WEST VIRGINIA UNIVERSITY SCHOOL OF DENTISTRY

Aug 2013

WVU DENTAL IMPLANT PROGRAM GUIDELINES

1. Purpose: To provide clinical guidelines for implant placement and restoration of completely and partially edentulous patients treated at the West Virginia University School of Dentistry by pre- and post-doctoral students under supervising faculty. 2. Goal: To provide a systematic approach to patient evaluation and treatment consistent ith contemporary scientific literature! accepted standards of care and ithin the operating resources of the School of Dentistry. The primary focus of the Dental "mplant #rogram ill be to support both pre-doctoral and post-doctoral training ithin the School of Dentistry and to reflect the re$uirements of the %merican Dental %ssociation Standards for Undergraduate and &raduate Dental 'ducation. Treatment goals ill be to provide the patient ith the most esthetic and functional restorations possible. This goal re$uires that all treatment be (restorative driven) ith the goal of treatment being not the (implant) but the (tooth). *. Scope: +linical guidelines ill apply to all pre-doctoral and post-doctoral students. %ll faculty are encouraged to participate in the educational opportunities and protocol guidelines. %dditional re$uirements and restrictions ill pertain to pre-doctoral students providing implant therapy to their patients ,see University Development "mplant #rogram-. .. Backgroun : The /ey elements of the implant program ill encompass the follo ing0 - Team approach to care - +omprehensive diagnosis and treatment planning - 1a2imum utili3ation of computer enhanced *D imaging! digital radiography! 4obel &uide and Surgplan5 and Simplant5 analyses. - Use of most current techni$ues for implant therapy! including hard and soft tissue grafting! site development! 6io-+ol techni$ues! immediate provisional implants! immediate loading! etc. - +onsider alternative conventional therapies - #atient education! consent and commitment - Strictly follo ed surgical protocols - %de$uate healing periods and progressive loading hen appropriate - #recision in fabrication and delivery of restoration - %2ial loading - minimi3ed lateral forces - Dental prosthesis designed for ease of hygiene - +areful follo -up and re-evaluation for at least one year - %vailability of care consistent ith resources and mission of the facility

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7. Sc#ool o$ Den%&s%r' Den%al I(plan% !o((&%%ee: The School of Dentistry "mplant +ommittee! acting for and ith the approval of the Dean! ill establish policy regarding treatment guidelines! revie all candidates ,student patients being considered for implant therapy-! recommendations for treatment! need for additional diagnostic and treatment procedures! determine costs! responsibilities! and other aspects of dental implant treatment. The "mplant +ommittee ill be composed of $ualified and privileged faculty appointed by the Dean of the School of Dentistry and normally include the follo ing members0 Dental "mplant +ommittee 1embers0 Director #rosthodontics 8esidency - +9%"8 +hair 8estorative Dentistry ,prn+hair :ral and 1a2illofacial Surgery :ral and 1a2illofacial 8adiologist ,prn8esidents +hair #eriodontics =. I(plan% !o((&%%ee Respons&)&l&%&es: ,1- #atients to be considered as candidates for dental implant treatment should be evaluated by the Dental "mplant +ommittee prior to placement of implants. These cases ill be presented by the assigned dental student and surgical ; prosthodontic resident team at the monthly "mplant +ommittee meeting. The 6oard re$uires an updated patient dental record! articulated study casts! and current radiographs to include panore2! periapicals and cross-sectional imaging hen appropriate. :rdinarily the presence of the patient is not re$uired! ho ever! if the prosthodontic or surgical situation is comple2! this policy may be modified. #rior to presentation to the 6oard! the prosthodontic and surgical consults should be completed and the (Important Considerations and Information for all Dental Implant Patients) ,consent form- signed. The assigned team should indicate a tentative treatment plan to include the type of dental implant! abutment and prosthodontic design. ,*- The +ommittee $uarterly basis. ill revie the progress of cases revie ed for treatment on at least a reported treatment complications as needed ,see Director :ral Surgery 8esidency "mplant +oordinator #eriodontists ; "mplant surgeons :ral Surgery < #ros ,non voting members-

,.- The +ommittee ill revie complications form-.

