Treatment Planning for Posterior Dental Implants

Case selection is important to avoid failures. There are few systemic health
contraindications to implant therapy, and research supports treatment in patients
with diabetes mellitus (unless uncontrolled), cardiac disease, or osteoporosis.1
Although smokers have been found to experience greater marginal bone loss than
nonsmokers, smoking tobacco is also not considered a contraindication. A full
medical history is essential to consider all potential absolute and relative
contraindications. Local contraindications must be considered, including but not
limited to anatomical structures, lack of bone, and parafunctional habits.

Anatomical considerations are critical when planning mandibular and

maxillary implants:
1-Mandibular Implants

The inferior alveolar nerve is the most critical anatomical landmark, and poor
treatment planning can result in iatrogenic nerve injury during implant placement
with outcomes that include paresthesia, a complete absence of sensation, or pain.
Although 2-dimensional radiographs have historically been used to assess
anatomical structures and bone prior to implant placement, these cannot
produce an accurate 3- dimensional assessment. Risk assessment using
computerized tomography (CT scans) has shown that <6 mm of bone separated
the inferior alveolar canal from teeth in 73% and 53% of mandibular second and
first molars respectively, and 65% of second bicuspids.

The inferior alveolar canal including an anterior loop, as well as the position of the
lingual and sublingual arteries, must be considered. Undercuts and/or anatomical
concavities in the lingual area of the lower mandible may present a risk for lingual
plate perforation.3 Based on CBCT (virtual) and CT scan studies,2,4 the greatest
risk is at mandibular second molar sites and at least three times greater than
other posterior sites. It is important for the clinician to understand the relative
position of arteries such as the submental artery to avoid very rare but important-

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to-understand complications. A small proportion of the population has an incisive
branch of the mental nerve. This should be isolated on CT and discussed with the
patient prior to surgery. Lastly, posterior ridge resorption has implications for the
final occlusion in addition to increasing the risk to anatomical structures—as the
ridge resorbs , it typically leads to a crossbite setup, especially if maxillary ridge
resorption also occurs. It is generally recommended that a minimum of 2 mm of
bone height be preserved as a safety margin between the inferior alveolar nerve
on the one end and between both the site preparation drilling and the implant on
the other.3 If this would not be possible, alternatives include bone grafting and
delayed implant placement, the use of short implants (or highly invasive specialist
nerve repositioning), or providing an alternative treatment.

2-Maxillary Implants

The most obvious anatomical landmark to consider is the position of the maxillary
sinus. This tends to pneumatize once the tooth has been extracted. If the sinus
drops too much, then bone grafting may be required to provide adequate bone
for primary implant stability. If bone grafting is required, it is prudent to assess
the patency of the ostium (the entrance and exit point of the sinus entering into
the middle meatus of the nasal cavity). Other areas of interest include the buccal
undercut in the anterior maxilla; this area can be palpated or reviewed using 3D
images to plan implant angulation and depth. Lastly, maxillary bone density may
be a concern. The bone has a thinner cortex and a larger spongy bone area than
the mandible, which enhances blood supply to osteotomy sites but also may
compromise the stability of the bone.

Prosthetic considerations
Bone Height, Width, and Length

Bone between implant and key anatomical structures----> At least 2 mm

Bone lingual to the implant----> At least 2 mm

Bone buccal to the implant----> At least 2 mm

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Bone between implant and adjacent teeth----> At least 1.5 mm

Care also must be taken to ensure that the implant does not impact roots due to a
general or local lack of mesio-distal width. A substantial lack of adequate mesio-
distal bone length may necessitate use of a narrow diameter implant or a
different solution.

Implant Depth and Angulation

It is important to pre-operatively determine implant depth and angulation

necessary to provide the inter-arch and intra-arch prosthetic space required for
restoration and adequate long-term strength. Although less critical in the
posterior region, the distance from the proposed restorative contact point to the
crestal bone should be considered. A distance of more than 5 mm results in poor
papillary form.

Implant angulation is determined by the best combination of safely utilizing

available bone and soft tissue relative to the planned tooth cervical emergence
from the implant and axial trajectory toward the occlusal surface.

How to choose a dental implant system?

It is difficult to make a clear decision, which implant system to choose for practice
if:

 Most of them look the same with a similar shape, lengths and diameters.

 The most implant system has similar materials like commercially pure
titanium (TiGr2, TiGr4), titanium alloy Ti6Al4V ELI (TiGr23) or ceramic
implants (Zirconium implants).

 Most of them have a similar surface treatment with moderate rough

implant surface packed under clean room conditions.

 And even most of the dental implant systems have a success rate over 95%
within 5 years and from 85% to  90% within 10 years, what is also almost
the same.

