[CN] 3

[CH] Diagnosis and Treatment Planning

Lars Holleander

Michael R. Arcuri

Brien R. Lang

[AU: Please confirm that each figure is called out in the appropriate place. Also, please verify that the hierarchy of headings is correct; it was not always clear.], DDS, MS

PATIENT SELECTION

Varying degrees of functional, esthetic, and psychologic impairment can result from the loss of one tooth to the loss of the entire dentition. Fortunately, in most of these situations, dental therapy is available that can be used for the rehabilitation of those patients who experience such a loss. The placement of a dental implant with predictable success followed by prosthetic rehabilitation is a therapy method that can be applied to the treatment of an edentulous space. In fact, it is an obligation on the part of the clinician to offer implant therapy to a patient as a treatment option should if conditions indicate that the patient is a candidate for such treatment. The decision on as to whether or not an implant therapy is a treatment n option or the selection of for a patient for this form of therapy requires can be made by adheringence to athe data- gathering process as outlined in Box 3-1.

The key to the success forf any dental treatment recommended is a well-organized and well-performed data gathering process. This process is best performed when the clinician follows sequential steps in gathering information, which gathering that begins at the initial patient examination appointment. The assembled information assembled, combined with a diagnostic mounting of dental casts made of the patient’s’ arches, will be used to differentiate between patients that who can be best served by placement of implants from and those who cwould be better served by conventional prosthodontic therapy. If implants are selected as an appropriate treatment option for the patient, the information gathered throughout this process will also assist in the selection of the surgical protocols to be followed and define the needed prosthodontic therapy.

[A]Patient Examination

A great deal of important information can be obtained during the initial examination about the overall demeanor and attitudes of the patient. For example, the patient who presents the clinician with a bag of recently fabricated prostheses, or who wears mismatched sets of dentures at the examination appointment, may have unrealistic expectations. Patients who claim they have “special needs” and express great doubt that anyone can successfully treat them are poor candidates for implants. These types of patients may also turn out to be successful implant patients, but they may require additional diagnostic procedures prior to implant therapy.

Patient Examination Appointment

The patient’s past medical and dental history,; the examination of the hard and soft tissues examination; and, radiographic evaluations, including panoramic, cephalometric, periapical and occlusal films, and possibly tomographic or (CT)computerized tomographic (CT) scans of the jaw(s) under consideration, provide valuable diagnostic information needed for optimal treatment planning.

[B]General hHealth

A thorough review of the medical history is important to determine if whether a patient is a candidate for dental implants. Certain medical conditions may preclude the patient from undergoing implant treatment. Any disease process that would compromise complete healing should exclude a patient from implant therapy. Diabetes, osteoporosis, and cardiac and vascular diseases might immediately come to mind as potential conditions of concern; however, these diseases, when controlled, have not been reported as contraindicating implant treatment.¹ [AU: Is Laney and Tolman 1989 the correct citation here? The references were not numbered in the original manuscript.] When present, these conditions require only that conventional precautions be followed throughout surgical intervention and prosthetic care to enassure success. Neither age nor prolonged steroid medications are considered factors that would eliminate a patient from implant therapy.

[C]Medical contraindications

. Medical contraindications primarily concern the ability of the patient’s tissues to heal. Implants should not be placed while a patient is undergoing treatments that cause a systemic impairment of healing, such as chemotherapy for the treatment of cancer and antimetabolic therapy (eg, methotrexate) for the treatment of arthritis. Patients who suffer from uncontrolled diabetes should also forego implant treatment until the disease is properly managed, as should patients with seriously impaired cardiovascular function. Active addictions to drugs, including alcohol, should also be considered medical contraindications to treatment with implants.

Patients with a history of radiation therapy to the maxillomandibular region should not be considered for implant treatment under routine protocols. Implants may be successfully placed in irradiated bone, but the procedures for placement and restoration of the implants are still in the investigative phase of development.

