Case selection for implant treatment/ dental implant courses

Case selection for implant
treatment
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Contents -
 Introduction
 Indications for treatment
 Contraindications
 Medical evaluation
 Dental evaluation
 Diagnostic aids
 Summary and conclusion
 References

Introduction

Indication for treatment
 Severe morphologic compromise of the denture supporting areas
 Poor oral muscular co-ordination
 Low tolerance of mucosal tissue
 Para functional habits leading to recurrent soreness and instability of the
prosthesis
 Hyperactive gag reflexes,elicited by removable prosthesis
 Psychological inability to wear the removable denture
 Unfavorable number and location of potential abutments in a residual
dentition
 Single tooth loss to avoid involving neighboring teeth as abutments

Contraindications
 Debilitating or uncontrolled disease.
 Pregnancy.
 Lack of adequate training of practitioner.
 Conditions, diseases, or treatment that severely compromise healing.
 Poor patient motivation.
 Psychiatric disorders that interfere with patient understanding and
compliance with necessary procedures.
 Unrealistic patient expectations.
 Unattainable prosthodontic reconstruction.
 Inability of patient to manage oral hygiene.
 Patient hypersensitivity to specific components of the implant.

Smoking –
 Occurrence and severity of the periodontal disease
 Wound healing
 Increased incidence of peri-implantitis
 Protocol suggested by Bain –
 Patient should cease smoking for a minimum of 1week prior to and
atleast 8weeks after implant surgery

Medical evaluation
 Medical history –
 Vital signs –
 Blood pressure (120/80mmHg)
 Pulse (60-90 beats/min)
 Temperature (96.8-99.40
f)
 Respiration (16-20 breaths/min)
 Laboratory evaluation –
 Complete blood count
 Bleeding disorder tests
 Urine analysis
 SMA
 Chest x ray
 ECG www.indiandentalacademy.com

Systemic disease
 Cardiovascular diseases –
 Hypertension
 Angina pectoris,Myocardial infraction and cardiac disease…
 Prosthetic valve replacement and rheumatic heart disease…

 Respiratory disease –
 Chronic bronchitis and emphysema…

 Endocrine disorders –
 Diabetes mellitus
 Liver dysfunction –.

 Bone disorders –
 Osteoporosis and osteosarcoma…
 Hyperparathyroidism…
 Fibrous dysplasia, pagets disease and multiple myeloma
 Blood disorders –
 Anemia
 Leukemia
 Haemophilia
 Pregnancy -
 Malignancy -
 Immunocompromised patients -

Dental evaluation
 Mouth opening
 Temporomandibular joint
 Oral pathology
 Periodontal parameters
 Dentition
 Jaw relationship
 Occlusion
 Soft tissue evaluation
 Hard tissue evaluation

 Mouth opening

 Periodontal evaluation –
 Pocket depth
 Plaque and gingival index
 Dentition -

 Jaw relation –
 Severe forms of Cl-II and Cl-III require orthodontic
treatment and orthognathic surgery
 Occlusion
 Evaluate present occlusion for interference, Occlusal wear,
prematurities,associated muscle tenderness and limited range of
mandibular movements

 Soft tissue examination
 The soft tissue specially should be examined for
 Unfavorable frenum and muscle attachments
 Presence of any lesions
 Keratinized tissue

 Lip line
 The lip positions are evaluated including resting lip line, maxillary high
lip line and mandibular low lip line. The resting lip line is especially
noted if maxillary anterior teeth are to be replaced.
 Crown height space
 Measured from the crest of the bone to the plane of occlusion
 Vertical cantilever
 Minimum crown height required for a fixed restoration is 8mm

 Parafunctional habits –
 Have been identified as concerns in implant treatment planning due to
the increased pressure on the implants, resulting in possible metal
fatigue and fracture
 Bruxism
 Clenching
 Tongue thrusting

 Once the dentist has identified these conditions, the treatment plan is
altered in an attempt to minimize their negative impact on the longevity
of the implants, bone and final restoration.
 Educating the patient
 Placing increased number of implants and larger implants
 Avoiding the use of cantilevers
 Bruxism appliance therapy
 Increasing time intervals during prosthetic restoration stage to provide
more opportunity for progressive loading
 Occlusal contact design
 Acrylic teeth in the prosthesis

