Preorthodontic Implant Placement in the Planned Postorthodontic Position: a Simplified Technique and Clinical Report

Preorthodontic implant placement in the planned postorthodontic position: A simplified technique and clinical report

Roger A. Solow, DDS

Interdisciplinary cases can require orthodontic correction with surgical template for preorthodontic imaging and correct implant anchorage prior to the placement of implant-supported implant placement in the planned postorthodontic position. This restorations. Definitive implants for orthodontic anchorage approach uses common materials to combine the information offer several advantages compared to temporary attachment from a preorthodontic diagnostic cast and the orthodontic devices. Preorthodontic definitive implant placement requires setup/diagnostic wax-up/trial equilibration cast. accurate and detailed treatment planning to visualize the final Received: July 8, 2011 orthodontic result and the optimal restoration position. This Accepted: August 25, 2011 article describes a simplified method for creating a radiographic-

rosthetically driven implant facilitate orthodontic movement • Definitive implants reduce the placement is the accepted that would not be possible other- time, cost, and complications Papproach when treatment plan- wise.8,9 Once the interdisciplinary associated with TADs. ning restorations require implant treatment goals are determined, Prior to any procedure, it is support.1-3 The restoration of eden- the orthodontist can finish TAD- essential for each dentist involved tulous areas with implant-supported assisted tooth movement; at that in the treatment plan to visualize crowns can be straightforward when point, the surgeon and restorative the final result of interdisciplin- the adjacent teeth are properly dentist can place the final implant- ary treatment. Definitive implant positioned. Treatment plans that supported restoration adjacent to placement for orthodontic involve orthodontic movement prior the properly positioned teeth. anchorage requires detailed and to implant-supported restorations Alternatively, the surgeon can accurate planning to establish are more complex. The restorative place definitive implants in the post- the implant sites away from dentist might ask an orthodontist orthodontic position prior to ortho- the current tooth position, cor- to complete tooth movement prior dontic therapy. The placement of relating to future orthodontic to planning the final restoration. definitive implants for orthodontic movement.10,11 A diagnostic When orthodontic movement is not anchorage offers several advantages wax-up and orthodontic setup possible without using implants for over the use of TADs: (that is, model surgery) are made anchorage, the restorative dentist • Implant-supported provisional to determine if the final result is required to determine the final restorations provide patients with will be clinically realistic. The restoration and implant positions immediate function and esthetic restorative dentist should confirm prior to orthodontic treatment. improvement while establishing a that the orthodontist can achieve The goal of restorative-orthodontic precise endpoint for orthodontic the planned tooth positions and communication is to ensure that the movement. that the surgeon can create the orthodontic correction permits a • The midcrestal position creates optimal periodontal environment harmonious final restoration. direct anchorage with a straight for predictable restoration. The Temporary attachment devices vector of force and simplifies preoperative and orthodontic (TADs) have revolutionized ortho- orthodontic movement. setup/diagnostic wax-up casts dontists’ ability to move teeth by • Treatment time is reduced, as can be shared with the patient to creating direct or indirect absolute gingival maturation occurs during communicate the anticipated result anchorage.4-7 Implant anchorage can orthodontics. and value of treatment.

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Fig. 2. A maxillary preoperative view. Note the narrow Fig. 1. Preoperative retracted view reveals missing posterior teeth, multiple gingival recessions, arch form, anterior teeth crowding, and palatally unesthetic gingival embrasures, exposed metal margins, bilateral crossbite, and distorted inclined teeth. There are no teeth distal to tooth No. 5 occlusal plane. to provide orthodontic anchorage.

Fig. 3. A mandibular preoperative view. Missing bilateral teeth create a lack of orthodontic anchorage Fig. 4. Full-mouth radiographs of the patient taken in 2008. Note the apical lesion on tooth to correct the anterior teeth crowding. No. 14 and severe caries on tooth No. 15.

