|Year : 2012 | Volume
| Issue : 3 | Page : 149-157
Single tooth implants: Pretreatment considerations and pretreatment evaluation
Vidya Kamalaksh Shenoy
Department of Prosthodontics, AJ Institute of Dental Sciences, Mangalore, Karnataka, India
|Date of Web Publication||11-Jun-2013|
Vidya Kamalaksh Shenoy
Department of Prosthodontics, AJ Institute of Dental Sciences, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Today, implants are considered as a first treatment option to replace missing teeth due to the considerable advantages over the other available options. The ultimate goal of implant treatment is to restore natural esthetics, function, long term health, and patient comfort. Hence, case selection and treatment planning are very crucial to achieve longevity and predictability of the restoration. This article presents a step-by-step protocol for gathering and analyzing the various factors at the pretreatment evaluation stage to set the groundwork for a dentist to consider implant as a restorative option.
Clinical Relevance to Interdisciplinary Dentistry
- To help the restorative dentist to identify the ideal implant receptor site.
- Sound periodontal and restorative status is prerequisite to consider implant treatment as an option.
- Restorative driven implant placement is paramount for overall integrity of the dentition.
Keywords: Missing tooth, pretreatment evaluation, single tooth implants
|How to cite this article:|
Shenoy VK. Single tooth implants: Pretreatment considerations and pretreatment evaluation. J Interdiscip Dentistry 2012;2:149-57
| Introduction|| |
Implant dentistry has become an integral part of everyday dentistry and should be considered as the first treatment alternative to replace missing teeth. There is a learning curve associated with placing and restoring dental implants. The implant is placed in an optimal position to effectively support the restoration and surrounding soft and hard tissues. To achieve a predictable and durable restoration, visualization of the final restorative reconstruction is necessary prior to onset of treatment. The term 'restorative-driven' treatment plan has been used to identify this process. 
The main goal of current implant restorative protocol is preservation of remaining tissues. Therefore, the set goals should be realistic, predictable, and maintainable. The introduction of newer therapeutic modalities, restorative materials, surgical, and restorative techniques have significantly expanded available treatment options and a greater demand is now placed on the diagnostic and treatment planning acumen of the clinician. Mastering a particular technique may be predictably accomplished by any clinician, however, when and how to apply these aforementioned modalities to their maximum benefit for the patient is a question which is confronted by each clinician. The objective of this review is to provide a framework for the factors to be considered while planning a single tooth implant for replacement of a missing tooth and help the clinician to identify the ideal implant receptor site to place and restore the dental implant.
| Rationale for Single Tooth Implants|| |
Single tooth implant restorations are individual free standing units similar to conventional single crowns and are normally cemented to prefabricated or customized abutments. They can be screw retained also.
Need to restore a single tooth in an otherwise non restored dentition often arise in a clinical practice. The posterior regions of the mouth, especially the first molars often require the replacement of a single tooth.  The most common reason for loss of posterior teeth includes caries, failed endodontic treatment, and failure of the post endodontic restorations.
Single-tooth replacement may be effected through use of a resin-bonded fixed partial denture (RBB), a conventional fixed dental prosthesis (FDP), a removable prosthesis, or a single implant-supported crown (SIC).  Each option has its own advantages and disadvantages. FDP offers the advantage of clinical ease, reduced treatment time, and also can meet the esthetic, functional requirements and the patient comfort. A major shortcoming of fixed dental prosthesis is the need for abutment preparation  and subgingival margins in esthetic situations, which can be associated with increased gingival inflammation. , In addition, a three unit fixed dental prosthesis presents a survival limitations to the restoration and the abutment teeth. ,
The most common cause for failure of FDP is caries, periodontal disease, endodontic pathology, retention failure and abutment fracture. Valderhaug  assessed the periapical and clinical status of crowned teeth over 25 years and observed caries, endodontic involvement, and periodontics pathology as the primary cause of complications with or without tooth loss.
