prospectively engineered implant placement · prospectively engineered implant placement ......

CONTINUING EDUCATION

Prospectively Engineered Implant Placement

Volume 36 No. 4 10

Authored by Joseph J. Massad, DDS; David Wong, DDS; Russell A. Wicks, DDS, MS; Swati Ahuja, BDS, MDS; and David R. Cagna, DMD, MS

Upon successful completion of this CE activity, 2 CE credit hours may be awarded.

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does

not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment

and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.


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Dr. Cagna is associate dean of postgraduate affairs and professor and director of the advanced prosthodontics program at UTHSC College of Dentistry, Mem-phis. He received his dental degree from the Medical University of South Carolina and completed his residency training and master of science degree at the Univer-sity of Texas Health Science Center Dental School of San Antonio in 1994. He is a Diplomate and director of the American Board of Prosthodontics and a Fellow

of the American College of Prosthodontists. Dr. Cagna conducts an active intra-mural private practice in Memphis. A co-author of the textbook Stewart’s Clinical Removable Partial Prosthodontics, he has also authored numerous professional articles. He can be reached at [email protected].

Disclosure: Dr. Cagna reports no disclosures.

INTRODUCTIONA majority of problems associated with implant prostheses can be avoided by thorough treatment planning and understanding the prosthetic aspects of dental implants, screw joint mechanics, and forces placed on implant prostheses.1 Implant placement must be accurate and precise to fabricate long-lasting functional and aesthetic prostheses. Improperly positioned implants will lead to fabrication of poorly contoured or weak prostheses.1

Several factors must be taken into consideration during treatment planning implant placement, including the following:2 facial and dental anatomy; aesthetics; planned tooth positions; prosthesis design;3-5 key implant positions; occlusion; force factors; bone quality and density;6 implant number, size, and design; healing; loading conditions; ridge relationship; restorative space;7 and implant and prosthesis maintenance. “Prospectively Engineered Implant Placement” refers to the comprehensive process of implant rehabilitation that goes beyond previously coined terms surgically driven or prosthetically driven4,5,8 approaches. A prospectively engineered approach not only utilizes the above-stated factors but also incorporates the influences of intraoral muscles of the tongue, muscles of mastication, and facial expression while planning implant placement.

Dr. Wilfred Fish described the concept of neutral zone and recommended that the denture polished surface be contoured to adapt to the moveable muscles of the lips, cheek, and tongue.9 When the polished surface of the denture is contoured to conform to the shape and function of the tongue, cheeks, and lips (neutral zone), it aids in achieving retention and stability of the denture and improving speech and patient comfort.10,11 It is critical to consider the neutral zone as a guide for developing the contours of the polished surface of the mandibular denture and for determining the appropriate bucco-lingual positioning of prosthetic teeth.11 Cameograms are based on the concept of neutral zone and permit the identification of the spatial boundaries of an arch and external surface locations of the structural mass of a complete removable dental prosthesis in a dentate patient.12 The cameogram record helps delineate the available bucco-lingual restorative space for the prosthesis within the confines of the muscular parameters. When the cameogram records indicate the presence of additional buccal or labial space for the prostheses, implants can be planned in a more labial position. This labial positioning may help to gain

Prospectively Engineered Implant PlacementEffective Date: 3/01/17 Expiration Date: 3/01/20

Dr. Massad is an associate professor in the department of graduate prosthodontics at Uni-versity of Tennessee Health Science Center (UTHSC) in Memphis; an associate faculty mem-ber at Tufts University School of Dental Medicine, Boston; an adjunct associate faculty member of the department of comprehensive dentistry at University of Texas Health Science Center Dental School in San Antonio, Texas; and an adjunct pro-fessor in the department of restorative dentistry at Loma Linda University, Loma Linda, Calif. He has a private practice in Tulsa, Okla. He can be reached at [email protected].

Disclosure: Dr. Massad has received royalties from Nobilium and Ivoclar Vivadent.

Dr. Wong is in private practice in Tulsa, Oklahoma. He is a board certified peri-odontist and can be reached at [email protected].