[C]Psychiatric contraindications

. Psychiatric contraindications are often the most difficult ones to identify. These conditions may be undiagnosed or unreported by the patient. Blomberg has identified the following as psychiatric contraindications to treatment.²

• Psychotic syndromes, such as schizophrenia or paranoia

• Severe character disorders and neurotic syndromes, such as hysteria and borderline personality disorders

• Dysmorphophobia (an irrational fear of deformity), and or patients with extreme and unrealistic expectations and demands regarding the cosmetic results of the operation, rather than the effects of retention problems

• Syndromes of cerebral lesions and presenile dementia

• Alcohol or drug abuse, if not diagnosed with great certainty as secondary to the oral problem.

Patients with impaired psychological function and personality patterns of avoidance behavior should be thoroughly reviewed examined by appropriate medical colleagues before they are accepted as implant candidates. Psychiatric disorders such as psychotic tendencies and severe neuroseis are general health conditions that should cause the dentist clinician to question implant therapy as the treatment of choice for these patients. Drug abuse and chemical dependency are habits that probably would prevent impair patients' compliance and limit their oral hygiene motivation, which that are needed for any complex reconstruction, including those involving dental implants.

Patients in reasonably good general health and who appearing psychologically stable are good candidates for implants. Above all else, patients must demonstrate that they are motivated to pursue treatment and that they will cooperate with recommendations made by the treating clinician(s).

[B]Dental Hhealth

The dental history may give some insight to the patient’s previous prosthetic experiences, dental knowledge, and expectations. Pretreatment evaluations of the dental health of a patient may vary as performed by different clinicians. However, the following steps must be considered because of their importance in diagnosis and treatment planning.

• Examination of Ssoft and hard tissues examination.

• Imaging, including but not limited to Rradiographicic examinations and photographss

• Diagnostic mounting.

[C]Examination of Ssoft and hard tissues examination.

The condition of the mucous membranes, the health of the jaws, and the status of the teeth are the primary local health factors to be considered in the soft and hard tissues examination. Healthy oral mucosa is a required criterion iforn implant placement, and any soft or hard tissue pathosis must be dealt withtreated before implant therapy can be considered. Herpetic stomatitis, candidiasis, denture- induced stomatitis, and hyperplastic tissues are conditions that negatively influence treatment success. Tooth impactions, bone cysts, root fragments, and residual bone infections contraindicate implant therapy, and the presence of a benign bone tumor in the jaw would also eliminate a patient from implant treatment until these conditions are treated.

Every edentulous space has thecan potentially be of being restored with dental implants. However, all reasonable types of prosthetic reconstructive procedures must also be considered during the examination. Implants are one option among the prosthodontic services available. The prosthetic choices are influenced by the adjacent teeth with respect to their periodontal health and the presence or absence of existing restorations. The pulp health, presence of caries, esthetic requirements, and shape, and contours, and bone density of the residual ridge in the edentulous space can also affect the decision on about which treatment option to suggest to the patient.. The alignment and orientation of the adjacent teeth can be an influence on whether to restore the edentulous space using a conventional fixed partial denture or to restore the space using implants.

The oral examination should include measurements of any edentulous spaces.^{3 3} [AU: Is Lekholm and Jemt 1989 in fact the correct reference here? The reference list was not numbered in the original manuscript.] A spaces of 7.0 mm in width between neighboring teeth is considered necessary for single implant placement of single implants that are 3.75 mm or 4.0 mm in diameter. Where spaces exist that are only 5.0 to 6.0 mm in width, narrower implants are available for these conditions. If the space available is a concern and could potentially compromise therapy, then implants should not be the treatment option placedselected.