,7- Direct the A *ance I(plan% !ourse for prosthodontic ! periodontic and oral surgery residents. >aculty interested in implant therapy are encouraged to attend. &oals are to train the oral surgery! periodontic and prosthodontic residents in the latest surgical techni$ues and re$uirements and in the prosthetic re$uirements and procedures for successful completion of treatment. The goals of cross learning are to provide the s/ills needed to converse ith colleagues and be successful in private practice! providing predictable esthetic and functional results.

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%s part of the residents %dvanced +ourse in "mplantology! the :ral 1a2illofacial Surgery! periodontal and #rosthodontic residents ill present both pre- and post-op treatment to the "mplant +ommittee. ,=- The "mplant +ommittee ill suggest faculty education and training in areas needed to improve the scope of faculty /no ledge. ?, Pa%&en% !an & ac' ,#atient Selection #rotocol-0 #rior to the placement of implants! a patient@s candidacy for this procedure must first be determined. "t must be established that there are no medical! surgical or prosthodontic contraindications to treatment. #atients accepted for implant placement must be advised as to the nature and intent of the treatment! and ill have signed a ritten consent form "Important Considerations and Information for all Dental Implant Patients" in addition to a Surgical Consent Form signed during the surgical consult. %. 1edical 9istory. The patient@s medical history should be revie ed by both the surgical and restorative providers! ho ever any subse$uent medical lab tests needed to either determine candidacy or for pre-surgical evaluation should be ordered by the implant surgeon. '2amples of possible medical contraindications to implant placement may include! but are not limited to0 Uncontrolled diabetes. '2cessive smo/ing ,more than one pac/ a day-. 9istory of radiation to the proposed site. "mmune or connective tissue disorders that affect healing. 1etabolic bone disease 6leeding or clotting disorders #sychiatric disorders 6. :ral health status0 #atients ith periodontal disease should! at a minimum! have successfully completed initial therapy prior to referral to the "mplant Team. All rou%&ne en%al care an e$&n&%&*e per&o on%al %#erap'- necessar' %o ren er %#e pa%&en% &sease $ree- (us% )e co(ple%e pr&or %o &(plan% place(en%, #atients should display the ability to maintain their oral health and be able to return for routine follo -up appointments as deemed necessary. ., Pa%&en% Work/up:

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%. +linical Wor/up - . The prosthodontics! periodontics and surgical resident assigned to the case should be the sole providers and present for all phases of treatment! including the surgical consult! tooth e2tractions and grafting! +one 6eam +T , hen indicated-! implant placement! follo -up and second stage surgery and post-op care. %gain! the primary goal of the School@s implant protocol is to improve communication and the team approach of the surgical and prosthodontic team. 6y or/ing closely together! both treatment planning and the esthetic and functional results should improve. "f a resident rotates or other ise is not available for the entire treatment phase! the ne ly assigned resident ill meet ith currently assigned prosthodontic or surgical resident to revie the treatment plan and for turn over of responsibilities. The minimal +linical Wor/up should consist of the follo ing0 - +linical e2amination - manual and visual! palpation! vertical spacing! occlusal clearance! bru2ism! character of epithelial tissue! :VD! etc. - #hotographs - Diagnostic casts - good impressions and clean! accurate and neatly trimmed casts are a AmustA. '2cept for a simple single tooth case these should be mounted on a semiadBustable articulator using a facebo transfer. - Diagnostic set-up ,accurate representation of desired final prosthesis- "mplant location mar/ed on cast - 8adiographic analysis ,see belo 6. 8adiographic %nalysis0 Surgical candidacy is determined after an e2amination and revie ing the radiographs needed to ma/e this decision. "n general! the follo ing radiographs should be ordered for the follo ing conditions0 % panograph should be ta/en on most patients. % periapical radiograph should be ta/en on any proposed single tooth site! or the site of an immediate implant. 1ultiple sites in the partially edentulous arch! or single tooth sites that involve either the ma2illary sinus or inferior alveolar nerve should normally have a +6+T scan. The oral surgery and prosthodontic resident should or/ Bointly to develop a radiological stent ith appropriate radiological mar/ers to be used ith both the panograph and +T. These films should then be analy3ed by the residents using appropriate soft ear to determine implant feasibility! si3e! number and potential locations. The residents ill be responsible for presenting and defending their decisions at the "mplant +ommittee meetings. >or UD# pre-doc cases the dental student should be present at all times. +omple2 totally edentulous ma2illary arches scheduled for full arch rehabilitation re$uiring C 7 implants most often ill re$uire a +6+T scan. The oral surgery and prosthodontic residents ill or/ Bointly to develop a radiological stent ith appropriate radiological mar/ers. The +%T scans should then be analy3ed by appropriate soft ear to determine implant feasibility si3e! number and potential locations.

