Treatment Planning Considerations for the Complex Implant Case

From the first meeting, the clinician should obtain an overall appraisal of the patient. Patients must be in reasonably good health to undergo surgical therapy for the placement of dental implants. As is the case for patients in need of any dental treatment, a thorough medical history is required. Because patients often omit information that they do not relate to their dental problems, they should be made aware of the role that smoking, systemic diseases such as diabetes and atherosclerosis, and medications such as steroids and bisphosphonates may play in the success or failure of dental implants.

The health history should be reviewed for any condition that might put the patient at risk for adverse reactions or complications. Any disorder that may impair the normal wound-healing process, especially as it relates to bone metabolism, should be carefully considered as a possible risk factor or contraindication to implant therapy. Knowing a patient's medical background assists the clinician in determining how the periodontal tissue may respond to the implant and what special precautions or modifications may be required in treatment procedures.

Dental Factors

A review of the patient's dental history is an essential part of the overall evaluation, including previous surgeries and prosthetics, recurrent or frequent abscesses, the number of dental restorations, compliance with previous dental recommendations and current oral hygiene practices. If there is a history of dissatisfaction with past treatment, the patient may have similar difficulties with implant therapy or implant-supported restorations. This may also be indicative of potential practice management problems.

After a thorough intraoral examination, the clinician can evaluate potential implant sites. All sites should be clinically assessed to measure the availability of sufficient bone for the placement of the implants and adequate interarch space for prosthetic tooth replacement with proper size and shape. The mesial-distal and buccal-lingual dimensions of edentulous spaces can be approximated wit a periodontal probe or other measuring instrument.

Keys to successful treatment planning begin with a thorough restorative evaluation.

Diagnostic Wax-Up: Mounted study models are an excellent means of assessing potential sites for dental implants. Properly articulated models with a wax representation of the proposed restorations allow both the restorative and surgical clinician to evaluate the available space and to determine potential limitations of the planned treatment. This is particularly useful when multiple teeth are to be replaced with implants or when dealing with a cosmetically sensitive restoration.

The amount of available bone is the next criteria to evaluate. A visual examination may identify deficient areas. Manual palpation can reveal anatomic defects and variations in the anatomy of the anterior region. It is essential to evaluate the timing of tooth extractions and consider bone grafting options for ridge preservation procedures before the teeth are removed. Treatment planning for these extractions can often avoid more involved ridge augmentation procedures after the alveolar ridge resorption has occurred.

The Timing of Implant Placement relative to the time of extraction depends on the quantity, quality and volume of existing bone, as well as the preferences of the clinician and patient.

Immediate implant placement occurs simultaneously with the extraction. The advantages of immediate implant placement is the prevention of ridge collapse and the maintenance of soft tissue papilla, in addition to the reduction of total surgical healing time. Because the implant is placed at the time of extraction, the bone-to-implant healing begins immediately with extraction site healing.

Delayed implant placement is performed approximately 6-8 weeks after extraction to allow for soft tissue healing. The primary advantage of delayed implant placement is that by allowing for soft tissue healing and closure of the extraction site, mucogingival flap advancement is not necessary. This is especially true when bone grafting procedures are anticipated because it alleviates the need for additional surgeries to correct mucogingival discrepancies.

Staged implant placement allows for substantial bone healing within the extraction site, which typically requires four to six months or longer. Staged implant placement allows for complete hard and soft tissue healing and permits the placement of implants into prosthetically favorable positions exhibiting adequate coverage by hard and soft tissues.

Maxillary-Sinus Elevation: When there is inadequate vertical height on the alveolus in the maxillary posterior region, it may be necessary to perform a sinus bone graft to elevate the Schneiderian membrane which creates space. The newly-created space can then be filled with bone or a suitable bone substitute material to increase the total vertical height of bone in the posterior maxilla.

The lateral window technique is probably the most effective and efficient way to elevate the sinus floor for multiple implants or when very limited crestal bone is present. If 3-4mm of alveolar bone height is available, an osteotome sinus lift technique can be utilized through the implant osteotomy site. The osteotome technique is usually performed simultaneous with implant placement. If there is minimal alveolar bone and/or multiple implants are planned, the lateral window approach is more advantages. Occasionally implants can also be placed at the time of the lateral window technique if there is sufficient native bone in a vertical dimension to stabilize the implant.

