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J Oral Maxillofac Surgxx:xxx, 2007

Treatment Planning Complications andSurgical Miscues

P.P. Binon, DDS, MSD
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ince the advent of osseo-integrated implants, manyajor innovations and improvements have takenlace. From a surgical perspective, the instrumenta-ion required to make the osteotomy has improved inutting efficiency and heat reduction.1 Bioactive im-lant surfaces have been developed that result in

aster integration and immediate loading.2,3 Flaplessurgery and improved long-term predictability of vir-ually all the major implant systems are now a reali-y.4,5 The ability for implant site development withredictable particulate and block grafting techniquesnd the use of recombinant proteins along with en-anced soft tissue modification has expanded appli-ations.6-10 The interface stability problems initiallyncountered with the external hexagonal connec-ions, when applied to single and fixed partial dentureFPD) applications, have also been resolved with theevelopment of the internal connection.11,12 Three-imensional computed tomography (CT) radio-raphic imaging and computer-assisted treatmentlanning software have revolutionized treatmentlanning and surgical placement.4,13,14

As a result, in the course of 25 years, dentistry hasndergone several major paradigm shifts. In the past

t was acceptable to place implants with little consid-ration of the restorative aspects of treatment, result-ng quite often in exceptional efforts on the part ofhe prosthodontist and restorative dentist to arrive attolerable functional and esthetic result. Today, the

xpectations of a more sophisticated and esthetic-riented patient base that demands a much higher

evel of treatment has significantly altered those initialaradigms.One significant factor remains unchanged. Restora-

ion of a dysfunctional dentition with conventionalxed or removable prosthodontic treatment, or with

ssistant Research Scientist, Department of Restorative Dentistry,

niversity of California at San Francisco, San Francisco, CA and

djunct Professor of Prosthodontics, Graduate Prosthodontics, In-

iana University, Indianapolis, IN.

Address correspondence and reprint requests to Dr Binon: De-

artment of Restorative Dentistry, University of California at San

rancisco, San Francisco, CA.e-mail: [email protected]

2007 American Association of Oral and Maxillofacial Surgeons

278-2391/07/xx0x-0$32.00/0

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mplant-supported restorations requires the same ba-ic treatment protocols that are consistent for all im-lant restorations. The common factor is that implantentistry is a restorative prosthodontic treatment mo-ality with a surgical component. The foundation isreated by the surgical placement of the implantshich has to be dictated by specific restorative re-uirements, both from a functional as well as ansthetic perspective. Without that symbiotic interre-ationship, the outcome will be less than ideal.

The hallmark of successful treatment lies in anrganized and complete diagnosis which then results

n a comprehensive treatment plan. To arrive at theiagnosis, the following has to be considered: softissue pathology, caries, periodontal evaluation, radio-raphic evaluation which may include CT imaging,ndodontic evaluation, occlusal considerations, para-unctional habits, transmandibular joint (TMJ) evalua-ion, vertical dimension of occlusion, intra-arch space,aw malrelationships, lip drape and lip support, pa-ient expectations, esthetic evaluation, mountedtudy casts and bite records, and a diagnostic wax-upf the partially edentulous area or a trial prosthesis.rom a surgical perspective, a medical assessment,

IGURE 1. The diameter of the implant is too wide for the availableone. Bone loss is apparent around the implant.

aul P. Binon. Treatment Plan Complications and Surgery. J Oral

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he patients healing and stress capacity, current med-cations, anesthesia risk factor, and bone quality anduantity have to be evaluated.The primary responsibility for dental evaluation and

reatment planning lies with the prosthodontist andr the restorative dentist. After the initial treatmentlan has been developed with the patient’s goals andbjectives in mind, the surgical aspects of treatmentre then assessed. At this point, communication be-ween the restorative and surgical counterparts isrucial for an ideal result.16

Implant placement, without restorative input, re-ults in a myriad of significant problems and compli-ations to the detriment of all parties involved. Thisrticle identifies major surgical miscues that affectrosthodontic outcome, and codifies them in an or-anized manner.16

IGURE 2. Too narrow an implant for the available space andequired load bearing. A, Occlusal functional area on an inappropri-te implant diameter results in mesial and distal cantilever. B, Func-

ional loading resulted in fatigue fracture of the implant walls. Theiameter of the implant is inadequate for the functional unit it replaces.

aul P. Binon. Treatment Plan Complications and Surgery. J Oralaxillofac Surg 2007.

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nappropriate Implant Selection andlacement

Selection of the implant is based on a variety ofactors such as available bone, type of restoration,oad bearing capacity, implant platform and nonrota-ional feature, the tooth it replaces, as well as thesthetic requirement. From a biomechanical stand-oint, it is desirable to place the widest and the

ongest implant that the available bone volume andnatomic features permit. Obviously, the greater sur-ace area available for integration the greater the dis-ipation of the functional load. A wide variety ofiameters and lengths are available from most of theanufacturers today.18

If an implant is too wide for the available bone, theesult is implant dehiscence through the bone, whichan contribute to implant failure (Fig 1). Conversely ifhe implant is too narrow to support the functionaload, the result can be progressive bone loss andailure of the implant itself due to fatigue fracture (Fig).19

Clinical studies have shown that implants of 10 mmr more in length may have a significantly greateruccess rate and a correlation between length and

IGURE 3. A, Inappropriate length implants for the bone volumevailable. Four of the 5 implants also were not inserted to the correctepth. B, Right distal implant late failure resulted in replacement androsthetic re-treatment.