A minimum vertical distance from the mucosa to the opposing dentition is needed for the implant prosthetic components. In some situations, the space available will be adequate for a transmucosal or abutment component followed by the placement of a conventional crown onto the abutment. Other situations may necessitate the design of an implant prosthetic crown that originates at the implant level as a single unit in order to accommodate the available vertical space. In situations with a greatly resorbed ridge, a greater vertical height in the edentulous space will result in the need for a very long prosthetic unit or clinical crown, which may compromise the eventual esthetic results. This is essential diagnostic information is essential needed for the development of a treatment plan to be presented to the patient.

Good oral hygiene is necessary for long-term implant success, but completely or partially edentulous patients with extremely poor oral hygiene should need not necessarily be excluded from implant treatment. After educating such patients are educated about the significance of good oral hygiene, however, it is advisable that the patient be subjected to a trial period of several months to demonstrate good oral hygiene practices. If the patient achieves and maintains adequate hygiene levels during this time period, the patient could then be considered for implant treatment.

[C]

Radiographic ExaminationImagings

[C]Imaging modalities

It is important to perform a radiographic survey during the initial patient evaluation. The initial radiographs may include but are not limited to panoramic, occlusal, and periapical radiographs. The quantity and quality of jawbone are two important factors to consider in patient selection for implant therapy (see Boxes 3-2 and 3-3).⁴ A panoramic radiograph is the first step in evaluating bone in the potential implant site (Fig 3-1); however, definitive determination of the quantity and quality of bone should not be made from this film alone. The nature of the cortical and cancellous portion of the bone sites cannot be accurately detected from the orthopantomogram, and there are also significant distortions in the spatial relationships with this type of radiograph.

The lateral jaw cephalogram gives a better indication of the thickness of cortical bone and the amount and nature of cancellous bone in the midline (Fig 3-2). There is also less spatial distortion with the cephalogram as compared tothan with the panoramic film. The cephalogram provides valuable information about the contour of the anterior alveolar ridge, the prominence of the genial tubercle, the location of the mandibular canal and mental foramina, and the patient's jaw relationships. An occlusal film will give some information about the width of the bone in the implant placement site.

The periapical radiographic survey provides valuable information about the health of the remaining teeth, root form and contours, and bone support around teeth. Additional radiographic analysis may include the use of computerized tomography (CT). All of this radiographic information is extremely important in decisions regarding implant treatment and the overall treatment plan for the patient.

Irrespective of the imaging modalities applied, it is very important that the radiographic technicians and other practitioners involved in the radiologic part of the implant treatment have adequate training and understanding of the principles of successful imaging. It is particularly important to be able to identify images of suboptimal quality, through which erroneous information might be obtained about dimensions and locations of critical structures.

[D]Panoramic radiography

The panoramic radiograph gives provides an enlarged image of the jaws. Usually the magnification factor is between 1.25 and 1.30 for ordinary panoramic radiographs. This magnification factor is valid only for the central parts of the layer in focus (focal trough). Outside this central part, the vertical and horizontal magnification will increases in those parts areas that are closer to the radiation source and decreases in parts areas that are closer to the film. The change in vertical magnification is less smaller than that in the horizontal. Furthermore, the change in horizontal magnification is greater in the anterior region than in the posterior. Since many patients are not placed ideally in the panoramic machine, horizontal dimensions in the panoramic image may deviate significantly from the true dimensions. Vertical dimensions are more reliable, but apart from the influence byof patient positioning, the anatomical shape of the jaws may introduce errors due toas a result of the projection angle (from below) of the panoramic machine and the angle or shape of the alveolar process. For instance, the vertical dimension of the alveolar process in the anterior region of the mandible and in the posterior region of the mandible may be exaggerated in the panoramic radiograph due to the angle of the symphyseal region in the sagittal plane. Similar exaggeration of the vertical dimension may occur and in the posterior region of the mandible, due to the projection of the lingual “shelf” of bone in the posterior mandible above the real superior border of the alveolar ridge. [AU: Please review the previous two sentences carefully for accuracy. The original single sentence was unclear to me.] Also, the buccal location of the mental foramen may create an overestimation of the distance between the alveolar crest and the foramen, since the crest is usually more lingual and therefore will be projected more superiorly. On the other hand, a lingual location of the mandibular canal may lead to an impression of a shorter distance between the canal and the alveolar crest. Also, the position of the genu of the mandibular canal can be projected more anteriorly than in reality, particularly if the patient is placed forward in the panoramic machine. The panoramic radiograph also offers an image with less geometric resolution than the intra-oral radiograph, which means that some of the bony trabeculation seen in the intra-oral radiograph will not be lost apparent in the panoramic radiograph.