Disclosure: Dr. Wong is a key opinion leader for Dentsply Sirona.

Dr. Wicks is professor and chairman of the department of prosthodontics at the UTHSC College of Dentistry. He received his dental degree from the UT and was in private general practice until 1990. He joined the UTHSC faculty after receiving a master’s degree and certificate in the specialty of prosthodontics from University of Texas Health Science Center Dental School at San Antonio in 1993. Since then, he has conducted prosthodontic research and directed the undergraduate curriculum in removable prosthodontics and dental implants at the university’s college of dentistry. He can be reached at [email protected].

Disclosure: Dr. Wicks reports no disclosures.

Dr. Ahuja is an adjunct assistant professor in the department of prosthodontics at UTHSC, Memphis. She is a prosthodontic consultant for Lutheran Medical Center, NY, and lectures internationally on implant overdentures, hybrid resto-rations, restorative space issues in implant overdentures, and the implementa-tion of CBCT in the dental practice. She can be reached via email at the address [email protected].

Disclosure: Dr. Ahuja reports no disclosures.

About the Authors


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additional vertical restorative space as well as complement a greater volume of available bone for the implants. Adequate restorative space is critical for fabrication of an optimally designed prosthesis.7 Fabrication of a prosthesis with inadequate restorative space may result in physiologically inappropriate contours, structurally weak prostheses, aesthetic compromise, encroachment into interocclusal rest space, and/or suboptimal retention and stability of the prostheses.7

CASE REPORTDiagnosis and Treatment Planning

A 46-year-old white female patient presented with a chief com-plaint of poor aesthetics, low self-esteem, and a loose maxillary fixed partial dental prosthesis along with pain, discomfort, and a bad mouth odor. She was very anxious and indicated that she wanted quick treatment, only for her maxillary arch and with a minimal number of surgical procedures.

She had been in 2 automobile accidents in the last 8 years with subsequent and reported severe neck and back injuries. She was taking several medications for pain control, which were prescribed by her physician. Her medical history was indicative of the following: (1) neuropathy complex regional pain syndromes type 2, (2) protruding cervical disc, (3) arthritis of the hands and knees, (4) pain-initiated hypertension, (5) dental infections, and (6) smoking.

Comprehensive assessment included performing detailed intra- and extraoral examinations and taking a series of full-mouth radiographs (Figures 1 and 2).

Diagnostic impressions were made for both the arches, and casts were generated. The diagnostic procedures revealed that the maxillary teeth were nonrestorable due to extensive caries, periodontal disease, and/or endodontic infections, and would need to be extracted.

The patient was informed that a few more procedures would need to be performed to develop the most appropriate treatment plan for her.

Recording the CameogramTreatment planning for an implant-supported prosthesis must begin with identifying proper prosthetic tooth positions.13 It is critical to evaluate and assess whether altering the position of the prosthetic teeth (compared to the natural teeth) would aid in improving aesthetics and function. It is also important to identify spatial boundaries (within the oral cavity) for an arch and relate this information to the design of the prostheses using the cameogram record.12 A maxillary cameogram was made utilizing a fast-setting rigid vinyl polysiloxane (VPS) impression material (Aquasil Rigid [Dentsply Sirona Restorative]). The lips were retracted bilaterally using metal retractors. The impression material was injected under the upper lip, spanning from the left tuberosity to the right tuberosity, filling the complete labial vestibule and covering the dentition (Figure 3).

The retractors were removed, and the patient was asked to pucker her lips outward and to smile forcibly to create a functional record. She was asked to perform these movements repeatedly until the impression material polymerized.12 Upon completion, the cameo gram was removed from the mouth and inspected (Figure 4).

A second cameogram was performed in the same manner and was compared to the first one to verify accuracy. There were no visible differences between the 2 records. A VPS putty index (Flexitime Easy Putty [Heraeus Kulzer]) was fabricated to surround the cameogram, oriented to an indexed position on the master cast (Figure 5).14

The space between the index and the maxillary teeth indicated that additional labial/buccal restorative space was available for the maxillary prosthesis, which would permit labial positioning of the maxillary prosthetic teeth and the denture base, and gaining extra vertical restorative space.

