Diagnosis, treatment planning and radiographic evaluation/ cosmetic dentistry training

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

 Introduction
 Rationale for dental implants
 Advantages of implant supported prosthesis
 Contraindication and implant failures
 Patients complaints and expectation
 Patients history
 Laboratory evaluation
 Clinical examination
 Diagnostic imaging and techniques
 Radiographic interpretation
 Diagnostic models
 Prosthetic option

 Available bone
 Division of bone
 Bone quality
 Treatment option for partially edentulous
 Treatment option for completely edentulous
 Treatment option for single tooth replacement
 Surgical guide
 Conclusion
 Reference

 Thorough patient assessment is prerequisite for
adequate treatment planning
 Practioner has to evaluate
 Whether implant is indicated
 For the patient
 In specific oral situation
 As comprehensive treatment planning.

Patient
assessment
Diagnostic
planning
Avoids
failure and
complication

 Combined effect of no of factors:-
Aging population
Tooth loss related to age
Anatomic consequences of edentulism
Roberts’ et al – 4% strain to skeletal system
maintain bone and helps balance the
resorption and formation phenomenon.

 Loss of bone width, height
 Keratinized mucosa decreases
 Tongue often enlarges
 Tongue takes active role in mastication
 Decrease neuromuscular control
 Prominent mylohyoid , internal oblique ridge,
genial tubercles.

 Esthetic consequences of edentulism
 Prognathic appearance
 Decrease horizontal lip angle
 Thin lips
 Decrease facial height
Poor performance of removable prosthesis
Psychological aspects of tooth loss
Complex and varied
Minimal to neurocticism

 Tooth positioned for aesthetics
 Maintainence of bone
 Maintainence of occlusal vertical dimension
 Development of Proper occlusion
 Improved psychological health
 Regained proprioception

 Increase survival time of the restoration
 Improved function, stability, retention and
phonetics
 Preserve intact adjacent natural tooth
 Improved chewing efficiency

Medical
contraindication
Intra oral
contraindication
Increased failure

 Acute infectious disease
 Chemotherapy
 Systemic bisphosphonate medication
 Metastatic bone disease
 Hypercalcaemia of malignancy
 multiple myeloma
BISPHOSPHONATE ASSOCIATED
OSTEONECROSIS

 Renal osteodystrophyia
 Severe psychosis
 Pregnancy
 Unfinished cranial growth with incomplete
tooth eruption
 General systemic diseases
 Patient on medications or radiation therapy

 Pathological finding at oral soft and hard tissue

 Post head and neck radiation
 Osteoporosis
 Uncontrolled diabetic
 Alcohol , drug abuse, heavy smoker
 h/o aggressive periodontits

 During initial consultation it is advisable to
have patient elicit his or her complaint,
concerns and treatment request.

 Confirms their complaints and expectation
The review of the patient’s medical history is the
first opportunity for the dentist to talk with the
patient
The time and consideration taken at the onset will
set the tone for the entire following treatment

 Level of dental disease
 Commitment towards its management
 Denture history
 Additional questions
 Age of prosthesis
 Reason for tooth loss
 H/o periodontal disease
 Tooth loss due to trauma

 Includes: Hematocrit evaluation
Complete blood cell count
Bleeding disorder tests
Blood sugar examination

 Correct facial proportion
 Facial symmetry
 Need for cheek and lip support
 Facial skeletal classification
 Intermaxillary relation
 Incisal edge of maxillary centrals
 TMJ movement and function
 Hypertrophy of facial musculature

 Dental examination
 Edentulous region
 Quantity and quality of mucosa and contour of
underlying bone
 Existing prosthesis
 Occlusal status and functional examination

 Overall evaluation
 Maxillary anterior tooth
 Occlusal vertical dimension
 Mandibular incisal edge
 Maxillary posterior plane
 Mandibular posterior plane

