
less specific placementless specific placement
 Improved estheticsImproved esthetics
Labial flangeLabial flange
Denture teethDenture teeth

 Soft tissue considerationsSoft tissue considerations
Improved periimplant probingImproved periimplant probing
HygieneHygiene
 Reduced stressReduced stress
Nocturnal parafunctionNocturnal parafunction
Stress-relief attachmentStress-relief attachment

 Less cost and laboratory costLess cost and laboratory cost
Fewer implantsFewer implants
Less bone graftingLess bone grafting
Easy repairEasy repair
Laboratory cost decreaseLaboratory cost decrease

Over denture disadvantagesOver denture disadvantages
1.1.Psychological (need for non removablePsychological (need for non removable
teeth)teeth)
2.2.Abutment crown height space requiredAbutment crown height space required
3.3.Long-term maintenanceLong-term maintenance
4.4.Attachments (change)Attachments (change)
5.5.RelinesRelines

6. New prosthesis every 7 years6. New prosthesis every 7 years
7. Continued posterior bone loss7. Continued posterior bone loss
8. Food impaction8. Food impaction
9. Movement9. Movement

Treatment options for ImplantTreatment options for Implant
retained overdentureretained overdenture

Categorization of potential implant site in mandible –Categorization of potential implant site in mandible –
By Carl E MischBy Carl E Misch

Option OneOption One
6767
Anatomical conditions
Cost is primary factor
Hygiene is improved
Arch form is tapered
Additional implants can be
placed
Dis advantages:

Option twoOption two

 AnatomicalAnatomical
conditions good toconditions good to
moderatemoderate
 Posterior ridgePosterior ridge
form is u shapedform is u shaped

Disadvantages of A and E splinted implantsDisadvantages of A and E splinted implants
Difficulty with speechDifficulty with speech
 Anterior tipping of over dentureAnterior tipping of over denture
 5 times greater flexure than B and D5 times greater flexure than B and D
positionspositions
Greater flexibility of bar when a curved bar splintGreater flexibility of bar when a curved bar splint
is used ( 9 times than B and D position)is used ( 9 times than B and D position)
BAB D
A E

 Increased screw looseningIncreased screw loosening
 Bite force is increased than B and DBite force is increased than B and D
positionspositions
 Greater lateral load than B and DGreater lateral load than B and D
positionspositions
 Greater bite force in posterior region thanGreater bite force in posterior region than
B and D positionB and D position

Option threeOption three
1st
option
Pt needs and desires
Improved retention and stability
Cost a moderate factor

 If posterior ridge formIf posterior ridge form
is good , implants areis good , implants are
placed on A, C, Eplaced on A, C, E
 if posterior ridge isif posterior ridge is
poor, implants placedpoor, implants placed
in B, C, D regions.in B, C, D regions.

advantagesadvantages
 Six times less bar flexure than A and ESix times less bar flexure than A and E
 Less screw looseningLess screw loosening
 Less flexure than A and E curve splintingLess flexure than A and E curve splinting
 Less stress to each abutment than A and ELess stress to each abutment than A and E
 Greater surface areaGreater surface area
 more implantsmore implants
 Greater a-p spreadGreater a-p spread
 Less prosthesis movementLess prosthesis movement
 One implant failure still gives good supportOne implant failure still gives good support

Option four (Resilient Hybrid bar design)Option four (Resilient Hybrid bar design)
Four implants areFour implants are
placed inplaced in
A, B, D and E position.A, B, D and E position.
IndicationsIndications
 Poor posteriorPoor posterior
anatomyanatomy
 Lack of retention andLack of retention and
stabilitystability
 Soft tissue abrasionSoft tissue abrasion
 Speech difficultiesSpeech difficulties
 Very high patientVery high patient
expectationsexpectations

 Typically fourTypically four
attachments areattachments are
placed evenly. Twoplaced evenly. Two
anterior and twoanterior and two
posterior.posterior.

advantagesadvantages
 Greater occlusal load distributionGreater occlusal load distribution
 Lateral prosthesis stabilityLateral prosthesis stability
 Cantilever not extended till molars soCantilever not extended till molars so
excessive stress on cantileverexcessive stress on cantilever

ALL ON FOUR CONCEPTALL ON FOUR CONCEPT

Option five (Rigid Hybrid bar design)Option five (Rigid Hybrid bar design)
Five implants are placed in (A, B, C, D, E).Five implants are placed in (A, B, C, D, E).