[D]Conventional tomography

Cross-sectional images of the jaws should be obtained with the tomographic plane at right angles to the buccal and lingual plates and at a right angle to the vertical long axis of the jaw section (Fig 3-3). Deviation from this requirement will cause geometric distortion and consequently provide erroneous information about jaw dimensions and the locations of critical structures relative to the alveolar crest. It will also impair the identification of the borders of the jaw in the radiographs. Small deviations from the ideal are of less importantce. However, significant deviations can occur in the premolar regions of the maxilla with regard to the position of the floor of the maxillary sinus, since the floor often curves upwards and thus will not be imaged at a right angle. The thickness of the sharp image layer should be between 2 and 4 mm. The advantage with thinner layers is that structures not belonging to the layer are blurred more efficiently than when thicker layers are used. The advantage with thicker layers is that structures that may not produce enough contrast to be seen in thinner layer images will be visible in the thicker layer images. For instance, the mandibular canal may be identified unequivocally in a 4- mm-thick tomographic layer but not— or more ambiguously— in a 2- or 1- mm- thick layer.

In conventional tomography, dense structures outside the tomographic layer, such as teeth, will cause “ghost images” and may at times compromise identification of the true shape and confines of the alveolar bone. Also, a thick, dense cortical plate will produce a diffuse dense structure around the “real” image of the cortical plate, compromising preventing the identification of the true borders of the section and causinga misinterpretation of the width of the cortical plate. All tomographic images are enlarged (typically between 1.25 and 1.5 times), andso measurements of dimensions have tomust be adjusted to obtain real actual values.

[D]Computerized tomography

This imaging modality renders tomographic images of the jaws in practically any direction, usually with usually easily identifiable borders of the alveolar bone and anatomical structures such as the mandibular canal (Fig 3-4). Usually axial sections are obtained directly from a contiguous helical scanning and are used thereafter used for reconstructions of desired imaging planes of the implant regions. As with conventional tomography, these planes should be at right angles to the buccal and lingual cortical plates and at a right angle to the vertical long axis of the jaw. There are no disturbing ghost imagesing from structures outside the imaged section in computerized tomography, but when structures with very high density such as metal objects are located within the imaged section, disturbing artifacts are produced that may render the image useless. Most computerized tomographyCT imaginge software will give actualreal (not distorted or enlarged) values for dimensions. Depending on the window used for the CT images, the width of the cortical bone will vary. So-called volume averaging may introduce minor errors, which are probably of little consequence for treatment planning.

[D]Photographs

Intraoral and extraoral photographs have proven invaluable as a record of the conditions that existed before treatment began. Obviously, they are also important as a visual record during the treatment planning stages of implant therapy.

[D]Preimplantation imaging

In all pre-implantation imaging procedures, an imaging guide or stent should be used where to indicate not only the site location fofr the intended implant is indicated but also the ideal direction of the implant. Such guides need to must be made customized to the imaging modality. Thus the guide typically used for CT, with crown replicas in acrylic containing a contrasting agent such as Bbarium, is not soas well suited for conventional tomography, because the image of such a crown will be superimposed on the blurred images of neighboring crowns or crown replicas. For conventional tomography, small metallic rods, are better suited or crown replicas in acrylic with a thin lead foil glued to itsthe surface, are better suited. Also, if several implants are planned for the same jaw sectionarea of the jaw, the guide for each individual implant site should have a unique shape or feature so that it cannot be confused with other guides if conventional tomography is used.

