DIAGNOSIS AND TREATMENT PLANNING FOR IMPLANT

CASES
CONTENTS
Introduction
Diagnosis
Indications
Contraindications
Medial history
- Systemic diseases
(1) Cardiovascular system
(2) Endocrine system
(3) Adrenal gland disorders
(4) Kidney and urinary tract disorsers
(5) Blood diseases
(6) Liver diseases
(7) Bone diseases
- Habit (Tobacco)
- Vital signs
- Lab evaluation
Dental history and examination
Diagnostic imaging techniques
Prosthodontic classification
Biomechanics
Summary
Bibliography

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 DIAGNOSIS AND TREATMENT PLANNING

INTRODUCTION :
The goal of modern dentistry is to restore the patient to normal contour, function,
comfort, esthetics, speech, and health, regardless of the atrophy, disease, or injury of the
stomatognathic system. However the more teeth a patient is missing, the more arduous
this goal becomes with traditional dentistry. As a result of continued research in
treatment planning implant designs, materials and techniques, predictable success is now
a reality for the rehabilitation of many challenging clinical situations.
Over 90% of interfacing specialty dentists currently provide dental implant
treatment on a routine basis in their practices, and more than 65% of general dentists
have used implants for supporting fixed and removable prosthesis.
The increased need and uses of implant-related treatments result from the
combined effect of a number of factors, including (1) psychological aspects of tooth loss.
(1) Aging population (2) Tooth loss related to age. (3) Anatomic consequences of
edentulism (4) Poor performance of removable prosthesis (5) Predictable long-term
results of implant supported prostheses and (6) Advantages of implant supported
prostheses.

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DIAGNOSIS :
It is very important that the general physical condition of a patient is checked
accurately in order to obtain on overall health assessment. Initial data gathered on each
patient should include medical history, dental history, radiographic study, study casts and
photographs, all essential in treatment planning. Based on the data and a thorough
clinical exam, a detailed treatment plan can be proposed including locations and
directions for fixtures.
Many patients who are partially or fully edentulous are better served with tissue
integrated prostheses, rather than other classical forms of therapy. However, not all
patients can, or should be considered for this procedure. Thus a medical and dental
evaluation to screen out those patients who can be better served by an alternate treatment
modality.
The patients will be treated by a team consisting of a prosthodontist, surgeon
(periodontist or oral and maxillofacial surgeon), restorative dentist, lab technician, dental
hygienists, dental assistants and other health care professionals. Therefore
communication during all phases of treatment is critical. The patient must be viewed in
totality, and the end result visualized prior to surgery. This reverse approach means that
the anticipated prosthetic result should be determined prior to surgery. The appropriate
steps in the treatment plan can then be designed to reach the desired goal, prior to the
first incision.

INDICATIONS AND CONTRAINDICATIONS :

Osseointegrated implant surgery is a treatment option available for any patient,
regardless of sex or age. The exceptions for this treatment are patients with chronic,
uncontrollable diseases on abnormalities of mucosal membranes / or jawbones.
Osseointegrated implant treatment is ideal for patients unable to wear complete dentures
and have adequate bone for insertion of fixtures.

INDICATIONS :
1) Edentulous patient
2) Partially edentulous patient with a history of difficulty in wearing removable
partial dentures.
3) Patient with missing dentition requiring long span fixed partial denture treatment.

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4) Patient who refuses using a removable type prosthesis.
5) Any edentulous area or severe change in complete denture bearing tissues.
6) Poor oral muscular coordination
7) Low tissue tolerance, i.e. more alveolar mucosa instead of attached mucosa.
8) Parafunctional habits leading to recurrent soreness and instability of prosthesis.
9) Active or hyperactive gag reflexes, elicited by a removable prosthesis.
10) Unrealistic prosthodontic expectations.
11) Psychological inability to wear a removable prosthesis, even if adequate denture
retention or stability is present.
12) Unfavorable number and location of potential abutments in a residual dentition.
Adjunctive location of optimally placed osseointegrated root analogues would
allow for provision of a fixed prosthesis.
13) Single tooth loss to avoid involving neighbouring teeth as abutments.

