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4. 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
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5. 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.
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6. 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
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7. 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
17. Periodontal evaluation –
Pocket depth
Plaque and gingival index
Dentition -
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18. 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
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19. Soft tissue examination
The soft tissue specially should be examined for
Unfavorable frenum and muscle attachments
Presence of any lesions
Keratinized tissue
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20. 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
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21. 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
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23. 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
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24. 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
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25. 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
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26. 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
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27. Division of available bone -
Division A
Dimensions –
>5mm width
>12mm heigth
>7mm length
<300
angulation
<15mm crown heigth
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28. 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
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29. 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
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36. RP5 – Removable prosthesis : overdenture supported by soft
tissue and implant
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37. 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
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38. Division C
Osteoplasty
Augmentation
Root form implants
Sub periosteal implant
Ramus frame implant
Transosteal implant
Division D
Augmentation
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39. 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
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40. 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
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41. 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
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42. 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
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44. 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.
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45. Diagnostic wax up
With this diagnostic tool, the centric
relationship,interocclusal clearance,
Occlusal discrepancies and the
opposite and adjacent dentition be
evaluated
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46. Diagnostic templates
The purpose of the diagnostic radiographic templates is to incorporate
the patients proposed treatment plan into the radiographic examination
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47. Diagnostic imaging and techniques -
Objectives –
Identify disease
Determine bone quality
Determine bone quantity
Determine implant position
Determine implant orientation
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49. 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
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50. 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
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51. 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 …
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52. 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…
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54. Tomography
Quantification of the bone
Spatial relationship of the critical structures
Not useful in determining bone quality
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55. 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.
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56. D1: More than 1250 Hounsfield unit
D2: 850 –1250 Hounsfield unit
D3: 350-850 Hounsfield unit
D4: 150-350 Hounsfield unit
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57. 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.
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58. 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
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59. 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
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60. Magnetic resonance imaging
Lauterbur (1972)
MRI are antithesis of CT
Its used in implant imaging as a secondary technique
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61. 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.
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62. 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
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63. 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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