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Surgical guidelines for dental implant placement

Article  in  British Dental Journal · September 2006

DOI: 10.1038/sj.bdj.4813947 · Source: PubMed

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 IN BRIEF
PRACTICE
●
●

●
Dental implant placement must be both biologically and restoratively driven.
Dental implants should only be placed following a comprehensive examination and
accurate diagnosis.
The deficient osseous ridge must be reconstructed prior to implant placement.
4
Surgical guidelines for dental implant placement
M. Handelsman1

The goal of an implant supported reconstruction is to obtain optimal aesthetics and function. In order to achieve this,
visualisation of the final restorative reconstruction is necessary prior to beginning treatment. The term ‘restorative-driven’
treatment planning has been used to identify this process.1 It requires a team approach of specialists, who can develop a multi-
disciplinary treatment plan. It starts with an accurate diagnosis, which will lead to a prognosis of each individual tooth and the
overall dentition. This information will help the clinician develop the treatment options suitable for tooth replacement. Only
when the goals have been defined can the sequence of therapy be established. Working backwards from the wax-up of the final
diagnostic model of the proposed treatment assists not only with the management of the complex case, but will help avoid
mishaps.2 Effective communication between the team and the patient is extremely important. Understanding the patient’s
expectations is key to a successful outcome. Deciding that these expectations are realistic requires a correct diagnosis and an
inter-disciplinary treatment plan that is logical. This approach takes time and requires a comprehensive treatment discussion
between the team members, and then a thorough case presentation to the patient.3 Only then will the patient begin to
understand the extent of their problem and the options available to reconstruct their mouth.

IMPLANTS DIAGNOSIS types: pronounced scalloped, scalloped and flat.

The restorative dentist will develop and direct A thin periodontium will be pronounced scal-
1. Rationale for dental implants the plan after gathering data, which includes loped or scalloped. A thick periodontium will
2. Treatment planning of implants in a complete medical and dental history, clini- present with flat gingival architecture, usually
posterior quadrants cal findings, photographs, mounted diagnostic supported by thick buccal and lingual plates of
3. Treatment planning of implants in casts and radiographs. Consultation with other alveolar bone. A thin skeletal pattern with scal-
the aesthetic zone specialists (periodontist, oral surgeon, ortho- loped architecture will have root dehiscence and
4. Surgical guidelines for dental dontist, endodontist) regarding the periodontal fenestrations even in a healthy periodontium. If
implant placement
and endodontic health, and any occlusal, skel- periodontal disease is present, it is important to
5. Immediate implant placement:
treatment planning and surgical etal and space problems will be required. establish the attachment level (probing depths
steps for successful outcomes A correct diagnosis with long-term prognos- and gingival recession) as well as any contrib-
6. Treatment planning of the tic information is mandatory, in order to devel- uting factors, such as mucogingival problems
edentulous maxilla op an interdisciplinary treatment plan. All the (lack of keratinised attached tissue) and furca-
7. Treatment planning of the treating specialists on the team need to collabo- tion involvement, which will alter the prognosis
edentulous mandible rate their findings, which includes the following of the remaining teeth. It is critical to measure
8. Impressions techniques for examinations. not only probing depths, but identify the level
implant dentistry of the crestal alveolar bone. Kois5 classified a
9. Screw versus cemented implant A. Periodontal examination (Figs 1-8) high crest when the crestal bone level is close to
supported restorations
A comprehensive periodontal examination the CEJ (delayed passive eruption). The normal
10. Designing abutments for
cement retained implant supported includes the soft and hard supporting tissues of crest is defined as 2 mm from the CEJ and the
restorations the dentition. The patient’s tissue biotype is clas- low crest is present in patients with recession.
11. Connecting implants to teeth sified according to how thick or thin the support- Sounding to bone is the best clinical param-
12. Transitioning a patient from ing bone and gingival soft tissues are defined. eter to help identify the attachment level. This
teeth to implants Becker and Oschenbein4 classified three distinct is extremely important in the aesthetic zone,
13. The role of orthodontics in when considering replacing partially edentu-
implant dentistry 1Diplomate: American Board of Periodontology / Private Practice: lous teeth. The interproximal attachment level
14. Interdisciplinary approach to Santa Monica, California on the teeth adjacent to a future implant site
implant dentistry Correspondence to: Dr Mark Handelsman, 1245 Sixteenth Street, will dictate the future gingival architecture.6
#206, Santa Monica, CA 90404, USA
15. Factors that affect individual Email: markhandelsman@aol.com In the aesthetic zone it is extremely important
tooth prognosis and choices in to identify the amount of teeth and soft tissues
contemporary treatment planning Refereed Paper visible not only from the frontal view, but also
16. Maintenance and failures © British Dental Journal 2006; 201: 139-152
DOI: 10.1038/sj.bdj.4813820 from the lateral view, both with the lip at rest

