Chapter 16
– Choosing the Appropriate Implant Modality
The three professionally accepted abutment-providing modalities covered in the teaching case
chapters are safe and effective for their intended purpose of providing abutment support, and are
sufficiently technique-permissive to be incorporated into the normal routine of most practitioners.
Whereas each is known to be scientifically acceptable in terms of safety and efficacy, [1][2][3][4][5][6] the
three differ markedly with regard to the clinical criteria for professional acceptance described in
Chapter 7 . This affects diagnosis and patient acceptance.
In most cases properly diagnosed for mainstream treatment, one of the modalities presents itself
as being the most appropriate for treatment in consideration of the preoperative volume of
available bone. In some cases, for example, only the plate/blade form modality can be used for
mainstream treatment, because available bone is insufficient for root form placement [7] and
overabundant available bone precludes subperiosteal implant placement. For other patients, only
the subperiosteal implant may be applicable, because a lack of available bone rules out use of
any endosteal modality without extensive non-mainstream bone augmentation procedures. [8][9]
In cases in which available bone is sufficient for use of the root form modality, plate/blade forms
may also be used. Because of frequent lack of adequate available bone depth posteriorly,
conventional root forms can be used in approximately half of the cases that present for
mainstream treatment. The Innova Endopore implant used in the posterior partial edentulism
teaching case presented in Chapter 11 increases the applicability of the root form modality,
because its diffusion-bonded microsphere interface increases its surface area to the extent that it
can be approximately two thirds the depth of a conventional root form. [10] These considerations
reaffirm the diagnostic importance of accurately quantifying available bone, in all its variations,
because of its profound effect on treatment planning and implant modality selection. It is precisely
because no one implant modality can be used for the mainstream treatment of every case that
practicing multimodal implant dentistry is of benefit to the practitioner and patient alike.
This chapter demonstrates how available bone governs much of diagnosis in implant dentistry.
Available bone requirements are quantified for mainstream treatment using each modality,
allowing one to empirically determine if any given modality is applicable to the case at hand. In
the presence of insufficient or overabundant bone, when one modality cannot be considered for
mainstream treatment, another one can. In cases of overlap, more than one modality is
appropriate for the available bone presented. Scientifically, the overlapping modalities are equally
valid, insofar as each can safely and effectively provide additional abutment support for
restorative dentistry. In such cases, one should apply the clinical criteria for an ideal implant
system, provided in Chapter 7 , to the modalities under consideration. If two modalities can be
used safely and effectively, considerations such as time, esthetics, cost, complexity, and trauma
become important, and can guide the practitioner to make the decision that most benefits the
patient.[11]
The broader message of this chapter is that the combined scope of treatment using all three
abutment-providing modalities—the multimodal approach—is far greater than the scope of
treatment exclusively using any one modality. Collectively, the use of these three modalities
represents the true scope of treatment possibilities afforded by implant dentistry. [12] Every
practitioner should understand the indications and contraindications of each modality, and share
this understanding with patients considering treatment.
DETERMINING WHETHER IMPLANT TREATMENT CAN SUCCEED
Determining whether implant treatment can succeed is one of the most important concepts in
implant dentistry, and is a consideration that must be incorporated into the diagnosis and
treatment planning routine of every implant dentistry practitioner in every case. If a dental implant
of any kind is placed successfully into or onto the available bone, heals properly, and is fitted with
its final prosthesis, will it be able to withstand the anticipated load? Can it do the job asked of it?
Just because an implant can be placed and heal successfully does not mean that it will be able to
withstand the forces to which it will be subjected. Not every implant configuration can support an
equal load long-term in health. The various implant configurations exist to advantageously use
the various volumes and configurations of available bone one encounters in candidate implant
dentistry patients.
If it is deemed likely that an implant considered for use in a case would not remain in health long-
term, the treatment plan should be changed, or the case may fail. This is the same consideration
applied to evaluate potential natural abutments in conventional prosthodontics, in that sometimes
a natural tooth available for abutment support may be deemed unable to bear the load in health
long-term, and therefore is avoided or splinted to other teeth.