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+. #ossible Surgical +ontraindications - '2amples of possible surgical contraindications to implant placement may include! but are not limited to0 -"nade$uate bone volume for implant placement. -"nade$uate bone volume to support the proposed prosthesis. - "nade$uate interocclusal space to support the proposed prosthesis. -Dac/ of attached /eratini3ed tissue. -+ontra-indications for bone grafting -"nability to surgically achieve precise implant placement for optimal esthetics < function. D. #rosthodontic candidacy. Determined by the prosthodontic resident < #rogram Director after an e2amination! mounting diagnostic casts and evaluation of the pre-operative radiographs and radiographic analysis by Surgplan5 or Simplant5 ith the surgeon. #rosthodontic +ontraindications - '2amples of possible prosthodontic contraindications to implant placement may include! but are not limited to0 -"nade$uate bone volume to support the proposed prosthesis. -Dac/ of intra-arch vertical dimension -Unrealistic e2pectations of the patient -+hronic 6ru2ism -#sychological contraindications "nade$uate interarch or interdental space "nability to attain acceptable aesthetics "nability to surgically achieve precise implant placement for optimal esthetics <function. '. #resurgical Treatment #lanning. % presurgical conference should be scheduled bet een surgeons and prosthodontists ,and dental student if UD# case- for identifying0 Surgeon revie s diagnostic a2 up and final site position ith prosthodontist. The proposed treatment plan and se$uence 4umber! si3e! location and depth of proposed fi2tures Type of restorative abutment planned %lternative sites! number and si3e of fi2tures should be discussed considering possible surgical limitations pre-operatively. The design of the radiographic and surgical guide! interim restoration! and information regarding post-operative management should be revie ed. Determine need for hard and soft tissue augmentation prior to implant placement. 9ard tissue augmentation to include bloc/ grafting! cortical channel e2pansion! lateral all and osteotome sinus lifts! alveolar ridge preservation! osseous grafting ith or ithout barrier placement.

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Soft tissue augmentation to include papilla preservation! /eratini3ed and connective tissue grafting! and cosmetic cro n lengthening.

3, Presen%a%&on o$ $&n &ngs %o I(plan% !o((&%%ee: %n analysis should be performed in either 4obel +linician! Surgplan5 or Simplant5 format! and the proposal should then be printed for presentation to the implant committee and the patient. Dental students should be present and assist in the presentation for their UD# patients.
8esidents presentation to the "mplant +ommittee should include0 O.S./Perio Resident 1. 1edical history revie O.S./Perio Resident 2. 8adiographs and tomographs or +%T scans Pros Resident *. #rosthodontic Treatment #lan and case design Pros Resident .. 1ounted study casts and diagnostic a2-up O.S./Perio Pros 7. Surgplan5 or Simplant5 analysis of case O.S./Perio Resident =. Surgical treatment plan including the need for implant site hard or soft tissue augmentation O.S./Perio Resident ?. Dist of implants! materials and supplies needed for surgery Pros Resident E. Dist of implants! materials and supplies needed for prosthodontics 1ounted models