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 PRACTICE

and also when smiling. Uneven gingival archi- lap as well as the restorative space available is
tecture, the position of teeth relative to the arch extremely important. Replacing teeth in partial-
shape and opposing occlusion will all affect and ly edentulous spaces, without comprehensive
dictate the decision making process. care of the remaining dentition, is sure to cause
The presence of bone loss due to periodon- failure in the long term.
tal disease or trauma will greatly affect the out-
come of treatment. If teeth are already missing C. Endodontic
then the amount of ridge collapse needs to be The endodontic integrity and vitality of remain-
measured according to both horizontal and ver- ing dentition must be established. Any patho-
tical collapse. (Siebert Classification type I, II logical changes, such as periapical lesions and
and III.) Lekholm and Zarb7 classified the hard existing root canals that are incomplete need to
tissue according to the shape of the ridge (mor- be evaluated. Any teeth with a poor endodontic
phology) and the bone quality; shape a–e and prognosis should have a thorough risk assess-
type 1-4 respectively. This will be discussed in ment completed, so as not to jeopardise future
greater detail later in the article as relating to implant sites.
surgical technique.
If the prognosis of teeth is deemed hopeless D. Restorative
due to periodontal, endodontic or non-restor- The integrity of all existing restorations should
ability factors, then anticipating the amount of be evaluated. This must include margin integ-
future ridge collapse needs to be estimated. In rity and soft tissue response to sub-gingival
this case, it is extremely important to identify placement. Teeth with biologic width violation,
the tissue biotype and the underlining missing that will require surgical crown lengthening,
bone, which will help determine the prognosis will affect the future level of the osseous crest at
and steps necessary to preserve or rebuild the sites adjacent to implants. In the aesthetic zone,
desired soft and hard tissue architecture after it is important to anticipate the future gingival
tooth loss. Thick tissue is much more forgiv- contours of the teeth adjacent to the implant
ing, easier to manipulate and provides a more site. Teeth that are fractured, broken down
predictable aesthetic outcome, as compared to beyond predictable restoration, or have com-
thin tissue which is more likely to shrink. Decid- promised support will be given a poor or hope-
ing when to extract a tooth is easy when it is less prognosis. The strategic value of each tooth
hopeless, but often more heroic attempts to save needs to be determined, prior to removal. Often
teeth that are broken down with a questionable in complex cases, even teeth with a poor prog-
prognosis is not as simple. In order to preserve nosis can be kept in the initial phases to support
the alveolar bone for implants, sacrificing teeth a fixed interim prosthesis, while implant healing
(early extraction) requires a change of thinking progresses. This phased approach of sequential
as compared to previous philosophical treat- extraction will help manage the complex case,
ment decisions. sometimes through long periods (two years)
while site development and healing of implant
B. Occlusal analysis sites is progressing.
Patients with occlusal wear or abfraction type
defects due to clenching or bruxism should E. Orthodontic
be identified. The parafunctional habits will Analysis of the restorative space is important
greatly affect the outcome and longevity of regarding future tooth restoration size, but it is
the type of reconstruction planned. The oppos- equally important to analyse the position and
ing occlusion along with the type of restorative angulation of the roots in the alveolar bone.
materials selected for the final prosthesis will Drifting and tipping of remaining teeth will
affect the ability of the bone-implant inter- often present problems with space mesially-dis-
face to withstand the occlusal load. In the peri- tally. The orthodontist needs to be given clear
odontally compromised patient, loss of teeth instructions when opening or closing spaces in
without replacement leads to lack of posterior regards to root positions. Taking radiographs
support. This often causes an unstable occlusal during treatment will give useful information
scheme with mesial drifting of posterior teeth to the treating team, prior to appliance removal
and flaring of anterior teeth with a loss of verti- and completion of treatment. It is always pref-
cal dimension. A full examination includes not erable in aesthetic cases to complete the ortho-
only the mobility of remaining teeth, but also dontic care prior to implant placement. In cases
the occlusal scheme and guidance in lateral and missing posterior teeth, provisional interim
protrusive movements. Over-eruption of any implants can be placed to help the orthodontist
teeth will cause occlusal interferences and also establish anchorage. The final implants should
decrease the inter-occlusal space necessary for only be placed posteriorly, if the orthodontic
implant restorative components. Lack of restor- wax-up of the final result allows for correct
ative space is a major contributor to mechani- positioning, without compromising the end
cal failure of implant restorations. Mounted result.
diagnostic casts are used to evaluate the occlu-
sion, the edentulous space ridge relationship to F. Radiographic examination. (Figs 28-33)
the adjacent teeth and the opposing dentition. The preliminary exam will include a set of full
The amount of vertical and horizontal over- mouth periapical and bitewing radiographs. A

