DIAGNOSIS IN IMPLANTOLOGY

Case Selection

Initial Information Gathering

Medical History Dental History Clinical Examination Study Models X-Rays

MEDICAL HISTORY

MEDICAL HISTORY

First appointment 2 basic categories Past medical history Review of the patients systemic status 6 month drug history Pregnancy elective procedure - contraindicated

Past medical history

Diabetes Hypertension h/o of chest pain Persistent cough or cold Is the patient aware of any thyroid problem h/o of abnormal bleeding after any surgery extraction or trauma h/o of blood transfusion any time in life Allergy to any drug

Smoking habits Use of alcohol

Specific evaluation of the bone

BONE DISORDERS

Often influence decisions in implantology as alveolar bone responds to systemic bone active agents

Most common agerelated Osteoporosis

IMPLANT BONE INTERFACE

THE BONE IN OSTEOPOROSIS

Microarchitectural deterioration Uncoupling of bone formation/resorption process Cortical plates thinner, trabecular bone pattern more discrete and advanced demineralization

IMPLICATIONS

Not a contraindication

Bone density
Greater width of implants, bioactive coats Bone stimulation will increase bone density even with advanced osteoporotic changes

HYPERPARATHYROIDISM
Not a contraindication in the absence of bony lesions

FIBROUS DYSPLASIA

Fibrous dysplasia Implant placement contraindicated in the regions of this disorder lack of bone, increased fibrous tissue

Problems with rigid fixation and increased susceptibility to local infection

PAGETS

Pagets inability to tolerate a prosthesis for considerable length of time continuous bone remodeling Increased osseous vascularity Fracture susceptibility

Implants contraindicated

OROFACIAL X-AMINATION

LOOK FOR PRESENCE OF ANY GROSS PATHOLOGY

EXISTING PERIODONTAL STATUS

PROBING

Score the Amount of Bleeding

Bleeding Index Chart

MOBILITY OF POTENTIAL ABUTMENTS

Keratinized gingiva - potential implant site

INADEQUATE ATTACHED GINGIVA

RESTORATIVE EVALUATION
Decay

Teeth

that require restorations and/or endodontic therapy

AESTHETIC EVALUATION

PATIENT PROFILE AND OTHER AESTHETIC PARAMETERS

DENTAL FORCE FACTORS

1. 2. 3. 4. 5. 6.

PARAFUNCTION POSITION OF THE ABUTMENT IN THE ARCH MASTICTORY DYNAMICS NATURE OF THE OPPOSING ARCH DIRECTION OF LOAD FORCES CROWN-IMPLANT RATIO

STRESS FACTOR I

PARAFUCTION

Repeated sustained occlusion

Most common cause of rigid implant fixation during the first year of implant loading Complications - Increased frequency in the maxilla 1. Poor bone density 2. Increase in the moment of force

NADLERS CLASSIFCATION Causes of nonfunctional tooth contact

LOCAL SYSTEMIC PSYCHOLOGIC OCCUPATIONAL INVOLUNTARY VOLUNTARY

LOCAL FACTORS OCCLUSION

THE VARIOUS HABITS

BRUXISM

Vertical, nonfunctional, horizontal grinding

Most common oral habit Significant excess of forces Gibbs CH et al A 37-yr old patient with a long history of bruxism recorded maximum force of 990 psi (Avg 170lb)

DIAGNOSIS

Increase in size of temporal and masseter muscles Deviation on opening, limited

Teeth

wear

IMPLICATIONS

Classified mild, moderate, severe

Forces of bruxism most difficult to contend with on a long term basis

Crestal bone loss, unretained abutments, fatigue stress fracture of implants

TONGUE THRUSTING

Sustained low magnitude forces lateral in direction stress at the permucosal site Lingual restoration contour difficult, tongue biting
Reflect the lip (anterior) or cheek (posterior) ask patient to swallow

STRESS FACTOR II

ABUTMENT POSITION IN ARCH

Posterior versus anterior

Implants shorter in the posterior region invariably due to anatomical limitations

STRESS FACTOR III

MASTICATORY DYNAMICS

Age, sex, muscle mass, diet, satus of the dentition influence muscle strength influence bite force In addition, the younger patient needs additional implant support for the prosthesis for a longer time. An 80-year old patient will need implant support or far fewer years than 20-yr old

STRESS FACTOR IV

OPPOSING ARCH

Natural dentition versus prosthesis

Implants> Conventional fpd>soft tissue borne prosthesis

Time period of prosthesis wear

STRESS FACTOR V& VI Stress multipliers

DIRECTION OF LOAD
Axial Vs lateral forces

All stresses occur in coronal half of alveolus. Excessive Crestal bone loss

CROWN HEIGHT EVALUTION

CROWN HEIGHT

Crown height lever with lateral force

Ideal CI ratio = 1 Crow height inversely proportional to implant height as resorption progresses