>ollo ing the approval of the implant committee a radiographic;surgical guide should be ordered or constructed by mutual input from both residents. ., Ra &ograp#&c an Surg&cal Gu& es: 8adiographic and Surgical guides ill be fabricated as a team effort by the surgical and prosthodontic residents and;or dental student for UD# case. "f +6+T scan radiographic studies are indicated to complete the diagnostic and treatment planning phases! they must be made ith a radiopa$ue reference stent in place that meet the re$uirements of the specific soft are to be used! i.e. 4obel &uide! Simplant! etc. The 6oard approves patients for the implant program based on the information presentedF ho ever! no commitment for treatment is made until a comprehensive clinical evaluation and treatment plan is completed by the assigned team members and signed by the patient. >abricate using duplicate of diagnostic a2-up cast and pre-op cast ith correct fi2ture location mar/ed. +onstruct ith radio-opa$ue mar/ers if to be used first for radiographic stent. +onstruct guide in clear acrylic % surgical guide must be used in conBunction ith all pre-fi2ture placement ridge augmentation and stage " surgeries. The prosthodontic resident is responsible for the fabrication of the surgical guide follo ing consultation ith the surgeon. The guide must be appropriately disinfected pre-operatively. Try in guide to verify fit. 6oth prosthodontist and surgeon must verify the useability of the guide for both the radiographic series and surgical procedure.

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5, Surg&cal Pro%ocol %traumatic e2traction ith grafting at the time of e2traction ill be the norm for patients to receive implants in those sites. Training in the use of periotone instrumentation and 6io+ol techni$ues ill be provided in Seminar or the %dvanced "mplant +ourse. Strict adherence to principles of implant placement and manufactures recommendations plus0 Sterile techni$ue Use of surgical guides "nternal and e2ternal irrigation ith chilled saline. Do 8#1@s ,C2!GGG #rimary closure ith vertical mattress sutures +hec/ films during placement %de$uate medication coverage for infection! pain and inflammation. Surgical &oals are for e2perience and training for both oral surgery and prosthodontic residents in several implant systems including titanium scre s! tap-ins! single and t o stage systems! immediate implants! immediate loading! mini implants for provisional interim and alternate approaches! etc. %. Stage " Surgery - #lacement of >i2tures0 ,1- !here - %ll Stage " surgical procedures ill be accomplished in Surgical suites designated for implant surgery here strict adherence to infection control and the above principles for implant placement can be achieved. ,2- Scheduling H With the assistance of the "mplant +oordinator surgical scheduling ill be done through the front des/ and the :ral and 1a2illofacial surgical appointment des/. Surgery times and dates must be mutually agreed upon by the surgeon and the prosthodontist team captain prior to patient scheduling. The implant fi2tures must be received and the Surgical Stent fabricated prior to patient scheduling. The prosthodontic and surgical providers assigned ill revie all aspects of the treatment! i.e. use of surgical guide! implant position and angulation! and all possible alternative treatment decisions that may be re$uired during surgery. 6oth the prosthodontic resident and surgical resident team members and dental student ,UD# case- should "e present during implant placement. 6. #ost-Surgical #rotocol0 ,1- #ost-op follo -up by surgical and prosthodontic resident ,dental student for UD#,2- >i2ed prostheses hich do not impinge on implant site can be placed at the time of surgery ,*- 4: remova"le prosthesis for ? - 1G days hile mucous membrane heals :8 place(en% o$ so$% l&ner o$ a% leas% "/+ (( %#&ckness o*er surg&cal s&%e )' en%al s%u en% 6UDP7 or res& en% &((e &a%el' a$%er surger' an a% S%age " surger'.