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Pros of Choosing Zirconia Dental Implants
For patients wishing to have dental implants but are concerned about metal-free
dentistry, zirconia is the only viable option. This material is completely inert and
can be a good choice for people with known metal allergies or
sensitivities. Zirconia implants may be more aesthetically pleasing, eliminating the
risk of any dark lines around the gum. Originally, they were only available as a
one-piece implant, but the introduction of two-piece zirconia implants now allows
for abutments to be fully customised, creating the best outcomes. A metal-free
zirconia implant could be healthier for gum tissue because this material retains
less plaque and calculus than titanium, especially when a one-piece zirconia
implant is selected. Zirconia has a good flexural strength and is known to be
superior to other ceramics in terms of fracture toughness. Its white colour, low
modulus of elasticity, and low thermal conductivity has made this material a very
attractive choice for implant dentistry. Clinical studies have shown zirconia to be
as good or even better than titanium in terms of osseointegration. This is due to
the high level of contact between the implant and the jaw bone, allowing the
bone to fuse firmly with the implant, resulting in good osseointegration.

Cons of Choosing Zirconia Dental Implants

One of the biggest drawbacks of choosing zirconia dental implants is low-
temperature degradation as the product ages. This could potentially result in the
mechanical properties of the material becoming degraded, reducing the strength,
density, and toughness of the material. As yet, there haven’t been many clinical
studies into the long-term success of these products. Most of the failures
recorded for two-piece dental implants were due to aseptic loosening. Due to the
lack of research into two-piece zirconia dental implants, some clinicians may
prefer to use one-piece dental implants, but the limitations of these systems
needs to be considered. The options for abutment angulation are reduced, and
this could compromise the surgical positioning of the implant. Additionally,
positioning a zirconia implant in a less-than-optimal location could have an
adverse effect on the physical properties of the material. Single-piece zirconia
dental implants also require a load-free healing period, which can sometimes be
tricky to achieve in normal clinical situations.

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CLINICAL STEPS FOR SCREW-RETAINED CROWN RESTORATION OF A
SINGLE IMPLANT

Taking the impression

 step-by-step, the technique of open tray direct impression.

1- Healing the abutment removal

(after removal )

2- A fixture mount/pick-up coping compatible with the dental implant should be

used. A fixture mount suitable for the open-tray impression technique is placed
on the implant body and tightened by manual clock-wise rotation of its inner
screw. When the mount is below the level of the mucosa, an intra-oral radiograph
should be done to ensure that the mount is properly seated on the implant.

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3- A plastic stock tray or a custom made acrylic tray should be customized by
cutting out a window over the area of the implant to allow clearance for the
fixture mount. The impression tray should be assessed in the oral cavity to verify
that the fixture mount and its screw protrudes through the tray .

4- Impression material application: A light-bodied addition silicone impression

material is syringed around the fixture mount. Meanwhile, the impression tray is
loaded with heavy-bodied addition silicone impression material and seated
directly in the mouth and exactly in its place. The excess impression material
should be wiped off the screw of the fixture mount before it sets. Opening of the
screw may be filled with wax or cotton to prevent impression material from being
trapped into screw opening .

5-After the impression material sets, the mount is separated from the implant by
un-screwing the long screw inside the. Then the impression tray is removed from
the mouth with the fixture mount remaining secured in the impression. The
impression material is verified to be completely adapted around the implant and
mount. Then the healing abutment is placed back onto the implant to prevent
soft tissue collapse till next visit when the restoration is to be delivered. An
interim crown may be fabricated to promote biologically and esthetically
appropriate soft tissue emergence for implants in the esthetic zone; the

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technique for preparing a single screw-retained interim crown is described
elsewhere.

6- Implant analog :The analog is mated with the fixture mount/transfer by holding
the analog in place while inserting the long screws through the access holes in the
impression tray and tightened by the hand screwing. The analog should be safely
and precisely attached to the impression fixture mount. Caution to avoid the
over-rotation of the mount is needed during screwing since any slight movement
may cause distortion of the impression
7- Impression with the fixture mount connected to the analog, bite registration,
opposing impression, and shade of the restoration is sent to the dental
laboratory.

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Full zirconium screw-retained crown

- The main advantage of screw-retained crowns is retrievability. It is always nice

to have the option to easily remove an implant crown or re-tighten the screw
whenever it is needed without any damage to the restoration

- When it comes to the restoration of implants, we typically have two treatment

options: Screw-retained or cement-retained crowns. Although both treatment
options can be used predictably, they have their own advantages and
disadvantages; known retention, retrievability, re-tightening possibility, and the
risk of not leaving residual cement are the main advantages of screw-retained
crowns. Implant angulation may be a limitation to the usage of screw-retained
restorations in some oral sites. While improved esthetic outcome and better
occlusion are the main advantages of cemented crowns, their main disadvantages
are less retention and difficulty of removal.

References

https://dentallearning.net/sites/default/files/Current_Protocols_Single_Implants.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4253117/

https://blog.ddslab.com/zirconia-dental-implants-pros-and-cons