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CONTRAINDICATIONS :
It is essential to know and understand the absolute constraints to implant
treatment, so that a failure does not result.
1. High dose irradiated patients
Patients who have received radiation therapeutic doses of more than 5000 Rads
should avoid having these procedures. The patients physician and radiotherapist
should be consulted on treatment, dosages and portals of entry. After large
amounts of radiation therapy the patient has a reduced wound healing capacity
and may not achieve successful osseointegration.
2. Patients with psychiatric problems such as psychoses, dysmorphophobia as the
treatment sometimes involves changes in appearances, either esthetics on facial
contours and these patients may have difficulty adjusting to their changed
appearance.
3. Hematologic systemic disorders
Patients who have blood dyscrasias such as leukemia, hemophilia, and
thrombocytopenia purpura should not have this type of treatment.
4. Existing pathology of hard or soft tissues, such as a benign tumors should be
evaluated on an individual basis. If a patient has a benign tumor present, the
tumor should be removed prior to implant procedures. After surgical procedures
for tumor removal, the prognosis for the patient and the status of the surgical site
determines whether the patient is a good candidate for osseointegrated implant
treatment. Patients with soft tissue problems, such as collagen or connections
tissue deficiency diseases, should be evaluated. Any active stage of disease must
be managed before considering implant treatment.
5. Patients who have had recent extractions done should be questioned to determine
the dates of extraction. If the extraction has been performed within six months to
one year, the surgeon should evaluate the site radiographically and decide if the
bone has healed adequately for further procedures. There is no reason to postpone
treatment greater than one year after an extraction since the greatest amount of
bone remodeling occurs within this time period.
6. Patients with a history of drug, alcohol or tobacco abuse should be evaluated
carefully. Patients with histories of habitual abuse usually have less resistance to
infection. Thirty percent of infection resistance is lost in these types of patients

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 and could result in delayed would healing. After surgery for implant installation,
all patients should abstain from alcohol or tobacco use a min of 2 weeks.
7. Irradiated patients need to have their medical histories evaluated. The history
should reveal the disease prognosis and amounts of radiation used in therapy.
Patients who have received less than 4,000 Rads of radiation therapy may
experience delayed would healing, a common occurrence after radiation
treatment. The second surgical procedure, abutment connection to supporting
fixtures, should be postponed for at least thrice the normal healing time.
8. Patients with chronic diseases such as diabetes or high blood pressure should be
evaluated on an individual basis, and consultation with the primary physician is
necessary.

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 DIAGNOSIS AND TREATMENT PLANNING FLOW SHEET

RESTORATING DENTIST ORAL SURGEON / PERIODONTIST

Initial consultation
Chief complaint
Medical history review
Intraoral examination
Extraoral examination
Evaluation of existing prosthesis Surgical consultation
Diagnostic impressions Radiographs
Radiographs Lateral cephalometric
Panoramic Tomograms
Periapical Conventional
Computerized axial (CAT)

Second consultation (if needed)

Facebow regestration
Interocclusal record
Mount diagnostic casts
Surgical guide fabrication

Consult technician
Regarding design

Surgical / Restorative joint

consultation surgeon and restorative
dentist discuss
Implant placement First stage surgery
Surgical guide design and Implant placement
Restorative goal

Prosthesis adjustment
releave prosthesis and tissue Second stage surgery
conditioner Healing abutment and soft
oesseointeegration (healing) maxillary tissue healing.
MAIN
arch 6STREAM
month (min)CASE
mand arch 4 months

Definitive abutment placement

Prosthesis fabrication

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The simple truth that one should start at the beginning is sometimes overlooked in
implant dentistry. Practitioners must heed many factors before being ready to insert and
restore a dental implant, but one consideration supereseds all others what is a main
stream case ? and how can it be recognized. Understanding this is paramount because
the way to begin is with the treatment of simple, predictable cases.
The term mainstream is not intended to mean that which is most popular or
neither if an implant modality is considered mainstream.
MAINSTREAM CASES ARE CLOSE TO IDEAL : The concept that
mainstream cases are close to ideal may sound self-evident, nonetheless, being
mindful of this tend is vital when determining whether the case at hand cant be
considered mainstream. No case is ideal however mainstream cases come close.
They meet the following conditions
(1) They rarely involve complications on atypical conditions.
(2) They are only performed in healed alveolar ridges, or in healing or immediate
extraction sites only under appropriate conditions.
(3) They do not require extensive bone enhancement.
(4) They do not require out of office radiography.
(5) They are predictable.
(6) They are preventive dentistry.
(7) They are performed in mainstream patients.
(8) They require restorations of five or fewer units.
(9) They are performed in cases in which the alveolar ridge is of appropriate
dimensions to accommodate the selected implant.
(10) They are professionally accepted implant modalities.

MAINSTREAM CASE INSERTION IS HIGHLY

PREDICTABLE: Cases in which only one or a few teeth are missing are the most
technique permissive and have the most favourable prognosis. One should begin
with this type of case. The exception is treatment of a fully edentulous mandible
using root forms supporting an overdenture.
Most implant candidates are partially edentulous and require simple,
predictable treatment that can be considered mainstream. The key is to screen for