Aesthetic Evaluation A complete facial analysis was performed to evaluate the


Figure 1. Panoramic radiograph of the patient. Figure 2. (a) Pretreatment view of the maxilla and (b) pretreatment view of the mandible.

a b


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patient’s aesthetics and also to permit patient viewing and understanding of the factors affecting it. Included in the facial analysis were the midline position, amount of tooth display (at rest, smiling, and speaking), and the positon of the anterior occlusal plane and lip support.15 Intraoral examination revealed the presence of a deviated midline. The cameogram was placed in the mouth, and the midline was marked on it to be coincident with the facial midline. There was a lack of maxillary tooth display at rest, and minimal display during speech and complete animation (Figure 6). The distance between the relaxed labial vestibule and the relaxed upper lip length and the distance between the relaxed labial vestibule and the incisal edges of maxillary central incisors were measured with a transparent ruler and found to be 21.0 mm and 19.0 mm, respectively. The distance between the relaxed labial vestibule and the upper lip length during smile was 16.0 mm. In order to display 2.0 to 3.0 mm of maxillary anterior teeth at repose and at least 80% length of the anterior teeth during smile, the incisal edges would need to be lengthened by 3.0 to 4.0 mm (Figure 7).

The optimal occlusal vertical dimension and centric relation

were determined and recorded using the central bearing device (Massad Jaw Recorder [Nobilium]) mounted on formed trial denture bases (Figure 8).16,17 Then, the casts were mounted on a semi-adjustable articulator (Whip Mix 2240 [Whip Mix]) using a face-bow transfer and the centric relation record.

CBCT-Aided Treatment PlanningRadiographic markers were incorporated in the maxillary cameogram above the location of the teeth, on its gingival sur-face (Figure 9). Dual CBCT scans were accomplished.18 One scan (CBCT ProMax 3D [Planmeca]) was made of the patient with the cameogram placed in her mouth and another scan was made of the cast with the cameogram appropriately positioned on it (Figure 10). The 2 scans permitted digitization of the patient’s anatomy and the cameogram. The raw data obtained from the scans was then converted to Digital Imaging and Communica-tions in Medicine (DICOM) data and used for planning optimal implant positions and angulations (Figure 11a).

The CBCT data provided information on the available bone and bone density that aided in selecting the size and number of

Figure 3. Injection of vinyl polysilox-ane impression material (Aquasil Rigid [Dentsply Sirona Restorative]) in the labial vestibule and on the labial and occlusal aspect of maxillary teeth to form maxillary cameogram.

a b

Figure 4. (a) Upon completion of polymerization, (b) cameogram removed from the mouth and inspected.

a b

Figure 5. (a) Cameogram trimmed and placed on the cast, (b) putty index fabricated to sorround the cameogram on the labial/buccal aspect. (c) Removal of cameogram displays the additional available buccal/labial space for maxillary prostheses.

c


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implants and in planning implant positions, while considering the loading forces and occlusion. The implants were planned with a labial inclination, within the confines of the cameogram record. The prosthetic space availability (restorative space) was calculated at every planned implant location by mea-suring the distance between the alveolar crest and the occlusal plane.19 Due to insufficient prosthetic space availability, all the implants were planned to be positioned 4.0 to 5.0 mm subcrestaly (Figure 11b).

The subcrestal placement of implants aided in gaining the necessary space required for the implant attachments as well as for the overlying prosthesis.

Using the above considerations as a guideline, the final treatment plan was developed with input from the restorative dentist, implant surgeon, and the patient. The treatment plan included the following:

1. Cessation protocol for smoking20

2. Extraction of maxillary teeth and immediate placement of 5 implants (ASTRA TECH Implant System EV [Dentsply Sirona Implants]) in the positions of teeth Nos. 4, 6, 9, 11, and 13

3. Placement of an immediate re movable complete denture transitional prosthesis

4. Placement of a definite implant-supported removable dental prosthesis following the healing of implants.

Extractions and Implant SurgeryAfter obtaining patient consent, the maxillary and mandibular mounted casts, maxillary cameogram (Figure 12a), and putty index were sent to the lab-oratory along with detailed instructions for fab-rication of an immediate transitional prosthesis (Figures 12b and 13).