SUMMARY
Identify sources of additional force on the implant system Magnitude, duration, direction, type, and magnification effects Treatment planned to negate them

LISTING OUT THE DIAGNOSTIC AIDS

Casts and mounts Wax ups Stents Radiographs

DIAGNOSTIC CASTS AND MOUNTING

Study Model Impressions

Take Two Sets

CENTRIC RECORD

Two Sets of Mounted Models

One Set of Models is kept as an Original Record The Other Set may be equilibrated and Waxed Up

CASTS MOUNTED ON A SEMIADJUSTABLE IN CRP

Premature contacts Edentulous ridge relationships to adjacent teeth and opposing arch Position of potential abutments including inclination, rotation, extrusion, spacing, parallelism and esthetic considerations

4. Tooth morphology and overall condition 5. Direction of forces in future implant site

6. Present occlusal scheme

7. Edentulous soft tissue angulation, length, width, locations, permucosal esthetic position, muscle attachments nd tuberosities

8. Interarch space

9. Overall occlusal curve of Wilson and Spee

10. Arch relationships 11. Opposing dentition 12. Potential future occlusal schemes 13. Number of missing teeth 14. Arch location of future abutments 15. Arch form and symmetry

WAX UP IN VIEW

WAX UP IN VIEW

DIAGOSTIC STENTS

FABRICATION

FROM WAX UPS

FROM EXISTING PROSTHESIS

Purpose of diagnostic templates

Assess position and angulation of prosthetic component Plan implant placement and angulation based on the same

Determine favorable crown contours

Also used as surgical template in some situations

EVALUATION OF AVAILABLE BONE AND DIAGNOSTIC AIDS USED

EVALUATION OF AVAILABLE BONE

QUALITY AND QUANTITY
CLINICAL
ON

THE DIAGNOSTIC CAST RADIOGRAPHIC

QUANTITY
Length of the edentulous span Height of available bone Buccolingual width

DIVISIONS OF AVAILABLE BONE

Progress of Bone Loss

W- > 5mm

H - > 10-13 mm L - > 7 mm < 30 degree angulation CL ratio <1

Abundant bone

Progress of Bone Loss

W- 4 - 5mm

H - > 10-13 mm L - > 12 mm < 20 degree angulation CL ratio <1

Barely sufficient bone

Progress of Bone Loss

W- > 2.5 -4mm

B-w

H - > 10-13 mm L - > 7 mm < 30 degree angulation CL ratio <1

Progress of Bone Loss

zz

C-w

zzzz
Unfavorable Angulation >30 CL ratio >/= 1

Compromised bone

Progress of Bone Loss

C-h

Progress of Bone Loss

D
Severe atrophy

Deficient bone

QUALITY
Density of available bone

MISCH JUDY BONE DENSITY CLASSIFICATION

D1 DENSE CORTICAL BONE D2 THICK DENSE TO POROUS CORTICL BONE ON CREST AND COARSE TRABECULAR BONE WITHIN D3 THIN POROUS CORTICAL BON ON CREST AND FINE TRABECULR BONE WITHIN D4 FINE TRABECULAR BONE D5 IMMATURE NONMINERALIZED BONE

SIGNIFICANCE OF RIDGE ASSESMENT

FAILED IMPLANT

PRESERVATION OF VITAL STRUCTURES

Clinical Ridge Assessment

By Observation

INADEQUATE MESIODISTAL WIDTH

INADEQUATE BUCCOLINGUAL WIDTH

by by Palpation Palpation

By Ridge mapping near the Crest of the Ridge

1.75mm

By Ridge mapping more Apically

3 mm

Ridge Height Assessment

Using a Boley Gauge on the base of the Nose

and on the Ridge

TRANSFERING RIDGE MEASUREMENTS TO THE DUPLICATED CAST

DIAGNOSTIC IMAGING

SUCCESSFUL IMPLANT IMAGING

Individualized to the needs of the patient and must recognize that the imaging as well as the implant process is prosthetically driven. Because the ultimate objective of fixture placement is a functional, aesthetic and maintainable restoration, imaging must provide a database that facilitates the safe placement of adequately sized fixtures in appropriate positions.