The literature offers several Willems et al employed a similar completed on one set; at that point, methods for planning the pre- method, using a flexible resin stent the implant-supported crown posi- orthodontic placement of definitive to transfer the location of the center tions (which were visible through implants in the postorthodontic of the prosthetic tooth outline as the the clear surface of the position position. Smalley transferred the implant position on the orthodontic plate) were marked and the plate position of wax-up teeth (represent- setup cast to the preoperative cast, was transferred to the preopera- ing future restorations on a model prior to surgical guide fabrication. tive cast to visualize the proposed surgery cast) to the preoperative The composite cast was used to pro- implant positions.15 cast, which was duplicated to form gram the provisional restorations.14 In a 1999 report, Drago altered a composite cast. A surgical guide More recently, Lai et al used cus- preoperative casts, set denture was created on this cast using tomized plastic cast bases and clear teeth in the anticipated restorative acrylic resin transfer templates position plates to fabricate identical positions, and created clear plastic and a molding machine to register duplicates of preoperative casts. A vacuum-formed surgical guides by implant location.12,13 diagnostic wax arrangement was using a molding machine.16 In a

e194 July/August 2012 General Dentistry www.agd.org Fig. 5. A panoramic radiograph taken in 2007 showing a history of periodontal disease, tooth loss, failed restorations, and altered occlusal plane. Fig. 6. Diagnostic casts mounted in CR.

1996 study, Kokich used a diagnos- Implant templates should also fixed-position radiographic-surgical tic wax-up to determine the implant be practical and easy to use during template for pilot drill control in position.17 The distance from surgery. Good design features that the placement of multiple implants this position to the nearest tooth make the template acceptable for in the planned orthodontic position that would not be moved during clinical use include: prior to tooth movement. A simple orthodontics was used as a guide for • inexpensive and commonly armamentarium of the preoperative implant placement.17 available materials; cast, an orthodontic setup/diag- The method described in this • simple design for fabrication nostic wax-up cast, and common article uses a surgical template by an assistant; materials are used. to transfer the planned implant • precise angulation, parallelism, positions on the orthodontic setup/ and spacing control for single Case report diagnostic wax-up cast intraorally. A or multiple implants; A periodontist referred a 57-year- plethora of surgical template designs • easy modification during surgery old man to the restorative dentist are currently available, ranging from without creating debris; for a comprehensive evaluation simple vacuum-formed outlines of a • small size with stability; after a series of emergency extrac- diagnostic cast to stereolithographic • versatile use with full or partial tions and socket preservation templates derived from computed edentulous cases; grafts. The patient’s chief concern tomography.18-23 All designs can be • the ability to function as both was difficulty in chewing following divided into fixed or variable surgi- a radiographic and a surgical tooth loss. His medical history was cal templates.24 Fixed designs deter- template; noncontributory. The patient’s pre- mine the implant drill position and • indexing to an abutment analog clinical interview, clinical examina- angulation for the surgeon, while so that a provisional restoration tion, radiographs, photographs, variable designs allow the surgeon to can be generated. and mounted diagnostic casts were alter position or angulation during A versatile radiographic-surgical used to generate a problem list and surgery. Ideal requirements for an template that fulfills these require- treatment plan (Fig. 1–6) (Tables 1 implant template include good ments and design features was and 2). The radiographs revealed implant orientation in the mesio- described by the author in 2001.26 that tooth No. 14 had an endodon- distal and buccolingual positions, It is a clear acrylic resin template tic infection with bone loss on contrast during diagnostic imaging, showing the planned prosthetic the short distobuccal root. Tooth stability during oral manipulation, tooth contour with the pilot drill No. 15 was not restorable due to surgical access and visibility during channel defined by radiopaque severe caries (Fig. 4). A significant external irrigation, and freedom to composite resin. posterior crossbite was evident on alter the implant position within the This clinical report illustrates the diagnostic casts, with the arc of confines of the surgical template.25 the fabrication and use of a closure interference on the palatally

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Table 1. Problem list generated from the Table 2. Treatment plan designed to address clinical examination, radiographs, diagnostic the comprehensive problem list. casts, and photographs. Tooth/Teeth No. Treatment Missing teeth No. 2–4, 18–20, and 29–31 6, 11, 12 Orthodontic correction of crossbite Crossbite relationship on teeth No. 6, 11, and 12 6–11 and 22–27 Orthodontic realignment Uneven incisal plane with crowded teeth No. 6–11 and 22–27 4, 19, 20, 29, 30 Implants with stock abutments; Generalized moderate to severe maxillary gingival recession single implant-supported all-porcelain crowns Worn, short buccal cusp on tooth No. 5 5 Buccal cusp composite resin augmentation Exposed metal collar and opaque porcelain crowns on 7 and 10 All-porcelain crowns teeth No. 7 and 10 Enlarged maxillary incisor gingival embrasures 8 and 9 Composite resin interproximal augmentation Root caries on teeth No. 14 and 15 11 Recontour incisal edge Distobuccal bone loss on tooth No. 14 14 Distobuccal root resection; endodontic treatment Apical radiolucency on tooth No. 14 Fractured enamel on tooth No. 28 14 Partial veneer gold crown Arc of closure interference on the crown of tooth No. 7 15 Extraction Non-working side occlusal interferences on teeth No. 21 and 28 28 Composite resin restoration Residual ridge crossbite sites on teeth No. 3 and 4 due to Full mouth Occlusal equilibration narrow maxilla