 Specific criteria
 Lip lines
 Maxillomandibular relation
 Existing occlusion
 Crown height space
 TMJ status
 Existing prosthesis
 Natural adjacent tooth
 Soft tissue of edentulous site

 Evaluated prior to any other segment
 Labial position determined with lip in repose
 Vertical position evaluated
 Maxillary canine is key

 Distance between two points
when occluding members are in
contact.
 Not a constant position.
 Change in OVD may modify
anterior guidance, function and
esthetic
 Kois and Phillips , three
situations mandate modification
of OVD
 Esthetic
 Function
 Structural needs of the dentition

 Esthetic is related to OVD for incisal edge,
facial measurement and occlusal plane
 Function is related for anterior guidance,
canine position and angle of load.
 Structural requirements are related to
dimension of teeth for restoration

 Mandibular incisal edge should contact lingual
aspect of upper anterior teeth.
 Incisal guidance evaluated.

 Maxillary occlusal plane
parallel to Camper’s line
 Occlusal plane of natural teeth
evaluated in partially
edentulous patient.
 Occlusal plane analyzer used
to evaluate pretreatment
condition and assist occlusal
plane correction.

 Lip position are evaluated for
 Resting lip position
 Maxillary high lip line
 Mandibular low lip line
 Lip position varies with age
 Smile line –
 Low
 Average
 High(gummy)

 Completely edentulous patient lip position
verified.
 Mandibular teeth more visible in middle age
and older patient
 Mandibular teeth evaluated during speech

 Assessed in vertical, horizontal and lateral
planes.
 Improper skeletal position corrected by
orthodontics or surgery
 Often effected in edentulous arches

 Maxillary arch width decreases 40% in expense
of labial plate – cantilevered force in implant
body.
 Long term complete denture patient mimic
class III relation

 It is best evaluated with facebow mounted
diagnostic cast
 Evaluate if existing occlusion be modified or
maintained.

 CHS measured from crest of bone to plane of
occlusion/ incisal region
 For FP1 CHS ranges 8 – 12mm
 Biological width
 Abument height
 Esthetic
 Hygiene
 Removable prosthesis > 12mm
 Denture teeth
 Acrylic base
 Attachments
 Hygiene

 Primary concerned in RP-5 prosthesis
 Ride shape, size, parallelism
 Square ridge – optimal resistance and stability
 Tapering ridge – poor stability

 Help to develop and implement a cohesive
and comprehensive treatment plan for the
implant team and the patient
 Organized under three phases
1. Preprosthetic implant imaging
2. Surgical and interventional implant imaging
3. Post prosthodontic implant imaging

PHASES OBJECTIVE
 Preprosthetic imaging  Identify disease
 Bone quantity
 Bone quality
 Critical structure
 Optimum presence of
implant placement

PHASES OBJECTIVE
 Surgical and
interventional imaging
 Depth of placement
 Position and orientation
of implant osteotomy
 Evaluate donor or graft
site

PHASES OBJECTIVE
 Post prosthetic phase  Status and prognosis
 Bony changes around
implant

 Intra oral radiography
 Extraoral radiography
 Tomography
 Computed tomography
 Cone beam volumetric tomography
 Magnetic resonance imaging

 Analog imaging modalities/2D:
1. Periapical radiographs
2. Panoramic radiographs
3. Occlusal radiography
4. Cephalometric radiography
 3-D imaging modalities
1. CT
2. MRI
3. CBVT
 Digital images can be produced in all the
modalities

PERIAPICAL R/G OCCLUSAL R/G
 Bisecting angle
 Paralleling technique
 Lateral view
 Cross sectional view
 Minimal application

 Popular form of radiograph
 Provides general overview of dentition and jaws.
 Disadvantages :
1. Both vertical and horizontal magnification are
present
2. Does not demonstrate bone quality and
mineralization
3. Accuracy depends on patients position
4. Image is 2 dimensional

Other problems:-
Soft tissue shadow
Airway shadow
Ghost image

 Bone availability in mid
sagittal region of maxilla and
mandible
 Cross sectional image in incisal
and canine region
 Check width of bone in
symphysis region and its
relationship between buccal
cortex and roots of anterior
teeth before harvesting bone
for augmentation.