IMAGING OBJECTIVES
PHASE I Objectives 1. Determine quantity, quality and angulation of bone 2. Relationship of critical structures to proposed implant sites 3. Presence or absence of disease PHASE II Surgical and interventional

IMAGING MODALITIES

DIGITAL

ANALOG

RADIOGRAPHIC IMAGING IN RIDGE ASSESMENT Quantitative- analog imaging

IOPA

INFORMATION YIELD IN IOPA RADIOGRAPHY

Details of region under investigation vital structures Periodontal and endodontic status of teeth Residual roots and pathology

FALLBACKS

Distortion and magnification

Does not depict the third dimension of bone width Little value in determining bone density
Spatial relationship not discernible

DENTAL PANAROMIC TOMOGRAPH

ADVANTAGES

The most utilized diagnostic modality in implant dentistry. Both jaws in one shot Ease of availability and speed of the procedure, cost factor Magnification error of approximately 1.3, good indicator of bone height

Panoral views are subject to magnification and distortion

BALL BEARING STENT WAX

BALL BEARING STENT ACRYLIC

Place the Ballbearing directly over the Centre of the Ridge

With 5 mm ball bearings in place

Horizontal Width of Ballbearing on Panoral X-ray = 6.2 mm

Menu

<

Magnification Ratio = 1.24

Mesio-distal Space on Panoral X-ray = 7.4 mm

7.4 / 1.24

7.4 / 1.24 = 5.92 mm

Vertical Height

Vertical Height 6.4 mm

Bone Height on X-ray = 20

Available vertical height 20 / 1.28 = 15.6 mm

OTHER APPLICATIONS OF PANOROGRAPHIC X RAY IN IMPLANT DIAGNOSIS

Pathology in relation to teeth

Related Anatomical structures

PITFALLS

Distortion

Does not demonstrate bone quality No cross sectional views

Spatial relationship

OTHER ANALOG IMAGING MODALITIES

Occlusal radioraphs

Used in conjunction with periapical radiography Buccolingual bone width

OTHER ANALOG IMAGING MODALITIES

Lateral Ceph

Evaluates facial profile, jaw relation, width of bone in midline

Conventional Tomograph Cross sectional, distorted, multiple exposures

COMPUTED TOMOGRAPHY IN RIDGE ASSESSMENT

Qualitative and quantitative- digital imaging

AXIAL SECTIONS
RECONSTRUCTED INTO 3-D IMAGES

ABOUT CT

Three dimensional imaging

Axial slice thickness 0.25 mm

Image can be reformatted or processed in all three planes

ABOUT CT

Density of the structures within the image is absolute and quantitative Most useful when it comes to imaging the posterior mandible Variables - bone ht, width, density, implant angulation, future prosthesis outline and angulation.

A REFORMATTED CT IMAGE IN THE CORONAL PLANE

DETERMINING BONE DENSITY USING CT

HOUNSIELD UNITS X-ray attenuation measurement of voxels Voxel Volume element of the image (512*512*0.25) HU range -1.024 to +3.071 (-1.024 air)

BONE DENSITY AND HU

DENSITY D1 D2 D3 D4 HOUNSFIELD UNITS >1250 850-1250 350-850 150-350

D5

<150

ROLE OF MRI IN IMPLANT IMAGING

Secondary imaging technique

Kircos LT Complex tomography fails to differentiate the IAN in 60% of the implant cases and CT fails to differentiate the IAN in 2% of the implant cases
Failure to differentiate the canal may be caused by osteoporotic trabecular bone and poorly corticated inferior alveolar canal MR visualizes the fat in trabecular bone and diferentiates the canal and neurovascular bundle from the adjacent trabecular bone

NEWER DIGITAL IMAGING MODALITIES

TACT, iCAT, ConeBeamCT.

TUNED APERTURE COMPUTED TOMOGRAPHY

Can selectively examine small sections without exposing the entire axial plane Isolate images to certain depth Ability to accommodate movement between exposures Flexibility to adjust contrast ad resolution

In office system Significantly lower radiation

CONEBEAM CT

CBCT

Cone shaped x ray beam rather than a conventional linear fan 2 dimensional array of detectors Compact, relatively low radiation

Fan Beam

Cone Beam

CONCLUSION

Todays clinician has a variety of diagnostic modalities at his disposal. But to date no modality has been deemed perfect.So the clinician has to carefully weigh the pros and cons of each modality.Our constant Endeavour as a clinicians is to provide our patients with predictable, functionally and esthetically sound treatment which is not at all possible without a good diagnosis.

REFERENCES
DENTAL IMPLANTS-the art and science by Charles a. babush. CONTEMPORARY IMPLANT DENTISTRY by Carl e.misch JPD VOLUME 59 YEAR 1988 DCNA- IMPLANT IMAGING

THANQ