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 those cases that are advanced. Such cases should be referred to an experienced
practitioner for treatment.
MAINSTREAM CASES REQUIRE MAINSTREAM PATIENTS:
a case that may be clinically ideal may ultimately prove not to be because of physical
and emotional considerations to the patient. Any condition that compromises
metabolism or healing is a cause for concern. Examples of possible contraindications
that require consultation with a physician include uncontrolled diabetes, existence of
an active malignancy, recent history of chemotherapy or radiation therapy, any
immunodeficiency disorder, cardiovascular disease, osteoporosis, liver disease
certain blood dyscrasias, and in general any other conditions that contraindicate oral
surgery.
A patient with a mainstream case presentation and reasonably good health may
still not be considered main steam because of detrimental personal health practices such
as heavy smoking, alcohol, or drug abuse, poor diet, high stress, compressive bruxing or
poor oral hygiene.
In addition to physical considerations the practitioner must evaluate the mental
fitness of the patient. Most long time implant practitioners have treated at least one
patient with healthy fully functional implants who requests that the implants be removed
for no other reason than that the patient must get them out. These types of patients
should be identified through screening beforehand and avoided.
MAINSTREAM CASES ARE PREVENTIVE :
Restoration with a fixed bridge that utilizes the additional abutment support
provided by dental implants is preventive dentistry, because it helps to arrest the serial
loss of natural teeth associated with removable partial dentures. A natural tooth that is
clasped to support a removable partial denture can be subjected to force beyond that
which nature designed it to withstand. Other reasons that RPDs can lead to the loss of
natural teeth include inadequate tooth preparation, lack of guide planes, and poor design
and / or location of clasps. Treatment with a fixed bridge supported entirely or partly by
additional abutments provided by implant dentistry can help prevent these problems
thereby preserving natural teeth. Residual ridge resorption is started as compared to
unimplanted ridges. Bone less almost always adds years to the appearance of the patient.
In general any procedure that conserves what nature originally provided in this
case the natural dentition and its surrounding bone should be favoured.

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 MAINSTREAM CASES OF PARTIAL EDENTULISM USUALLY
REQUIRE PROSTHESES OF FIVE OR FEWER UNITS: In nonimplant cases,
most conventional fixed bridge cases are of five or fewer units for numerous
reasons. Most of the patients in our population who are candidates for prosthetic
dentistry need small bridges. Ideally, for any given patient, implant treatment should
first be performed when the serial loss of teeth has just begun. The first teeth to be
lost usually are in the molar and premolar regions, where the forces of mastication
are 4 times greater than in the anterior region. If a case can be treated with implants
in this early stage, more extensive treatment may be avoided in the future.
Fortunately, if the patient is not treated with implants in this early stage of partial
edentulism, the use of root forms restored with an overdenture is one technique
permissive.
MAINSTREAM CASES PRESENT WITH ALVEOLAR RIDGES
OF IDEAL DIMENSIONS FOR AN APPROPRIATE IMPLANT:
Fundamental to choosing the implant modality system, and configuration in any
given case is evaluation of the bone. It is important to understand that is a
mainstream case, length, width and depth of available bone must be sufficient to
accommodate an appropriate implant modality and configuration.(Further more the
axial inclination of the alveolar process must be sufficiently close to that required of
the implant abutment to be able to achieve prosthodontic parallelism) finally
interocclusal clearance must be acceptable.
Mainstream cases use professionally accepted modalities.
Modalities viz root forms, plate / blade forms, subperiosteal implants, endodontic
stabilizer. Implants and intramucosal inserts are all professionally accepted.

MEDICAL HISTORY :
The review of the patients medical history is the first opportunity for the dentist
to talk with the patient. The time and consideration taken on the onset will set the tone
for the entire following treatment. The first impression could be a warm caring
practitioner.
The two basic categories of information addressed during the review of the
medical history include the past medical history and a review of the patients systemic
health. The dental office uses a medical evaluation form to obtain most of this

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information. Of particular note is medication usage within the preceding 6 months,
allergies and a review of the systems of the body. The pathophysiology of the system, the
degree of involvement and the medications being used to treat the conditions are
evaluated.

EXTRAORAL AND INTRAORAL EXAMINATIONS :

Once the medical history is reviewed, the medical physical examination begins. A
complete evaluation of the head and neck is important initially and all subsequent
preventive maintenance (recall) appointments. The patient is informed of the need for
periodic examination for cysts, for benign or malignant tumors.

SYSTEMIC DISEASES :
Systemic diseases have a wide range of effects on a patient, depending on their
severity. The systemic conditions addressed are those most commonly observed in
implant practice.
A disease entirely affects the host with varied intensity. Hence mild diabetes may
permit implant treatment, yet the same disease in the severe form may contraindicate
most implant therapy. Therefore a mild diabetic patient should be treated differently than
the severe diabetic patient. A systemic condition may contraindicate one class of
treatment, yet a more simple implant procedure can still be performed. In addition to the
range of disease expression, a variety of implant treatments may be delivered to a
patient. There are 4 levels of treatment ranging from noninvasive procedures with little
or no risk of gingival bleeding to those that are most complicated and invasive.
TYPE 1 procedures can be performed on most patient regardless of systemic
condition.
TYPE 2 procedures are more likely to cause gingival bleeding on bacterial
invasion of the bony structures.
TYPE 3 procedures are surgical procedure that require more their and technique.
TYPE 4 procedures are advanced surgical procedures with more bleeding and
greater risk of postoperative infection and complications. A relationship can be
established between the severity of the disease and the maximum movement of the dental
implant procedure.