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 PRACTICE

panorex is helpful as well, but limited compared Quantity: Ridge shape a–e.
to 3-D CT scan imaging. Once the patient has Shape ‘a’ represents no bone resorption, while
had the initial consultation and accepted the ‘e’ represents advanced ridge resorption.
proposed options, a diagnostic wax-up of the The pattern of resorption in the anterior max-
final proposed treatment will be a template to illa (Figs 5–8) advances posteriorly and supe-
fabricate a radiographic guide. This radiograph- riorly, which greatly affects the aesthetic zone
ic guide can be placed in the mouth at the time and lip support. The pattern of resorption of the
of the CT scan. Transferring the restorative tem- posterior ridges greatly affects the occlusion and
plate on to the radiographic images is the most horizontal overlap of the dentition8 (Figs 9-13).
useful information for determining the surgical
plan. Lack of bone and ridge collapse both hori- SURGICAL GUIDELINES — TOOTH OR TEETH
zontally and vertically can be accurately meas- ALREADY MISSING
ured. The surgical needs can be identified and Adequate osseous ridge
the most predictable options can be presented The Brånemark surgical protocol9 established
to the patient prior to beginning treatment. The osseointegration as an extremely predictable
goals of the final reconstruction, whether fixed option for tooth replacement with excellent
or removable, can be determined. The treatment long term stability. Many implant systems have
expectations can be presented to the patient, since been developed which use this concept. The
with realistic steps of what can and cannot be numerous shapes and sizes of implants available
accomplished. Only then can the treatment plan for use on patients today continue to change and
in a phased approach, be determined by all the are overwhelming. It is extremely important for
treating doctors on the team. All financial obli- all members of the team to discuss which compo-
gations, treatment consent as well as aesthetic nents are to be used surgically and restoratively,
goals are established prior to taking any further so that the benefits and limitations are defined.
steps. Whether the prosthesis will be screw retained or
Occasionally, when questionable teeth are cement retained can affect the axial inclination
still present, it may be beneficial to have a CT and angle of placement. Due to common ana-
scan prior to removing teeth. This can help make tomical limitations post-extraction (concavities
treatment decisions regarding surgical options and collapse of the ridge circumference), using
of timing of implant placement (see discussion cement retained restorations allows greater flex-
later in article). ibility at the time of surgical placement.

Pre-surgical planning Flap design

Viewing the CT images which have the cross- The original Brånemark protocol required a
sectional reformatted images of the bone vestibular flap with a two stage approach. The
quantity and quality at each desired implant implant was placed and buried under the soft
site, allows the surgeon to develop the surgi- tissue and after an adequate period of healing
cal plan. The question most often asked — ‘Do (three months mandible, six months maxilla), a
I have enough bone?’ — can be answered with second stage surgery was performed with cre-
an educated answer. The goals of the restora- stal incisions to expose the fixtures and connect
tive dentist can be accomplished or cannot be a trans-epithelial abutment. After adequate soft
achieved. In complex fully edentulous cases, tissue healing, the restorative dentist could fab-
whether fixed or removable reconstruction will ricate the prosthesis. One stage surgical proto-
be the best outcome can be determined. The sur- cols were developed by ITI in Switzerland10 that
geon can then modify the radiographic guide to allowed the implant fixture to extend through
be used as a surgical guide on the day of sur- the soft tissues during the period of initial heal-
gery. Recent developments in CAD-CAM tech- ing. This protocol was duplicated and shown to
nology allow the team to perform pre-surgical be effective using a two stage system with the
planning on a virtual model and then transfer same predictability.11 Today this trend contin-
this information to a clinical surgical guide to ues with most implants placed with a one stage
assist accurate placement of implants (eg Nobel protocol allowing adequate time for healing
Biocare ARK, Simplant). prior to loading the fixtures. Using the one stage
The hard tissue classification by Lekholm and technique requires a crestal incision or even a
Zarb defined quantity and quality of the eden- flapless approach, drilling directly through the
tulous ridge. soft tissues. Obviously, deciding which cases
are suitable for the flapless technique is the key
Quality to a successful outcome; adequate bone width
Type 1: Almost the entire jaw is composed of with plenty of keratinised soft tissue is desired.
homogenous compact bone. Compromising the site while drilling due to lack
Type 2: A thick layer of compact bone surrounds of visibility is not advised. In the aesthetic zone
a core of dense trabecular bone. it is important to maintain adequate thickness
Type 3: A thin layer of cortical bone surrounds on the buccal aspect of the implant for long
a core of dense trabecular bone of favourable term stability of the soft tissue contours. Usu-
strength. ally this area lacks enough tissue due to resorp-
Type 4: A thin layer of cortical bone surrounds a tion subsequent to tooth loss, and augmenta-
core of low density trabecular bone. tion techniques are required. The L. Abram’s roll