The pre-implantation imaging aims at identification of pathologic changes in the regions intended for implants, assessment of bony structures and dimensions, and the location of important anatomic structures, such as the mandibular canal, mental foramen, and floor of the maxillary sinus. To accomplish this, a radiographic three-dimensional evaluation is needed in the majority of cases. A three-dimensional evaluation will also provide information about the buccal and lingual contours of the bone, including concavities and irregularities that may interfere with successful implant placement. In many cases, such information may result in the use of implants of different dimensions, versus implants that were planned with only a two-dimensional evaluation.

Typically, panoramic and/or intraoral radiographs are combined with tomographic images, which render cross-sectional views of the implant region. Panoramic and lateral (cephalometric) radiographs of the jaws can be used to obtain adequate three-dimensional information regarding the anterior regions of the maxilla and mandible. CT is frequently applied to obtain cross-sectional images of the jaws, but conventional tomography can give the desired cross-sectional information at a lower cost, and many times also at lower doses of radiation.

[D]Post-implantation imaging

The principles of post-implantation imaging are not different from those applied for the x-rayradiographic examinations of the ordinary dental patient. However, there seems to be a documented need for checking the fit between abutment and implant after abutment connection. This is best done by using intra-oral radiographic film with a beam direction that is optimal favorable for detecting a misfit between implant and abutment. Individual images may be required for optimal assessment of individual implants may require individual images in order to obtain optimal imaging. If implants are threaded, an optimal image would show the threads clearly and equally depicted on both sides of the implant (Fig 3-5). Deviations from the ideal beam direction will result in overlap of the threads, creating a diffuse image of them, and depending on the direction of the beam one side will show more “blurring” or overlap than the other, depending on the direction of the beam. For Brånemark-type [AU: “type” OK? Or should this be more generalized—eg, “standard threaded 2-stage implants”? Or do you mean specifically Brånemark System implants only?] implants, the left side of the implant will show more overlap when the radiation is directed from below compared versusto the ideal beam direction. This means that implants in the upper jawmaxilla will show more overlap on the right side than the left if the beam was directed more from above than the ideal beam direction.

Radiographic examination may also be warranted when the implant prosthesis is placed to check the fit between the components, including that between implant and abutment.

Routinely Rrepeated radiographic examinations of implants are not warranted, but a one1-year follow-up examination to establish the level of the alveolar bone around the implants appears to be desirable. Thereafter, cClinical signs and symptoms shwould thereafter be the factors that govern the timing of future radiographic examinations (Figs 3-6a to 3-6c);. Tthere seems to be no need for annually repeated x-ray radiographic examinations of implants.

In a few cases there may be a need for a three-dimensional evaluation of an implant, for instance, to demonstrate the relationship between the implant and critical anatomical structures, such as the mandibular canal, or if the implant has perforated the cortical plate of the bone on the buccal or lingual side. Conventional tomography may then be the modality of choice, since the metallic implant may prevent successful imaging with CT.

A successful implant is characterized by an unchanged level of the crestal bone after the initial “bone loss” (ie, the 1.0 to 1.5 mm of loss that typically takes place in the first year after an implant is placed) [AU: Correct? Seemed necessary to define “bone loss.” (It’s not clear to me why “bone loss” is in quotation marks.)]. Many times bone is formed around the implant. Radiographically, this can be seen as a fine radiopaque line parallel with to the implant (Figs 3-7a and 3-7b). This line denotes the outer border of this new bone formation but is not seen in all cases.