tilted tooth No. 7. In addition, Using a laboratory carbide bur, the casts were trial-equilibrated non-working crossover excursion three fiducial indents (5 mm x 5 mm) so that all teeth contacted within interferences were present on teeth were created in a tripod arrange- 20 µ in occlusion. Smooth anterior No. 21 and 28 (Fig. 6). ment on the lingual land area of guidance on the central incisors For occlusal analysis and subse- the mandibular cast. The diagnostic and canines was established, as quent treatment planning to have casts were duplicated with irreversible was immediate disclusion of the any clinical significance, the diag- hydrocolloid placed in the indents to posterior teeth in all eccentric nostic casts must accurately identify ensure accurate reproduction of this excursions (Fig. 8). the true maxillomandibular critical area. The duplicate casts were Consultation with the orthodon- relationship. Patients with limited mounted on a second identical artic- tist concluded that the ideal ortho- remaining teeth can unintention- ulator with the same facebow and dontic setup/diagnostic wax-up ally move the mandible, masking CR record. The diagnostic casts must position could not be obtained the type and degree of malocclu- be preserved so that alterations to without moving teeth through exist- sion, to establish more contact the duplicate casts during treatment ing alveolar bone and exacerbating between teeth. planning can be compared accurately. the gingival recessions. The patient Using Dawson bimanual The tripod indents serve as a refer- declined root coverage grafting. It guidance and an anterior acrylic ence position for the accurate transfer was decided that creating anterior platform, a bite record was obtained of matrices and indexes between the guidance on the central incisors and in centric relation (CR).27,28 The diagnostic and duplicate casts. canines would create a predictable casts were mounted on a semi- The duplicate casts were altered outcome and that restoring teeth adjustable articulator, with the CR (using an orthodontic setup) to pre- No. 19, 20, 29, and 30 with crowns record and facebow. The intraoral view ideal orthodontic correction. in a crossbite relationship (without mandibular incisor contact on the Missing teeth were restored with a excursive contact interferences) was acrylic platform was identical to diagnostic wax-up so that the posi- the best way to optimize the occlu- the mounted cast incisor contact, tion of implant-supported crowns sion and preserve the current root- verifying CR (Fig. 7). could be previewed. At that point, to-buccal bone relationship.29,30

e196 July/August 2012 General Dentistry www.agd.org Fig. 7. The anterior acrylic platform placed Fig. 8. Orthodontic setup/diagnostic wax-up Fig. 9. Cast No. 1 is a duplicated, unmounted on the models, showing the contact of casts mounted in centric relation. This portrays preoperative cast. Note the flat land area the mandibular incisor, identical to the the ideal occlusion. plaster and tripod indents. intraoral contact.

The diagnostic wax-up demon- The treatment plan included strated that additional restorations restoring the sites of teeth No. distal to tooth No. 4 would create 19, 20, 29, and 30 with implant- a problematic horizontal cantilever supported crowns. Since the from the crossbite of the right orthodontic correction would residual ridges. No molar replace- involve moving teeth No. 21 and ment was planned for tooth No. 28 distally, the implants would 3; this resulted in a shortened need to be placed further distal to dental arch on the right side. As the current positions of teeth No. with natural teeth, the shortened 21 and 28 and align with their Fig. 10. Pink baseplate wax applied to dental arch design can be used with postorthodontic root inclination. cast No. 1 to create the retentive area of implant dentistry and did not create The information obtained from the radiographic-surgical template. White an esthetic deficit in the present the orthodontic setup/diagnostic orthodontic wax provides blockout over the case.31-34 The patient declined the wax-up cast was combined with planned implant supported restorations sites. alternative option of surgical sec- the preorthodontic cast so that tioning and expanding the maxilla. the radiographic-surgical template During treatment planning, it would fit precisely on the teeth was determined that tooth No. 4 during surgery while also creating was the only tooth in the maxillary the proper implant placement. Baseplate wax was placed on the arch that would be restored using teeth of cast No. 1 to create the an implant-supported crown. The Mandibular radiographic- retention pad of the radiographic- implant and crown for site No. 4 surgical template procedure surgical template. Soft orthodontic were determined from the diagnostic The preorthodontic mounted wax was placed in the edentulous wax-up to be placed in the existing mandibular cast was duplicated areas that were to be restored mesial-distal dimension since only with irreversible hydrocolloid and with implant-supported crowns. buccal tilting of tooth No. 5 was poured in vacuum-mixed dental The volume of this blockout wax planned, without mesial-distal move- stone. It is important to preserve should be greater than the antici- ment. The maxillary surgical guide the original diagnostic casts for the pated contour of the final restora- could be made on the existing pre- patient’s permanent record, as casts tions (Fig. 10). orthodontic cast (using the author’s can be damaged during fabrication A putty matrix was formed technique cited above) and the pilot of the radiographic-surgical tem- over cast No. 1 and pushed into hole orientation could be tilted plate. This duplicate cast (referred the tripod indents for complete buccally to match the anticipated to as cast No. 1) does not need to be adaptation. After setting, the final alignment of tooth No. 5.26 mounted (Fig. 9). borders of the matrix were cut back