Although fixed dental prosthesis is a viable treatment alternative in certain situations, the implant restoration has definite advantages. Literature report demonstrates that implant-supported single-tooth replacement is a predictable procedure with higher survival rates for single tooth implants. ,
The success rate for replacement of a molar or premolar with a dental implant restoration has been shown to be greater than 95%.  Many clinicians feel that, due to the substantial success rate, implants should be considered as the definitive choice over other tooth-replacement alternatives.  This is supported by the dental literature for many implant systems in every area of the mouth. 
The first rationale of placing a single dental implant includes prevention of the needless restoration of sound teeth adjacent to the edentulous area as would be required for a fixed partial denture. It also avoids the pulpal, periodontal, and endodontic complications of the supporting abutments associated with the fixed dental prosthesis. By replacing the tooth root with implants, it becomes the anchor in the bone and the supports the clinical crown, providing stimulation, and thus preservation of the surrounding bone. 
| Treatment Planning Considerations|| |
The preservation of existing intact oral structures requires execution of a careful and conservative treatment. The final success of implant restoration depends on the careful patient selection and comprehensive treatment plan. Before any treatment all patients should be evaluated for overall health during the initial examination. If the patient is a candidate for implant therapy, a systematic protocol should be followed to assess the site-specific considerations.
Bone density is a key determinant in treatment planning, implant design, surgical approach, healing time, and type of loading during prosthetic reconstruction. Four types of mineralized bone have been described by Misch  [Table 1], [Figure 1]. It may be determined by the general location, radiographic evaluation, and tactile sense during surgery.
| Edentulous Space Considerations|| |
Available bone is that portion of a partially or totally edentulous alveolar ridge that can be used to insert an endosteal implant. The available bone has three dimensions: Length, width, and depth. Length is the mesiodistal dimension, width is the buccolingual dimension, and depth is measured from the crest of the ridge to the nearest limiting landmark [Table 2], [Figure 2].
Available bone length or mesiodistal dimension of the edentulous space
Depending on the tooth being replaced, adequate mesiodistal space must be present to provide a restoration that simulates natural tooth contours. It gives an indication of the number of implants that can be accommodated; however, this has to be correlated with the buccolingual width of the bone, diagnostic wax up of proposed location, and angulation of the adjacent tooth roots. If inadequate prosthetic space exists, it must be created through enameloplasty of adjacent teeth or orthodontic repositioning.
Spacing requirements [Table 3], [Figure 3]
The following guidelines  should be used when selecting implant size and evaluating mesiodistal space for implant placement:
- The implant should be at least 1.5 mm away from the adjacent teeth.
- The implant should be at least 3 mm away from an adjacent implant.
- A wider diameter implant should be selected for molar teeth because of the high occlusal loads.
Spacing is required to provide the following:
Considering the above guidelines, a 4 mm regular platform implant will require a 7 mm mesiodistal space between the adjacent teeth at the coronal region. If an implant is placed too close to the adjacent teeth, compromised contours and unnecessary loss of hard and soft tissue adjacent to the implant will result. Placing the restoration too far from the adjacent tooth also results in unfavorable contours and development of cantilever type forces on the restoration.
- To allow for 1.5 mm of crestal bone interproximally, this in turn will allow for proper development of a healthy papilla. ,,
- To develop proper contacts and the contours in the restoration.
- To allow for an adequate width of soft tissue between implants and adjacent teeth. 
- For the prosthetic components not to impact on each other. 
- For the effective cleaning of the prosthesis by the patient. 
- To develop harmonious occlusion.
- To allow for at least 1 mm space from the implant to the adjacent root.
Available buccolingual bone width
The available bone width is measured from the facial cortical plate to the lingual cortical plate at the crest of the prospective implant site [Figure 2].
The minimum available bone width should be such that >1 mm of bone should be present on either side of the implant faciolingually to keep the soft tissue levels stable [Figure 4]. This is critical on the facial side since any bone resorption and ensuing change in the position of the gingival margin will be nonesthetic. 
Considering the above guideline, in an ideal situation the implant diameter chosen should be at least 3 mm less than the available mesiodistal dimension of the bone and 3 mm narrower than the buccolingual dimension of bone.