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te to place implants of the greatest length possible.20

ailure to apply these principles can result in implantoss and failure (Fig 3). Consideration has to be giveno the emergence profile of the restoration if optimalsthetics is to be achieved. Mismatched implant diam-ters, especially in the esthetic zone, will lead toncontrolled emergence profiles, soft tissue dishar-ony and significant uncontrollable esthetic prob-

ems (Fig 4).For single tooth restorations and FPD applications,

n anti-rotational engagement between the implantnd the abutment is necessary to enhance the stabilityf the restoration.21 Placement of an implant devoidf this feature, especially for single tooth restorations,esults in a nonrestorable and untenable situation.he resulting options are to remove the implant andeplace it with the appropriate type or abandon im-lant restoration and revert to a FPD (Fig 5).In selecting an implant, consideration also has to be

iven to the implant abutment connection. This isritical when angulation changes have to be made inrder to meet restorative requirements. Failure to

IGURE 4. Mismatched implant diameters in the esthetic zone. Thisreates significant restorative emergence profile and soft tissue estheticroblems.


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elect the appropriate implant leads to significantdditional laboratory work and additional expensend a compromised design (Fig 6).

Another implant type selection consideration oc-urs when additional implants need to be placed dueo conversion from a removable prosthesis to a fixedrosthesis or when more implants are required due to

mminent failure of one or more implants. In theseircumstances, it is prudent to select compatible im-lant types rather than multiple different designs of

mplants. Mismatching implants results in added chairime, additional instrumentation, complications re-arding tracking part, added laboratory time, andosts (Fig 7).

umber of Implants Placed

A variety of prosthodontic protocols have beenstablished to restore the fully edentulous mandiblend maxilla.22-25 In general, the maxillary arch can beestored with a bar-supported removable prosthesisith 6 to 8 implants depending on the quality and

IGURE 5. A, Inappropriate implant selection for single tooth replace-ent function. B, Implant had no anti-rotation feature and was

emoved.


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uantity of bone available. For completely fixed ap-lications (Ceramo Metal Bridge) typically 4 implants

n the cuspid to molar area on each side are requiredo support the FPD (Fig 8). When the anterior canti-ever arm is significant a single anterior implant can

IGURE 7. Upper arch with several different implant designs inlace. This resulted in additional instrumentation, a variety of compo-ent parts, added restorative chair time, and unnecessary complexity.

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Fe added. This applies also for a fixed mandibularartial denture restoration. In the mandible, support

or an implant supported hybrid bone anchoredridge is usually obtained from 4, 5, or 6 implants inhe symphysis area, depending on arch size and boneolume (Fig 9). Using an excessive number of im-lants to support the functional load is not desirablend can lead to both esthetic and hygienic complica-ions (Fig 10).

Optimal number of implants and appropriate spac-ng is also critical in the partially edentulous pa-

IGURE 8. Failing partially edentulous arch to be restored withequential implant placement. Blue circles indicate placement of therst series of implants. After extraction of the cuspids, additional im-lants were inserted (yellow) to restore the arch with a porcelain-fused-

o-metal bridge. Adjacent implants in the anterior segment wouldompromise ability to create esthetic soft tissue contours.


URE 6. A, Press-fit design negated angulation changes required toh a screw-retained tissue bar for an overdenture. B, Flare of therior implants resulted in abutment head modifications (C) that compro-d the screw retention threads and required custom lingual set screwstain the bar.

l P. Binon. Treatment Plan Complications and Surgery. J Oralillofac Surg 2007.

FIGattacantemiseto re

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ient.23,25 In those applications however, the proto-ols are less well defined in the literature.In general, for maxillary FPD a 1 to 1 or 1 to 2

mplant to tooth ratio applies. Whenever grafted boneupports the implants, current protocols usually rec-mmend a higher number of implants, although evi-ence-based analysis is lacking.Decisions relative to the number of implants are

estoratively driven. It is expected and necessary thathe surgeon communicate with the restorative doctorhenever there are differences in the number of

mplants prescribed, prior to surgery. It is not accept-ble to increase or decrease the number of implantsithout consensus. The patient’s predetermined re-

torative treatment plan and financial commitmentannot be altered without prior consent of the restor-tive doctor and the patient.

ncroachment

In partially edentulous cases the risk of root injurys always present. Adequate diagnostic planning with

FIGURE 9. Typical arrangement of implants in the symphysis area.


IGURE 10. Example of overzealous treatment planning. More im-lants than necessary were placed to restore the maxilla and theandible. Spacing, loading axis, and angulation was also problem-tic. Of the 19 implants placed, 11 failed within one year.

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Fadiographic marker stents derived from diagnosticax-ups is necessary to avoid damage and tooth loss

Fig 11). Complications of this type usually result indditional implants being required along with addi-ional restorative costs and potential professional lia-ility.Disregard of surgical stents that mark the loca-

ion and axial orientation of implants in fully eden-ulous cases can also lead to encroachment of ad-acent implants (Fig 12). This occurrence mayesult in one or more early implant failures, a sig-ificant time delay for completion of treatment,reater laboratory costs and additional chair timeor the restorative dentist.

Even more compromising is encroachment of theongue. In two of the examples cited, no prostheticonsultation or collaborative treatment plan waseveloped. The patient was referred after the factor restoration. In the first case, the implants were

IGURE 11. Encroachment on natural teeth. In both instances, theeeth had to be removed. A, The implant and the tooth failed and bothad to be replaced with additional implants. B, After extraction of toothwenty-eight, the implant bridge was remade and a pontic was added.