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 PRACTICE

Fig. 1 (left) Anterior X-section of

thick periodontium with high crest
(bone at level of CEJ)

Fig. 2 (right) Thin periodontium

with low crest (Note the bone
dehiscence on the buccal surface)

Fig. 3 (left) Periodontitis with

advanced bone loss and probing
depths; expect vertical ridge collapse
after tooth extracted

Fig. 4 (right) Recession; attachment

loss with advanced horizontal bone
loss; expect even larger ridge defect
after tooth loss

Fig. 5 (left) Type ‘a’ ridge (thick

periodontium) with no collapse

Fig. 6 (right) Loss of vertical height

after extraction of teeth with
moderate to advanced periodontitis
(normal to thick periodontium). This
will also present with loss of papilla
height, due to previous interproximal
bone defect

Fig. 7 (left) Expected collapse of

ridge after extraction with thin
periodontium (even in healthy
environment)

Fig. 8 (right) Shape ‘c’ or ‘d’. Thin

periodontium with pronounced
scalloped biotype and disease (see
Figs 3-4) will usually shrink more,
leaving concavity type defect with
knife edge ridge

Fig. 9 (left) Posterior x-section

showing horizontal overlap and ridge
relationship in health

Fig. 10 (right) Tooth loss with

minimal ridge collapse. (Type ‘a’ and
‘b’ ridge shape)

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 PRACTICE

Fig. 11 (left) Further resorption

creates greater interarch distance
with less bone available to place only
shorter implants

Fig. 12 (right) Minimal resorption

allows occlusal scheme to remain the
same as prior to extraction, and ideal
emergence for crown contours

Fig. 13 (left) Buccal collapse of the

ridges (left) requires implants to be
placed in a more lingual position. This
creates restorations with buccal over-
contouring and unfavourable loading
conditions on the implant. The
alternative option is to restore with
an x-bite relationship. Note on the
other side of diagram, short clinical
crowns require countersinking of the
implants to allow adequate space for
restorative components

Fig. 14 (right) Intra-oral graft sites

include ramus and chin

Fig. 15 (left) Posterior maxilla

presents with enlarged sinus and
not enough bone height to place
implants. Note minimal amount of
vertical ridge height collapse

Fig. 16 (right) Sinus Lift using

window approach through the lateral
wall. After adequate bone healing
(four to six months), implants are
then placed. Simultaneous bone
grafting and implant placement is
a risker procedure. Note crown to
implant ratio will be favourable

Fig. 17 (left) Note more advanced

ridge resorption. Sinus Lift without
reconstruction of ridge height leads
to less favourable crown to implant
ratio. Placement of the most mesial
implant adjacent to the cuspid tooth
on the incline creates problem with
Interproximal tissues and forces
implant placement slightly more
distal than ideal in order to protect
attachment on distal of cuspid
Fig. 18 (right) Onlay block graft
with fixation screws to reconstruct
the ridge height and improve crown
contours

Fig. 19 (left) After adequate

healing, screws are removed and
implants are placed. Note ideal
crown/implant ratio

