28 Parameterr ofCum

6. Implant Prosthodontics Parameter

Preface
Prosthodontic restoration supported and/or retained by dental implants is perhaps the most exciting area of
prosthodontics. The well-documented sequelae of loss of alveolar structure and concomitant decrease in
prosthetic function can now be delayed along with a dramatic increasc in function versus conventional
tissue-borne appliances.
Dental implant restoration is primarily a prosthodontic procedure because the end result is the replacement
of a tooth, multiple teeth, and/or contiguous structures surrounding the oral and facial region alongwith many
extra-oral applications. The diagnosis for the need of a dental implant is a prosthodontic diagnosis that reflects
all the usual criteria for tooth and contiguous structure replacement. Only after a prosthodontic need has been
established is the surgical diagnosis made to determine if the prosthodontic need can be satisfied. A dental
implant has little intrinsicvalue to a patient other than to support or retain a prosthodontic replacement.
Thus, dental implant restoration is a prosthodontically driven procedure that requires extensivc prcsurgical
consultations and treatment planning. The appropriate specialist is responsible for the placement of the dental
implant according to the prescription of the prosthodontist. The prosthodontist is responsible for conveying
sufficient diagnostic information to insure the accurate placement of dental implant ( s ) to maximize
prosthodontic function. Sufficient presurgical consultations should identify alternative implant sites so that
surgical flexibility is maintained to deal with unforeseen anatomic limitations. With the rapid advancement in
the technique of surgically placing implants (bone grafting, membrane assisted grafting, nerve repositioning,
etc.), the placement of implants outside the normal anatomic location to support prosthodontic replacement is
becoming less acceptable unless there has been informed consent by the patient for alternative implant
location and angulation.
Because prosthodontists are the recognized specialists in tooth and contiguous structure rcplaccment,
prosthodontists must strive to position the implants in the most advantageous location and angulation for
future prosthodontic procedures. The prosthodontist must evaliiate the patient to determine the number,
type, length, and location of the dental implants so that the prosthodontic restoration will remain healthy and
functional. The prosthodontist, in cooperation with the patient, must remain flexible in the final prosthodontic
reconstruction to account for surgical variability and anatomic limitations. In those instances where the
treating prosthodontist has not had presurgical input, the prosthodontist, in conjunction with the patient and
the surgical specialist, should attempt to develop a prosthodontic treatment plan that achieves as many
treatment goals as possible without compromising implant integrity. It is the responsibility of the prosthodon-
tist to be familiar with the different types of implants because each system has ils own intricacies arid
capabilities. The prosthodontist should be especially knowledgeable about any implant system recommended
and/or used in patient treatment.
Initially, prosthodontic restorations supported and/or retained by implants have had the greatest impact on
completely edentulous patients by improving mastication, comfort, facial appearance, gag response, degluti-
tion, self-esteem, and well-being. However, long-term conservation of tooth and contiguous structure is being
investigated. Whether it is the conservation of healthy abutment teeth by using single or multiple implant
replacements of teeth instead of conventional fixed prosthodontics or perhaps the reduction in prosthetically
influenced alveolar resorption by implant-supported/retained complete dentures, the impact of implant
prosthodontics will continue to improve the health and comfort of patients.
Because prosthodontic restorations supported by dental implants is a rapidly expanding field, both
prosthodontically arid surgically, the parameter developed will certainly undergo revision as research helps
identify those procedures with the greatest predictability, longevity, and risk/benefit ratio.

General Criteria and Standards

Informed cuwent: All implant prosthodontic procedures should be preceded by the patient’s consent. Informed
consent is obtained after the patient has been informed of the indications for the procedure(s), the goals of
treatment: the known bcnefits and risks of thc procedure(s), the factor(s) that may affect the known risks and

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complications, thc trcatment options, the need for active maintenance by the patient and the need for future
replacement/revisions, and the favorable outcome.
Bocumentutzon: Parameters of care for prosthodontic procedures include documentation of objective findings,
diagnosis, and patient-management intervention.