Assessment of the available bone width
The width of the available bone cannot be quantified on intraoral radiographs, because they are two dimensional and has to be determined clinically.
Visual assessment and palpation
The height, buccolingual width, and contour of the ridge can be visually assessed. The careful palpation of the ridge will detect any presence of concavities. If the overlying tissue is fibrous or thicker, accurate assessment may be difficult with visual assessment and palpation.
Ridge mapping  is a procedure that allows the implant surgeon to determine the thickness or width of the alveolar bone. In this technique, a needle with an endodontic stopper or a specially designed caliper is penetrated through the soft tissue in the area under evaluation for implants. The soft tissue thickness at the ridge crest, at two points vertically down on the buccal and the lingual areas, is measured. The edentulous area of the diagnostic cast is sectioned perpendicular to the ridge. The tissue thickness is then mapped out on the sectioned diagnostic cast using a pencil [Figure 5]. This gives an idea of approximate ridge width as well as a rough estimation of the ridge contour. Even though it gives better picture of the ridge profile than visual assessment, it is still prone to error.
| Crown Height Space|| |
Crown height space is considered as the key vertical parameter in treatment planning for the implant restorations. The crown height space is the distance from the occlusal plane to the crest of the alveolar ridge in the posterior region and from the incisal edge of the arch in question in the anterior region  [Figure 6]. This will influence the type of prosthesis, material choices, and surgical technique that will be used.
This factor is often overlooked until the prosthetic phase. A satisfactory restorative outcome is obtained only if adequate crown height space is available. To provide sufficient room for the prosthetic components, an adequate space should be present between the edentulous ridge and the opposing dentition. Ideally, for cement retained prosthesis 8-12 mm crown height space is needed, measuring from the soft tissue of the edentulous ridge to the occlusal plane at the middle of the implant receptor site. 
The ideal vertical dimensions of each region are 3 mm for the soft tissue,  5 mm for the abutment height,  and 2 mm for the occlusal metal or porcelain. The screw retained restorations generally require lesser crown height space compared to the cement retained prosthesis since it can screw directly onto the implant body.
The consequences of inadequate crown height space include a decrease in abutment height, inadequate bulk of restorative material for strength and esthetics, and poor hygiene conditions.
If there is inadequate crown height space, the use of metal occlusal surface may be required which may be least esthetic option. However, when heavy occlusal forces are expected, metal may be the preferred choice of restoration.
When the available space is inadequate due to over eruption of the opposing teeth, depending on the extent of available space minimal enameloplasty, orthodontic intervention, elective endodontics, crown lengthening, and crown in the opposing quadrant may be indicated.
Excessive crown height space acts as a vertical cantilever when any lateral or cantilevered load is applied and, therefore, is a force magnifier.  As a result, it can increase mechanical complications related to implant prosthesis.
| Periodontal Health|| |
Periodontal examination includes assessment of both soft and hard supporting tissues of the dentition. An assessment of soft tissue should determine the thickness of the fibrous connective tissue, amount of attached keratinized tissue, and symmetry of gingival scallop.
The tissue biotypes are classified according to how thick or thin the supporting bone and gingival soft tissues are defined. Thick and fibrous tissue is much more forgiving, easier to manipulate, and provides a more predictable aesthetic outcome, as compared to thin tissue, which is more likely to shrink. Thick and fibrous gingival biotype is considered more resistant to recession and result in more predictable and stable outcome, as opposed to a thin biotype.  A thin biotype with a highly scalloped gingival architecture has a reduced soft tissue thickness when compared with a thick biotype featuring blunted contours of the papillae. 
An adequate collar of keratinized tissue provides a healthy emergence suitable to resist trauma from mastication, and allows for more convenient prosthetic procedures  and oral hygiene measures.
If periodontal disease is present the attachment level, mucogingival problems and furcation involvement that may alter the prognosis of the remaining teeth need to be assessed. It is crucial to measure the probing depth as well as the level of crestal bone. Kois  classified a high crest when the crestal bone level is close to the cemento-enamel junction (CEJ), the normal crest is defined as 2 mm from the CEJ, and the low crest is present in patients with recession.
| Restorative and Endodontic Status|| |
A sound dental status must exist prior to implant placement so as not to risk future implant sites.