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,.- Ten days post surgery - denture ith a tissue conditioning material in it may be returned to the patient. ,7- 'valuate to ensure no tissue perforations. +. Stage "" Surgery - Uncovering of >i2tures0 ,1- The healing interval bet een Stage " and "" surgery ill reflect bone density! implant si3e ,diameter;area-! fi2ture stability on placement! and use of grafting materials and currently accepted guidelines. Single stage surgical procedures and immediate placement after e2traction and immediate loading ill be permitted only under ideal conditions and re$uire approval by the "mplant +ommittee. %ccelerated implant treatment guidelines are changing due to ne implant surface technology and treatment! ho ever standard healing guidelines for t o stage implant surgery are as follo s0 - mandibular anterior0 2 to * months - ma2illary arch and mandibular posterior0 * - = months - bone graft or Type "V bone0 . - I months ,2- Surgical +onsiderations - #rior to Stage "" surgery the treating team should reevaluate the implant site revie ing the need for developing appropriate contours for aesthetics and hygiene. >lap design and the need for hard or soft tissue grafting should be discussed along ith need for contoured healing abutment. ,*- A #eal&ng a)u%(en% 8&%# proper con*ergence angle or a pro*&s&onal res%ora%&on 8&ll )e place a% S%age II, 3or %o%all' e en%ulous pa%&en%s a ne8 so$% %&ssue rel&ne &s re9u&re , ,.- Surgical procedures ill be conducted in accordance ith accepted surgical standards! proper infection control techni$ues! and manufacturers protocols. %ny grafting or tissue guidance techni$ues ill be done in compliance ith approved research protocols or standards of care. 1G. Pros%#o on%&c Pro%ocol: - 8emove healing abutment;ma/e impression and;or place provisional or definitive ,ApermanentA or AfinalA- abutment. %t &(press&on appo&n%(en% and $&nal a)u%(en% place(en% co(ple%e sea%&ng s#oul )e ra &ograp#&call' *er&$&e . - %pply appropriate tor$ue - The use of provisional restorations to follo the philosophy of progressive loading! development of soft tissue contours and verify final prosthodontic design is recommended. - %ll implant superstructures must be carefully evaluated to insure passive fit to abutments. - :cclusal forces should be directed in an a2ial direction and occlusal schemes designed to minimi3e hori3ontal stresses. 11. Ma&n%enance !are an 3ollo8/up: - %t a minimum! all implant prostheses should be re-evaluated one month after restoration! then every * months first year! then one to . times a year depending on hygiene. 8outine removal of definitive abutments is not recommended.

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- Specific areas to be re-evaluated at follo -up appointments include0 - occlusion - oral hygiene and periabutment soft tissue health - crestal bone levels as vie ed annually on serial radiographs or tomograms if possible - ,4:T'0 if 2-sectional imaging in the buccal;lingual dimension ere originally ta/en this format should be continued to enable postop measuring! etc.- proper tor$ue on scre Boints - integrity of attachment systems - stability of the implant,s- "mplant 8ecall #rogram The Dental "mplant +oordinator ill develop a comprehensive 8ecall #rogram for all implant patients treated at WVU. The "mplant +oordinator ith the assistance of the Director of &raduate #rosthodontics and #eriodontics ill assign faculty;residents;students to coordinate this program. All pa%&en%s 8&ll )e place &n %#e Den%al I(plan% Recall Progra(, 12. !o(pl&ca%&ons: The "mplant +ommittee +hair must be notified henever a complication related to treatment is encountered. % Dental Implant Complication Report ,%ppendi2 %- form ill be filled out by the implant team and given to the "mplant +ommittee +hair. 8eported complications ill be revie ed by the "mplant +ommittee. +omplications hich re$uire notification include0 1. 2. *. .. 7. =. ?. "nfection0 post-surgical or post restoration delivery #ersistent ,J2 mo- nerve dysesthesia or paresthesia Damage to adBacent teeth during surgical treatment Doss of osseointegration >ailure to manage soft tissue properly resulting in non-restorability Significant crestal bone loss "ncorrect position;angulation of implant placement resulting in non-restorable implant or functional and esthetic failure. E. #rosthetic >ailure H Doss of osseointegration due to occlusal overload 8eported complications ill be revie ed monthly by the "mplant +ommittee 1*. I(plan% 3ees: >ee changes ill be recommended by the "mplant +ommittee and approved by the U9% Dental +orporation. Different fee levels ill be established as needed to meet teaching and accreditation re$uirements of both the pre and postdoctoral programs. 'ducational discount fees ill be given to promote and ensure specific patient treatments are available. &rant monies and