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 CARDIOVASCULAR DISEASES

HYPERTENSION :
Hypertension accounts for about 40% of all organic heart disease. A patient is
classified as hypertensive when the mean value after three or more blood pressure
reading taken at three or more medical visits reveals a resting arterial systolic blood
pressure at or above 140 mm Hg and / or mean diastolic blood pressure at or above 90
mm Hg.
This condition is treated with medications, many of which have an impact on
implant thereby because of their numerous side effects these include orthostatic
hypotension, dehydration, sedation, xerostomia and depression. The side effects may
alter treatment or require special preconditions. For eg. Orthostatic hypotension affects a
patient brought from a supine to an upright position. The patient may feel lightheaded or
even faint. The dental chair should be set upright gradually. Xerostomia was the most
common side effect. This may lead to frequent candida infections, increased periodontal
and periimplant diseases, caries and bacterial infections caused by loss of protection
from saliva. Xerostomia also decreases the value seal of soft tissue-borne removable
prosthesis and increases the risk of abrasions and sore spots. Suggested management
includes salivary substitutes, salivary stimulants, frequent glasses of water throughout
the day, strict control of the diet to decrease cariogenecity psychological stress and dental
rental stress.

MYOCARDIAL INFARCTION :
MI is a prolonged ischemia or lack of oxygen that causes injury to the heart.
Approximately 1.3% of patients over 30 and 10% of patients 40 years or older indicate a
history of previous MI. the implant dentist primarily treats patients in this age group and
therefore sees many such patients.
The patients usually have severe chest pain in the substernal or left pericardial are
a during MI episode. It may radiate to the left arm or mandible. The pain is similar to
angina pectoris but more severe. Cyanosis, cold sweat, weakness, nausea or vomiting,
and irregular and increased pulse rate are all signs and symptoms of MI.
The complications of MI include arrhythmias and congestive heart failure. The
larger the ischemic area, the greater the risk of heart failure or life threatening

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arrhythmias. High morbidity and death rates with even simple elective surgery is
common.
Approximately 18% to 20% of patients with a recent history of MI will have
complications of recurrent MI, with a high mortality rate of 40% to 70%. If surgery is
done within 3 months of MI, the risk of another MI is 30%, if within 3-6 months and
avoidance of tobacco or alcohol products. Calcium channel blockers are used to treat
hypertension or congestive heart failures which can cause gingival hyperplasia around
teeth or implants.

ANGINA PECTORIS :
Angina pectoris, or chest pain or cramp of the cardiac muscle, is a form of
coronary heart disease occasionally the myocardium needs more oxygen laden blood
than it receives. Transient myocardial oxygen demand is in excess of supply. It is a
symptomatic expression of temporary myocardial ischemia, the classical symptom of
retrosternal pain often develops during stress or physical exertion, radiates to the
shoulders, left arm, or mandible, or right arm, neck, palate and tongue, these symptoms
of retrosternal pain are relieved by rest. Sublingual nitroglycerin is beneficial. Risk
factors for angina pectoris are smoking, hypertension, high cholesterol, obesity and
diabetes.
If a patient reports a history of angina, the severity of the disease is evaluated by
the last attack, change in frequency, frequency and severity of attacks and the
medications prescribed.
The major concern for the implant dentist is the precipitation and / or
management of the angina attack precipitating factors are exertion, cold, heat, large
meals, humidity it is 15%. After 12 months the incidence of recurrent MI stabilizes at
about 5%.

CONGESTIVE HEART FAILURE :

CHF is a chronic heart condition in which the heart is failing as a pump.
The heart pumps about 2000 gallons of blood per day to the other organs and
body tissues. It coordinates the function of two pumps simultaneously the left side, the
longer of the two sides, pushes the blood out into the body, the right side sends the blood
to the lump for oxygenation.

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 When the heart has been damaged the blood begins to back up in the lungs or
body. The heart will attempt to compensate by increasing the rate of contraction and
stretching the muscle to accommodate a large volume of blood to contract with a greater
force and eject more blood.
Both of these means maintain circulatory needs in the short term, but they exact a
long-term price. Less blood is circulated because in beating faster the heart is left with
less time to refill while the extra effort increases the heart muscles demand for oxygen.
When this need is unmet, the heart rhythms can become dangerously abnormal and lead
to death.