Existing pathological changes, restorations, and root canal treatment need to be evaluated to determine the long term prognosis of the tooth.
| Inclination of The Adjacent Teeth|| |
The inclination of the adjacent teeth is a very important parameter to assure adequate implant teeth distance, to avoid interference from a convergent root during implant placement. A panoramic or periapical radiograph can offer a basic clue to inter-root space [Figure 7]. Drifting and tipping of remaining teeth will often compromise mesiodistal space available for implant placement. Hence, a clear communication with the orthodontist is needed with regard to root positions. Orthodontic treatment should always precede implant placement.
| Available Bone Height|| |
The height of the available bone is measured from the crest of the edentulous ridge to the anatomical landmarks that limit the placement of the implant. The assessment of implant length should allow an adequate safety margin of approximately 2 mm, particularly as many drills are designed to prepare the implant site slightly longer than the chosen implant. There should be at least 2 mm of bone between the apical end of the implant and neurovascular structures [Figure 8].
The anatomical structures to be considered before planning the implant length are as follows:
These landmarks can be outlined directly on a periapical and panoramic radiograph to clearly indicate the amount of available height of bone.
- In the maxilla: Floor of the maxillary sinus, floor of the nose
- In the mandible: Mental foramina, roof of the inferior alveolar canal, submandibular fossa
- Teeth: Adjacent tooth roots.
| Occlusal Analysis|| |
Masticatory forces developed by a patient restored with implant supported restorations are equivalent to those of a natural dentition  and implants can tolerate the axial load better as opposed to lateral loads.  Also, implant supported restorations are more susceptible to occlusal overloading than natural teeth.  Therefore, it is important to understand the factors contributing to the anticipated load on the implant.
Intraoral examination along with mounted diagnostic casts is used to evaluate the type of occlusal scheme and guidance in lateral and protrusive movements. To avoid excessive lateral loads on a posterior implant, favorable occlusal schemes would include those that have good, immediate anterior guidance.  The amount of vertical and horizontal overlap and the relationship of the opposing dentition play a vital role in the long term predictability of the implant. The restorative space available is also a key parameter in implant treatment planning. The adjacent teeth and the opposing dentition should be evaluated as over-eruption of any teeth will cause occlusal interferences and also decrease the crown height space necessary for implant restorative components. Patients with occlusal wear or abfraction type defects due to clenching or bruxism should be identified since the parafunctional habits will affect the long term predictability of the implant. 
| Pretreatment Aids Used for Optimal Position of The Implant|| |
All clinical findings should be considered in association with the pretreatment aids.
Diagnostic casts and wax up
A set of mounted diagnostic casts and wax up are very essential in the treatment planning process. Articulated diagnostic casts will allow for assessment of the remaining dentition, existing occlusion, residual ridge, and available space in the implant receptor site.
A diagnostic wax up can be done by positioning denture teeth in the edentulous area on the cast. This helps to determine the implant location, direction, relation to the remaining teeth, number and position of the teeth to be replaced, and their occlusal relationship with the opposing dentition. This also will assist in determining esthetic placement of teeth in the anterior region.
A resin template can be prepared from the finished diagnostic wax up to serve as a radiographic and surgical template.
| Preimplant Imaging|| |
The preimplant imaging involves all radiographic examinations that assist in determining the patient's implant treatment plan. Various imaging modalities are available for the presurgical implant assessment. Intraoral periapical radiographs with panoramic images are a minimum requirement during this phase.
Conventional panoramic radiographs provide information on the approximate bone height, the position of the inferior alveolar canal, the size and the position of the maxillary antrum, and any pathological condition which may be present. However, these images are subjected to distortion. 
The above information can be supplemented by a periapical radiograph. A long cone paralleling technique  used with periapical radiograph gives an image with minimal distortion. Millimeter radiopaque grids  [Figure 9] may sometimes be superimposed over the film before it is exposed. However, they may obscure underlying anatomical structure and do not compensate for magnification.