In a way, asking an entry-level practitioner to make this determination is premature. Realistically,
one cannot accurately determine how much load an implant should be able to withstand until one
has gained experience observing the course of several mainstream cases. Generally, if one
follows the guidelines established in Chapter 1 to determine whether a case is mainstream, an
implant appropriate for the available bone will be able to withstand the anticipated load. Cases
similar to the teaching cases discussed in the step-by-step procedure chapters should succeed.
However, in any type of case, including the most predictable of mainstream cases, it is important
to be sure that one is asking the implants to do a realistic job. The case must not be
underengineered. This consideration gains in importance as one progresses toward treating
intermediate and advanced cases, in which the capability of the implants to withstand anticipated
load cannot be taken for granted. Proper case engineering is essential. In intermediate and
advanced cases, the judgment of the practitioner has a greater influence on the ultimate outcome
of the case.
In addition to evaluating available bone, the practitioner must consider the nature of the patient. Is
the patient a gentle, weak, or aged person, or a vigorous person and a habitual bruxer? Other
factors such as the opposing dentition must also be taken into consideration. For example, an
opposing removable denture affords more shock absorption than natural teeth and therefore will
impart less force to the implant-supported prosthesis. Proper occlusion is also an important
consideration
AVAILABLE BONE AS THE PRIMARY DIAGNOSTIC CONSIDERATION
Mainstream Cases Use Existing Available Bone
Mainstream cases use the available bone that exists preoperatively. It is a fundamental precept of
mainstream implant dentistry that the implant should be selected to fit the anatomy and volume of
the available bone, and that the available bone should not need to be altered or augmented
substantially to accommodate a specific implant modality. As discussed in Chapter 15 , bone
enhancement techniques can change the anatomy of the alveolar ridge, sometimes radically.
However, such techniques are not considered mainstream because of the complexity of
treatment, insufficient long-term success and survival data, and lack of general consensus on
preferred materials and methods of placement for different types of treatment. The prognostic
value of altering an alveolar ridge to fit a preselected implant modality or configuration is
questionable. It is certainly easier to select an implant that fits the available bone as presented.
Abundant long-term success and survival data support such a course of action. Chapter 8
presents some of these data.
Range of Available Bone Volume Suitable for Each Implant Modality
This section analyzes the available bone that is typically required for each of the abutment-
providing modalities, dimension by dimension, and identifies the conditions in which only one
modality can fit the available bone to provide mainstream treatment.
Root Forms.
The ideal available bone parameters for a typical conventional root form configuration are shown
in Box 16-1 . No available bone presentations exist for which only the root form modality can be
used to provide mainstream treatment.
Box 16-1
IDEAL AVAILABLE BONE PARAMETERS FOR A ROOT FORM WITH 4-MM DIAMETER
AND 10-MM DEPTH
Bucco/labio-lingual width: 6 mm
Mesio-distal length: 8 mm
Depth: 12 mm
Bucco/Labio-Lingual Available Bone Width.
The width of a root form implant is its diameter. It is best to have 1 mm of crestal bone width at
the bucco/labiolingual borders of any endosteal implant on the day of insertion. Three-
dimensional finite element analysis in conjunction with clinical observation indicates that this is
generally the minimum amount of investing bucco/ labio-lingual bone required at the ridge crest to
absorb functional loads within physiologic limits of health. [13] The reason that the amount of
required investing bone at the ridge crest is smaller than in other areas is because cortical bone
offers more support. Clinically, in mainstream cases, this means that a conventional root form
implant with a diameter of 4 mm requires a pretreatment ridge width of 6 mm as measured 1 to 2
mm apical to the ridge crest.
Mesio-Distal Available Bone Length.
Because a root form is round in cross section, its length is its diameter. If a root form is inserted
adjacent to a tooth or another root form, a minimum of 2 mm of clearance between them is
recommended in mainstream cases. This amount of proximal bone is required because the
mesial and distal of the implant interface is almost entirely against cancellous bone. There is a
much higher percentage of cortical contact against the buccal/labial and lingual interfaces. [14]
Available Bone Depth.
Conventional root forms used for mainstream implant dentistry treatment are typically 10 mm
deep. It is advised to have approximately 2 mm of clearance beyond the apical end of the implant
to the nearest landmark. Thus, for conventional root forms, 12 mm of available bone depth is
generally recommended. It is permissible to reduce the height of the ridge crest to create the
sufficient ridge width provided that in doing so a sufficient depth of available bone remains from
the reduced crest to the nearest landmark to place the implant with 2 mm of clearance.