Failingure of implants at an early stage areis usually seen radiographically with via a radiolucent zone along the implantir borders. However, such radiolucent zones can be created by so- called Mach Bband effects. Later stage failing iImplants that fail in later stages usually show an increasing bone loss at the alveolar margin. Many times this bone loss produces vV-shaped defects around the implant. Such bony defects can also be seen in conjunction with implant fractures (Figs 3-8a and 3-8b). Many of these fractures occur at the level of the abutment screw. In rare instances “periapical” osteolytic changes occur. [AU: why the quotation marks? Do osteolytic changes merely appear to occur periapically but do not actually occur?]

In cases wherepatients in whom bone has been transplanted on the buccal or lingual surfaces of the alveolar process, ordinary peariapical radiographs serve little purpose to disclose failure or success. In such cases, Ttomography or CT, or in a few cases sometimes occlusal radiographs, should then be employed. The outcome of sinus lift procedures can be studied by intra-oral and panoramic radiographs, but CT is an all probability needed to demonstrate unequivocally whether the transplanted bone has successfully integrated with the border of the maxillary sinus border. In cases where a radiolucent space seems to separate the transplanted bone from the border of the maxillary sinus border, one has to consider the possibility of that the transplanted bone being is separated from the host bone by a soft tissue “capsule”.

Photographs. Intra- and extraoral photographs have proven invaluable as a record of the conditions that existed before treatment began. Obviously, they are also important as a visual record during the treatment planning stages of implant therapy.

[A]

Diagnostic Mounting

Dental casts mounted on a dental articulator, along withnd intraoral -and extraoral photographs, are essential in helping to selecting appropriate treatment options. The diagnostic mounting should provide the answers to several questions that must be addresseds by the clinician.

1. Would the missing tooth structure or the edentulous space be better restored or replaced by a fixed or removable partial denture?

2. Does an acceptable occlusal plane exist, and if not, could one be developed in conjunction with implant treatment?

3. Does Is there adequate interarch space exist for the implant and restoration?

4. Does anIs there adequate distance exist between teeth adjacent to the edentulous space for placement of an implant and restoration?

Securing dental casts of the patient and mounting these casts on the dental articulator will provide a great deal of information about the existing oral conditions that may not be obvious during the oral examination. The diagnostic mounting offers the clinician the opportunity to design optimal occlusal contacts and to determine the need for additional restorative care.

Initial sSelection of the implant design for a patient can initially be made from the diagnostic mounting. Once the implant has been selected, the choice of the surgical approach can be considered. Clearly, the mounted casts can help the members of the implant team toin decideing the number of implants that will be needed and the best positions for their placement in the bone.

The design of the implant prosthesis can also be initiated with the diagnostic mounting. The definitive prosthesis will obviously differ, depending on the location and dimensions of the edentulous space, and the success achieved in implant placement. Single- tooth replacement, multiple- tooth spans in partially edentulous jaws, and the totally edentulous arch are the most frequent clinical situations treated with implants. The presence or absence of specific factors in each of these situations, as observed clinically, and/or determined from the diagnostic mounting, is aare determinants in the decision to use implants.

In general, the absence of one or more teeth may be an indication for implant therapy, provided thating the patient understands the treatment, is able to maintain the prosthesis hygienically, and has no factors conditions that would impair the development of osseointegration.

Long- standing short edentulous spaces might be better suited for restoration with a fixed partial denture rather than with implants. This condition often has bony topography containing with buccal concavities, which may make successful placement of an implant difficult because of limited available bone. (Fig 7-1).

Irregular cusp heights in the posterior dentition may result in premature occlusal contacts and interferences during lateral jaw movements that could result in unwanted stresses being transmitted to the implants,. These stresses which may decrease the long-term success of the implant.

If minimal space exists between the edentulous ridge and the opposing teeth and the roots of adjacent teeth converge on the edentulous space, then damage could occur to the adjacent tooth -root structures when placing the implants are placed. When the coronal proximity to adjacent teeth is limited, the development of less -than optimal embrasure and occlusal contours in the restoration may be a problem. Inadequate interarch space may make fabrication of the restoration difficult, producing less- than optimal esthetic and functional results.

