Supporting Success in Implant Therapy

Due to the technique’s high success rate, dental implant therapy is an increasingly popular option to replace missing teeth. As is the case in all dental procedures, dental implants are not risk free. Prior to beginning implant therapy, a full assessment should be completed, including but not limited to taking a detailed patient history and consulting with specialists in order to formulate a comprehensive treatment plan. Planning for prosthetically and surgically driven implant placement with the use of a diagnostic wax up and surgical guide supports optimal implant treatment planning. Diagnostic images—such as cone-beam computed tomography (CBCT)—have become the gold standard for evaluating potential surgical sites. Post-surgical complications—although rare—can occur, and every effort should be made to avoid them, or, if prevention is impossible, monitor closely. This edition of the American Academy of Periodontology’s “The Team Approach” E-Newsletter will provide clinicians with the key elements required both pre- and post-implant placement to achieve the best possible outcomes.

Diagnostic Data Collection

A thorough medical and dental history that includes the patient’s current and previous medication usage and any allergies is fundamentally important to successfully planning any surgical procedure. Patients with certain medical conditions, such as diabetes, hypertension, and osteoporosis, and those taking medications, such as antihypertensives, bisphosphonates, selective serotonin reuptake inhibitors, and proton pump inhibitors, require a more in-depth evaluation in order to determine risks posed by surgery.^1–8 Following this discussion, clinical data are captured through radiographic and clinical assessment. Radiographic data should be collected via a combination of full-mouth radiographs, panoramic radiographs, and/or CBCT as recommended by the European Academy of Osseointegration and the Academy of Osseointegration, while remaining conscious of the ALARA (as low as reasonably achieved) principle.^9,10 Clinical assessment consists of a full periodontal charting, soft tissue evaluation (gingival biotype and adequacy of attached keratinized gingiva), status of existing restorations (caries risk and etiology of missing teeth), occlusion evaluation, temporomandibular joint evaluation, and oral cancer screening.^11–18

Whether the clinician is the sole provider for implant therapy or the surgeon/restorative dentist, the restorative phase should be considered at this time. To aid in the restorative process, photographs should be taken of the patient’s full face, with smile, frontal, and lateral reviews with teeth in occlusion and resting, as well as occlusal views (referenced on photographs at implant assessment). Impressions and bite registration should be sent to the lab for diagnostic cast fabrication and a radiographic template, which will be used for the CBCT scan. Also, the tooth shade, shape, and size of the restoration can be determined at this time.

Risk Factors

Several risk factors can contribute to the success and failure of implant surgery. These can be divided into general risk factors, esthetic risk factors, and occlusion risk factors. General risk factors include: compromised medical condition, smoking, presence of periodontal diseases, small jaw opening, poor oral hygiene, vertical bone resorption, reduced vertical distance between bone crest and opposing tooth, and chronic lesions distant from proposed implant site.^8,19–21 Esthetic risk factors include: high maxillary or low mandibular gingival smile line; thin gingiva, causing high possibility of recession; poor oral hygiene; papillae of adjacent teeth (if long and thin, complete regeneration is difficult to achieve); position of interdental contact (contact < 5 mm from bone margin, regeneration takes place in practically all cases, but chances decrease as the distance increases); existence of adjacent implant (difficult to achieve papillary regeneration between two implants because of absence of bony septum); and vertical bone resorption (leading to deep implant placement and more difficult papillary regeneration).^22–24 Occlusion risk factors include: bruxism, clenching, tongue thrusting, tongue size, optical implant positioning (improper position or angulation leading to bone and soft tissue loss), unbalanced occlusion, and posterior bite collapse.^25–28

Cone-Beam Computed Tomography Evaluation

Effective assessment of a CBCT scan depends on the proposed implant placement in either the maxilla or mandible. With a mandibular implant placement, the evaluation of the inferior alveolar nerve, mental nerve, and incisive mandibular canal for their respective positions, paths, and diameter is important.²⁹ The anatomy of the alveolar ridge/bone should be assessed for potential undercuts (crestal ridge irregularities, suborbital, submandibular fossa, subdigastric fossa).³⁰ Any possible pathologies in the bone or the nerve canals should be evaluated in addition to any root remnants at the proposed implant site(s).³¹ Finally, evaluating the alveolar dimensions in both height and width for single or multiple implants is necessary. With a maxilla implant placement, the location of the incisive foramen and the greater palatine artery must be determined.³² The distance available for implant placement under the sinus floor and nasal floor and the potential existence and location of septa or soft tissue pathologies in the sinus should be considered.³³

Post-Implant Surgery Considerations

After the implant surgery for a single or multiple implants, comprehensive and thorough post-operative instructions should be provided. If appropriate, medications should be prescribed (antibiotics, analgesics, and chlorhexidine rinse) with directions.³⁴ Patients should be advised to avoid sucking liquid through a straw and smoking.³⁵ They should be informed that swelling, pain, and ecchymosis at the surgical site are all common occurrences post-implant surgery.³⁶ Patients should avoid wearing a provisional prosthesis for 2 weeks after implant placement. After the 2 weeks, a provisional prosthesis can be worn, but not while eating and not overnight.³⁷ Brushing or flossing near the surgical site should be avoided for a few days. In immediate loading cases, mastication on implant crown should be avoided for 6 weeks to 8 weeks.³⁸

Sutures will be removed 2 weeks post-surgery. Patients should be advised to call the office if they experience fever, excessive bleeding, unusual pain, or reaction to medications. If a sinus lift procedure was performed, patients should not blow their nose for 2 weeks, as this creates pressure and spreads air through confluent soft tissue planes, creating soft tissue emphysema. Patients should try not to sneeze or cough. If such is unavoidable, patients should keep their mouths open to decrease internal natural pressure and elevate their heads to prevent airway obstruction and aspiration of blood and saliva, and diminish edema. If a sinus communication has occurred during surgery, patients should avoid swimming and strenuous exercise for at least 1 week. If a sinus communication persists, a second procedure may be required to close communication. If a block graft is performed, contact sports and toothbrushing should be avoided immediately after the surgery, but can be resumed the second day after surgery.

Conclusion

Although we have much to learn about potential implant therapy complications, this summary of pre- and post-implant surgery complications can serve as a guide for clinicians. Remaining abreast of new research regarding implant complications will help clinicians prepare for potential problems and help improve patient outcomes and implant success rates.

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