Implant Therapy in the Esthetic Zone

Current Treatment Modalities and Materials for Single-Tooth Replacements

Daniel Buser, Stephen Chen, Daniel Wismeijer

• Publisher: Quintessence Publishing
• Year: 2019
• ISBN:
  9783868674064
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

Volume 10 of the ITI Treatment Guide series starts out with the most recent statements and recommendations of the 5th ITI Consensus Conference, followed by a detailed protocol for the evaluation and treatment planning of patients with esthetic demands requiring single-tooth replacement with a dental implant. Various surgical situations commonly encountered in the esthetic zone will be presented and recommendations on their treatment will be provided. In addition, the clinical management of the planned implant site before and after placement through the use of provisional prostheses, laboratory communication, abutment design, restorative material selection, and delivery will be examined. This volume of the ITI Treatment Guide series provides a comprehensive, evidence-based approach to single-tooth replacement in the esthetic zone, from consultation to follow-up, with a focus on current treatment modalities and on the materials that present-day implant dentistry has to offer.The ITI Treatment Guide series is a compendium of evidence-based implant-therapy techniques and procedures for daily practice. Written by renowned clinicians and supported by contributions from expert practitioners, the ITI Treatment Guides provide a comprehensive overview of various clinical options. The management of different clinical situations is discussed with an emphasis on sound diagnostics, evidence-based treatment concepts, and predictable treatment outcomes with minimal risk to the patient.

1	Introduction
	W. Martin, V. Chappuis

The history of successful dental implant treatment has led to its large-scale use in today’s clinical practice, providing patients with solutions for the treatment of all forms of edentulism. Clinicians and patients alike benefit from the possibility to use these implants to retain prostheses in a variety of situations, ranging from anterior to posterior tooth replacement to fully edentulous situations. Several authors have reported long-term survival rates of > 90%, leading to a higher acceptance of the dental implant as a primary option for tooth replacement (Adell and coworkers 1990; Lindquist and coworkers 1996; Wennström and coworkers 2005; Buser and coworkers 2012; Chappuis and coworkers 2013a). Of critical note, implant survival does not necessarily correlate with successful esthetic rehabilitation, since success criteria have varied over time. For esthetically sensitive areas, success criteria must include measurements of the peri-implant mucosa as well as the restoration and its relationship to the surrounding dentition (Belser and coworkers 2004; Smith and Zarb 1989).

Patients with failing or missing teeth in the esthetic zone present with their own set of clinical challenges for the clinician to achieve a natural-looking outcome. Any esthetic rehabilitation has to be predictable, which requires a reproducible and stable outcome in the short and long term. The ability to achieve this depends on the interaction between clinicians and technicians (experience) as well as biologic (anatomic factors, host response), surgical (procedures, materials, techniques), implant (dimensions, compositions, surface characteristics, designs), and prosthetic factors (techniques and materials).

The ITI has recognized the challenge of treating patients with esthetic needs and focused attention on them in its numerous publications (SAC Classification, ITI Treatment Guides) and the Proceedings of the 1st through 5th ITI Consensus Conferences over the past sixteen years. The SAC Classification provides information on the degree of restorative and surgical difficulty in the treatment of patients with dental implants and incorporates the use of the Esthetic Risk Assessment (ERA) in determining the risks to achieving an esthetic outcome based upon clinical factors associated with individualized treatment situations. Several ITI Treatment Guides have described the influence of treatment protocols on esthetic outcomes, beginning with Volume 1, Implant Therapy in the Esthetic Zone: Single-tooth Replacements and continuing with volumes 2 through 8. The Proceedings of the (1st to 5th) Consensus Conferences with its consensus statements and clinical recommendations have focused on the treatment of patients with high esthetic needs through treatment guidelines focusing on patient evaluation and treatment, timing of implant placement, loading protocols, and complications related to restorative materials.

In 2007, the ITI published the first volume of the ITI Treatment Guide series, focusing on single-tooth replacement in the esthetic zone. Since then there have been many advances in patient evaluation, implant design, surgical techniques and materials, abutment design and restorative materials, necessitating a revisit to this timely topic.

This volume of the ITI Treatment Guide series begins with the most recent consensus statements and clinical recommendations of the 5th ITI Consensus Conference, followed by a detailed protocol for evaluation and treatment planning for patients with esthetic needs requiring single-tooth replacement with a dental implant and restoration. The ERA table will be reviewed, and an updated version will be presented that is in line with current evaluation procedures and techniques incorporating digital technology.

Implant therapy performed in the esthetic zone requires careful attention to surgical procedures and materials utilized to regain lost tissue support for placing implants in ideal three-dimensional positions based upon the restorative plan. Implant materials, bone grafts, bone substitutes, biologics, and membranes will be presented and indications and techniques for their use outlined. Various surgical situations commonly encountered in the esthetic zone will be presented and treatment recommendations provided.

Prosthetic treatment in the esthetic zone requires advanced knowledge of clinical techniques and materials that can contribute to creating predictable and long-term esthetic outcomes. This volume will highlight the clinical management of the proposed implant site before and after implant placement through the use of interim prostheses, laboratory communication, abutment design, restorative material selection, and prosthesis delivery.

A unique characteristic of all ITI Treatment Guides has been the incorporation of clinical case presentations contributed by clinicians from all over the world that embrace the ITI’s philosophy of an evidence-based approach to treatment and treatment planning. This volume will present several clinical cases highlighting various approaches, both surgical and restorative, in the treatment of patients requiring single teeth to be replaced with a dental implant. In addition, causes and case management approaches related to esthetic implant complications will be reviewed, highlighting surgical and prosthetic options to recover from compromised outcomes.