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nd the implants were removed and the patientetreated (Fig 13). In the second case the implantsere placed in line with the distal of the cupids,

esulting in a significant cantilever and an exit pointn a sensitive phonetic area. To restore these im-lants, two thin palatal straps were incorporated

nto the 4-unit FPD. This resulted in a functional butompromised outcome (Fig 14).Posterior tongue encroachment may also occur.

his case illustrates 2 points from a restorativeerspective. The patient presented with 2 unre-tored implants in the left upper quadrant and bi-ateral sinus augmentations. Her goal was to haveingle restorations in both posterior quadrants. Af-er an exam, study casts, radiographs, and a diag-ostic wax-up (Fig 15) and surgical stent (Fig 16)ere made. Referral and appropriate communica-

ions were established with a different clinician aso the location, number, and type of implants to belaced. It also was pointed out that one of thereviously placed posterior implants (fifteenth po-ition) was inappropriately located too far palatallynd consequently encroached on the posteriorongue space. The locations of the additional im-

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Flants were re-affirmed prior to surgery. The postin-ertion panographic film indicated that one implantad not been placed (fifth position) but the mesio-istal spacing of the 3 implants that were placedppeared to be acceptable and in the locationsndicated by the surgical stent. At uncovering, it

as obvious that although the general location ofhe implants was correct, the axial orientation wasot (Fig 17). All of the additional implants placedere palatally located and lingually inclined from

5 to 45 degrees off axis (Fig 18). The additionalmplant placed on the left (position fourteen) mir-ored the tongue encroachment location of themplant in the fifteenth position. It was apparenthat the surgical stent was not used and that there-surgery instructions were ignored. To restorehe case, custom abutments were made that wereeverely off axis. The resulting crowns were grosslyver-contoured (Fig 19). Even with a maximumffort to minimize the palatal intrusion, a notableifference in tongue space was seen (Fig 20). Con-equently, a maxilla with ample bone to place im-lants in ideal locations was compromised becausehe surgical prescription was ignored.

URE 12. Encroachment when multiple implants are placed. A) Par-edentulous area with three implant placements. Two are contacting

out any bone matrix in between. The most distal implant failed torate. B, A grafted edentulous upper arch with ample bone present forl placement and spacing. The left two implants were placed too closether and failed to integrate. C, Clinical result with 6 load-bearingants. A transitional bar and provisional denture had to be made duringegrafting and placement of additional implants.


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ertical Orientation

In partially edentulous arches, it is important to beware of the crestal bone levels of the adjacenteeth.26 Not only is this of critical importance for thereservation of the papillae but it is also a factor inygiene maintenance. If the implant is placed tooeep relative to the adjacent teeth, a peri-implantocket develops that leads to further bone loss anduite often, a fistulous tract (Fig 21). In the case

llustrated, the site would have been better servedith a particulate or block graft prior to implantlacement. Another frequent complication is whenhe implant is placed below the bone crest and crestalone has to be removed in order to permit mating ofhe impression coping and the abutment. The secondxample illustrates that this can seriously compro-ise adjacent teeth and ultimately several millimeters

f bone are sacrificed (Fig 22).Equally challenging is when implants are not placed

eeply enough. In the example shown in Figure 23panel A), both implants were placed 40% to 50% in

IGURE 13. A, Inappropriate location of 2 implants that werentended to support a restoration from tooth position 9 to 11. Themplants were in the palate and not the alveolar ridge. B, Indicateshere the implants should have been located. It is obvious that blockr veneer grafts were indicated before any implants were inserted.oth implants were removed. This resulted in additional unnecessaryurgeries and substantial time loss to completion.


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he posterior mandible. The implants were placedithout prior knowledge or direction of the generalentist. This patient was left without restorations forany months and finally sought out another dentist to

estore the implants. After examination, the optionsresented were to remove the implants and placelock grafts to correct the mandibular insufficiency oro place provisional restorations and load the implantsnd evaluate the response (Fig 23 B). Within monthshe implants failed and the patient rejected any fur-her implant treatment. It’s obvious that the originaliagnosis and treatment plan was inadequate. Theatient required grafting prior to implant placement.ommunication with the patient’s restorative dentistas also lacking.

nadequate Spacing in the Anterior-osterior Spread

In the mandibular arch one of the most commonestorations treatment-planned for the edentulousrch is the classic hybrid fixed prosthesis. To supportfixed lower denture 5 or 6 implants are placed

etween the mental foramen. Because it is a cantile-er restoration, the greatest distance between the

IGURE 14. A, Two palatally located implants inserted after ridgeugmentation. Their location approximated the distal of the cuspids. B,estored with a 4-unit porcelain-fused-to-metal bridge supported bywo palatal straps; location did compromise phonetics and restorationas quite difficult to minimize the consequences of the surgical miscue.


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ost anterior and the most posterior implants resultsn the best mechanical force distribution.27,28 Whenmplants are placed in a near straight line the cantile-er length has to be limited to avoid overload andomponent failure. Figure 24 shows two examples ofnadequate implant spacing when adequate room ex-sted between the foramina. The net result was un-ecessary crowding of the implants and most impor-antly, reduction of the anterior-posterior (AP) spread.n both instances, adequate space was available tolace the posterior implants more distally. Had the

mplants been spaced more appropriately, the APpread would have been doubled.

Coincident with inadequate spacing is the closeervical proximity of the abutments resulting in softissue management problems and hygiene difficultiesFig 25). Ideal spacing between implants is 3 mm orore.26,29 When this is violated, the papilla is com-

IGURE 15. Example of posterior tongue encroachment that couldave been avoided. A, Radiograph indicates the palatal placement ofhe number 15 implant, placed before the second surgical experience., Diagnostic wax-up, used to make radiographic and surgical stent.

t illustrates the correct location of the posterior teeth.


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FIGURE 16. A, Cast marked with the location of the prescribed newmplant locations. Diameter and length are also noted on the cast. B,urgical stent provided to the surgeon.