Fig. 20 (right) Posterior maxilla with

ideal bone height and width

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 PRACTICE

technique12 is often used to transfer the crestal to debride the osteotomy site from bone debris
thicker tissue onto the buccal aspect, rather than and to widen the site to the manufacturer’s rec-
using a punch technique (flapless approach) ommended diameter prior to tapping the site.
which is subtractive. Placing the implant into too tight a site can lead
Using a two stage protocol in the aesthetic to failure due to pressure necrosis. The shape of
zone also allows for an additional opportunity the implant, parallel walled vs. tapered will also
for surgical intervention with further hard or greatly affect the tightness (primary stability).
soft tissue grafting procedures. Langer13 intro-
duced the sub-epithelial connective tissue graft Softer bone
as a predictable technique for augmenting thin Type 3 and 4 bone requires modification of the
tissue and it is especially useful when minor drilling protocol. Care must be taken to under-
ridge resorption is present. The most common prepare the osteotomy site. Over-preparation
donor site is the palatal tissue mesial to the first or inadvertent implant angulation changes
molar. Another popular donor site is the tuberos- can preclude placement of the implant. Using
ity tissue. This area is especially desirable when the Osteotome technique18 can also help ini-
a thicker graft is needed for ridge augmenta- tial stabilisation by compressing the available
tion procedures (inlay or pouch technique)14 in soft bone instead of compromising the site with
the anterior aesthetic zone. Palacci15 has also drilling. Tapered implants have an advantage in
described rotated flap techniques for papilla softer bone due to the wedging effect at the time
regeneration. It is always important to define the of placement. The tapered implant is more chal-
type of defect, and realise that building the sup- lenging at the time of placement, because the
porting bone beneath the soft tissue will produce depth of the prepared site needs to be exactly
the most predictable outcome. The bony archi- at the level of where the desired final position
tecture provides the scaffold that supports the of the implant needs to be placed. As opposed
soft tissue around proper implant positioning. to a parallel wall implant that can be placed
deeper if desired, due to the ability to sink the
POSITION AND ANGULATION OF IMPLANT implant into the prepared site. The twist drills
Presurgical analysis has determined the best for the parallel wall implants have markings,
available sites for placement. In the partially which prepare the depth slightly longer than
edentulous case, being aware of the root mor- the implant length. Due to this design and extra
phology and inclination of teeth adjacent to tip at the end of the drill, care should always be
the implant site is crucial. If a radiographic taken when drilling above vital structures such
guide was used at the time of CT scan and then as the alveolar canal in the posterior mandible.
adapted for use as a surgical guide, mishaps will Bi-cortical fixation in softer sites helps
be prevented. If a surgical guide is fabricated anchor the fixture especially in the posterior
without the knowledge of the root positions or maxilla. Engaging the sinus floor is suggested
bony deficiencies, then careful interpretation to achieve this anchorage.
and adjustments by the surgeon is required. The Countersinking into the crestal bone may
initial drilling (round bur) starting point can be cause loss of initial stabilisation at the time of
moved and the angulation of the implant tipped placement. The need to countersink the implant
to avoid bone dehiscence or fenestration. The is usually restorative driven for aesthetic and
more palatal the movement, the deeper sub-gin- emergence purposes or due to lack of restora-
givally the implant platform must be positioned tive space. The original protocol required
to accommodate for the emergence of the restor- countersinking to protect the implant from
ative components through the soft tissue. Ideal trans-mucosal forces generated by remov-
dimensions16 are 3–4 mm subgingival, with the able appliances over the implant head. In softer
buccal aspect of the implant platform at least 1 bone, it is preferable to place the platform of
mm or more palatal or lingual to the future buc- the implant at the crest or supra-crestal if space
cal aspect of the restoration at the level of the allows for adequate emergence.
gingival margin. Placing a wider platform in the
anterior aesthetic region provides for a smoother The deficient osseous ridge (Figs 34-61)
gingival restorative interface (platform does not Lack of vertical height
have to be as deep), but invites greater risk of Anterior maxilla: Vertical resorption of the
apical migration of the soft tissue margin. The ridge will affect the aesthetic result in partially
concept of ‘platform switching’ – using a nar- edentulous cases. In fully edentulous cases the
rower restorative component on a wider implant amount of loss might limit treatment to remov-
platform (possible only with some implant able overdentures.
systems, eg 3i) – is interesting.17 It appears to Options for surgical correction include:
help support the soft tissue and prevent crestal • Onlay bone grafting
resorption of the bone at the level of the implant • Distraction osteogenesis.
platform. At this time further research is needed.
The onlay block graft19 requires an autog-
Dense bone enous block of bone be taken from either intra-
Dense bone (Type 1 & 2) requires careful atten- oral sites (Ramus or chin) (see Fig. 14) or extra-
tion to drilling with adequate irrigation in order oral site (iliac crest or calvaria). The greater the
not to overheat the bone. Care should be taken defect, the more bone required. Analysis of the