 Greek words “tomo”- slice and “graph”-
picture in 1962.
 International commision on radiological nits
and measurement.
 Types
 Linear
 Spiral
 hypocycloidal

 Digital and mathematical imaging technique that
creates tomographic sections
 Enables differentiation and quantification of both
soft and hard issues
 Density of the structure within the image is
absolute and quantitative and used to differentiate
tissue in the region and the bone quality
 Enables evaluation of the proposed implant site

 CT imaging software designed to produce life
size images in an easy to read format.

 High radiation dose
 Cost
 Inferior dental canal not always shown well
 Beam hardening artifact
 Low density structure beyond resolution
 The software may not always be available

 CBVT permits 3D visualization of dental hard
tissue in a similar manner to multislice CT.
 Patient is seating or standing
 Cone shaped beam
 Image acqisition time varies
 Radiation dose is lower

 Magnetic properties of hydrogen atoms
 Suited for soft tissue
 Inferior alveolar nerve appears as black void
within high signal cancellous bone.
 Contraindication
 Metal foreign bodies
 Cardiac pacemakers
 1st trimester of pregnancy
 claustrophobia

 Roots of adjacent tooth
 Course of inferior alverior nerve
 Floor of nose
 Incisal canal
 Morphology of maxillary sinus

 Identified as narrow radiolucent ribbon
bordered by radio-opaque lines.
 Wadi et al found that this line was disrupted or
absent in some cases.
 May appear as area of increased density

 In buccal cortex in premolar region
 In residual ridge may be close to crest of ridge
 Loops backward, not always visible

 Lies below mylohyoid ridge on lingual aspect
 Well demonstrated by tomography, CT, CBVT.

 Extends anteriorly from mental foramen
 Some studies have shown life threatening
complication caused by profuse bleeding
 Usually poorly demonstrated on conventional
radiograph

 Funnel shaped hole between two halves of
maxilla
 Contains nasopalatine nerve and descending
palatine artery

 First paranasal sinus to develop
 Don’t extend beyond apex of upper canine
 Visualized as air filled space on r/g

 Prosthetic criteria in absence of
patient
 Implant site selection
 Bone resorption
 Diagnostic set up – used for
surgical template or provisional
restoration
 Permanent record
 Motivation

 Centric relation and occlusal contact
 Natural abutment and its orientation
 Interarch distance
 Wear facets
 Arch form and symmetry
 Arch relationship

 In 1989 Misch, reported five prosthetic options
 FP1
 FP2
 FP3
 RP4
 RP5

 FP1- bone augmentation required
difficult to achieve when 2
adjacent teeth missing
FP2- implant position chosen in
relation to bone width, angulation
or hygienic consideration.
Implant should be placed in correct
F-L position to ensure contour
hygiene and direction of forces not
comprised.

 FP3 – Two approaches
 Hybrid restoration of denture teeth and acrylic and metal
substructure
 Porcelain metal restoration.

RP4
RP5
The removable
categories are
determined by
amount of
implant
support.

 RP 4 – completely supported by implant, teeth
or both.
 5-6 implants in mandible
 6-8 implants in maxilla
 RP5 – combine implant and soft tissue support

 In 1985 Misch and Judy established four basic
divisions of available for implant dentistry in
maxilla and mandible which follow the natural
resorption phenomena represented by
Atwood.