Plate/Blade Forms.
The ideal available bone parameters for a typical plate/blade form configuration are shown in Box
16-2 . When evaluating available bone for insertion of a plate/blade form implant, it is useful to
know that in general, an inverse relationship exists between the implant’s length and depth. A
longer configuration requires less depth to function within physiologic limits of health long-term,
whereas a configuration that is shorter mesio-distally requires greater depth.
Box 16-2
IDEAL AVAILABLE BONE PARAMETERS FOR A PLATE/BLADE FORM WITH 18-MM
LENGTH AND 8-MM DEPTH
Bucco/labio-lingual width: 3.35 mm
Mesio-distal length: 22 mm
Depth: 10 mm
The plate/blade form is the only modality that can provide mainstream treatment in cases within
certain ranges of available bone depth and width.
Bucco/Labio-Lingual Available Bone Width.
Most plate/blade forms are 1.2 to 1.35 mm in width. Thus, with 1 mm as the minimum required
width of investing bone buccally and lingually, the minimum ridge width for insertion of a
plate/blade form in a mainstream case is 3.35 mm as measured 1 to 2 mm below the crest. This
relatively small width requirement is the primary reason that plate/blade forms have such wide
diagnostic applicability.
In cases with sufficient depth of available bone for the insertion of an endosteal implant but width
less than 6 mm, the plate/blade form modality is indicated.
Mesio-Distal Available Bone Length.
A minimum of approximately 2 mm of clearance should exist between the mesial or distal border
of a plate/blade form and an adjacent tooth root or other implant.
Available Bone Depth.
Using any plate/blade form configuration, 2 mm of clearance is ideal between the implant and any
landmarks beyond its depth. In mainstream cases, ridge crest height rarely needs to be reduced
to create the sufficient ridge width of 3.35 mm. In cases in which depth of available bone is 6 to
10 mm, the plate/blade form modality is usually the only modality indicated.
Subperiosteal Implants.
The maximum available bone parameters for placement of a subperiosteal implant are shown in
Box 16-3 . Whereas in endosteal implant dentistry insufficient available bone can contraindicate
the use of a configuration, in subperiosteal implant dentistry overabundant alveolar bone is a
contraindicating factor. Therefore, whereas in endosteal implant dentistry minimum available
bone requirements are considered, in subperiosteal implantology the maximum available bone
that allows a satisfactory prognosis is considered.
Box 16-3
AVAILABLE BONE MAXIMUMS FOR A SUBPERIOSTEAL IMPLANT
Bucco/labio-lingual width: No limit
Mesio-distal length: No limit
Depth: 6-8 mm posteriorly, 8-12 mm anteriorly
Subperiosteal implants are the only modality that can offer mainstream treatment when available
bone depth is insufficient for placement of an endosteal implant.
Bucco/Labio-Lingual Width.
In subperiosteal implant dentistry, width is not a limiting factor, although greater width is
desirable.
Mesio-Distal Length.
Length of available bone is not a limiting factor in subperiosteal implant dentistry. In mainstream
unilateral subperiosteal cases, in which the prosthesis is supported by a combination of implant
and natural co-abutments, the length of the implant is naturally dictated by the length of the
edentulous span. When relatively fewer teeth have been lost, the length of the implant is relatively
short, and total support of the prosthesis is compensated by the fact that more natural tooth co-
abutment support remains. When more teeth have been lost, the implant length, and therefore
the amount of support offered by the implant, increases with the length of the edentulous span
onto which the implant is designed, and the number of teeth planned for the overlying prosthesis
increases.
Available Bone Depth.
Excessive depth from the ridge crest to the nearest landmark contraindicates the use of a
subperiosteal implant. In cases in which there is sufficient residual alveolar ridge to insert
endosteal implants that can function within physiologic limits of health, endosteal implants should
be used.