SUBACUTE BACTERIAL ENDOCARDITIS :

It is an infection of the heart values on the endothelial surfaces of the heart. It is
the result of the growth of bacteria on damaged / altered cardiac surfaces. The
microorganisms most often associated with endocarditis following dental treatment are
streptococcus viridans. The disorder is serious with a mortality rate of about 10%. Dental
procedures casing transient bacteremia are a major cause of bacterial endocarditis. As a
result the implant dentist should identify the patient at risk and implement prophylactic
procedures. The reoccurrence of endocarditis in a patient with previous history is high.
The risk of a second infection is 10% per year. Once the second infection occurs, the risk
factor increases t 25%. The risk of bacterial endocarditis increases with the amount of
intraoral soft tissue trauma.
However if scaling and root planning are performed before subsequent soft tissue
surgery, the risk of endocarditis is greatly reduced.

MEDICAL EVALUATION
Since the head, neck and maxillofacial region constitute an integral part of the
human mechanism, no means exist by which these structures can be evaluated without a
review of the medical aspects of each potential candidate.
MEDICAL HISTORY
A health questionnaire should be handed over to the potential candidate.
These areas that should receive primary attention are as follows.

Cardiovascular system:

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 These individuals who have a past history of cardiac disease, angina, myocardial,
infarction, or various arrhythmias are subject to recurrent episodes when placed in a
stressful situation, even the placement of a single implant could create enough stress to
initiate a compromise of cardiovascular function.
Many of the cardiovascular abnormalities that are manifest today, such as
vascular defects on coronary artery disease, are amenable to surgical correction. Many of
these patients are then susceptible to infections, complications of the graft site on both.
Rheumatic heart disease and intra valve prolapse are categories to which the doctor must
give special attention. Careful consideration should be given to the prophylactic use of
antibiotics and consultation with physician in charge of the case.
Diseases of the gastrointestinal tract:
Such states as nervous stomach with vomiting, hyper secretions, xerostomia,
hyperacidity all contribute to changes in the PH of saliva, which interferes with healing
of the mucous membranes various ulcers of the GIT are sometimes indicative of paternal
life stresses and strains. This may be revealing to the overall treatment because this
individual may manifest these emotional states in the form of brusixm, clenching or
various tongue habits, which in turn may contribute to eccentric forces being applied to
the implant and had to its failure abutment neck and should be warned of this possibility
as subsequent surgical corrections may be necessary.
Diseases of the endocrine system :
Endocrine glands in the body are responsible for numerous functions dealing with
growth, sexual development, metabolism and reproduction.
The parathyroid glands are responsible primarily for calcium and phosphorus
metabolism in the body. Ninety-nine percent of body calcium is found in the organic
matrix of bone and teeth. Calcium is essential for numerous functions in the body. The
formations of bone and teeth as well as the minerals necessity in the coagulation of
blood are among the more important actions of calcium. Therefore any abnormal calcium
activity in the body would require complete review prior to placement of dental implants.
Eating disorders such as anorexia and bulimia have been recognized as being
detrimental to the oral structures. The patient should be carefully warned prior to implant
therapy. In addition, consultation with the treating professional staff is strongly
recommended.

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Diseases of the kidney and urinary tract :
The kidneys are responsible for the chemical composition of the blood. They
excrete the waste products of protein metabolism. Such disease states as nephritis,
glomerulonephritis, chronic urinary tract infections and tumors of the kidney all cause
disturbances of normal kidney function and therefore a change on the normal
composition of the blood if should be sought prior to implant procedure.
Disease of the nervous system :
Epileptics are subject to convulsive disorders followed by states of
unconsciousness. The forces that can be exerted during these seizures can be traumatic to
implants.
In addition many of these patients are treated with phenytoin sodium (dilantin) an
anticonsultant.
One of the effects of phenytoin sodium is gingival hypertrophy, which occurs
only when teeth are present. The epileptic patient with implants may be subject to
gingival hypertrophy around for increased complications or facture related to the pre-
existing disease.
Diseases of the blood :
The patient with anemia should be treated with care, as even an elective surgical
procedure can cause a sudden drop in the blood count. A marked increase of leukocytes
and hyperplasia of those tissues that form white blood cells leukemia. Any form of
acute leukemia would contraindicate dental implants.
Haemophelia is found only in males and is characterized by a deficiency of
plasma factor VIII. These patients have prolonged bleeding following the most minute
trauma or surgical procedure. Usually these patients are not considered for dental
implants unless proper prophylactic therapy is instituted.
Patients with pathologic entities known as pupuras characterized by hemorrhage
into the skin and mucous membranes, such patients should not be considered for dental
implants.
Patients on anticoagulants are poor candidates for implants as both these drugs
cause hemorrhage.
Diseases of the skin and mucous membrane :
Pathologic states as lichen planus, erythema multiforms, lupus arythematosis and
pemphigus all affect the mucous membranes and skin. This group of diseases has also

16
been categorized as epithelial, collagen and connective tissue defects. This group is a
poor one for implant restoration, because the physiologic healing mechanism is impaired.
Malignant disease :
Many patients with malignant pathology are treated by radiation therapy,
antimetobolites. Such patients experience a change in the normal physiologic process of
the mucous membrane and bone. The vascular supply is impaired. When an implant is
inserted, the additional interruption of the tissues may be sufficient to cause further
impaired vascular supply with a resultant failure.
Chemotherapeutic agents severely affect the overall physiologic composition of
the body with a resultant decrease in its ability to protect itself against infection.