 Describes the amount of bone in the edentulous
area considered for implantation
 Measured in: height
width
length
angulation
crown-implant body ratio

 Available bone height is measured from the crest of the
edentulous ridge to opposing landmark
 Maxillary sinus
 mandibular canal
 Nares
 Inferior border of mandible
 Maxillary canine offers greater height
 Mandibular first premolar present reduced height

 Minimum height of available bone for
endosteal implants is in part related to the
density of the bone
 Once the minimum height is established for
each implant design and bone density, width
is more important than additional length

 Measured between facial and
lingual plates at the crest of the
potential implant site
 Minimum bone thickness is in the
midfacial and midline contour of
the crestal bone
 4 mm implant requires >5mm
width allow predictable blood
supply around the implant

 Mesio- distal length of available bone in the edentulous
area is often limited by the adjacent teeth or implant
 Depends on the width of the bone
 For a 5mm width minimum 7mm length is sufficient
 If width is less than 5mm, a 3.2 mm implant is placed
 In narrower ridge it is better to place 2 small implants

 Ideally it is aligned with the forces of occlusion
and is parallel to the long axis of the restoration
 Represent root trajectory in relation to roots
 Rarely does the available bone angulation
remain constant after the loss of teeth specially
in the anterior edentulous maxilla

 Here the teeth are angulated most to the occlusal forces
 Accepted bone angulation in wider ridges is 30degrees
 In the posterior mandible, the submandibular fossa
mandates greater angulation as implants are placed
more distally


 2nd PM region 10 ° angulation to the horizontal
 1st M – 15 degrees
 2nd M – 20 to 25°
 Limiting factor of angulation of force between
body and abutment is correlated to the width
of the bone

 Impacts the appearance of the final prosthesis
and the amount of moment of forces on the
implant and the surrounding crestal bone
 Crown height measured from the occlusal
plane to the crest of the ridge
 Implant body is measured from the crest to the
apex

• >crown Height >moment of
force
• As the crown implant ratio
increases more number of
implants or wider implants
should be Inserted to
counteract the increase in
stresses

 Division A
 Division B
 Division C
 Division D

 Forms soon after the tooth extraction
 Abundant bone volume remains for few years
 Interseptal bone height decreases and crestal bone
width decreased by 30% within the first 2 years
 There is abundant bone in all dimensions
 Width >5mm
 Height >10-13mm
 Mesiodistal length > 7mm

 4 to 5mm implant can be placed
 In A plus bone 7mm Implant can be placed
 Angulation of load doesn’t excced 30 ̊
 Crown implant ratio less than 1
 Restored with division A root form implants

 Width of the available bone first decreases at
the expense of facial cortical plate
 25% decrease in bone width in first year, 40%
decrease in one to three years
 Division B once reached may remain for more
than twenty years
 Offers sufficient available bone height

 Depending on available bone width division B
can be further classified into
- 4-5mm
- B minus width [B-w] 2.5 to 4mm
Crown implant ratio less than one

 Three treatment option:-
 Osteoplasty
 Narrow implant
 Augmentation
 In order to select the proper approach the final
prosthesis must be considered.

 FP1 requires augmentation
 RP4, RP5 requires osteoplasty
 Disadvantage of division B root form implants
 Twice stress concentrated at crestal bone
 Lateral loads 3 times
 Emergence profile less esthetic
 Angle of load less than 20 ̊
 Two implants required

 Available bone is deficient in one or
more dimensions [W, L, Ht, ANG,
CR/I ratio]
 W may be less than 2.5
 Ht maybe less than 10mm
 Cr/I ratio may be >or equal to one
 Angulation may be greater than or
equal to 30

 Division C is most commonly present in
posterior maxilla and mandible
 C-w resorbs to C-h as fast as A to B occurs
 C-h eventually leads to division D
 Division C prosthetic treatment is complicated
and greater complications are seen during
healing prosthetic design and maintenance.