A diagnostic wax-up should be performed using the mounted casts. This will provide information on the feasibility of developing a successful restoration. The diagnostic casts with the wax-up may also be shown to the patient to demonstrate the type of restoration planned (fixed or removable) and areas of potential complications.

[A]Diagnosis andFinalizing the Treatment Planning

The final step prior to acceptance ofing a patient for implant treatment is to ensure that the patient understands the procedures, timing of treatment, projected treatment outcomes, and cost. It is important that the patient understands comprehends the need for routine follow-up visits and possible periodic maintenance of the prosthesis.

As long-term studies data on implant therapy have progressedaccumulated, it has become apparent that the placement of an endosseous implant not only provides a source of retention and stability for a prosthesis, but also generates some stimulation to the surrounding bone. This stimulation appears to inhibit the loss of alveolar bone that follows tooth extraction, which has been described as both chronic and irreversible, and whose long-term effects produce numerous morphological changes that adversely affect denture-bearing areas and facial esthetics. By decreasing bone loss, an implant provides a system for bone maintenance; this, enhancesing the therapeutic value of implant treatment.

Indications for implant therapy in an edentulous alveolus could include any patient who meets the following requirements:

• Has adequate quality and quantity of bone available for implant placement.

• Is healthy enough to undergo the surgical procedure.

• Is able to maintain optimal levels of oral hygiene.

• Is psychologically stable and understands implant therapy, its limitations, and theits accompanying patient’s responsibilities.

[A]Presentation of the Treatment Plan to the Patient.

Without general health contraindications to treatment and in the presence of favorable local conditions, the treatment plan and the kinds of restorations required, including implant therapy, should be presented in some detail to the patient. The numbers and kinds of prosthetic improvements planned and overall economic considerations are part of this presentation to the patient. The esthetic and functional desires of the patient must be discussed and evaluated to determine whetherif the patient has unrealistic expectations. A careful evaluation of the patient's willingness and ability to provide the necessary home care before, during, and after active treatment is also necessary. Decisions concerning immediate placement of an implant following extraction of a natural tooth should be discussed if the treatment plan calls for such therapy. The numbers and kinds of implants to be placed and the type of anchoragewhether the implant prosthesis will be (ie, fixed or removable) also must be presented. Retention of an Whether a single implant crown restorationplacement will be (ie, screw-ed retained or cemented) needs to be discussed. Some treatment options may need to be deferred until the implants have osseointegrated and the results achieved evaluated before the final decisions can be made on the prosthetic therapy. Whatever the situation, the patient should be informed about these many issues, all of which must be resolved before implant surgery begins.

[A]REFERENCESeferences

1. Laney WR, Tolman DE. The Mayo Clinic experience with tissue-integrated prostheses. In: Albrektsson T, Zarb GA (eds). The Brånemark Osseointegrated Implant. Chicago: Quintessence, 1989:165–195.

2. Blomberg S. Psychological response.. In: Brånemark P-I. Introduction to osseointegration. In: Brånemark P-I, Zarb GA, Albrektsson T, (eds). Tissue-Integrated Prostheses: - Osseointegration in Clinical Dentistry. Chicago:; Quintessence Publ Co;, 1985:165.

Laney WR and Tolman DE. The Mayo Clinic experience with tissue-integrated prostheses. In: Albrektsson Tomas and Zarb GA, eds. The Brånemark Osseointegrated Implant. Chicago; Quintessence Publ Co; 1989:165-195.

3. Lekholm U, and Jemt T. Principles for single tooth replacement. In: Albrektsson Tomas and, Zarb GA, (eds). The Brånemark Osseointegrated Implant. Chicago:; Quintessence, Publ Co; 1989:117-–126.

4. Lekholm U, and Zarb GA. Patient selection and preparation. In: Bråanemark P-I, Zarb GA, Albrektsson T, (eds). Tissue-Integrated Prostheses: - Osseointegration in Clinical Dentistry. Chicago: Quintessence, Publ Co; 1985:199–-209.