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Fig. 12. Intaglio of putty matrix prior to Fig. 11. Cast No. 1 with a putty matrix. retention hole placement. Note the tripod Retention holes will retain the impression registration and the relief created after Fig. 13. Cast No. 2 is the mandibular material without the use of adhesive. removing wax retention pads and blockout. orthodontic setup/diagnostic wax-up cast.

Fig. 14. Cast No. 2 with the teeth, after Fig. 16. Intaglio of putty matrix with white removal of the teeth that are to be moved Fig. 15. Putty matrix on cast No. 2 with access orthodontic wax barriers to contain impression orthodontically. window over planned restorations. material.

to confirm the intimate fit to the was held against cast No. 2 and land portion of the cast. All wax low-viscosity vinyl polysiloxane retained in the matrix was removed (VPS) impression material was (Fig. 11 and 12). injected around the wax teeth The mandibular orthodontic (Fig. 16 and 17). The matrix was setup/diagnostic wax-up cast is separated from cast No. 2 after the referred to as cast No. 2. The teeth impression material had set. The Fig. 17. Wax-up teeth retained in putty matrix that were to be moved orthodonti- pickup impression in the matrix by low-viscosity VPS impression material. cally were removed. The wax-up contained the wax-up teeth. The teeth and the teeth that were not to wax-up teeth and barriers were be moved were preserved (Fig. 13 removed, and the matrix was and 14). The matrix derived from returned to cast No. 1 to confirm cast No. 1 was placed on cast No. 2 complete seating. to confirm complete seating. Cast No. 1 was lightly lubricated Windows in the matrix were cut to avoid any lubricant pooling in out in the diagnostic wax-up sites the indents that would prevent to create an access for impression adaptation of the matrix. A thin Fig. 18. The gingival contour of the material with the pickup impres- mix of clear acrylic resin was poured radiographic-surgical template prosthetic teeth sion (Fig 15). Soft orthodontic wax into the matrix; at that point, the are outlined on cast No. 1. Mesiodistal and was placed in the matrix, confining matrix was firmly reseated on cast buccolingual lines intersect at the center of the the impression material to the area No. 1 until all excess acrylic resin prosthetic outline, the target for the pilot drill. of the wax-up teeth. The matrix was expressed past the borders of

e198 July/August 2012 General Dentistry www.agd.org Fig. 19. The radiographic-surgical template fitted on the preoperative cast, showing Fig. 20. Mandibular right and left provisionals at surgery. Note the amount of horizontal and vertical postorthodontic prosthetic tooth position and space available for tooth movement. pilot drill channel alignment. The lines indicate the divergence of the existing tooth inclination and the vertical planned position of the implants.