The maximum acceptable depth of available bone for mainstream treatment using a posterior
unilateral subperiosteal implant is 6 to 8 mm. In the presence of less than this depth,
subperiosteal implants are ideal. In fact, in such cases, only the subperiosteal implant modality is
indicated. This is also true in cases with 6 to 8 mm of available bone depth but less than 3.35 mm
of width as measured 1 mm below the ridge crest, because this lack of width contraindicates
insertion of a shallow plate/blade form despite adequate depth. When more than 6 to 8 mm of
bone depth is available with sufficient ridge width, endosteal implants are better suited for the
case at hand. Anteriorly, the maximum available depth allowable for mainstream treatment using
a subperiosteal implant increases by 2 to 4 mm, and sometimes more, depending on the width of
the ridge crest and other factors.
Incidence of Appropriate Available Bone for Each Modality
Having a general idea of the range of anatomic presentations typically encountered in implant
dentistry candidates is helpful in deciding which modality or modalities to learn first. For
practitioners who use one modality exclusively, general knowledge of the range of anatomic
presentations helps one determine which modality to learn next to offer mainstream treatment to
more patients.
Root Forms.
Many partially edentulous implant dentistry candidates who present for treatment have insufficient
available bone for mainstream root form implant insertion. It is interesting to note, however, that
most implant treatment performed today uses root form implants. In essence, the majority of our
resources has been devoted to treating a minority of implant candidates.
This fact highlights the benefits of the multimodal approach, which enables the treatment of a
broader range of patients. At the same time, our discipline’s focus on the root form implant has
provided abundant data on the modality’s long-term safety and efficacy, voluminous scientific
literature detailing various insertion and restoration techniques, and an established network of
corporate entities and practitioners to whom one can turn for support.
Plate/Blade Forms.
Plate/blade forms have the broadest range of applicability of the abutment-providing modalities.
Most patients who are candidates for implant dentistry can be treated using the plate/blade form
modality. A patient whose anatomy allows use of root form implants can receive plate/blade form
implants. In cases in which either mainstream root form or plate/blade form treatment can be
performed, the practitioner should, in consultation with the patient, decide which modality is better
suited based on important clinical criteria such as length of treatment, the desirability of using or
avoiding natural co-abutments, number of patient visits, total weeks in treatment, and cost.
Practitioner comfort and familiarity with the modality options may be the most important
consideration in such cases.
Despite the high percentage of candidate patients who can be treated using the plate/blade form
implant modality, one should not adopt a single-modality approach in favor of plate/blade forms.
The number of patients who can be treated using multiple modalities remains substantially higher.
Subperiosteal Implants.
Only a small percentage of implant dentistry candidates can undergo mainstream treatment using
a unilateral subperiosteal implant, because most patients present with sufficient available bone
for insertion of an endosteal implant. However, this does not mean that the subperiosteal is the
least important modality. On the contrary, it is the small percentage of patients for whom
mainstream treatment using a unilateral subperiosteal is appropriate who have the greatest need.
These patients typically have had the most dental complications in their lives and are almost out
of treatment options. Furthermore, in most cases in which mainstream treatment using a
unilateral subperiosteal implant is indicated, no other modality can be used without extensive
non-mainstream bone augmentation. There is very little overlap with this modality. Therefore, the
subperiosteal implant is one of the most important modalities to learn, because it is usually the
only mainstream option for those patients who require it.
MAINSTREAM CASE ANALYSIS— WHEN MORE THAN ONE
MODALITY CAN BE USED
In overlap cases, in which more than one modality may be applicable to the available bone,
clinical acceptance criteria help the practitioner determine the appropriate modality for use. The
underlying assumption when using clinical criteria to assist in selecting the most appropriate
modality in any given overlap case is that everything else is equal. In other words, the two
modalities that are applicable have equal scientific validity—that is, they each have been proven
safe and effective for their intended purpose. All of the professionally accepted implant modalities
discussed in this book have proven scientific validity. That is why the clinical criteria are so
important in choosing between them. Using clinical criteria also presupposes that the available
bone requirement is equally suitable for either modality—that there is, in fact, overlap. If not,
mainstream implant dentistry treatment dictates that the modality that fits the available bone be
used.
Overlap Between the Subperiosteal and Plate/Blade Form Modalities
In cases in which either the subperiosteal or plate/blade form implant modality may be used ( Fig.