ENDOCRINE DISORDERS
Diabetes Mellitus :
It is related to an absolute on relative insulin insufficiency. It is one of the most
common metabolic disorders and the major cause of blindness in adults. Because the
implant dentist treats patients order than 40 years, more than 5% of patients will have
diabetes. In addition an estimated half of diabetic patients an undiagnosed. In major
symptoms of diabetes are polyuria, polydyspsia, polyphagia and weight loss. With
insulin deficiency the glucose remains in the blood stream and increases the blood
glucose level. Diabetics are proving to develop infections and vascular complications.
The healing function is affected by impaired vascular function, chemotaxis, impaired
neutrophil function and an anaerobic milieu. Protein metabolism is decreased and
healing of soft and hard tissue is delayed. Nerve regeneration is altered and angiogenesis
is impaired.
Implant dentistry is not contraindicated in most diabetic patients, however, then
medical care should be as controlled as possible specific questions are asked during the
review of the medical history to evaluate the level of control achieved.

THYROID DISORDERS
Most common problem affecting approximately 1% of the general population is
principally women. Because the vast majority of patients in the implant dentistry are
women, a slightly higher prevalence of this disorder is seen in the dental implant
practice.

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 The major function of the thyroid gland is the production of the hormone
thyroxine. Thyroxin is responsible for the regulation of carbohydrate protein and lipid
metabolism. In addition the hormone potentiates the action of other hormones such as
catecholomines and growth hormones.
Abnormalities in the anterior pituitary grand on the thyroid can result in disorders
of thyroxine production. Excessive production of thyroxine results in hyperthyroidism.
Such patients are essentially sensitive to catecholamines such as epinephrine in LA and
gingival retraction cords. When exposure to catecholamines is coupled with stress and
tissue damage, an exacerbation of the symptoms of hyperthyroidism may occur. The
result is termed thyroid storm
. The result is very high temperature, CNS alterations such as agitation and psychosis,
and a high risk of life threatening arrhythmias and a congestive heart failure.

ADRENAL GLAND DISORDERS :

The adrenal glands are endocrine organs located just above the kidney.
Epinephrine and non-epinephrine are easily responsible for the control of blood pressure,
myocardial contractility and excitability and general metabolism.
Pregnancy :
Implant surgery procedures are contraindicated for the pregnant patient. Not only
is the mother the responsibility of the dentist so is the fetus. The radiographs or
medications that may be needed for implant therapy and the increased stress are all
reasons the elective implant surgical procedure should be postponed until after child
birth.
However, after implant surgery has occurred, the patient may become pregnant
while waiting for the restorative procedures, especially as modalities may require 3
months to a year of a healing phase. Periodontal disease is often exacerbated during
pregnancy. All elective dental care, with the exception of dental prophylaxis, should be
deferred until after birth. The only eruptions to this are caries control on emergency
dental procedures. In these instances, medical clearance should be obtained for all drugs,
including anesthetics, analgesics and antibiotics.
Usually lidocaine, penicillin, erythromycin are approved. Aspirin,
vasoconstrictors (epinephrine) and drugs that cause respiratory depression are usually
contraindicated. Valium (diazepam), nitrous oxide, and tetracycline are almost always
contraindicated.
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 HEMATOLOGIC DISORDERS
Erythrocytic disorders :
In a healthy patient, 4-6 million RBCs per ml of blood are in circulation. Red
blood cells make up the largest portion of the formed elements in blood. There are two
main categories of erythrocyte disorders; polycythemia (increases erythrocyte count) and
anemia (decrease in haemoglobin).
Polycythemia :
Is a rather rare chronic disorders characterized by spleenic enlargement,
hemorrhages, and thrombosis of peripheral veins. Death usually occurs within 6 to 10
years and complicated implant or reconstruction procedures are usually contraindicated.
Anemia :
Most common hematological disorder. Anemia is not a disease entity; rather it is
a symptom complex that results forms a decreased production of erythrocytes, an
increased rate of their destruction or form deficiency in iron. It is defined as a reduction
in the oxygen carrying capacity of the blood and results from a decrease in the number of
erythrocytes or the abnormality of hemoglobin common being iron deficiency and
relative bone marrow failure.
The oral signs of anemia affect the tongue; symptoms include a sore, painful,
smooth tongue, less of papillae, redness, and loss of taste sensation and parathesia of oral
tissues.
Anemia complications:
Complications in the implant patient may affect both short-term and long-term
prognosis. Bone maturation and development are often impaired in the long-term anemic
patient. A faint, large trabecular pattern of bone may even appear radiographically, which
indicates 25% to a 40% less in trabecular pattern. Therefore the character of the bone
needed to support the implant can be significantly affected. The decreased bone density
affects the initial placement and may influence the initial amount of mature lamellar
bone forming at the interface of an osteointegrated implant. Time needed for a proper
interface formation is longer in poor density bone.
Abnormal bleeding is also a common complication of anemia, during extensive
surgery. A decreased vision from the hemorrhage or difficulty in bone impressions for
subperiosteal implants may be encountered. Increased edema and subsequent increased