Maxillary Ridge Width Defects: In cases where there are large horizontal deficiencies in the maxillary ridge which may result in significant exposure of implant threads beyond the confines of the alveolar bone, it may be advisable to reconstruct the bone before implant placement. Horizontal alveolar deficiencies may be reconstructed with bone augmentation (onlay) grafts or ridge splitting techniques.

Fabrication of a Surgical Guide: Surgical guides are most often created from the diagnostic wax-up provided by the restorative dentist. However, advanced surgical guidance to guarantee precise implant placement in complex implant cases is now possible using sophisticated computed tomography (CT).

Utilizing one of several software programs, the clinician can simulate the placement of implants on the computer screen.

These interactive planning programs provide the clinician the opportunity to perform "virtual surgery," placing implants in optimal positions. Furthermore, such advanced technology ensures that the sites chosen will provide sufficient surrounding bone for each implant and good positioning of the implants in relation to each other. Additionally, the clinician can measure the quality (density) of alveolar bone surrounding each implant fixture.

Implant planning software can reformat the CT into a three-dimensional image from which a stereolithographic model can be constructed. The model is machined with CAD CAM technology into an accurate anatomic replica of the jaw.

Once a treatment plan has been carefully evaluated and designed, a customized surgical drill guide can be constructed from the three-dimensional reconstruction of the CT data. Built precisely from the selected treatment plan and based on the patient's exact measurements, these guides ensure safe, predictable implant surgery.

Anatomical Factors Affecting Implant Placement: Familiarity with several important anatomic structures found close to desired areas of implant placement in the maxilla and mandible is important in treatment planning and implant placement. In the maxilla, these include the floor and anterior loop of the mandibular canal and submandibular fossa.

The existence of anatomic variants, such as incomplete healing of an extraction site, sinus location, or absence of a well-defined, corticated canal should be recognized.

Tri-dimensional positioning will aid surgical placement of the implant and prevent encroachment on these structures, thereby avoiding unwanted complication and unnecessary morbidity.

Soft Tissue Considerations: Evaluation of the quality, quantity and location of soft tissue in relation to the proposed implant site helps identify the type of tissue - keratinized or nonkeratinized -- that will surround the implants after treatment is completed. Areas with minimal or nonexistent keratinized mucosa may be augmented with gingival or connective tissue grafts. Additionally, any mucogingival concerns, such as frenum attachments or pulls, should be thoroughly evaluated.

To learn more about treatment planning complex dental implant cases, visit http://www.theperiogroup.com/ and submit your questions to Philadelphia Periodontist Dr. I. Stephen Brown.

Transitional Implants Prove Effective in Protecting Implant Surgical Sites

Recently, mini transitional implants have been used to support fixed and removable provisional restorations. They have proven to be effective in protecting implant surgical sites, as well as providing the other prerequisites of an acceptable temporary restoration.

These narrow diameter implants are similar to root form implants, providing immediate tooth replacement, and allowing the patient to immediately experience the positive benefits of implant dentistry.

Some important considerations when using transitional implants are as follows: One must maintain adequate space between "temporary" and "permanent" implants. Similarly, adequate space maintenance between transitional implants and natural teeth is essential. Furthermore, to prevent failure from occlusal overload, it is advisable to use an adequate number of mini implants to support the interim prosthesis.

Transitional implants appear to be more successful in the mandible than the maxilla. It has been suggested that this maty be due to enhanced bone density in the mandible. The noticeable deficiency may be overcome by increasing the number of mini implants in the maxilla. Following confirmation of osseointegration of the permanent implants, the transitional implants can be easily removed.

If immediate loading of the implant is desired, three methods of provisionalization are commonly selected:

• A restoration may be delivered the day of implantation, or at the time of uncovering, by indexing the implant platform with a fixture level impression.
• A temporary cylinder or abutment can be used upon which to fabricate a provisional restoration.
• A laboratory processed acrylic tooth shell can be relined and adapted to a temporary or custom abutment.