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dimensions required will dictate which donor for single tooth replacement, but with less
site is preferable. Extra-oral sites require gen- predictability, due to the greater potential for
eral anaesthesia and increase the risk of greater sinus membrane perforation.
morbidity. Intra-oral block grafts are better suit- Posterior mandible: The inferior alveolar
ed for partially edentulous situations. The block nerve needs to be visualised in order not to cause
of cortical cancellous bone is carefully adapted nerve damage such as paraesthesia. It often limits
to the recipient site and fixated with screws to implant placement to short wide implants. Alter-
stabilise the graft during the healing period. native options are the nerve transposition pro-
Building vertical height is the least predictable cedure24 which has a high morbidity and rate of
of all the grafting options. nerve damage, or to consider distal cantilevering
Distraction Osteogenesis20 allows the exist- of the prosthesis off implants placed mesial to the
ing bone to be transferred to a more coronal foramina. Distraction osteogenesis can also be
position after surgical osteotomy cuts and used if inter-arch space is not a problem.
placement of a device that is activated daily in
the mouth. After several weeks of movement, Lack of horizontal width
the bone is left to mature for a few months prior Anterior maxilla: The pattern of resorption usu-
to implant placement. ally creates knife-edge ridges or ridges that are
Posterior maxilla: The posterior maxilla has his- too thin due to concavities (Fig. 8). The ante-
torically always been the most challenging site to rior incisal foramen is sometimes large and can
achieve success. The most common site for tooth restrict implant placement in the maxillary cen-
loss in the periodontally compromised patient is tral positions (Fig. 37).
the maxillary molars due to furcation involve- Knife-edge ridges are best treated with veneer
ment.21 Due to a combination of periodontal bone grafts19 using an intra-oral block of cortical-
loss and sinus proximity, limited bone height is cancellous autogenous bone stabilised with fix-
usually available for implants (Fig. 15). The bone ation screws (Figs 25-26). Unlike onlay grafts,
is also usually soft (type 3 or 4), which makes ini- these veneer grafts are more predictable. Con-
tial stabilisation difficult to achieve. Several tech- cavity defects can be treated with block grafts,
niques have been developed and perfected over but these also respond favourably to GBR25 pro-
the last decade to improve the surgical options in cedures (Fig. 27). An intra-oral block harvested
the posterior maxilla (Figs 16-24). from the ramus can be ground, or a scraping
The Sinus Lift procedure22 reported by device (Safescraper, 3i Palm Beach, Florida, USA
Boyne et al. showed that it is possible to open or Ebner 502 grafter, Maxillon Lab Inc. Hollis,
the maxillary sinus through the lateral wall, NH. USA) can harvest scrapings off the ramus
elevate the sinus membrane and pack bone cortical plate which can then be mixed with an
grafting material into the space. Many types of osteo-conductive material to create a particu-
bone grafting materials are available. Autog- late graft. A resorbable or non-resorbable mem-
enous bone has always been the most predict- brane is then fixated with pins over the graft
able option that has set the gold standard. material. A titanium re-inforced membrane26
Intra-oral bone can be harvested from the chin, can be used if spacemaking is desired.
ramus or tuberosity areas. This bone is ground Narrow ridges in the maxilla can also be
and the particulated graft material is best com- treated by spreading the bone with osteotomes
bined with an osteo-conductive material of the or a more aggressive approach, the Split-Ridge
surgeon’s choice (eg Hydroxy-apatite, Bio-oss technique, which widens the existing bone with
or freeze dried bone). Using Platelet Rich Plas- simultaneous implant placement.
ma23 to aid the healing response is an addi-
tional option. It is more predictable to perform Anterior and posterior mandible: Block grafts
the sinus lift graft, and then wait 5-6 months with fixation screws (GBR) as described above
for healing prior to implant placement. If 5 mm are possible. Determining the depth of the
or more of bone height is available, simultane- vestibule and the ability to advance the flap for
ous implant placement with sinus lift and bone graft coverage without any tension, is the key
grafting is possible, with less predictability. If 7 to achieve success.
or 8 mm of height is available, then placement
of the implants with an osteotome technique SURGICAL GUIDELINES — TOOTH OR TEETH
for increasing the length of implant is possible NEED TO BE REMOVED
(see Figs 20-24). The protocol calls for drilling If the tooth or teeth need to be removed, then
the initial twist drills at least 3 mm short of ask the following questions.
the sinus floor. The osteotome is placed into • Is the tooth in the aesthetic zone?
the osteotomy. The sinus floor is in-fractured, • Type of tissue biotype? Thin scalloped or thick
thereby raising the membrane and creating flat.
space for the graft. Bone graft material can • Amount of bone loss due to periodontal dis-
then be pushed into the preparation site prior ease or endodontic failure?
to placing the implant. This technique is popu- • How predictable is the stability of the future
lar, because it seems less invasive as compared gingival architecture?
to the sinus lift via the lateral wall technique, There are several timing options to consider:
but obviously it requires careful patient selec- 1. Extract and wait several months prior to
tion. It is a technique sensitive procedure, good implant placement.