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manufactures promotional contributions should be used hen possible to off set overhead and enable reduced fees to increase numbers and types of patient treatment.
17.

The University Development Implant Program / Pre oc%oral S%u en% E<per&ence,

The School of Dentistry provides multidisciplinary didactic! laboratory and clinical instruction related to oral implants for all predoctoral dental students ith primary emphasis being placed on comprehensive diagnosis and treatment planning as the /ey to successful implant treatment. The predoctoral students clinical e2perience ill be limited to the University Development "mplant #rogram ,UD#- sponsored by several implant manufactures ho provide t o implants and components on a one time basis to each student. T o types of cases ill be authori3ed in the student clinic0 ,1- a noncomple2 single tooth implant in a non-esthetic 3one ,i.e. posterior implants only- and ,2- t o implants in the totally edentulous mandibular anterior arch to receive Docator or appropriate attachments or . to 7 1ini-Dental "mplants ,1D"- and attachments. The protocol for the mandibular implant overdenture ill be for the dental student to $a)r&ca%e ne8 co(ple%e en%ures $or %#e pa%&en% $&rs%- pr&or %o &(plan% place(en%. +6+T ill be re$uired for all 1D" and most overdenture cases. The ne mandibular denture ill be utili3ed to fabricate a surgical guide for implant placement. This provides the dental student the opportunity to fabricate conventional complete dentures and then have the implant e2perience. 1ore importantly! it assures that the denture utili3ed to fabricate the surgical guide has teeth in the proper position hen fabricating the surgical guide. These patients should have ideal attached tissue! bone and soft tissue for simple implant placement. Students must have all prospective patients screened by a $ualified prosthodontist for initial approval. Wor/ing under the Directors of &raduate #rosthodontics and :ral Surgery! an oral surgery resident ill be assigned as the surgical mentor and a prosthodontic faculty member or resident assigned as the prosthodontic mentor. %fter initial prosthodontic approval! the student can obtain a surgical consult and obtain necessary radiographs. % properly se$uenced #hase "V yello Treatment #lan form ith the patientKs signature of acceptance! and a (#rosthodontics 8evie ) ith final approval is re$uired, 3&nal appro*al $or accep%ance &n%o %#e UDP 8&ll )e g&*en )' %#e I(plan% !o((&%%ee a$%er presen%a%&on %o %#e !o((&%%ee )' %#e s%u en%, #roper implant procedure codes must be included. When indicated! and under the guidance of the oral surgery and prosthodontic mentors! students ill obtain 2-sectional imaging or a +6+T scan of the proposed implant site,s-. Students must utili3e all re$uired forms in %2ium and ensure all re$uired signatures are obtained on the Dental Implant Procedure Chec# $ist and the Important Considerations and Information for all Dental Implant Patients %patient consent form&. These forms are found in %2ium under (&raduate #ros >orms). 2G. Re9u&re 3or(s: - "mportant +onsiderations and "nformation for all Dental "mplant #atients ,consent form H see "mplant +oordinator- Surgical Treatment +onsent >orm ,(:sseo "mplant "+) form in %2ium- Dental "mplant #rocedure +hec/ Dist - "mplant +omplications 8eport >orm