NMDA Journal Summer 2020

New Mexico Dental Journal, Summer 2020 18 maintain interproximal bone. So there seems to be a distinct advantage in using an implant with a platform switch, especially in areas where the mesial- distal width of the implant site is limited. All of these factors affect case selection and treatment planning. Including them in your diagnosis will increase success and minimize complications and failures. Clinical evaluation begins with a periodontal examination and an evaluation of the soft tis- sues in edentulous areas. Patients with uncon- trolled periodontal disease are poor candidates for implant placement. Patients who have peri- odontal disease should have treatment and have the disease under control prior to implant placement. The American Association of Perio- dontists stated that there is strong evidence that mucositis is caused by plaque and that peri-implantitis is associatedwith poor plaque control andwith patients with a history of severe periodontitis. An adequate zone of attached gingiva is also desirablewhen consid- ering implant placement. An adequate zone of attached gingiva around implants has been associatedwith less plaque, less gingival reces- sion, better hard and soft tissue stability, and lessmucositis all of which should lead to a bet- ter long-termprognosis. An examination of hopeless teeth outlined by Dr. Kois in his article entitled “Predictable Single Tooth Periimplant Esthetics: Five Diagnostic Keys” published in compendium in 2001 is applicable to case selection. He states that hopeless teeth should be evaluated by the relative tooth posi- tion, the formof the peridontium, the biotype of the peridontium, the tooth size, and the position of the osseous crest. The relative position of a hopeless anterior tooth may be evaluated in three positions relative to the adjacent teeth; the apical-coronal position, the facial-lingual position and themesial-distal position. A hopeless toothwhich is in amore coronal position relative to the free gingival margins of the adjacent teeth is a favorable sit- uation. Gingival recession following extraction and implant placement is possible and if that occurs, there still may be a pleasing esthetic result. A toothwhich is in amore apical position relative to the adjacent teeth is less favorable because if gingival recession occurs it will be more difficult to achieve a pleasing esthetic result without additional grafting or the use of pink porcelain in the restoration. A toothwhich is positionedmore to the lingual ismore favor- able as there is usuallymore soft tissue and bone facially whichmakes the need for soft and hard tissue grafting less likely. A toothwhich is positionedmore faciallymay require both hard and soft tissue grafting to achieve a pleasing esthetic result. A toothwhich is positionedwith 1.5mmof tissuemesially and distally at the crest from the adjacent teeth is less likely to lose the papillae and is a favorable situation. Patients with high and normal scalloped gin- giva are less favorable as they aremore likely to experience recession following tooth extraction and implant placement. Patients with a flatter scallop aremore favorable as they are less likely to have gingival recession. Patients with a thick biotype aremore favorable as they are less likely to experience recession while patients with thin biotypesmay require soft tissue grafting and aremore likely to experi- ence recession. Teethwith a square shape aremore favorable supragingivally as contact areas are longer and black holes are less likely. Square teeth are less favorable subgingivally as there is less interprox- imal bone. Triangular teeth are less favorable supragingivally as black holesmay develop and more favorable subgingivally as there ismore interproximal bone. Ovoid teeth are less favor- able both supragingivally and subgingivally. Bone sounding prior to extraction can deter- mine the position of the osseous crest facially and interproximally. Patients with a high crest (< 3mm) aremore favorable as recession is less likely while patients with a lowcrest (>4mm) are more likely to experience recession. This is just a summary of the article by Dr. Kois and I would encourage you to read the article as it can helpwith case selection and informed consent. It is always better to discuss possible recession in the anterior prior to treatment and if you are a general dentist, depending on your level of experiencewith grafting, youmay want to refer less favorable cases to a clinicianwith more experience. Examination of theOcclusion, Musculature, and the TMJ are essential for case selection. Palpa- tion of themuscles of mastication and exami- nation of the TMJ can allow the dentist to identify pathology and create a stablemastica- tory systemprior to implant placement. Para- functional habits such as bruxism, clenching and tongue thrusting can create undesirable forces on implants which can increase pros- thetic complications and compromise long termsuccess. Implants havemuch less surface area than the natural teethwhich they replace. In addition, implants lack a periodontal ligament which results in occlusal forces being directly transmit- ted to the implant-bone interphase. Most implant failures are due to occlusal overload or peri-implant disease and occlusal overload is one of the predisposing factors in peri-implant disease. Therefore implant restorations should be loaded as close to the long axis of the implant as possible to limit unfavorable forces on the implant. The occlusal table should be more narrow than that of the natural teeth and catilevered contacts should be avoided in both mesiodistal and buccal-lingual directions. One contact per tooth is optimal. When restoring anterior teeth a light centric contact is ideal with shallowguidance and smooth crossover. When restoring posterior teeth, a light centric contact with no excursive contact is preferable. The best way to evaluate occlusion is with diag- nostic castsmounted in centric relation on a semi-adjustable articulator. Mounted diagnos- tic casts provide a great deal of information. They allowus to determine premature occlusal contacts, evaluate inter-occlusal space, vertical dimension, toothmorphology, anterior guid- ance, arch relationships, directions of forces in implant sites, opposing dentition, curves of Wil- son and Spee, arch formand symmetry, and transition zone, all of which have an effect on case selection. They allowus to do diagnostic wax ups which can help determine the optimal occlusal scheme and the optimal tooth position which determines the optimal implant position. We can then evaluate the need for bone graft- ing prior to implant placement or discuss a compromise. Diagnosticwax ups can then be used to create provisional restorations and cre- ate surgical guides. Photographs are also useful in evaluating gingi- val display, lip lines, transition zone, and docu- mentation of pre-operative conditions. They can be helpful in explaining to the patient the options for using pink porcelain or surgical cor- rection to repair defects. Case selection goes hand in handwith the examination, diagnosis, and treatment plan- ning process. By keeping the factors inmind that were presented in this article, we can opti- mize the success of our implant cases andmini- mize our failures. Case Selection to Optimize Success in Implant Dentistry  continued from page 17 It is important to evaluate what stepsmay be taken to relieve dental anxiety.