Computerized digital radiovisiography  is becoming a routine in implant practice. As the detectors are solid state the doses used can be greatly reduced and also they can indicate relative bone densities.
The two dimensional imaging techniques cannot indicate bone width. Advanced three dimensional imaging techniques like interactive computed tomography  have changed the way implant dentistry is practiced today. They are more accurate and also are able to determine the quality of bone by providing a density value.
Use of steel radio opaque marker
The orthopantomograph may undergo distortion and can lead to erroneous determination of the available bone height and selection of wrong implant length. Hence, a calibration of the orthopantamograph is required for more near accurate determination of the available bone height. The simplest method uses a radiographic marker or a steel ball bearing  of known diameter when taking OPG [Figure 10]. The actual available height can be calculated using the following formula:
Surgical guide template
Surgical guides are fabricated after the diagnosis and prosthetic planning. They guide the surgeon for precise positioning and angulation of the implant during placement in relation to remaining natural dentition and residual alveolar ridges. The surgical guide should be stable and rigid when positioned in the mouth. It should be easy to place and remove. It should not be bulky and must not interfere with tissue reflection, visualization of surrounding landmarks. Also, it should be transparent and allow easy access for the surgeon. 
The surgical guides can serve dual purposes as both a radiograph measuring device and a surgical guide. There are several methods of fabricating the surgical guide templates.
Dentures as guides
Either the existing denture which is satisfactory or a denture can be fabricated from the wax up of the diagnostic cast [Figure 11] to serve as a guide. This guide can be used initially as a radiographic stent and then as a surgical stent.
When used as radiographic stent, radiopaque markers like gutta percha or any other opaque material can be embedded in the denture teeth. The choice of radiographic marker is important in that it should be visible on the radiographic image but not interfere with the imaging.  This will give exact location of the available bone in relation to particular tooth in the radiographic guide. This can then be modified as a surgical guide by drilling holes corresponding to the ideal implant position.
Guides from the diagnostic wax up
Either vacuum formed matrix or clear acrylic resin  [Figure 1] is used to fabricate the surgical guide from the diagnostic wax up. This can be used as a radiographic as well as a surgical guide.
When used as a surgical guide to allow better visualization of the pilot drill, buccal, and lingual aspects of the stent can be trimmed off. Once the entry point is drilled the stent can be removed and drilling protocol is continued. This will provide guideline for two dimensional positioning of the implant i.e., the mesiodistal and buccolingual position.
A surgical guide, which aids in depth determination in addition to mesiodistal and buccolingual positioning of the implant, can be used in the anterior region to obtain optimum emergence profile. On the diagnostic cast, the missing tooth is replaced with a pontic with the margin of the pontic depicting the free margin of the final restoration. A guide is prepared on this using clear acrylic resin [Figure 12] or vacuum formed matrix.
| Effective Communication|| |
Effective communication between the clinician and the patient is very crucial. After the evaluation of the data, a separate consultation appointment is arranged to present the ideal treatment plan to the patient along with the predictable treatment alternatives. This will help the patients to understand the extent of the problem  and options available to reconstruct their mouth. It is important to realize, however, that a thorough examination begins with an open discussion with the individual patient. The patient's need and expectations should be correlated to the clinical findings for successful outcome. In this way, treatment plans may be formulated that are in the best interest of the patient and that represent a greater value for the patient.
| Informed Consent|| |
A rule of thumb in dentistry should be to obtain a signed, written informed consent from the patient for all the procedures. Treating a patient without informed consent amounts to negligence. Irrespective of the best efforts, unforeseen complications can sometimes occur on the dental chair. A signed, written informed consent can serve as the evidence for any legal issues.
| Conclusion|| |
Implant supported restorations provide considerable advantages over other available treatment options and, therefore, must be considered as a treatment option for restoration of missing teeth. The implant is placed in an optimal position to effectively support the restoration and surrounding soft and hard tissues. The clinician must carefully evaluate all the factors outlined to ensure a long term predictable outcome.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2], [Table 3]
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