Given the patient’s anxiety, extractions and implant surgery were performed under general and local anesthesia. Prior to surgery, a 3-D stereolithic surgical guide was acquired for the patient using the data generated during implant planning (Anatomage Guide [Anatomage]) (Figure 14).

Following extractions of the maxillary teeth, the surgical guide was placed and fixated to the premaxilla. The implants were placed with a flapless procedure using the surgical guide. Per the planning, all the implants were placed 4.0 to 5.0 mm apical to the crestal bone. Once the implants were placed,

minimal flap reflection was utilized to reduce the crestal bone up to the level of the implant platforms with rotary instrumentation. Bone graft material (SYMBIOS [Dentsply Sirona Implants]) was used to graft the voids around the implants. Healing abutments were then placed and the flaps were closed with 4-0 Vicryl Sutures (Figure 15a).

The immediate transitional complete removable prosthesis

a b

Figure 6. (a) Lack of maxillary tooth display at rest. (b) Minimal tooth display during complete animation.

a b

Figure 7. (a) Distance between the relaxed labial vestibule and the relaxed upper lip length measured 21 mm with a transparent ruler. (b) Distance between the relaxed labial vestibule and the incisal edges of maxillary central incisors measured 19 mm with a transparent ruler.

Figure 8. Centric relation record at the pre-determined occlusal vertical dimension reg-istered with the central bearing device.

Figure 9. Radiographic markers incorpo-rated in the cameogram above the location of the teeth, on the gingival surface.


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was relined with a soft material (MucoSoft [Parkell]) and placed in the patient’s mouth following the extractions, implant placement, and individual osseous reductions. At the 24-hour postoperative recall appointment, the patient had minimal swelling and discomfort. Sutures were removed at 2 weeks, and the patient reported that postoperative healing was uneventful. However, at week 3, the patient developed pain associated with the implant in position of tooth No. 4 and it was removed one week later. The patient was asked to return after 4 months for the fabrication of the definitive restoration.

Fabrication of Definitive RestorationThe implants were allowed to heal for 4 months. The patient pre-sented with good tissue health, with no apparent trauma caused by the transitional denture (Figure 15b).

Primary impressions, definitive impressions, maxilloman-dibular jaw relationship records, and wax try-in procedures were accomplished following current best-practice procedures.21,22 A definitive maxillary re movable dental prosthesis with an open palate design, supported by nonsplinted LOCATOR attachments (Zest Dental Solutions), was planned for the patient.

The maxillary implants could not be planned and/or

placed parallel to each other due to the limited amount and labial inclination of the maxillary bone. There was a 30° to 35° divergence between the maxillary implants, making it challenging to fabricate a removable dental prosthesis supported by nonsplinted attachments. The divergence between the implants would affect the retention and the longevity of the nonsplinted attachments. Hence, newly introduced LOCATOR R-Tx abutments (Zest Dental Solutions)—said to handle implant divergence of up to 60°—were used as attachments for the implants in position Nos. 6, 9, and 11, and a standard LOCATOR abutment was used for the implant in position No. 13. The respective LOCATOR abutments were attached to the implants intraorally and torqued as per manufacturer’s recommendations (Figure 16).

A metal framework was incorporated in the maxillary implant-supported removable dental prosthesis to reinforce and strengthen it (Figure 17).23,24

The prosthesis was inserted in the mouth, and its fit and the occlusion were evaluated and adjusted. The retentive housings of the respective attachments were directly picked up in the prosthesis, and it was finished, polished, and placed in the patient’s mouth. The patient was given oral hygiene demonstrations

a b

Figure 10. Dual CBCT scans taken. (a) One scan was made of the patient with the cameogram placed in the patient’s mouth (b) and another scan was made of the cast with the cameogram appropriately positioned on it. (c) The 2 scans permitted digitization of the patient’s anatomy and the cameogram.

c

a

Figure 11a. Implants were planned with a labial inclination: right lateral view, frontal view, left lateral view.