Bone
An assessment of the characterstics of the recepient osseous site is criticle
as the bone quality and quantity are the two of the most important
factors that determine the fixture longevity
Available bone –
 Width
 Height
 Length
 Angulation
 Crown height/implant body ratio

 Height
 Measured from the crest of the ridge to the opposing
landmark.
 8-12mm height
 Bone height determines the crown height ,esthetics
 Bone augmentation
 Width
 Width is measured between the facial and lingual
plates at the crest

 Length
 Mesiodistal length of the available bone in the edentulous area
 Angulation
 Depend upon the width and density of the bone
 Crown height
 Its measured from the occlusal plane to the crest of the ridge
 It acts as a vertical cantilever

Division of available bone -
 Division A
 Dimensions –
 >5mm width
 >12mm heigth
 >7mm length
 <300
angulation
 <15mm crown heigth

 Advantages of Division A
 Greatest surface area
 Improved stress distribution
 Designed for variable bone density
 Greatest range of prosthetic options
 Less fracture of implant and components
 More esthetic conditions
 Less abutment screw loosening

 Division B –
 2.5 to 5mm wide(B+ 4-5mm, B- 2.5-4mm)
 >12mm height
 >6mm length
 <20 degree angulation
 <15mm crown height
 Division C
 O-2.5mm width
 <12mm height
 >30 degree angulation
 >15 mm crown height
 Division D
 Severe atrophy
 Basal bone loss – Flat maxilla and pencil thin mandible
 >20 mm crown height

Lekholm and Zarb

Prosthodontic treatment classification
 FP-1
 FP-2
 FP-3
 RP-4
 RP-5

 FP1 – Fixed prosthesis that replaces only the crown

 FP-2 - Fixed prosthesis :replaces the crown and a portion
of the root

 FP3 – Fixed prosthesis : replacing missing crowns and
gingival color and portion of the edentulous site

 RP4 – Removable prosthesis: Overdenture supported
completely by implants

 RP5 – Removable prosthesis : overdenture supported by soft
tissue and implant

Prosthetic options
 Division A
 Mandatory for FP1
 RP4 and RP5 may require osteoplasty
 Full range of prosthetic options
 Division B
 Osteoplasty –
converts to div A when > 12mm bone results
div C when < 12mm bone height results
 Insert div B root form implants
 Augmentation procedure

 Division C
 Osteoplasty
 Augmentation
 Root form implants
 Sub periosteal implant
 Ramus frame implant
 Transosteal implant
 Division D
 Augmentation

Bone density
 Mechanical immobilization and stress distribution
 Bone density is an implant treatment modifier in several ways:
prosthetic factors, implant size, implant design, implant surface
condition,implant number, and progressive loading

Classification of bone density
 Linkow and Chercheve
 Class I – Ideal bone type consisting of evenly spaced trabeculas with
small cancellated spaces
 Class II – Larger cancellated spaces with less uniformity of the osseous
pattern
 Class III – Larger marrow filled spaces exist between trabeculas

 Lekholm and Zarb
Quality 1: composed of homogenous compact bone.
Quality 2: thick layer of compact 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 a core of low density
trabecular bone

Misch
D1: Dense cortical bone
D2: Thick dense to porous cortical bone on crest and course trabecular
bone within.
D3: Thin porous cortical bone on crest and fine trabecular bone within.
D4: Fine trabecular bone

Diagnostic aids

Study models
 Diagnostic study models are
helpful in treatment planning and
projecting goals to the patient
pre-operatively. They also aid in
the retrospective analysis of the
progress of therapy.

Diagnostic wax up
 With this diagnostic tool, the centric
relationship,interocclusal clearance,
Occlusal discrepancies and the
opposite and adjacent dentition be
evaluated

Diagnostic templates
 The purpose of the diagnostic radiographic templates is to incorporate
the patients proposed treatment plan into the radiographic examination

Diagnostic imaging and techniques -
 Objectives –
 Identify disease
 Determine bone quality
 Determine bone quantity
 Determine implant position
 Determine implant orientation

Imaging modalities -
 Periapical radiography
 Panoromic radiography
 Occlusal radiography
 Cephalometric radiography
 Tomography
 Computed tomography
 Magnetic resonance imaging
 Interactive computed tomography