16-1 ), in which the depth of available bone is approximately 6 to 8 mm and the width equals at
least 3.35 mm as measured approximately 1 mm below the ridge crest, the practitioner must
determine which modality is preferable. Interocclusal clearance, the presence of adequate natural
co-abutments, the presence of natural teeth or a denture in the opposing arch, habits, emotional
need, the practitioner’s familiarity and comfort level with the two modality options, and the like all
bear on this decision. Other important considerations are related more closely to the patient’s
desires, needs, and temperament. If the patient is reluctant to undergo the two-stage surgical
protocol usually followed to place a subperiosteal implant, then inserting one or several shallow
blades may be a superior option.
Figure 16-1
Figure 16-1 Similar shallow available bone presentations treated with maxillary
plate/blade form implant (upper left), mandibular plate/blade form implant (lower
left), maxillary unilateral subperiosteal implant (upper right), and mandibular
unilateral subperiosteal implant (lower right).
The practitioner must determine which modality has less potential for complications. The risk
using a subperiosteal implant in a borderline case is that the bone on which the implant is placed
may further resorb under portions of the implant to the extent that struts may dehisce through the
gingiva into the oral cavity. The risk using shallow plate/blade forms in a borderline case is that
the anticipated occlusal load may not permit the implants to function long-term within physiologic
limits of health. The case must be sufficiently engineered. Another important consideration is
whether the patient is able to perform acceptable home care. Because the subperiosteal implant
requires more conscientious home care, it may be advisable to use shallow plate/blade forms
when possible for patients who have a history of inadequate home care.
The option of inserting shallow blades and reserving the placement of a subperiosteal implant as
a fallback plan is worthy of consideration in such cases. Subperiosteal implants are often the final
resort in implant dentistry,[15] and it is sometimes advisable to treat with another modality first,
knowing that the subperiosteal implant may be used later if the initial endosteal treatment is
unsuccessful, or after years of successful function when the useful lifetime of the endosteal
implant has finished.
The rare cases in which available bone width is less than 3.35 mm but available bone height is
greater than 6 to 8 mm are not considered mainstream for any modality. In such cases, ridge
height reduction may be performed to remove bone that is anticipated to resorb anyway to allow
the placement of a subperiosteal implant, or bone augmentation may be undertaken to increase
available bone width to the extent that a plate/blade form may be inserted. Of these two options,
ridge height reduction and the use of a subperiosteal implant is considered closer to mainstream.
If the patient has a history of bruxism, or if for any reason the anticipated functional load may
allow neither long, shallow plate/blade forms nor a subperiosteal implant to function successfully
long-term within physiologic limits of health, the use of either may be questionable. In the maxilla,
intramucosal inserts to improve retention and stability of a maxillary denture may be an option
worth considering. An intramucosal insert teaching case is presented in Chapter 20 .
Overlap Between the Root Form and Plate/Blade Form Modalities
General Considerations.
Cases that present with sufficient available bone for insertion of root form implants can also be
treated using plate/blade form implants ( Fig. 16-2 ). Numerous clinical considerations help guide
the practitioner to determine which modality should be used in such cases.
Figure 16-2
Figure 16-2 Similar deep available bone presentations treated with root form
implants (A), and plate/blade form implants (B). (A, Courtesy Yasunori Hotta,
Nagoya, Japan.)
In addition to weighing all the clinical pros and cons of each modality for any given case, one
must also consider that the practitioner’s comfort and familiarity with a particular modality and
system contribute greatly to successful treatment. The appropriate question is not, “Which implant
is best?” The appropriate question is, “Which implant works best in my hands?” Although it is
important not to use exclusively the implant modality with which one is most comfortable at the
expense of using a more appropriate modality when it is indicated, comfort and familiarity with a
modality and/or system is a valid and important factor in diagnosing overlap cases.
Evaluate the Desirability and Availability of Natural Co-Abutments.
A primary factor in helping the practitioner determine whether to use the root form or plate/blade
form modality in an overlap case is the availability and desirability of using natural co-abutments.
In mainstream cases, plate/blade forms should be used with natural co-abutments under a
prosthesis, whereas root form implants should not be used with natural coabutments. Therefore,
in mainstream overlap cases, the availability and desirability of using natural co-abutments is a
vital factor to guide the practitioner in deciding between these two modalities.