19
discomfort post surgically are common consequences. Not only are anemic patients
prone to more immediate infection from surgery.
They are also more sensitive to chronic infection throughout their lives. This may
affect the longterm maintenance of the proposed implant or abutment teeth.
Leukocytic disorders :
Leukocytic disorders are an important consideration in hematological disorders.
Normal WBC count 5000 10000 / mm 3 is an adult.
Leukocytosis is an increase in circulating WBCs in excess of 10,000 / mm3.
Leucopoenia is a reduction in the number of circulating WBCs to less than 5000 /
mm3. A decreased leukocyte count may accompany certain infections, bone marrow
damage, nutritional deficiency and blood disease.
Potential implant candidates with leukocytosis or leucopoenia, many
complications can compromise the sucess of the implant prosthesis. The most common is
infection, not only during the initial healing phase but also long term. Delayed healing is
also a consequence of WBC disorders. For most implant procedures, the first few months
are critical for long-term success. Delayed healing may increased he risk of secondary
infection.
Most oral implant procedures are contraindicated for the patient with acute or
chronic leukemia. Acute leukemia is an inevitably fatal disease. These patient
experiences serious oral complications following chemotherapy.
Patient with chronic leukemia will experience anemia and thrombocytopenia.
Although the infection is less severe than in acute leukemia, radiolucent lesions of the
jaws, oral ulcerations, hyperplastic gingiva, and bleeding complications develop in these
patients.
Treatment planning modifications should shift toward a conservative approach
when dealing with leukocyte disorders.
If the condition is temporary, as an acute infection, surgical procedures should be
delayed until the infection has been controlled and the patient has returned to a normal
condition.

LIVER DYSFUNCTION (CIRRHOSIS)

Cirrhosis is the third leading cause of death in young men between the ages of 35
and 54 years. It occurs as a result of injury to the liver with resultant loss of liver cells
and progressive scarring. The major cause is alcoholic liver disease.

20
 Two of the more important functions to the implant dentist are the synthesis of
clothing factors and the ability to detoxify drugs. Haemostatic defects of liver disease are
not only the reduced synthesis of clotting factors, abnormal synthesis of fibrinolytic
activity and quantitative and qualitative platelet defects results. The inability to detoxify
drugs may result in over sedation or respiratory depression.

BONE DISEASES
Diseases of the skeletal system and specifically the jaws often influence decisions
regarding treatment in the field of oral implants. Bone and calcium metabolism are
directly related.
Osteoporosis :
The most common disease of bone metabolism the implant dentist will encounter
is osteoporosis, an age related order characterized by a decrease in bone mass, increased
micro architectural deterioration and susceptibility to fractures.
The osteoporotic changes in the jaws are similar to other bones in the body. The
structure of the bone is normal, however due to uncoupling of the bone resorption /
formation process, the cortical plates become thinner, the trabecular patter more discrete
and advanced demineralization occurs.
Although osteoporosis is a significant factor for bone volume and density, it is
not a contraindication for dental implants. The bone density does affect the treatment
plan, surgical approach, length of healing and the need for progressive loading. Implant
designs should be greater in width and coated with hydroxyapatite to increase bone
contact and density. Bone stimulation will increase bone density, even in advanced
osteoporotic changes.