Periapical radiographs
 Useful in ruling out local bone diseases
 Limited value - bone quantity and density
 Identifying critical structures
 These films are used for single tooth implants

Occlusal radiography
 Rarely indicated
 Mandibular –widest width of the bone in the symphysis region
 Degree of mineralization and trabecular pattern and spatial relations
between implant site and critical structures cannot be determined

Cephalometric radiography
 Useful tool for the development of treatment
plan
 Cross sectional image of the alveolus in the
midsagital plane
 Loss of vertical dimension, skeletal arch inter-
relationship, anterior crown to implant ratio and
anterior tooth position…
 Spatial relationship between the implant site and
critical structures …

Panoromic radiography
 Advantages :
 Opposing landmark is easily identified
 Vertical height can be initially assessed
 Performed with convenience, ease and speed
 Gross anatomy of the jaws
 Disadvantages:
 Does not demonstrate bone quality
 Misleading quantitatively…
 Critical structures can be demonstrated…

Tomography
 Quantification of the bone
 Spatial relationship of the critical structures
 Not useful in determining bone quality

Computed tomography
 Discovered by Sir Hounsfield – 1972
 Discovery of CT revolutionized medical imaging.
 CT produces axial images of patients anatomy which are
perpendicular to the long axis of the body.
 The x ray source rotates 360 degrees around the patient and collects
the data.
 The image detector produces electronic signals that serves as a input
data to the computer.The computer processes the data using Fourier
algorithm techniques
 The individual element of the CT image is called the voxel which
demonstrates the density of the CT image at that point.

D1: More than 1250 Hounsfield unit
D2: 850 –1250 Hounsfield unit
D3: 350-850 Hounsfield unit
D4: 150-350 Hounsfield unit

 CT enables
 Identification of the disease
 Determines bone quality
 Determines bone quantity
 Determines implant position
 Determine implant orientation
 The access to this imaging technique was limited as a radiologist was
required to communicate about the prospective surgery ,reformat the
study and interpret the resulting images to the referring doctor.

Dentascan
 Dentascan imaging provides the programmed reformation,organization,
and display of the imaging study
 The radiologist simply indicates the curvature of the arch and the
computer is programmed to generate referred cross sectional and
tangential panoramic images of the alveolus along with three
dimensional image of the arch

Interactive computed tomography
 ICT was developed to bridge the gap in information transfer between
the radiologist and practitioner
 This technique enables the radiologist to transfer the imaging study
to the practitioner as a computer file and enables the the practitioner
to view and interact with the imaging study on a personal computer

Magnetic resonance imaging
Lauterbur (1972)
MRI are antithesis of CT
Its used in implant imaging as a secondary technique

Summary and conclusion
 Comprehensive treatment with osseointegrated implants
begins with patient evaluation and selection.A thorough
healthy history, review of systems, and physical assessment
should be performed.

References
 Carl E Misch :Dental implant prosthetics
 Carl E Misch :Contemporary implant dentistry: 2 edition
 Charles A .Babbush :Dental implants principles and practice
 Hobo:Ichida:Garcia :Osseointegration and occlusal rehabilitation
 Hobkrik:Watson:Searson :Introducing dental implants
 Hobkrik :Watson :Dental and maxillofacial implantology
 Micheal Nortan : Dental implants : A guide for general practitioners
 Richard A Rasmussan :A colour atlas:The Branemark system of
osseointegration
 Ralph V McKinney : Endosteal dental implants

 Anthony J Casino :Systemic factors contributing to implant failure :Oral
and maxillofacial surgery clinics of North America :1998:10:177
 Igor J Pesun :Fabrication of guide for radiographic evaluation and
surgical placement of implants :JPD:1995:73:548-52
 Kevin C. Kopp: Predictable implant placement with a diagnostic/
surgical template and advanced radiographic imaging :JPD:2003 :
89:611-615
 Malaine r wood ;A review of selected dental literature on evidence
based treatment planning for dental implants :JPD:2004 92 : 447-62
 Philip B sugerman : Patient selection for endosseous dental implants:
oral and systemic considerations ;IJOMI :2002 17 ;191-20
 Zinner:Panno:Small: Landa : Implant dentistry from failure to success
Peter Floyd: Richard palmer :Treatment planning for implant restoration
BDJ:1999:187:297-305

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