In cases in which the practitioner and/or the patient does not want to reduce the teeth adjacent to
the edentulous area to be treated, the root form modality may be considered a superior option.
However, in cases in which the additional support that could be afforded by the use of natural co-
abutments may be necessary to ensure the long-term survival of the restoration, the plate/blade
form option may be considered superior. One must evaluate whether the adjacent teeth require
treatment unrelated to implant treatment, and if so, whether this treatment influences the
desirability of using these teeth as co-abutments.
Reconciling Treatment Requirements With Patient Needs and Desires.
The patient should help decide what treatment should be performed. The patient can and should
provide the practitioner with information that directly bears on which modality should be chosen.
The information that the practitioner should elicit from the patient is related to the patient’s
experience. It is information that the patient clearly understands and can easily provide. In
addition, intuition and analysis of the patient’s history is important. Does the patient have any
strong preferences regarding the total number of weeks that will be spent in treatment? Some
patients want their treatment to be finished as quickly as possible, whereas others are not
concerned with the timeframe. This consideration has a direct bearing on whether the practitioner
should choose to use an osteointegrated or osteopreserved implant, because of their differing
case sequencing requirements. Does the patient have a strong preference regarding the total
number of treatment visits that will be required? Some patients have very flexible schedules, and
can come in for treatment as often as the practitioner sees fit, whereas others have busy
schedules that limit the number of treatment visits to which they can realistically commit. Is the
patient’s primary interest in the esthetic result, or is being able to function properly the primary
goal? In most cases these options are not mutually exclusive, but the esthetics associated with
each modality have differences that can affect one’s decision. Can the patient reasonably be
expected to perform sufficient home care following completion of the case? If not, a modality that
is easier to maintain may be a superior option, whereas for a patient who can provide adequate
home care this is not a determining factor.
Treatment Time and Expense.
The amount of total elapsed time and number of visits for a typical mainstream case using each
of the abutment-providing modalities, important considerations when choosing the modality in
overlap cases, are discussed in each of the step-by-step treatment chapters. Another important
consideration is cost. In general, the direct cost to the practitioner for implants and laboratory fees
associated with the root form modality is higher than for the plate/blade form or sub-periosteal
implant modalities.
Overlap Between the Root Form and Subperiosteal Implant
Modalities
There is no overlap between mainstream root form treatment and mainstream subperiosteal
implant treatment. Mainstream subperiosteal treatment is always unilateral. In posterior
edentulism cases, the available bone depth and width requirements for root form and
subperiosteal implants are mutually exclusive. The only overlap between these two modalities is
in cases of total mandibular edentulism, in which mainstream treatment can be performed using
root forms anteriorly with an overdenture restoration, or a non-mainstream total subperiosteal
implant can be inserted[16] ( Fig. 16-3 ).
Figure 16-3
Figure 16-3 Similar available bone presentations treated with anterior root forms for
overdenture restoration (A), and total subperiosteal implant (B). (A, Courtesy Edward
Amet, Overland Park, Kan. B, Courtesy Walter Knouse, Lumberville, Pa.)
INFORMED CONSENT—PRESENTING ALL TREATMENT OPTIONS
Obtaining informed consent is, of course, essential. However, informed consent does not merely
mean having the patient sign a release form indicating awareness of the proposed treatment and
its relative risks. The truly informed patient is educated by the practitioner regarding all of the
treatment options or alternatives that apply to the case. Therefore, it is not sufficient, nor is it
appropriate, for the practitioner to determine which implant modality to use in a case in which
more than one is applicable, and then only inform the patient about the preselected option to
obtain consent. It is the responsibility of the practitioner to explain to the patient that several
courses of treatment may achieve the goal of providing fixed bridgework in the edentulous area.
Each of these options should be discussed in some detail, covering points such as treatment time
and expense. It is then the responsibility of the practitioner to make a sound recommendation.
Only when the patient has heard all of the applicable treatment options and has agreed to the
practitioner’s recommended course of treatment, or has requested a modified treatment plan in
consultation with the practitioner, has informed consent truly been obtained.
A more detailed discussion of informed consent is presented in Chapter 23 .
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