IGURE 17. Lingual contours illustrated by the yellow line had im-lants been placed in prescribed locations. The photo on the rightemonstrates the resulting encroachment on tongue space due to thealatal placement of the implants.


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romised and progressive long-term apical tissue mi-ration is often the result (Fig 26).29,30 Even whenourglass shaped custom abutments are used, hy-ienic access is difficult. Proximity problems are typ-cally the result of inadequate diagnosis and coinci-ent with not using radiographic and surgical stents.rom a surgical standpoint the implants may be con-idered a success. However, from a restorative per-pective it resulted in a significant prosthesis designhallenge along with potential long-term complica-ions.

nadequate Intra-Arch Distance

Another complication that can be traced directly tonadequate diagnosis and failure to have collaborativereatment planning with the restorative dentist is thelacement of implants without attention to the inter-rch and interocclusal space. This is especially critical

IGURE 18. A, Abutments required severe angle corrections. Notehe screw access locations in abutments 3, 4, 14 and 15. B, Sideiew indicates angulations of 35 to 45 degrees.


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n partially edentulous patients where there is exces-ive loss of vertical dimension of occlusion, distortionf the occlusal plane or migration of the opposingental segment. Whenever multiple implants are toe placed, it is necessary to have mounted casts withdiagnostic wax-up in order to evaluate the implant

ocation, the occlusal scheme, and determine if theres adequate vertical room for the abutment and thelinical crown. In tight spaces, a screw retained di-ectly to the implant restoration can be placed. How-ver, that results in crowns that are short, bulbousnd esthetically unattractive, which is not an accept-

IGURE 19. Bilateral palatal location of the implants resulted inrossly over contoured crowns.


IGURE 20. Overlay of what the clinical crown size would haveeen had the implants been located in the correct location. It graph-

cally illustrates the extent of the difference in size and the degree ofongue encroachment.


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ble result. The example used to illustrate this di-emma is depicted in Figure 27. The patient waself-referred after being informed that an extensiveeconstruction to open her vertical dimension of oc-lusion was recommended after the implants hadeen placed. The patient denied any preexistingnowledge of this and indicated that there had beenimited interaction between the restorative doctornd the implant surgeon. Implant placement wasdeal as to inter-implant distance, axis, and angulationFig 27). The existing dentition indicated extensiveear and attrition, with a slight Class III tendency andeavy anterior contact. Mounted cast indicated thatetention would be an issue due to the limited space.he patient was sensitive to having occlusal accessoles present, which added to the treatment di-

IGURE 21. A, Implant located too far apically relative to thedjacent teeth. This resulted in an unmanageable soft tissue pocketnd a fistulous tract. B, Red line indicates the implant/abutment inter-

ace. Crown/root relationship is also beyond normal limits.


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emma. She also dismissed having a complete restora-ion of her occlusal relationship at that time. A com-lete diagnostic and treatment workup would haveenefited the surgeon and the restorative dentist be-ore the placement of the implants. The end pointas that they lost an excellent patient. The implantsere restored to her satisfaction after a considerable

estorative effort.

IGURE 22. A, Posterior implant inserted below the crestal area ofhe adjacent teeth. B, At uncovering, several millimeters of bone had toe removed in order to seat impression coping and abutment. Con-equently, the adjacent teeth lost bone support.


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ngulation

Improper implant angulation is the greatest chal-enge and the most problematic challenge for theestorative dentist.31-36 This problem is not limited toomplex multi-implant combination treatment plans.reatment plans involving one or two implants oftenemonstrate a lack or loss of anatomic orientation (Fig8). In the example illustrated, the implant waslaced in the correct location with the exception ofhe 30 degree buccal angulation. This resulted inabrication of a custom abutment, with additionalaboratory expenses and compromised loading. Even

inor angulation changes can impact the restorativeutcome as illustrated in the second case involvingwo implants and an over denture (Fig 29). The slightivergence of the implants restored with ball attach-ents resulted in a problematic path of insertion and

equired modification of the head of the ball attach-

IGURE 23. A, Example of implant not seated deep into the mandi-le. Both implants were 40% to 50% outside the bone matrix. B,rovisional loading resulted in more bone loss and ultimate failure.


ent. This resulted in a higher maintenance profile a

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or the patient who has had to have the O ringseplaced at more frequent intervals.

Two other examples illustrate complete loss of ori-ntation in the edentulous mandible (Fig 30). Theesulting implants were placed at 35 to 40 degrees ofngulation to the correct angulation. In the one caset resulted in the fracture of the implant body and inhe second, a significantly compromised overdentureesign.

IMPLANTS MAY BE ANGLED ACCORDING TO THELEFT OR RIGHT HANDEDNESS OF THE CLINICIAN

The case in Figure 31 illustrates a bilaterally graftedatient with a more than adequate bone bed in whicho place implants. Eight implants were placed, all ofhich were off angled to the left. The implants were

5 to 40 degrees off axis angulation, when in all siteshe implants could have been placed vertically inarallel. This resulted in a restorative design chal-

enge, extra laboratory expenses, and more restor-tive chair time.