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and provided with the cleaning aids25 necessary to maintain hygiene of the prosthesis and the oral cavity including the LOCATOR abutments.26 She was also given a printed copy of detailed home-care instructions and placed on a 6-month recall schedule. The patient was pleased with the retention, stability, and aesthetics of the definitive prosthesis (Figure 18).

CLOSING COMMENTSThe planned tooth positions in the definitive resto-ration,2 anatomy of bone,6 occlusion,27 and forces of mastication6 are taken into consideration when planning implant locations and orientations. The planned tooth positions in the definitive restoration should not only be based on aesthetics, phonetics, and occlusion, but also on the available bucco-lin-gual space as determined by the muscles of masti-cation, facial expression, and the tongue. In dentate patients, the extent of this space can be determined by the cameogram that records the physiologic dy-namics of oral and perioral muscle function and aids in identification of optimal denture tooth po-sitions and development of appropriate prosthetic contours.12

In this case, recording the CBCT scans with the cameogram record (in the mouth and on the cast) enabled viewing of the additional labial/buccal restorative space while planning implant locations. The availability of this additional buccal/labial restorative space permitted planning the implants in a more labial position, thereby providing additional restorative space. The use of the cameogram in con-junction with the CBCT imaging was a vital part of the treatment planning process in the case described herein as it aided in saving time and incorporating a digital workflow into the implant and prosthesis planning, osseous surgery and/or fabrication, and the delivery of the definitive prosthesis.F

References1. Chee W, Jivraj S. Failures in implant dentistry. Br Dent J. 2007;202:123-129.2. Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby

Elsevier; 2008:105-177.3. Salama H, Salama MA, Li TF, et al. Treatment planning 2000: an esthet-

ically oriented revision of the original implant protocol. J Esthet Dent. 1997;9:55-67.

4. Garber DA. The esthetic dental implant: letting restoration be the guide. J Am Dent Assoc. 1995;126:319-325.

5. Garber DA, Belser UC. Restoration-driven implant placement with res-toration-generated site development. Compend Contin Educ Dent. 1995;16:796-804.

6. Bryington M, De Kok IJ, Thalji G, et al. Patient selection and treatment planning for implant restorations. Dent Clin North Am. 2014;58:193-206.

7. Ahuja S, Cagna DR. Classification and management of restorative space in edentulous implant overdenture patients. J Prosthet Dent. 2011;105:332-337.

8. Katsoulis J, Pazera P, Mericske-Stern R. Prosthetically driven, comput-er-guided implant planning for the edentulous maxilla: a model study. Clin Implant Dent Relat Res. 2009;11:238-245.

9. Fish EW. Using the muscles to stabilize the full lower denture. J Am Dent Assoc. 1933;20:2163-2169.

Figure 13. Development of the immediate transitional prosthesis.

b

Figure 11b. All the implants were planned to be positioned 4.0 to 5.0 mm subcrestaly.

a b

Figure 12a. Maxillary cameogram with the midline marked on it.

Figure 12b. (Left) Prosthetic teeth set in a more labial position within the confines of the putty index. (Right) Incisal edges of the maxil-lary anterior teeth were lengthened by 3.5 mm.


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10. Beresin VE, Schiesser FJ. The Neutral Zone in Complete and Partial Den-tures. 2nd ed. St. Louis, MO: Mosby; 1978:15,73-108,158-183.

11. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone revisited: from histor-ical concepts to modern application. J Prosthet Dent. 2009;101:405-412.

12. Massad JJ, Cagna DR, Wicks RA, et al. Cameograms: a new technique for prosthodontic applications. Dent Today. 2016;35:80-85.

13. Cooper L, De Kok IJ, Reside GJ, et al. Immediate fixed restoration of the edentulous maxilla after implant placement. J Oral Maxillofac Surg. 2005;63(9 suppl 2):97-110.

14. McDonald GT, Larsen HD. Laboratory procedures for the neutral zone den-ture technique. Quintessence Dent Technol. 1985;9:287-290.