Parameter Guidelines:Implant Prosthodontics

A. Indicators for care
1. Unmanageable gagging
2. Alveolar atrophy
n. Moderate: localized morphology not conducive to prosthesis support, stability and retention;
alveolar bone height of 15-20 mm measured at the least vertical height of the mandible
b. Severe: Generalized morphology not conducive to prosthesis support, stability and retention;
alveolar bone height of 10-15 mm measured at the least vertical height of the mandible
c. Extreme atrophy
i. Alveolar bone height of 10 inm or less measured at the least vertical height of the mandible
ii. Maxillary bone loss to the level ofthe nasal floor
3. High muscle attachments
4. Tongue position, morphology, and activity
5. Psychosocial considerations
6. Complete or partial edentulism
7. Patient inability to tolerate conventional prosthesis
8. Skeletal deformities
9. Congenital deformities
I 0. Alveolar deformities
11. Maxillofacial deformities
12. Mucosal irritabilities and diseases
1.4. Lack of neuromuscular control of orofacial n~usclecomplex
14. Neurological considerations
15. Esthetic considerations
B. Therapeutic Goals
I . Preserve alveolar bone
2. Improved function
3. Improved speech
4. Improved swallowing
5. Improved retention, support, and stability of dental prostheses
6. Improved esthetics
7.Psychosocial
8. Reduced gagging response
9. Reduced pain during function
I 0. Provide posterior bone-borne support stops
11. Rcstorc vertical dimension of occlusion
12. Preserve and maintain vertical dimension of occlusion
13. Conserve tooth structure
C. Risk Factors Affecting Quality of Treatment
1. Bone factors (quantity and quality)
2. Surgical factors
3. Implant type
4. Implant location
5. Implant size and length
6. Implant angulation

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30 ParamebrJ of Care

7. Pre-existing systemic disease

8. Active periodontal disease
9. Psychosocial factors
10. Number of implants relative to number of teeth to be replaced
11. Biomechanical loading factors
12. History of radiation therapy
13. Peri-implant tissue quality and contour
14. Occlusal factors
25. Tobacco use
16. Current and past pharmaceutical therapies
D. Standards of Care
Complete prost hodontic examination
Diagnostic imaging
Preprosthetic preparation and treatment planning
a. Nonsurgical
6. Surgical
c. Endodontic
d. Periodontal
e. Orthodontic
J: TMD
Restorative and prosthodontic procedures
Patient education
6.Post-treatment follow up
7. Informed consent
E. Specialty Perforrnancc Assessmenl
1. Favorable outcomes
a. Long-term preservation of supporting bone
6. Improved function
c. Irnprovrd speech
d. Improved swallowing
e. Improved retention, stability, and support of dental prosthesis
j Improved esthetics
g. Positive psycho-socialresponse
h. Reduced gagging
i. Reduced pain during function
j . Establish bone-borne support stops
k. Re-establish and maintain vertical dimension of occlusion
1. Preserve tooth structure
2. Known risks and complications
a. 1,oss of implant within first year after restoration
b. Loss of supporting bone-more than 2 mm in the first year of function and 0.5 mm per year
thereafter
C. Mobile implant

d. New or increased pain

e. Tnfect i on
.f: Mandibular fracture
g. Nonrestorable implant
h. Materials failure
2 . Biomechanical implant overload

.i. <:ompromised phonetics

k. Compromised esthetics due to implant location
1. Prolonged disability period

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m. Unfavorable psychosocial responses

n. Reduction and/or loss of use of current prosthesis during entire healing phase
0. Inability of patient to adapt to new implant supported/retained prosthesis

Selected References (Implant Prosthodontics Parameter)