Inappropriate angulation leads to multiple compli-ations, and most often significant restorative difficul-ies. This is well documented with two posteriorartially edentulous cases. In the first case, two im-lants were each placed by two different surgeons atifferent times. The cuspid and bicuspid implantsere placed first with ideal spacing and angulation.

ubsequently two additional implants were placed toeplace the molars. These were placed to the lingualnd at 40 degree angulation (Fig 32). Restoring theseequired custom abutments. The emergence profileas also compromised because they were not in-

erted deep enough (Fig 33).In the second example, 3 implants were placed

nitially in a grafted site, one of which compromisedhe right cuspid (encroachment) (Fig 34). An addi-ional implant was placed in the cuspid site and themplants were restored. The patient, who had expe-ienced chronic discomfort for several months andas displeased with the esthetic result, self-referred

o this author. Radiographs indicated multiple prob-ems: sinus perforation, severe implant angulation (35egrees), and considerable bone loss (Fig 35). Theone loss was attributed to angulation overload and

nsufficient initial grafting. The implants in site 3, 4,nd 5 were removed and the area was re-grafted.hree implants were placed at 17 degree angulationnd subsequently restored (Fig 36). The end resultas an increased time line of more than 12 months

nd a major re-treatment expense.Improper angulation in the esthetic zone with se-

ere facial off axis orientation can result in severelyompromised clinical crown contours. As seen inigure 37, two implants were placed immediatelyfter tooth extraction, replacing tooth numbers six

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nd eight. At second stage it was obvious that themplants had been placed too far to the labial and atngles exceeding 45 degrees (Fig 37). Temporary cyl-nders were placed on the master cast and a wax-up

as completed to determine the projected contoursFig 38). It was apparent that the resulting clinicalrowns and pontic area would be much longer thanhe adjacent natural teeth. The patient was given theption to have the implants removed and the areaetreated. Because of the extended additional timeine and more surgery she declined. The end result

as a severe esthetic compromise along with long-erm biomechanical and component challenges (Fig9). What could have been a routine restorative caseurned into an extended series of complications withustom abutments, extensive additional chair time,everal reapplications of porcelain and increased lab-ratory costs.The mechanical and biomechanical complications

elated to adverse angulation to load cannot be un-erstated. Angulation to load of 15 to 20 degrees leadso “some difficulties” and angulation of 30 degrees orore leads to “substantial difficulties.”39 The compli-

ations reported are loose screws, fractured screws,one loss, implant fracture and the loss of integration.he previous clinical cases exemplify some of thoseomplications. More graphic from an economic im-

IGURE 24. A, Implants placed in nearly straight line. Radiographsnterior-posterior (A/P) spread would have been double had the imp

deally and crowding could have been avoided. C, Another case whndicates what the proper spacing of the implants should have been.

aul P. Binon. Treatment Plan Complications and Surgery. J Ora

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indicated that the implants could have been placed further distally. B, Thelants been located in the more distal site. Implants could have spaced moreere the A/P spread could have been significantly improved. D, Radiograph

l Maxillofac Surg 2007.

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IGURE 25. A, Inadequate spacing resulting from implants notlaced perpendicular to each other. The axial orientation resulted inear contact of the cervical areas of the implant. B, As a consequence,ygiene access was extremely difficult to manage even with hourglassodified abutment contours between the most distal implants.


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act was the report by Rubenstein and Taylor wherehey followed a patient for 10 years with severelyuccally angled implants.40 During that time thereere 24 screw fractures, approximately 2 screws ev-

ry 7 months. The author conservatively assessed aost of $4,000 in chair time, lost production, assistantnd office staff expense as well as the replacementarts and supplies. Since the restorative doctor didot place the implants, whose responsibility is it toaintain and absorb those additional costs? An even

reater loss however is the loss of confidence of theestorative doctor and patient and its long-term im-

IGURE 28. A, Implant placed with angulation that does not corre-pond (red line) to natural tooth orientation and occlusal loading axisblue line). B, Blue line shows the correct angulation for a mandibularolar. The neurovascular canal was not an issue in this case.


IGURE 26. A, Partially edentulous case where implants werelaced too close together. The abutments could not be reduced prox-

mally any further. B, Distance of less than 3 mm resulted in compres-ion of the interproximal tissue leading to eventual apical migration.ervical embrasures were inadequate for optimal access.


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IGURE 27. A, Inadequate intra-arch space in a patient that shouldave had a more extensive treatment plan, including opening herertical dimension of occlusion, resulted in abnormally short bulbousrown contours (B).


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nadequate Spacing

To appreciate the profound impact that minor sur-ical placement deviation can have on the restorativespects of a case, this last case is explored. The pa-ient was referred after the implants had been placed.he original restorative doctor had not completed a

ull implant workup on the patient and did not supplyhe surgeon with a surgical stent or a cast indicatinghe desired locations of the implants. The surgeon

IGURE 29. A, Placement where the implants are slightly divergentblue lines). Because this is a press fit implant/abutment interface,butment angulation changes (yellow line) are not easily made. B, Theroblematic path (blue line) of insertion and removal created by theivergence resulted in having to modify the head of the ballttachment.


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IGURE 30. A, Loss of orientation resulted in the severe facialngulation (red lines) of these 2 implants. The overdenture had a largeoncavity (food trap; blue line) along the facial flange in order toccommodate the improper location and permit insertion. B, Func-

ional loading resulted in implant fracture. Patient declined any addi-ional treatment effort with implants. C, Another example of severeacial angulation. The red dots indicate the ridge crest where themplants should have been located. Tissue bar design was modified tollow anterior-posterior rotation and minimize excessive loads to the

mplants. D, Connector arm areas had to be relieved in the denturease, and resulted in some food impaction in the void.


E

IGURE 31. Disorientation in the maxilla. A, Implants placed by aight-handed surgeon. B, Guide pins in place to illustrate the inappro-riate angulation. This was a bilaterally grafted case and the bonease was perfect. In the anterior right area, two of the implantsontacted, resulting in the loss of one implant.