the matrix. The matrix was secured against the model with rubber bands and placed in a pressure pot for 10 minutes (at 30 psi) to polym- erize the acrylic resin. The radiographic-surgical template was separated from the cast. The excess acrylic resin was trimmed with acrylic resin burs and the template was polished with pumice. The template was placed on cast No. 1 and the cervical margin was outlined for each tooth for which Fig. 21. Orthodontic brackets and archwires, placed 10 days after implant surgery and immediate implants were planned (Fig. 18). provisionalization. The center of each implant site was marked and an access opening of 3 mm was cut in the occlusal aspect of the radiographic-surgical template over these centers. position) and photocured. Flowable Treatment Using a round bur, a rest was composite resin was injected and Implants with stock abutments placed at the center of each implant photocured around the shank on the (NobelReplace and NobelActive, site (1 mm depth). A straight intaglio of the radiographic-surgical Nobel Biocare USA, LLC) were handpiece bur shank was inserted template. The bur shanks were placed in tooth sites No. 4, 19, 20, through the access opening into removed by rotating with a pliers. 29, and 30. The composite shells each rest. Each bur shank was The long, smooth composite resin generated from the diagnostic oriented within the long axis of the channel centered over the implant wax-up were relined with acrylic acrylic resin tooth and perpendicular site was 2.35 mm wide, providing resin at the surgical appoint- to the bony ridge (Fig. 19). Flow- precise guidance for the 2 mm pilot ment and provisionally cemented able composite resin was injected drill.35 The radiopaque composite (Fig. 20).36 The adjacent provisional through the access opening around resin indicates the central axis of restorations were splinted to resist the bur shank (to stabilize its each implant site during imaging. orthodontic forces. Orthodontic

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Fig. 22. A radiograph of tooth No. 14 after endodontic treatment and resection of the Fig. 24. A preoperative portrait view of the distobuccal root with bone loss, eliminating patient’s smile. the periodontal pathology. All sulci probed 3 mm or less.

appliances were placed 10 days later (Fig. 21); endodontic treatment was completed on tooth No. 14 and the distobuccal root was resected Fig. 23. Anterior and buccal views of the (Fig. 22). After orthodontics, the modified postorthodontic provisional provisionals were augmented with restorations. Note the crossbite relationship of the same composite resin to finalize the mandibular implant-supported provisional Fig. 25. A portrait view of the patient after the their contours (Fig. 23). Casts of restorations. restorations were completed. the provisional restorations served as a guide for the final restorations, which were completed using con- ventional procedures. The implant- supported single porcelain crowns posterior teeth, improve anterior appropriate treatment plan. First, had a harmonious relationship to the esthetics, and establish an occlusion each tooth repositioned during the orthodontic-corrected arch and were compatible with the periodontium, orthodontic setup was recorded the most hygienic and biomimetic teeth, and implants. The diagnostic as a mesiodistal and buccolingual restoration option (Fig. 24–26).37-41 work made the restorative dentist change (in mm) relative to the The planned implant placement and familiar with the tooth size and adjacent tooth. Second, wax occlusal orthodontic correction created the position, posterior occlusion, and matrices of the preoperative and desired vertical alignment, parallel to anterior guidance factors needed orthodontic setup casts were made the adjacent roots (Fig. 27). for predictable implant-supported prior to adding the diagnostic restorations. Each item on the prob- wax-up teeth. The orthodontic setup Discussion lem and treatment plan lists could cast was placed into the wax record Interdisciplinary dental teams rely then be discussed with the specialist of the preoperative cast, oriented by on each member’s specialized skills (Tables 1 and 2). A comprehensive tooth No. 32 (which was not moved to create the optimum result for treatment plan should address all of during orthodontics) and the resid- the patient. In the present case, the patient’s problems and allow the ual ridge. It was determined that the the restorative dentist did the specialist to predictably accomplish mandibular teeth would occupy a orthodontic setup and diagnostic the preparation for restorative work. smaller arch circumference than they wax-up and made the radiographic- The amount of planned orth- had originally, as the premolar teeth surgical template. The final step in odontic movement for each tooth moved distally toward the anchor- this interdisciplinary case utilized was quantified in three ways so that ing implants. The preoperative cast restorative dentistry to recreate lost the orthodontist could design an tooth indents could be visualized to

e200 July/August 2012 General Dentistry www.agd.org Fig. 26. Anterior and occlusal views of the patient after orthodontic correction and the placement of porcelain single-tooth restorations on teeth No. 4, 7, 10, 19, 20, 29, and 30.

Fig. 27. Periapical radiographs of the implant-supported porcelain single unit restorations at sites No. 4, 19, 20, 29, and 30. Note the vertical axis of the implants with the parallel alignment of the adjacent roots.