IndicationsIndications
Inability to wear conventional denturesInability to wear conventional dentures
Very high expectationsVery high expectations
Unfavourable anatomyUnfavourable anatomy
Problems with function and stabilityProblems with function and stability
Posterior sore spotsPosterior sore spots
8080www.indiandentalacademy.comwww.indiandentalacademy.com

Mandibular full arch implantMandibular full arch implant
fixed prosthetic optionsfixed prosthetic options

Prosthodontic classificationProsthodontic classification
 Fp 1Fp 1 fixed prosthesis; replaces only crown; looks like afixed prosthesis; replaces only crown; looks like a
natural tooth.natural tooth.
 Fp 2Fp 2 fixed prosthesis; replaces crown and portion of root.fixed prosthesis; replaces crown and portion of root.
 Fp 3Fp 3 fixed prosthesis; replaces missing crowns andfixed prosthesis; replaces missing crowns and
gingival color and portion of the edentulous site.gingival color and portion of the edentulous site.

Rp-4Rp-4 Removable prosthesis ; over dentureRemovable prosthesis ; over denture
supported completely by implantsupported completely by implant
Rp-5Rp-5 Removable prosthesis ; over dentureRemovable prosthesis ; over denture
supported by soft tissue and implantsupported by soft tissue and implant

Mandibular full arch implant fixed prostheticMandibular full arch implant fixed prosthetic
optionsoptions
Advantages:Advantages:
1.1. Psychological: feels like teethPsychological: feels like teeth
2.2. Less prosthetic maintainenceLess prosthetic maintainence
AttachmentsAttachments
RelinesRelines
New over dentureNew over denture
3. Less food entrapment3. Less food entrapment

Medial movementMedial movement
800 micro m
1500 micro m

TorsionTorsion

Consequences of cross arch connectionConsequences of cross arch connection
includes:includes:
1.1.Bone loss around implantsBone loss around implants
2.2.Loss of implant fixationLoss of implant fixation
3.3.Components fractureComponents fracture
4.4.Unretained restorationsUnretained restorations
5.5.Discomfort on openingDiscomfort on opening

Implant treatment optionsImplant treatment options
Treatment option 1: the branemarkTreatment option 1: the branemark
approachapproach
Force factors
Number
Size
design www.indiandentalacademy.comwww.indiandentalacademy.com

Antero posterior distanceAntero posterior distance

Treatment option 2Treatment option 2
12 mm

A-P spread is 1.5 – 2 times

Division C-H , subperiosteal or disc implantswww.indiandentalacademy.comwww.indiandentalacademy.com

CONCLUSIONCONCLUSION
Treatment planning for implant restorationsTreatment planning for implant restorations
may at first appear complicated. It is imperative tomay at first appear complicated. It is imperative to
consider all treatment options with the patient, andconsider all treatment options with the patient, and
during detailed planning it may become apparent that anduring detailed planning it may become apparent that an
alternative solution is preferred. In all cases the implantalternative solution is preferred. In all cases the implant
treatment should be part of an overall plan to ensuretreatment should be part of an overall plan to ensure
health of any remaining teeth. The cost of the proposedhealth of any remaining teeth. The cost of the proposed
treatment plan is also of great relevance.treatment plan is also of great relevance.

REFERENCESREFERENCES
1.1. Atlas of oral implantology – A.Norman CraninAtlas of oral implantology – A.Norman Cranin
2.2. Contemporary implant dentistry – Carl.E.mischContemporary implant dentistry – Carl.E.misch
3.3. Implants in clinical dentistry –Implants in clinical dentistry –
Richard.M.PalmerRichard.M.Palmer
4.4. Implant prosthodontics – Stevens FriedricksonImplant prosthodontics – Stevens Friedrickson

5.5. Atlas of tooth and implant supportedAtlas of tooth and implant supported
prosthodontics – Lawrence.A.Weinbergprosthodontics – Lawrence.A.Weinberg
6.6. color atlas of implantology – hubertuscolor atlas of implantology – hubertus
spiekermanspiekerman
7. Treatment planning for implant restorations.7. Treatment planning for implant restorations.
British dental journal, volume 187, no. 6,British dental journal, volume 187, no. 6,
september 25 1999september 25 1999

8. “All-on-four” immediate function concept and clinlical
report of treatment of an edentulous mandible with a
fixed complete denture. J Prosthodont 2008;17:47-51.
9. Classification system for complete edentulism.
J Prosthodont 1999;8:27-39.
10. implants in the esthetic zone. Dent Clin N Am10. implants in the esthetic zone. Dent Clin N Am
2006:50:391-407.2006:50:391-407.

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