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stimated the locations of the implants and com-leted the surgery (Fig 40). The patient presentedith failing temporaries immediately prior to second

tage. Impressions were made, mounted and a fullouth wax-up completed (Fig 41). New provisional

estorations were placed and the projected estheticesults were then presented to the patient. The loca-ions and spacing of the left mandibular implantsere excellent. Normal crown contours were easily

ttainable (Fig 42). The right mandibular implantsere evenly distributed in the edentulous segmentowever two of the three were outside the confinesf normal clinical crown contours. The most anterior

mplant was located directly in the interproximalpace (Fig 43 A, B). The resulting restoration waseverely compromised. Each of the maxillary edentu-ous areas had two implants placed. In both instanceshese were placed equidistant to the adjacent teethnd to each other (Fig 44 A, B). The resulting bridgeegments had constricted and abnormal pontic con-ours with minimal embrasures (Fig 44 C, D). In 7 outf the 9 implants placed, a few millimeters change inpacing would have made the difference from a prob-ematic result to perfection. Fortunately, after majorestorative efforts, the patient’s expectations wereealized (Fig 44 E).

IGURE 32. A, Two implants located with angulation to the lingualnd not in alignment with the previously placed implants or normalxial inclination of the dentition. B, Custom abutments, in place toeceive single crowns.

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The responsibility for the incorrect spacing in thisase is equally shared by the original restorative den-ist and the surgeon. When a restorative dentist isevoid of adequate experience and knowledge andails to meet the required responsibilities to carry anmplant case to completion, it is incumbent on the

IGURE 33. Implants were not placed deep resulting in a compro-ised emergence profile (A, B; red lines). The angulation discrepancy

s easily visualized (A, blue line).


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urgeon to get an implant workup by another restor-tive dentist prior to placing the implants, if for nother reason than to insure that the surgical part ofhe treatment is successful.

IGURE 34. Original 3 implants showed sinus perforation and rootncroachment. Implants were placed after a sinus augmentation.


IGURE 35. Clinical condition at the time the implants were removednd the segment regrafted. A, Initial restoration with 35-degree angu-

ation (red line) and bulbous cervical contours. B, Radiographs showedrogressive bone loss, attributed to angulation overload.


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ummary

It is critical to have an accurate understanding ofhe educational limitations of dentists because of aack of formal training with implants. It is not a uni-ateral problem, as can be easily discerned from theases illustrated in this article. The team must payttention to specific direction as to the number, loca-ion, depth, angulation, spacing, and distribution ofmplants in their patients. As a consequence, morend more experienced restorative dentists are incor-orating implant treatment in their practice. There isore awareness and concern at having simple restor-

tive cases turn into very complex undertakings thatequire extra chair time and additional laboratory ex-enses. To avoid treatment planning complicationsnd surgical miscues the following is recommended:) Always complete a detailed restorative and surgical

IGURE 36. A, Radiograph of new implants in place with neararallel alignment. Once the implants were integrated, the number 2olar that had been used as a temporary abutment for a provisionalridge was extracted. B, The entire dentition was retreated and newrowns were placed on the implants. The corrected angulation was 17egrees (red line). The resulting emergence profile and cervical con-

our was dramatically improved.


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Fxamination; 2) Do not place implants without aestorative prosthodontic workup; 3) Refer the pa-ient to an experienced dentist for the workup; 4)nsist on a diagnostic wax-up; 5) Insist on a radio-raphic and a surgical stent and use it during place-ent; 6) Determine that the entire treatment teamas the knowledge and experience to complete thease; 7) As a surgeon, be sure you understand thexigencies of fixed and removable restorative care; 8)ake sure that team members have the same treat-

IGURE 39. A, Custom milled abutments were hallow-ground on theacial to reduce the thickness of the porcelain-fused-to-metal bridge. B,efinitive bridge in place. Numerous ceramic modifications and try-inppointments were necessary to meet the patient’s estheticxpectations.


IGURE 40. Radiograph of the implants in situ during initialxamination.


IGURE 37. A, Incorrect angulation of implants in the esthetic zone.hoto was taken after several attempts had been made to improve the softissue coverage. B, Angulation of implants was totally out of harmony withhe adjacent natural teeth. Discrepancy exceeded 45 degrees.


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IGURE 38. A, Temporary cylinders in place with the facial aspectemoved to visualize the incisal orientation. B, Diagnostic wax-up tovaluate crown morphology and probable esthetic result. Crown

ength was significantly different than the adjacent natural teeth. Cer-ical pink wax was used in an effort to reduce the dramatic differencen crown length.


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IGURE 41. Diagnostic wax-up of the mandibular arch (after themplants had been placed). This gave a clear indication of the specialroblems inherent on the right posterior quadrant.

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IGURE 42. Lower arch working cast with abutments in place. Rightegment shows the equidistant location of the 3 implants.


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FIGURE 43. A, The most distal implant in the right segment was well inthe clinical crown contour of the second molar. The remaining 2 implantswere not in the clinical crown confines of the first molar and bicuspid. B,Dramatic modification of the crown contour to accommodate the spacingmiscue. C, Intaglio surface of the bridge segment clearly shows theaberrant crown contours necessary to restore the implants.