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Fig. 21 (left) Extraction due to

periodontal bone loss, along with
sinus enlargement, leads to reduced
height for implant placement

Fig. 22 (right) The Osteotome

technique is useful when 7 mm or
more bone height is available. Drill
to within 3 mm of sinus floor, then
start with osteotome

Fig. 23 (left) Use wider osteotome

to fracture sinus floor upwards,
and then pack bone graft material
into osteotomy site prior to implant
placement (shown in grey in this
diagram)

Fig. 24 (right) Place implant into

site

Fig. 25 (left) Stabilisation of

intra-oral autogenous cortical block
bone with fixation screws to correct
knife-edge ridge with some vertical
loss

Fig. 26 (right) Screws are removed

after six months

Fig. 27 (left) Concavity type

defects with no vertical loss can be
reconstructed using Guided Bone
Regeneration using particulate graft
and membranes

Fig. 28 (right) Surgical Guide. This

guide was adapted for use as a
radiographic guide. The holes were
filled with gutta-percha. The outside
surface of the teeth (palatal, occlusal
and buccal) were wrapped with foil.
This produces the following images
(Figs 29, 31, 33)

Fig. 29 (left) CT scan axial cut

showing radiographic markers
transferred onto images

Fig. 30 (right) Oblique cuts showing

posterior maxilla pre-bone grafting.
No radiographic guide at time of
scan

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 PRACTICE

Fig. 31 (left) Oblique cuts showing

posterior maxilla post – bone
grafting with sinus lift procedure.
Note radiographic marker shows
outline of desired crown contours
and internally desired implant
location and angulation

Fig. 32 (right) Oblique cuts

showing maxillary anterior region
pre-grafting. Note no radiographic
marker and knife-edge ridge

Fig. 33 (left) Oblique cuts showing

anterior region post- bone grafting
with intra-oral autogenous block
graft buccal veneer. Note fixation
screw (red arrows)

Fig. 34 (right) Patient presented

with missing central incisors,
diastemata and uneven occlusal
plane. Initial radiographs of the
maxillary anterior region

Figs 35-36 CT scan of oblique cuts

showing advanced bone resorption
with thin ridge and concavity defect.
The anterior incisal foramen is
extremely large

Fig. 37 (left) CT scan of maxilla.

The axial cut shows the problem of
the large foramen which restricts
implant placement

Fig. 38 (right) Clinical anterior

view during orthodontic therapy
to correct occlusal plane and space
problems

Fig. 39 (left) Clinical occlusal view

showing advanced ridge resorption

Fig. 40 (right) Flap reflection shows

buccal concavity. Periodontal probes
indicate location of foramen

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Fig. 41 (left) Palatal flap with

neuro-vascular bundle removed from
foramen

Fig. 42 (right) Harvesting

autogenous block bone from lateral
region of the ramus

Figs 43-44 Cortical block of bone

prior to shaping

Fig. 45 Preparation of the recipient

site requires drilling small holes into
the cortical layer to expose bleeding
sites

Fig. 46-47 Close approximation of

graft to recipient site is required.
Block is stabilised with fixation
screws

Fig. 48 (left) Particulate bone mixed

with osteo-conductive bone graft
material (Hydroxy-apetite) is packed
around the block edges to fill voids
and also into the foramen space.
This was covered with a resorbable
collagen membrane (Ossix, 3i, West
Palm Beach, Florida)

Fig. 49 (right) Advanced flap closed

without any tension using resorbable
sutures. Note the flap design places
the vertical incisions at least one
tooth distant to the graft area

Figs 50-51 Six months later,

the flap is elevated for implant
placement. Note residual membrane
and layer of soft connective tissue
under it, which are then removed
along with the fixation screws

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Fig. 52 (left) Occlusal view shows

implant fixtures placed, with more
than 3 mm inter-implant distance
and slightly countersunk for
aesthetic emergence

Fig. 53 (right) Flangeless interim

removable appliance

Fig. 54 (left) Six months later, flap

reflection for implant uncovering.
Note flap design allows the crestal
tissue over implants to be moved to
the buccal aspect

Fig. 55 (right) Occlusal view of

implants

Figs 56-57 Healing abutments

placed with sutures

Fig. 58 (left) Several months

of loading the implants with a
provisional restoration will allow the
soft tissue to mature into desired
contours prior to placement of final
restorations. Note the development
of central papilla tissue