15. Bidra AS. Three-dimensional esthetic analysis in treatment planning for implant-supported fixed prosthesis in the edentulous maxilla: review of the esthetics literature. J Esthet Restor Dent. 2011;23:219-236.

16. Massad JJ, Ahuja S, Verma M. Treating a failing dentition: stable implant-sup-ported removable restorations. Dent Today. Jan 2014;33:134-139.

17. Massad JJ, Ahuja S, Verma M. Consideration of aesthetic and restorative spaces: a protocol for the fabrication of definitive implant-supported overdentures. Dent Today. Oct 2014;33:134-140.

18. Greenberg AM. Dental implants and evolving discipline. Oral Maxillofac Surg Clin North Am. 2015;27:ix-x.

19. Ahuja S, Cagna DR. Defining available restorative space for implant overden-tures. J Prosthet Dent. 2010;104:133-136.

20. Bain CA. Smoking and implant failure—benefits of a smoking cessation protocol. Int J Oral Maxillofac Implants. 1996;11:756-759.

21. Zarb G, Hobkirk JA, Eckert SE, et al. Prosthodontic Treatment for Edentulous Patients: Complete Dentures and Implant-Supported Prostheses. 13th ed. St. Louis, MO: Mosby; 2013:161-254.

22. Rahn AO, Ivanhoe JR, Plummer KD. Textbook of Complete Dentures. 6th ed. Shelton, CT: People’s Medical Publishing House; 2009:85-228.

23. Rodrigues AH. Metal reinforcement for implant-supported mandibular overdentures. J Prosthet Dent. 2000;83:511-513.

24. Ahuja S, Jain V, Cagna D, et al. Fabricating a mandibular implant supported overdenture with a suspended framework. J Indian Prosthodont Soc. 2013;13:132-136.

25. Cagna DR, Massad JJ, Daher T. Use of a powered toothbrush for hygiene of edentulous implant-supported prostheses. Compend Contin Educ Dent. 2011;32:84-88.

26. Ahuja S, Wicks R, Selecman A. Fabrication of new restorations with a con-sideration of oral hygiene. J Indian Prosthodont Soc. 2016;16:307-310.

27. Nikolopoulou F, Ktena-Agapitou P. Rationale for choices of occlusal schemes for complete dentures supported by implants. J Oral Implantol. 2006;32:200-203.

Figure 14. A 3-D stereolithic surgical guide.

a b

Figure 15a. Panoramic radiograph depicting the placement of 5 maxillary implants.

Figure 15b. Healthy tissues with no apparent trauma caused by the transitional denture.

Figure 16. LOCATOR abutments (Zest Den-tal Solutions) attached to implants in posi-tion of Nos. 6, 9, 11, and 13.

Figure 17. Definitive maxillary removable dental prosthesis: (left) occlusal view, and (right) lateral view.

Figure 18. Patient’s smile with the defini-tive prosthesis.


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1. Improperly positioned implants will lead to fabrication of poorly contoured or weak prostheses.

a. True b. False

2. It is critical to consider the neutral zone as a guide for developing the contours of the polished surface of the man-dibular denture and for determining the appropriate bucco-lingual positioning of prosthetic teeth.

a. True b. False

3. The cameogram record helps delineate the available verti-cal dimension for the prosthesis within the confines of the muscular parameters.

a. True b. False

4. Treatment planning for an implant-supported prosthesis must begin with identifying proper prosthetic tooth positions.

a. True b. False

5. The prosthetic space availability (restorative space) was

calculated at every planned implant location by measuring the distance between the alveolar crest and the occlusal plane.

a. True b. False

6. In the case described in this article, the implants were allowed to heal for one full year before any further work could begin.

a. True b. False

7. In the clinical case in this article, there was a 30º to 35º divergence between the maxillary implants, making it very easy to fabricate a removable dental prosthesis supported by non-splinted attachments.

a. True b. False

8. The use of the cameogram in conjunction with the CBCT imaging was a vital part of the treatment planning pro-cess in the case described.

a. True b. False

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