BOX 3-1 - An outline for planning implant therapy [AU: Renamed and eliminated some headings, since this chapter covers treatment planning only.]N OUTLINE FOR IMPLANT THERAPY

1. The pPatient Eexamination

The General Hhealth

The Dental Hhealth

Radiographic Eevaluations

Photographic rRecord

2. The Ddiagnostic Mmounting

3. Presentation Oof Tthe Ttreatment Pplan Tto Tthe Ppatient

4. Stage One Surgery - Implant Placement

Healing Period

3-month minimum for the mandible

6-month minimum for the maxilla

Prosthodontic Procedures

5. Stage Two Surgery - Abutment Placement

Healing Period

2-3 weeks before start of definitive prosthodontic care

Prosthodontic Procedures

6. Definitive Prosthodontic Treatment

7. Periodic Recall Appointments and Maintenance Program

[Jen: Boxes 2 and 3 don’t seem to be called out in the text. If you can see where they belong, please go ahead and add the citations, or perhaps just incorporate them as lists in the text since they are so simple. If not, just query the author.]

BOXox 3-2 - Assessment of bone quantity according to Lekholm and Zarb⁴BONE QUANTITY

A - Most of the alveolar ridge is present.

B - Moderate alveolar ridge resorption has occurred.

C - Advanced alveolar ridge resorption has occurred and only basal bone remains.

D - Some resorption of the basal bone has taken place.

E - Extreme resorption of the basal bone has taken place.

BoxOX 3-3 Assessment of - Bbone qualityONE QUALITY according to Lekholm and Zarb⁴

1. Almost the entire jaw is comprised of homogenous compact bone.

2. A thick layer of compact bone surrounds a core of dense trabecular bone.

3. A thin layer of cortical bone surrounds a core of dense trabecular bone of favorable strength.

4. A thin layer of cortical bone surrounds a core of low- density trabecular bone.

[Jen: None of the figures seem to be cited in the text. I think they all go in the Radiographic Examinations section (pp 5–10). If you can tell by the legends where they go, please go ahead and cite them in the text. Otherwise, I guess we’ll just have to query the author on all of them.]

Fig. 3-1. Panoramic radiograph with metal guides in the upper jawmaxilla.

Fig. 3-2. Lateral cephalometric radiograph demonstrating showing the sagittal midline dimensions of the mandibular and maxillary anterior regions.

Fig. 3-3. Conventional tomograms of the lower jawmandible demonstrating showing the mandibular canal and mental foramen, as well as the tapering width of the superior parts of the alveolar ridge. Note the relative unsharpness of the cortical borders due to blurring of adjacent parts.

Fig. 3-4. Reformatted computerized tomographyCT images of the right maxilla.

[Katie: Figs 5, 6, 7, 8 may not be appropriate (see my comments to you in email) since the chapter is supposed to cover treatment planning, NOT follow-up and maintenance.]

Fig. 3-5. Follow-up intraoral radiograph with an optimal projection disclosing the threading of the fixture implant on both sides.

Fig. 3-6. a. Panoramic radiograph of a patient with two implants in the lower jawmandible and symptoms of paresthesia and numbness.

Fig 3-6b. tTomogram showing the anterior implant above the mandibular canal.

Fig 3-6c. tTomogram showing the posterior implant placed partially into the mandibular canal.

Fig. 3-7a. and 3-7b Follow-up intraoral radiographs from two different occasions demonstrating progressive bone loss around a maxillaryn implant in the upper jaw. [AU: How long after the first radiograph was the second radiograph taken?]

Fig. 3-8a Follow-up intraoral radiographs from two different occasions. ashowing. bone loss along the implant to the level of the abutment screw.

Fig 3-8b. Radiograph taken 6 months later showing a horizontal fracture below the abutment screw. The radiograph is taken 6 months after the one in a.