To read more about transitional implants and other methods of provisionalization, visit The Perio Group on the web at http://www.theperiogroup.com/.

How Much Does a Dental Implant Philadelphia Cost?

With the continually rising costs of health care, patients must recognize that fees for dental implants, beyond inventory and overhead, are a reflection of significant additional educational requirements and considerable investment in the highly technical equipment which is required to assure you the most favorable, predictable and long-lasting clinical outcomes.

When compared to routine dental procedures like fillings, cleanings, extractions and root canals, dental implants might be considered expensive. However, unlike conventional methods of tooth replacement, a successful dental implant can last a lifetime.

Multiple published studies have shown that virtually every other form of tooth replacement has a finite life, and requires replacement on a regular basis. For instance, caps or crowns and bridges represent short term solutions to tooth loss, and need to be replaced every 5-7 years. Every time a crown is replaced it causes additional loss of tooth and gum tissue, a potential need for root canal treatment and / or periodontal therapy.

Furthermore, each time a crown is replaced, the current fee is considerably greater than the original fee, simply due to inflation. Consider the initial cost of a dental implant versus the continuing costs of replacing existing restorations. Many studies have shown that the success rate of implants and implant supported crowns and bridges is around 95% or better. Every other form of tooth replacement, or medical procedure, pales by comparison.

Unfortunately, it’s hard to provide an “average” fee for dental implants. Fees are determined based on type and number of implants required. Costs are also related to the extent of related procedures which are often necessary to properly prepare the site of a missing tooth to receive an implant. These procedures may be required to build up bone and gum tissue. The condition of the jaw bone, medical issues such as Diabetes and smoking, are all elements which also must be factored into the establishment a fair fee.

It should be remembered that nobody comes to a dentist for an implant. Discerning patients expect that an implant is placed to insure a functional and cosmetically acceptable tooth replacement. Providing such an outcome requires significantly more skill than simply placing an implant in the jaw bone.

All things considered, dental implant treatment represents not only the most technologically advanced, but the most cost effective form of tooth replacement. Coupled with the level of care, skill and judgment exercised by a well trained implant surgeon, one would be hard pressed to find a more affordable option. Dental implants can provide a permanent solution to your dental problems, while avoiding the long term inconvenience and escalating costs associated with less permanent options for tooth replacement.

Montgomery County Patient Chooses Dental Implant Specialist Dr. Stephen Brown To Permanenty Replacement His Missing Tooth

Case Study #3 - Dental Implant vs. A Removable Tooth Replacement

This Montgomery County man was missing a lower front tooth for a very long time. His previous dentist only offered him the choice of a removable tooth replacement. While a removable prosthesis can be an esthetically desirable temporary restoration, providing tooth support, ensuring retention, and preventing pressure on a grafted implant site, a dental implant can provide a more advanced replacement for a missing tooth.

A dental implant provided him with an esthetic and permanent solution to his problem. During the procedure, a small titanium screw was implanted into his jawbone, providing a highly biocompatible surface that encourages bone to attach to it during the healing process ensuring long-term success. The dental implant also creates stimulation to the underlying bone, preserving the integrity of the jaw. The implant is made of titanium which is very strong and is also naturally accepted by the body.

The implant was then restored with a ceramic crown resulting in a beautiful and natural-looking permanent restoration.

Everyone deserves a beautiful smile. With the advances in dental implants Philadelphia, there is no longer a need to settle for anything less. A beautiful tooth replacement like the one in this example can give you back the confidence you may have lost and transform your life. To learn more about this life-changing tooth replacement procedure, call Philadelphia Periodontist Dr. Stephen Brown (215) 735-3660 or visit him on the web at http://www.theperiogroup.com/. What are you waiting for? A beautiful smile is just a click away.