Fig. 29. The mandibular orthodontic setup cast seated in the same matrix. Fig. 28. The mandibular preoperative cast, creating indents in the Note the change in position of the anterior teeth representing the planned wax matrix. orthodontic movement.

the facial aspect of the orthodontic to baseplate wax. The index was can use teeth for which orthodontic setup cast and measured (Fig. 28 and transferred to the preoperative cast movement is not planned—or a 29). Finally, using the provisional to show the amount of movement combination of teeth and indents in restoration composite shells gener- required for the teeth adjacent to the the residual ridge away from planned ated from the diagnostic wax-up, index (Fig. 30 and 31). implant sites—as a reference tripod. a wax index was constructed. The The tripod indents in the cast When creating the planned res- shells were positioned in the same provided accurate positioning of the toration form, a diagnostic wax-up location as the wax-up teeth in the matrix on both the preoperative cast is preferable to denture teeth.12 orthodontic setup cast and attached and its duplicate. Alternatively, one Custom wax teeth create a detailed

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Fig. 30. Composite resin provisional shells are placed in the correct Fig. 31. The wax index, transferred to the preoperative cast. The distance position on the orthodontic setup/diagnostic wax-up cast and luted to and inclination of the planned prosthetic teeth compared to teeth No. 21 baseplate wax. and 28 is the amount of planned orthodontic movement.

occlusion, with the optimum size template should not preclude place- the bur hole (that is, the pilot drill and contour to occlude with the ment of the pilot drill. The template target) can be displaced from the opposing dentition. This wax-up is should have a 2 mm minimum center of the prosthetic outline used to program the fabrication of thickness of acrylic resin to avoid on the cast to provide a 0.5 mm the provisional restorations, pre- fracture during intraoral placement margin of error in implant position serving their size and contour and and pilot drill insertion. If access for each tooth; if necessary, final maintaining the planned endpoint is restricted due to limited mouth crown contours can close extra of orthodontic movement. Alter- opening, a buccal slot can be cut in space to the natural tooth. natively, denture teeth can be used the radiographic-surgical template, and modified with wax added to allowing for lateral entry of the pilot Summary the occlusal and proximal surfaces. drill while preserving the lingual This article describes the process for The surgeon should be consulted aspect of the composite resin chan- fabricating a radiographic-surgical for preferences of design of the nel to maintain guidance. template, using a diagnostic cast, radiographic-surgical template so Posterior site implant angulation an orthodontic setup/diagnostic that it will actually be used during should be vertical so that compres- wax-up cast, and common materials. implant placement. For example, sive force through the final restora- This template is used to determine the gingival aspect of the template tion is distributed optimally.42,43 implant placement in a planned can contact the ridge (so that The root angulation of the teeth postorthodontic position prior to prosthetic tooth position is evident) that are being moved should paral- tooth movement. Implants can be or be reduced (to provide space for lel the vertical implants for ideal used for orthodontic anchorage and external irrigation). Also, the reten- crown position. Treatment plan- to provide immediate provisional- tion pad can be extended so that a ning must consider that if an error ization, restoring lost function and finger rest will further stabilize the in position occurs, the implant esthetics. Orthodontic movement is template. The template should be should be placed too far from the direct with a straight vector of force evaluated intraorally before surgery adjacent tooth instead of too close and a precise three-dimensional to ensure complete seating and sta- to it. Lack of available space limits endpoint of treatment. bility. Interproximal septae around the amount of tooth movement and crowded teeth should be relieved reduces the ability to achieve the Disclaimer prior to seating. The occlusal thick- orthodontic and restorative goal. Dr. Solow has lectured for Nobel ness of the radiographic-surgical During fabrication of the template, Biocare, USA, LLC.

e202 July/August 2012 General Dentistry www.agd.org Acknowledgements treatment of partially edentulous adult patients. 29. Kim Y, Oh TJ, Misch CE Wang HL. Occlusal con- The author would like to thank Int J Periodontics Restorative Dent 2009;29(3): siderations in implant therapy: Clinical guide- 333-340. lines with biomechanical rationale. Clin Oral Michael Seda, DMD, MS; Sean K. 12. Smalley WM. Implants for tooth movement: Impl Res 2005;16(1):26-35. Carlson, DMD, MS; and Darron Determining implant location and orientation. 30. Gross MD. Occlusion in implant dentistry. A re- Rishwain, DDS, for their surgical, J Esthet Dent 1995;7(2):62-72. view of the literature of prosthetic determinants 13. Smalley WM. Treatment of debilitated dentitions and current concepts. Aust Dental J 2008;53 orthodontic, and endodontic exper- with implant anchorage. In: McNamara JA, Rib- Suppl 1:S60-S68. tise. Porcelain restorations were bens KA, eds. Implants, microimplants, onplants, 31. Kayser AF. 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