Treatment option
1. Osteoplasty
2. Root form implants
3. Subperiosteal implants
4. Augmentation procedures
5. Ramus frame
6. Transosteal implants

 Osteoplasty converts C-w to C-h
 Augmentation requires greater block bone
 Subperiosteal implants show more predictable
results in mandibular arch

 There Is complete loss of alveolar bone with
basal bone atrophy
 Most difficult to treat In implant industry
 If implant failure occurs the patient may
become a dental cripple unable to wear any
prosthesis
 So benefits must be carefully weighed against
risks before treatment

 Available bone is particularly important in
implant dentistry and describes the external
architecture or volume of edentulous area
considered for implants
 Multiple independent groups have reported
higher failure rates in poor quality bone
compared to a higher quality bone

Bone classification schemes related to implant dentistry
 Linkow in 1970
- Class 1 bone structure
- Class 2
- Class 3
 Class 3 results in loose implants,
 Class 2 is satisfactory for implants
 Class 1 is ideal for implants

 Lekholm and Zarb in 1985, gave four bone
qualities found in the anterior region of the jaw
-Quality 1: homologous compact bone
-Quality 2: thick layer of cortical bone surrounding a core of
dense trabecular bone
-Quality 3: thin layer of cortical bone surrounding dense
trabecular bone of favorable strength
-Quality 4: thin layer of cortical bone surrounding low density
trabecular bone

 In 1988 Misch extended the four bone density
groups independent of the region of jaws based
on macroscopic cortical and trabecular bone
characteristics
 Suggested implant design, surgical protocol,
healing, treatment plans loading time for each
bone density types.

 D1: dense cortical
 D2: thick dense to porous cortical
bone on the crest and coarse
trabecular bone within
 D3: thin porous cortical bone on the
crest and fine trabeculae within
 D4: fine trabecular bone {almost no
crestal or cortical bone}
 D5: immature non mineralized bone

 Bone density determined by
- tactile sense during surgery
- general location and
- radiographic evaluation
 Tactile D1: drilling into oak on maple
D2: drilling into white pine/ spruce
D3: drilling into balsa
D4: drilling into Styrofoam

 D1 – anterior mandible
 D2 - mandible
 D3 – maxilla, posterior mandible
 D4 – posterior maxilla

 Periapical or OPG are not beneficial
 D2 D3 changes are not quantifiable
 More precisely determined by tomography
especially CT
 Most critical region of bone density is the crestal 7-
10mm of bone
 When bone density varies from crest to apex,
crestal 7-10mm determines the treatment plan

 CT Bone quality in Hounsfield units

 Numerous classifications have been proposed
for partially edentulous arches
 The Kennedy classification is most commonly
used
 The implant dentistry bone volume
classification may be used to build on the four
classes of partial edentulism described in the
Kennedy Applegate system

 By using this classification the doctor is able to
convey the dimensions of the bone available in
the edentulous area and also indicate the
strategic position of the segment to be restored
 The Implant dentistry classification for
partially edentulous patients also includes the
same 4 available bone volume divisions
discussed for the edentulous area

 Other intradental edentulous regions not responsible
for the Kennedy Applegate class determination are not
specified within the available bone section of the
Misch- Judy system if implants are not considered in
the modification region
 However if the modification segment is also included
in the treatment than it is listed followed by available
bone division it characterizes

Independent
implant
supported
prosthesis
indicated

•Osteoplasty
•Small diameter
implants
•Augmentation

•No implants
•Bone
Augmentation
•Sinus graft
•Subperiosteal
implants or
disc implants
•Nerve
repositioning

 A history of edentulous classification primarily
includes the Classification of Kent and Louisiana
Dental school
 This classification treats all regions of the
edentulous arch in similar fashion and does not
address regional variations
 The classification was for ridge augmentation
with hydroxyapatite and a conventional denture

 The divisions of bone presented by Misch are
the basis of the classification of the completely
edentulous patient
 Its objective is to communicate the volume of
bone and its location
 Each edentulous jaw is divided into three
regions

 Division of bone is similar in all three
anatomic segments
 Four different categories present
 Type 1 division A: abundant bone in all
three regions
 Type 1 division B: adequate born in all
three sections
 Type 1 division C-w: inadequate bone
width
 Type 1 division C-h: inadequate bone
height
 Type 1 division D