Paul P. Binon. Treatment Plan Complications and Surgery. J OralMaxillofac Surg 2007.
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hing for granted. Communicate.

eferences1. Chacon GE, Bower DL, Larsen PE, McGlumphy EA, Beck FM:

Heat production by 3 implant drill systems after repeateddrilling and sterilization. J Oral Maxillofac Surg 64:265, 2006

2. Grassi S, Piattelli A, de Figueiredo LC, et al: Histologic evalua-tion of early human bone response to different implant sur-faces. J Periodontol 77:1736, 2006

3. Shibli JA, Grassi S, de Figueiredo LC, et al: Influence of implantsurface topography on early osseointegration: A histologicalstudy in human jaws. J Biomed Mater Res B Appl Biomater80:377, 2007

4. Wittwer G, Adeyemo WL, Schicho K, Gigovic N, Turhani D,Enislidis G: Computer-guided flapless transmucosal implantplacement in the mandible: A new combination of two inno-vative techniques. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 101:718, 2006

5. Becker W, Goldstein M, Becker BE, Sennerby L: Minimallyinvasive flapless implant surgery: A prospective multicenterstudy. Clin Implant Dent Relat Res 7:S21, 2005

6. Pikos MA: Atrophic posterior maxilla and mandible: Alveolarridge reconstruction with mandibular block autografts. AlphaOmegan 98:34, 2005

7. Petrungaro PS, Amar S: Localized ridge augmentation withallogenic block grafts prior to implant placement: Case reportsand histologic evaluations. Implant Dent 14:139, 2005

8. Block MS, Baughman DG: Reconstruction of severe anteriormaxillary defects using distraction osteogenesis, bone grafts,
and implants. J Oral Maxillofac Surg 63:291, 2005
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F9. Seol YJ, Park YJ, Lee SC, et al: Enhanced osteogenic promotion

around dental implants with synthetic binding motif mimickingbone morphogenetic protein (BMP)-2. J Biomed Mater Res A77:599, 2006

0. Mannai C: Early implant loading in severely resorbed maxillausing xenograft, autograft, and platelet-rich plasma in 97 pa-tients. J Oral Maxillofac Surg 64:1420, 2006

1. Finger IM, Castellon P, Block M, Elian N: The evolution ofexternal and internal implant/abutment connections.PractProced Aesthet Dent 15:625, 2003

2. Mollersten L, Lockowandt P, Linden LA: Comparison ofstrength and failure mode of seven implant systems: An in vitrotest. J Prosthet Dent 78:582, 1997

3. Ganz SD: Conventional CT and cone beam CT for improveddental diagnostics and implant planning. Dent Implantol Up-date 16:89, 2005

4. Verstreken K, Van Cleynenbreugel J, Marchal G, van Steen-berghe D, Suetens P: Computer-assisted planning of oral im-plant surgery. An approach using virtual reality. Stud HealthTechnol Inform 29:423, 1996

5. Jivraj SA, Corrado P, Chee WW: An interdisciplinary approachto treatment planning in implant dentistry. J Calif Dent Assoc33:293, 2005

6. Garg AK: Complications associated with implant surgical pro-cedures part II: Treatment. Dent Implantol Update 15:33, 2004

7. Winkler S, Morris HF, Ochi S: Implant survival to 36 months asrelated to length and diameter. Ann Periodontol 5:22, 2000

8. Binon PP: Implants and components: Entering the new millen-nium. Int J Oral Maxillofac Implants 15:76, 2000

9. Tagger-Green N, Horwitz J, Machtei EE, Peled M: Implantfracture: A complication of treatment with dental implants–review of the literature. Refuat Hapeh Vehashinayim 19:19,2002

URE 44. A, Upper right implant placement in sites 3 and 5. Spacinguidistant rather than in harmony with the projected crown shape. B,left implant placement mirrored the right side. In both cases there wasfficient room for a normal shaped pontic. C, Resulting right bridge withow constricted pontic area. D, Left bridge pontic was even morepromised. Angulation convergence of the implants contributed tonification of the spacing problem. E, Anterior view of the completednstruction. Reasonable posterior esthetic was attainable under difficultitions.


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0. Porter JA, von Fraunhofer JA: Success or failure of dentalimplants? A literature review with treatment considerations.Gen Dent 53:423, 2005

1. Karlsson U, Gotfredsen K, Olsson C: Single-tooth replacementby osseointegrated Astra Tech dental implants: A 2-year report.Int J Prosthodont 10:318, 1997

2. Henry PJ: A review of guidelines for implant rehabilitation ofthe edentulous maxilla. J Prosthet Dent 87:281, 2002

3. Cochran DL, Morton D, Weber HP: Consensus statements andrecommended clinical procedures regarding loading protocolsfor endosseous dental implants. Int J Oral Maxillofac Implants19 Suppl:109, 2004

4. Dario LJ, Aschaffenburg PH, English R Jr, Nager MC: Fixedimplant rehabilitation of the edentulous maxilla: Clinical guide-lines and case reports. Part II. Implant Dent 9:102, 2000

5. Morton D, Jaffin R, Weber HP: Immediate restoration andloading of dental implants: Clinical considerations and proto-cols. Int J Oral Maxillofac Implants 19 Suppl:103, 2004

6. Gastaldo JF, Cury PR, Sendyk WR: Effect of the vertical andhorizontal distances between adjacent implants and between atooth and an implant on the incidence of interproximal papilla.J Periodontol 75:1242, 2004

7. McAlarney ME, Stavropoulos DN: Theoretical cantileverlengths versus clinical variables in fifty-five clinical cases. JProsthet Dent 83:332, 2000

8. McAlarney ME, Stavropoulos DN: Determination of cantileverlength-anterior-posterior spread ratio assuming failure criteriato be the compromise of the prosthesis retaining screw-pros-thesis joint. Int J Oral Maxillofac Implants 11:331, 1996

9. Tarnow DP, Cho SC, Wallace SS: The effect of inter-implantdistance on the height of inter-implant bone crest. J Periodon-

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Ttol 71:546, 2000

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0. Cardaropoli G, Wennstrom JL, Lekholm U: Peri-implant bonealterations in relation to inter-unit distances. A 3-year retrospec-tive study. Clin Oral Implants Res 14:430, 2003

1. Walton JN, Huizinga SC, Peck CC: Implant angulation: A mea-surement technique, implant overdenture maintenance, andthe influence of surgical experience. Int J Prosthodont 14:523,2001