Our goal with this Treatment Guide has been to present a comprehensive, evidence-based approach to assist practitioners in the successful treatment of their patients who desire esthetic outcomes, from the initial consultation to follow-up.

2	Consensus Statements: Statements and Recommendations Obtained from the 5th ITI Consensus Conference
	V. Chappuis, W. Martin

2.1	Contemporary Surgical and Radiographic Techniques in Implant Dentistry

International Journal of Oral and Maxillofacial Implants 2014, Vol. 29 (Supplement): Contemporary Surgical and Radiographic Techniques in Implant Dentistry (Michael M. Bornstein and coworkers 2014)

Introductory remarks

Successful dental implant rehabilitation requires accurate preoperative planning of the surgical intervention based on prosthodontic considerations and validated treatment methods. The introduction and widespread use of cross-sectional imaging in implant dentistry using cone-beam computed tomography (CBCT) over the last decade has enabled clinicians to diagnose and evaluate the jaws in three dimensions before and after insertion of dental implants, thus replacing computed tomography (CT) as the standard of care. Furthermore, computer-guided implant surgery uses data from cross-sectional imaging derived from CBCT scans on a routine basis. Considering rapid changes in science and clinical practice, two systematic reviews in this group, by Bornstein and coworkers (2014 a) and Tahmaseb and coworkers (2014), have centered their focus questions on these topics.

There are two possible surgical interventions for the treatment of the narrow edentulous ridge. The use of narrow-diameter implants has been suggested to avoid augmentation procedures and thus decrease patient morbidity. Nevertheless, this has not been validated in a systematic review of the literature to date. Horizontal augmentation procedures are widely used to increase the bone available for subsequent implant placement. However, knowledge on the efficacy and long-term outcomes of this procedure in the anterior maxilla is still limited. Therefore, the systematic reviews prepared by Klein and coworkers (2014) and by Kuchler and von Arx (2014) evaluated the existing data for these two rather different treatment approaches.

Cone-beam computed tomography (CBCT) in implant dentistry

Consensus statements

With respect to CBCT imaging in dental implant therapy and respective use guidelines, specific indications and contraindications for use, and the associated relative radiation does risk, the following statements can be made:

•Current clinical practice guidelines for CBCT use in implant dentistry provide recommendations that are consensus-based or derived from non-standardized methodological approaches.

•Published indication for CBCT use in implant dentistry vary from preoperative analysis to postoperative evaluation, including complications. However, a clinically significant benefit for CBCT imaging over conventional two-dimensional methods resulting in treatment plan alteration, improved implant success, survival rates, and reduced complications has not been reported to date.

•CBCT imaging exhibits a significantly lower radiation does risk than conventional CT, but higher than that of two-dimension radiographic imaging. Different CBCT devices deliver a wide range of radiation doses. Substantial dose reduction can be achieved by using appropriate exposure parameters and reducing the field of view (FOV) to the actual region of interest (ROI).

Treatment guidelines

•The clinician performing or interpreting CBCT scans for implant dentistry should take into consideration current radiologic guidelines.

•The decision to perform CBCT imaging for treatment planning in implant dentistry should be based on individual patient needs following thorough clinical examination.

•When cross-sectional imaging is indicated, CBCT is preferable over CT.

•CBCT imaging is indicated when information supplemental to the clinical examination and conventional radiographic imaging is considered necessary. CBCT may be an appropriate primary imaging modality in specific circumstances (e.g., when multiple treatment needs are anticipated or when jawbone or sinus pathology is suspected).

•The use of a radiographic template in CBCT imaging is advisable to maximize surgical and prosthetic information.

•The FOV of the CBCT examination should be restricted to the ROI whenever possible.

•Patient- and equipment-specific dose reduction measures should be used at all times.

•To improve image data transfer, clinicians should request radiographic devices and third-party dental implant software applications that offer fully compliant DICOM data export.

For a pdf copy of the full article (free of charge) from the ITI Consensus Paper, please check out the ITI Online Academy’s ITI Consensus Database. See what else the Online Academy has to offer (charges may apply) at academy.iti.org

Computer-guided implant surgery

Consensus statements

•Implants placed utilizing computer-guided surgery with a follow-up period of at least 12 months demonstrate a mean survival rate of 97.3% (n = 1,941), which is comparable to implants placed following conventional procedures.

•There are significantly more data to support the accuracy of computer-guided implant surgery compared to 2008. Meta-analysis of the accuracy revealed a mean error of 0.9 mm at the entry pint (n = 1,530), 1.3 mm at the implant apex (n = 1,465), and a mean angular deviation of 3.5 degrees (n = 1,854) with a wide range in all measurements.

•Mucosa-, tooth-, and mini-implant-supported templates demonstrated accuracy of implant placement superior to that of bone-supported guides.

•After template osteotomy preparation, the accuracy of template implant insertion was superior to free-hand implant insertion.

Treatment guidelines

•Guided surgery should be viewed as an adjunct to, not a replacement for, appropriate diagnosis and treatment planning.

•Guided surgery should always be prosthetically driven. This includes either a radiographic template generated from a wax-up, or appropriate software application t...

Table of contents

• ITI Treatment Guide
• Title
• Copyright
• Preface
• Acknowledgment
• Editors and Authors
• Contributors
• Table of Contents
• 1. Introduction
• 2. Consensus Statements: Statements and Recommendations Obtained from the 5th ITI Consensus Conference
• 3. Preoperative Risk Assessment and Treatment Planning for Optimal Esthetic Outcomes
• 4. Selecting Biomaterials for Implant Procedures
• 5. Surgical Considerations for Optimal Esthetic Outcomes
• 6. Prosthetic Management for Optimal Esthetic Outcomes
• 7. Clinical Case Presentations
• 8. Esthetic Complications
• 9. Conclusions
• 10. References