 Posterior sections are similar but different from
anterior segment
 Described by two division letters following
Type 2
 Common in
mandible

 Two main treatment
option
 Osteoplasty in anterior
section then treated as
Type2 A,C
 Augmentation the
treated as Type 1 B

 Posterior section of
maxilla/mandible differ from
each other
 It is less common
 Seen more in the maxilla
 Anterior bone volume listed
first then right posterior then
left posterior segment
 Anterior section usually
determines the treatment planwww.indiandentalacademy.com

 Removable partial denture
 Resin bonded prosthesis
 Fixed partial denture
 Implant prosthesis

 Inadequate bone volume
 Inadequate intra tooth space
 Observable mobility of adjacent tooth
 Time frame

 Decreased risk of caries, endodontics
 Improved ability to clean
 Less risk of porcelain fracture
 Decreased cold or root contact sensitivity
 Maintenance of bone
 Decreased risk of abutment tooth loss
 Psychological need of patient

 Crest module and abutment connection that
decrease force to abutment screw are indicated.
 Antirotational feature
 Titanium alloy
 Threaded implant design
 If facial bone thickness less than 1.4mm bone
loss may result in implant failure
 1.5- 2 mm from adjacent tooth and 1.5mm from
lateral width of ridge

 Implant replacing maxillary premolar is
positioned under buccal cusp
 Care should be taken of canine root, implant
placed parallel to canine root
 Second premolar apices may be located over
mandibular neurovascular canal or maxillary
sinus.
 First molar M-D dimension is 8 to 12mm, if
4mm implant placed 4-5 mm cantilever on
marginal ridge

 Traditional fixed prosthesis
 Cantilever FPD
 Resin bonded bridge
 Removable prosthesis
 Implant supported prosthesis

 Most challenging restoration
 Factors influencing treatment
 Patient compliance
 Patient desire
 Treatment time
 Age
 Esthetics
 Soft tissue drape
 Bone height and width
 M-D space

 Implant placed 1.5mm from adjacent tooth
 Midcrestal position of edentulous site should
be 2mm below the CEJ of adjacent teeth
 Interproximal bone scalloped 3mm more
incisal then midcrestal bone

 To establish logical continuity between
diagnosis, prosthetic planning and surgical
phase
 Dictates implant placement that offers best
combination of
 Support
 Esthetics
 hygiene

1. Rendered to be stable and rigid in correct position
2. If the arch treated has remaining teeth the
template should fit over and around enough teeth
to stabilize it in position
3. When no remaining teeth are present the template
should extend onto unreflected soft tissue regions
[tuberosity, palate, retromolar pad]
4. In this way it can be used after the soft tissues
have been reflected from the implants site

 Other requirements include
 Size
 Surgical asepsis
 Transparent
 Ability to revise the template as required
 Should relate to ideal facial contour

 Until recently, no method existed to transfer an
ideal implant position to surgical guide
 Innovative developments in software
technology and manufacturing techniques have
been applied
 These technologies allow accurate position of
implants by forcing the drills into steady
position
 Flapless technique
 Less operative time

 Computed
tomography
prerequisite for
analysis
 Necessitate a
software- supported
rendering to improve
planning by three
dimensional
visualization

 Surgical guidance can be classified in two
categories
 Computer-aided manufacturing of guides
 Navigation technique

 Laser sintering
 Streolithography
 Layer of liquid polymer is
deposited and cured by
computer driven laser
 3D printers to fabricate
guides

 Despite benefits associated with implant
therapy, a more predictable outcome seems to
be with conventional therapy
 Need for discriminating patient assessment
and comprehensive treatment plan that
includes different option with pretreatment
necessities.
 Practitioner’s role to give honest treatment
recommendation based on his/ her
specialization and experience.

 Contemporary implant industry , Carl E Misch,
third edition
 Fundamentals of implant dentistry, Weiss and
Weiss
 Implants in restorative dentistry, Scortsessi
 Australian dental journal 2008;53 : S3-S10

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