2. Lima Verde MA, Morgano SM, Hashem A: Technique to restoreunfavorably inclined implants. J Prosthet Dent 71:359, 1994

3. Zinner ID, Panno FV, Abrahamson BD, Small SA: Prosthodonticsolutions for compromised implant placement. Int J Prosth-odont 6:270, 1993

4. Grossmann Y, Madjar D: Prosthetic treatment for severely mis-aligned implants: A clinical report. J Prosthet Dent 88:259,2002

5. Kallus T, Henry P, Jemt T, Jorneus L: Clinical evaluation ofangulated abutments for the Branemark system: A pilot study.Int J Oral Maxillofac Implants 5:39, 1990

6. Goodacre CJ, Kan JY, Rungcharassaeng K: Clinical compli-cations of osseointegrated implants. J Prosthet Dent 81:537,1999

7. Tinsley D, Watson CJ, Preston AJ: Implant complications andfailures: The fixed prosthesis. Dent Update 29:456,2002

8. Khadivi V: Correcting a nonparallel implant abutment for amandibular overdenture retained by two implants: A clinicalreport. J Prosthet Dent 92:216, 2004

9. Beumer J. Personal communication.0. Rubenstein JE, Taylor TD: Apical nerve transection resulting

from implant placement: A 10-year follow-up report. J Prosthet
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JOBNAME: AUTHOR QUERIES PAGE: 1 SESS: 1 OUTPUT: Wed Apr 25 08:58:12 2007/tapraid2/zgf�joms/zgf�joms/zgf00707/zgf2649d07z

AQ31— Edit OK?

AQ32— PFM meaning porcelain-fused-to-metal here, and in legend for figures 14 and 39A?

AQ33— Please note journal style: do not reference teeth by number, rather, use words; and, use‘after’ instead of ‘following.’ Please confirm meaning retained in edited sentence.

AQ34— Edit OK?

AQ35— Please confirm labels A and B in legend are used correctly to identify the correspondingpanel of the illustration.

AQ36— Meaning retained in edited sentence?

AQ37— Edit OK?

AQ38— Edit OK?

AQ39— Please confirm meaning of red and blue lines is correct in legend.

AQ40— Please confirm meaning of yellow line and blue line in panel B is correct in legend.

AQ41— Please confirm meaning of red and blue lines shown in panel A are correct in legend.

AQ42— Please provide art for figure 30, panels B, C, and D and confirm in-text citation andlegend are appropriate. Alternatively, delete unrelated text from legend.

AQ43— Panel A meant here?

AQ44— Edit OK?

AQ45— Legend revised per journal style and preference for use of the word, “show” instead of“demonstrate.” Please confirm edit is OK and meaning of red line correctly indicated for panelA.

AQ46— Please confirm meaning of red line in panel A is correctly indicated.

AQ47— Figure legends should stand on their own. For clarity, “that” segment changed to “theright” segment. Please confirm edit is OK, or modify to indicate which segment is meant by“that” segment.

AQ48— Figures originally numbered 45 A and B and 46 have been incorporated as a continuation

AUTHOR QUERIES

AUTHOR PLEASE ANSWER ALL QUERIES 1


of figure 44, and are now labeled as panels C, D, and E (here, and in text).

AQ1— Please approve or modify short title for running head.

AQ2— Please note spelling change to use root of the word, ‘cue,’ meaning anything said or donethat is followed by a specific action.

AQ3— Please add street address and postal code to correspondence address.

AQ49— AUTHOR: Is figure quality acceptable? Figure files received were low resolution.

AQ4— Per journal style, acronym must be spelled out then cited parenthetically at first use: Pleaseconfirm ‘fixed partial denture’ is correct for acronym FPD.

AQ5— Please confirm computed tomography meant for acronym CT, and meaning is correct inedited sentence (both CT imaging and computer-assisted TP software have revolutionized).

AQ6— ‘fixed or removable’ meant?

AQ7— Acronym TMJ means transmandibular joint?

AQ8— Sentence edit OK?


AQ10— Please confirm spelling change is correct: ‘immanent’ (meaning ‘remaining within, orinherent’) changed to imminent, meaning ‘likely to occur at any moment, or impending.’

AQ11— Please clarify; when referring to product by brand name, the name and location ofmanufacturer must also be specified.

AQ12— possessive cupids’ changed to plural cupids here, OK?

AQ13— Edit OK for indication of tooth number ?

AQ14— Edit OK for indication of teeth #’s?

AQ15— Please note journal preference for the term ‘use’ instead of ‘utilize.’ Edit OK?

AQ16— Please confirm edited heading is OK. Also, please note per journal style, first use anddefinition of acronym AP has been taken out of heading.

AUTHOR QUERIES



AQ17— Meant?

AQ18— Meant?

AQ19— Please confirm meaning retained in edited sentence.


AQ21— Please confirm ‘loss of integration’ meant.

AQ22— Edited sentence OK?

AQ23— e-pub reference updated to print-published report, OK?

AQ24— Please cite sequentially in text or delete from list and renumber remaining references andcorresponding text citations.




AQ28— Personal communications are not allowed as references; please update this reference withpublished report, or, 1) delete from reference list and cite parenthetically in text including yearof communication, and 2) renumber references as appropriate in text and in reference list.

AQ29— Please confirm labels A and B in legend are used correctly to identify the correspondingpanel of the illustration.

AQ30— Please confirm labels A, B, and C in legend are used correctly to identify thecorresponding panel of the illustration.

AUTHOR QUERIES


Documents

Journal of Oral and Maxillofacial Surgeryc1-preview.prosites.com/.../wy/docs/Publication/Surgical_Miscues_Proof.pdf · Journal of Oral and Maxillofacial Surgery Copy of e-mail Notification