Fig. 59 (right) Occlusal view of final

restoration. Note the reconstruction
of the buccal contours

Fig. 60 (left) Final restorations

(Restoration courtesy Dr Seon Ha)

Fig. 61 (right) Radiographs after

the bone graft prior to implant
placement, and then two years after
placement of final restorations. Note
stable level of the crestal bone with
the interproximal bone supporting
the soft tissue architecture

Fig. 62 Initial clinical photo. Patient

presents with advanced periodontitis
and root resorption of the left
maxillary cuspid (Tooth 23 )

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Figs 63-64 Orthodontic forced

eruption at two months and
five months to help reduce the
bony defect prior to extraction.
Orthodontic therapy by Dr Kishibay

result in the anterior zone requires the site be

over-built more than nature provided. Further-
more, during the first year of bone remodelling,
crestal resorption down to the first thread of the
implant is not restricted only to the interproxi-
mal zone as seen on dental radiographs, but also
occurs on the buccal aspect and thus affects the
supporting hard and soft tissues. This leads to
Figs 65-67 Radiographs: Initial, further buccal shrinkage and recession around
during and after movement the implant restoration. Buser29 suggests a
staged approach to GBR. Build the bone with a
2. Orthodontic forced eruption27 to move the block or particulate graft and membrane using
gingival complex and crestal bone into a fixation screws for stability, and only after six
more favourable position prior to extraction months healing, then place the implant. At
(Figs 62-67). that time the options of one stage (exposed
3. Extract and bone graft the socket to help healing abutment or immediate loading with
preserve soft tissue contours and minimise a provisional restoration) vs. buried two stage
collapse of the ridge, if the buccal plate is approach can be considered (see clinical case
thin or has a slight dehiscence. presented in Figs 34-61). If soft tissue grafting
4. Extract and place implant immediately into is also required, the option to do the soft tissue
socket (single rooted teeth and buccal plate is graft simultaneously with implant placement is
thick and intact). possible. Later, it is easier to surgically manipu-
a. Two stage buried. late these augmented soft tissues at the second
b. One stage with healing abutment or stage uncovering procedure.
customised healing abutment.
c. Immediate load implant with provisional Timing of loading
restoration. Changing the implant surface from a smooth
5. Extract and wait two to three months, then machined finish to a roughened surface has
bone graft (Intra-oral block or GBR). After been shown to improve the rate of bone healing
five to six months healing, place the implant. adjacent to the implant. This allows a quicker
healing time for osseointegration to be estab-
If you expect to have advanced ridge resorp- lished. With improved and modified drilling
tion subsequent to tooth removal, then staging techniques, the primary stability of the implant
the case with several procedures is going to be at the time of placement has improved. This has
the more predictable option. Extract the tooth led to the now popular immediate loading with
and wait two to three months for soft tissue provisional restorations at the time of place-
maturity. If it is possible to place the implant ment.30 At the present time, long term research
in an ideal position, then Gruender28 suggests is not available to show that this will be as pre-
a simultaneous approach; placing the implant dictable as the success rates achieved with the
with buccal particulate bone graft (suggests original delayed loading protocol.
Bio-OSS) with a membrane over it, known as The primary factor for success at the time of
Guided Bone Regeneration (GBR). His treatment placement is achieving primary stability. Recent
philosophy for achieving the optimal aesthetic development of the OsstellTM machine that

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quantifies stability of the fixture using sound 2. Bahat O, Handelsman M. Presurgical treatment planning
resonance31 has helped to give the surgeon an and surgical guidelines for dental implants. In Wilson T et al.
Advanced periodontics. pp 323-340. Chicago: Quintessence.
objective measurement to determine treat- 3. Spear F. The challenges of presenting interdisciplinary
ment outcomes. Any micro-motion during the treatment. Advanced Esthetics Interdiscip Dent 2005; 1: 2.
initial phases of bone healing will cause a lack 4. Becker B, Ochenbein C, Tibetts L et al. Alveolar bone
anatomic profiles as measured from dry skulls. Clinical
of integration. Failure is most often caused by ramification. J Clin Periodontol 1997; 24: 727-731.
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6. Tarnow D P, Magner A W, Fletcher P. The effect of the
attempt to keep a patient functioning with fixed distance from the contact point to the crest of bone on the
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Preprosthetic oral and maxillofacial surgery. p 15. The CV
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11. Becker W, Becker B E et al. A prospective multicenter clinical
extremely tight, but control of the occlusion trial comparing one– and two– stage titanium screw shaped
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