Montgomery County Man Chooses a Dental Implant Instead of a Bridge to Replace His Missing Front Tooth

Case Study #2 - The 3-unit Bridge vs. The Single Tooth Implant

3-unit bridges have traditionally been used to replace a single missing tooth. A bridge uses the teeth adjacent to the missing tooth to provide support for an artificial tooth that fills in the void left by the missing tooth. Although the goal of a bridge is to restore function and achieve an aesthetically favorable outcome, it does so at the expense of the bone under the replacement tooth. Because that space is no longer stimulated by chewing, bone in that area tends to get resorbed into the body, creating a gap between the replacement tooth and the gums.

Fortunately, a more state-of-the-art solution exists - a dental implant. Dental implants provide an esthetically pleasing single tooth replacement without compromising surrounding teeth. Now you can start over! With man-made, substitute tooth roots, Dr. I. Stephen Brown can offer you a unique and permanent solution to missing teeth that look, feel, and function just like natural teeth. These modern miracles of tooth replacement can be matched exactly to your own teeth, restoring your smile to its optimal state. Dental implants can be your doorway to renewed self-confidence and peace of mind.


This Philadelphia man suffered a fractured front tooth. He did not want his adjacent teeth cut down for crowns, or to be forced to wear a removable bridge. A dental implant provided him with a functional and cosmetically pleasing tooth replacement. Philadelphia Dental Implant Specialist Dr. Stephen Brown placed a titanium implant in order to attain a superior esthetic result, and since titanium is strong and naturally accepted by the body, the results will be long-term. The patient was incredibly pleased with the outcome.

To see more cases like this one or to learn more about Dental Implants Philadelphia, visit Dr. Stephen Brown on the web at http://www.theperiogroup.com/. Questions about whether you're a candidate for dental implants? Call 215.735.3660.

Philadelphia Dental Patient Chooses a Dental Implant to Replace Her Lost Tooth

Dental Implant Case Study #1

This Philadelphia dental patient lost her tooth due to a gum abscess. Periodontal abscesses usually happen in patients who have existing periodontal disease that is advanced enough to have resulted in bone loss around the root of a tooth. As destructive species of periodontal disease bacteria move into the gum pocket, byproducts of the bacteria cause more extensive bone destuction. Sometimes an obvious swelling is seen around the tooth as the infection around that tooth becomes more severe. This is called a Periodontal abscess.

This patient wanted a tooth replacement that looked, felt and functioned like a natural tooth. A dental implant filled the bill. It took one visit to place the implant. The procedure was painless. Alternative treatments would have involved cutting down her adjacent teeth or would have caused her to wear an uncomfortable, removable partial denture. She says the dental implant, placed by Philadelphia Dental Implant Specialist Dr. I. Stephen Brown, looks, feels and functions so naturally, she is unaware that she has had a tooth replaced.

Below are the before and after photos:

If have questions about this case or about having your own dental implant placed, contact Dr. I. Stephen Brown at the Perio Group 215.735.3660. To read more about Montgomery County dental implant placement, visit Dr. Brown's website at http://www.theperiogroup.com/.

Montgomery County Periodontist Provides Tooth Extractions Without Trauma

The offices of Periodontal and Implant Dentistry Specialist Dr. I. Stephen Brown are unconditionally committed to the lifelong retention of natural teeth in function and health. However, as a dental implant specialist, Philadelphia Periodontist, Dr. Stephen Brown is frequently faced with the difficult decision of how to most appropriately manage severely-compromised teeth from a periodontal or restorative standpoint.

The clinical challenges which result from the extraction of periodontally-hopeless teeth are profound. Treatment planning and atraumatic management of extration sites must focus upon the retention or re-creation of sufficient volume of bone and soft tissue and adequate crestal height and contours to achieve esthetic and functional restorations.

It is extremely important to envision a functionally and cosmetically acceptable tooth replacement and consider ridge preservation or immediate implant placement before the removal of any tooth. Patients are encouraged to consult with Dr. I. Stephen Brown regardging the most efficient way to handle such treatment and to click here to read more about atraumatic extraction and ridge preservation.

By anticipating the possibility of alveolar loss subsequent to the extraction of a tooth, Camden, NJ dental implant specialist Dr. I. Stephen Brown can also minimize the number of surgical procedures a patient may have to endure to achieve optimal treatment results.