This list of selected references is intended only to acknowledge some of the sources of'information drawn on in
the preparation of this document. Citation of the reference material is not meant to imply endorsement of any
statement contained in the rcference material, or that the list is an exhaustive compilation of information on
the topic. Readers should consult other sources to obtain a complete bibliography.
Adell R, Eriksson B, Lekholm U, Branemark P-I, Jcmt '1. A long-trrrn lOllow,-up study of osseointegrated implants in the treatment of
totally edentuloujaws. 1nt.JOral Maxillofac Implants, 5:347-59, 1990
.4lbrektsson T, Zarb GA, Worthington P, Eriksson A. The long-term efficacy of currently used dental implants: .4 rc\iccv and ~iroposcd
criteria for succcss. Int J Oral Maxillnlir Implanls, 1 :11-22. 1986
Astrand P, Borg K, Gunne J, Olsson hl. Combination of natural tceth and osseointegrated implantb as prosthesis abutments: A 2-year
longitudinal study. Int J Oral Maxillofac Implants, 630.5-12, 1992
Bosker H, Van Dijk L. The transmandibular implant: 1112-year follow-upstudy.J Oral Madofacial Surgcry, 47:442-50, 1989
Branemark P-I. Osseointegration arid its experimental background., J Prosthet Dent, 1983:50:499-410
Buser U. Weber HP, Bragger U, Balsiger C. Tissue integration of one-stage ITI implants: 3-year results of a longitudinal study with
hollnwscrrw implants. Int J Oral Maxillofac Implants, 6405-12, I991
De B r u p H, C:ollacrt R, Linden U, Flygare IA. A comparative study of the clinical e f i c a i q of screwvent implant vs. Branemark fixtures,
installed in a periodontal clinic. Clin Oral Imp1 Rcs 3:32-41, 1992
Goldberg NI. Risk of subperinsteal implants. Drntal Implants: Benrfit and Risk, L J . S Ikpartment of Health and Human Seivices, 89-95,
1980
Hollender L. Radiographic examination of endoseous implants in the j a w . In: Advanced Osscointegration Surgcry, P. Worthington and
P-I Branemark, (eds.),Advanced Osseointegration Surgery, Quintesscncc Publishing C h . , Berlin pp. 80-93, I992
Kent j N , Block hfS, Finger IM, Guerra, Larsen H, Misiek D. Biointegrated hydroxyapatite-coated dental implants: 5-year clinical
observations.JAm Dent Assoc, 121:138-44, 1990
Kirsch A, Ackerman KI,. Thc TML osseointegrated implant system. Dent Clin North Am, 33:733-791,1989
Laney WR, Tolman DE, Kellcr EE, Desjardins RP, Van Koekcl NB,Branemark P-I. Dental implants: Tissue-integrated prosthesis utilizing
the Osseointegrationconcept. Mayo Clinic Prnc 6191.7, 1986
Laney WR. Selecting edentulous patients for tissue-integrated prostheses. Int J Oral Maxillofac Impl, 1: 129-38, 1986
Lekholm U, Zarb G.4. Patient selection and preparation. Tissue-Integrated Prostheses. P-I Branemark, G.A. Zarb, T. Albrektsson, eds.,
Quintrsscncr Prihlidiing C h , 199-210, 198.5
Lewis SG, Llamas D, Avrra S. Thr UCLA abutment: A 4-year review. J Prosthetic Ucnt, 67:509-15, 1992
Naert I, Ouirynen M, Theuniers G, van Steenberghe D. Prosthetic aspects of osseointegrated fixtures supporting overdentures: .4 +year
report.J Prosthet Dent, 65:671-80, 1991
Shalak R. Biomechanical considerations in osseointegrated prostheses. Proceedings of the Toronto Conference on Osseointegration in
Clinical Dentistry; GA Zarb, cd. J Prosthrt k n t , 49:8.1.3-8, 1983
Small IA.Benefit and risk of mandibular staplr bone plates. Dcntal Implants: Benefit and Risk, U.S. Department ol'Healtti and Human
Sewices, 139-51, 1980
Smith RG, Berger R, DodsonTB. Risk factors associated withdcntal implants in healthy and medically compromised patients. Int J Oral
hlaxillofac Implants, 7:367-72, 1992
Srnithloff hl, Fritz M. The use of blade implants in a selected population of partially edcntulous adults, a 15-year report, J Peridontics,
58589-93. 1987
Taylor R, Bergman G. Laboratory techniques for the Branemark system, Quintessence Publishing Co.; Chicago, 22-77, 1990
Tolman DE, Laney WR. 'I'issuc-integrated prophesies complications, 1ntl.J Oral Maxillofac Implants, 7A77-84, 1992
van Stccnberghc D, Lckholm U, Bolender C, Folnier T, Henry P, Herrrnan I, Higuchi K, Laney W, Linden U: Astrand. The applicability of
osseointegrated oral implants in the rehabilitation of partial rdcntulism: .4 prospective multicenter study on 558 Lixtures. Int ,J Oral
Maxillofac Implants, 5972-81, 1990
Zarb GA,Jansson T. Laboratory procedures and protocol. Tissue-Integrated Prmt hews. P-I Brancmark, Gd4.%arb,7'. Albrektsson, rds.,
Quintessence Publishing Co., 293-3 16, 1985
Zarb C;A> Jansson 'l~. Prosthoduntic procedures. Tissue-Integrated Prostheses, P-I Branemark, GA. Zarb, T. Albrektsson, eds.,
Quintessence Publishing Co., 199.210, 1985
Zarb GA, Jansson T, Jemt T. Other prosthodontic applications. Tissue-Integrated Prosthrsrs. P-I Branemark, G.A. Zarb, T. Albrektsson,
cds., Quintrssencc Publishing Co., 283-292, 1985
Zarb GA, Schmiti A. The longitudinal cliriiral elrectivencss ofosseointegrated dental implants: The Toronto Study. Part I1 The prosthetic
results,J Prosthet Dent, 6453-61, 1990
Zarb GA, Schmitt A. The lorigitudirial clinical effectiveness of osseointegrated dental implants: The Toronto Study. Part In: Problems and
cornpliLations Encountered,J Prosthet Dent, 64: 185-91, I990