21
Vitamin D disorders:
Deficiency of vitamin D in the adult leads to osteomalacia. Vitamin D increases
calcium and phosphate absorption from the intestine and kidney resorption. The major
cause of osteomalacia is dietary vitamin D deficiency or lack of exposure to sunlight. A
decrease in trabecular bone, indistinct lamina dura and an increase in chronic periodontal
disease have been reported. Once the condition has been identified, it may be treated,
implants are not contraindicated, although treatment is similar to the osteoporatic patient.
Fibrous dysplasia:
Is a disorder in which fibrous connective tissue replaces areas of normal bone.
Implant dentistry is contraindicated in the regions of this disorder. The lack of
bone and increased fibrous tissue decrease rigid fixation of the implant and is more
susceptible to local infection processes. These local infections may spread through the
bone and result in more advanced complications. Excision of fibrous dysplasia areas is
usually the treatment choice. Once the condition is converted long-term, the area may
receive an implant.
Ostitis Deformans : (Pagets disease)
Is a slowly progressing chronic bone disease. Osteoblasts and osteoclasts are
involved in this disorder,but osteoclastic activity is predominant. Bony enlargements
may often be palpated. Spontaneous fractures are relatively common because the
increase in osseous vascularity is significant.
There is no specific treatment for pagets disease and implants are contraindicated
in the regions affected by this disorder.
TOBACCO
The definitive association between smoking and poorer levels of periodontal
health has already been established.
In fact the whole stomatognathic septum suffers from the effect of tobacco by
products. Tobacco smoke decreases PMNS activity, resulting in lower motility, a lower
rate of chemotactic migration and reduced phagocytic activity. These conditions
contribute to a decreased resistance to inflammation, infection and impaired wound
healing potential.
IJOMI Vol 17, No. 2, 2002 Review art by PhilipB Sugerman Michael T Barker.
According to many studies have shown that smoking interferes with
osseointegration and accelerates bone resorption around dental implants. Smoking
cessation during the healing phase following implant surgery improved implant survival.
22
It is now clear that smokers are at greater risk of periimplantitis. In this condition, a
conventional denture or fixed partial prosthesis may be preferred to endosseous implants
for patients who continue to smoke.

VITAL SIGNS
The recording of vital signs (blood pressure, pulse, temperature, respiration,
weight and height) is also point of the physical examination. Trained dental auxillary
personnel can often gather this information before the patients history is recorded by the
dentist.
Blood pressure :
Approximately 10% of dental offices record the patients blood pressure. This
proves worthwhile for the implant dentist because surgery and long prosthodontic
procedures are frequently required. The sphygmomanometer is used to measure the
blood pressure.
Hypertension is the abnormal elevation of the resting arterial systolic and / or
diastolic blood pressure.
Pulse :
Much patient information is available from this simple procedure. The pulse
represents the force of the blood against the aortic walls fro each contraction f the left
ventricle. The pulse wave travels through the arteries and reaches the wrist 0.1-0.2
seconds after each contraction. The radial artery or carotid artery a temporal artery is
convenient to use.
Pulse rate :
The normal pulse rate varies from 60 90 beats per minute in a relaxed,
nonanxious patient. The beats are both strong and regular. The upper limit of normal is
considered 100 beats / min, people in excellent physical condition may have a pulse rate
of 40 60 beats / min .A pulse rate less than 60 beats / min or above 110 beats / min in
the non-athlete is suspect and warrants and medical consultation.
A decreased pulse rate of normal rhythm ( < 60 beats / min) signals sinus
bradycardia. It is natural for some patients and may reach as low as 40 beats / min,
although most patients become unconscious below this rate. During implant surgery,
inappropriate bradyeardia may indicate impending sudden death. If the pulse rate of the
patient decreases to less than 60 beats / min and is accompanied by sweating, weakness,

23
chest pain or dyspnea, the implant procedure should be stopped, oxygen administered
and immediate medical assistance obtained.
An increased pulse rate of regular rhythm (more than 100 betas / min) is called
sinus tachycardia. This rate is normal if experienced during exercise or anxiety.
However in patients with anemia or severe hemorrhage, the heart rate increases to
compensate for the depletion of oxygen in the tissue. If vision becomes blurred during
surgery because of bleeding evaluate the pulse rate and blood pressure. When elevated,
an increase in bleeding is readily observed. Pulse rate and temperature are also related,
the pulse rate increasing 5 beats / min for each degree as the body temperature rises.
All these conditions affect the surgery or may increase post operative swelling.
The increased swelling favors the occurrence of infections and complications during the
first critical weeks after implant placement. This can compromise the subsequent years
of implant service to the patient.
Pulse Rhythm :
Two types of abnormal pulse rhythm are needed regular and irregular.
An irregular abnormal pulse rhythm includes premature ventricular contractions
(PVCs), which are noticed as a distinct pause in an otherwise normal rhythm. This
condition may be associated with fatigue, stress, or excessive use of tobacco or coffee,
but it is also observed during myocardial infarction. If during implant surgery, five or
more PVCs are recorded within 1 minute, especially when accompanied by dyspnea or
pain, the surgery should be stopped, oxygen administered, the patient placed in a supine
position, and immediate medical assistance obtained. Sudden death in persons older than
30 years with PVC is 6 times more frequent than in younger persons.
Temperature :
Normal body temperature ranges from 96.80 to 99.40 F is a healthy individual.
The usual cause of elevated body temperature is bacterial infection and its toxic
byproducts.
No elective surgery should be performed on febrile patients. The cause of fever
may complicate the post surgical phase of healing. In addition because elevated
temperature increases the patients pulse rate, the risks of hemorrhage, edema, infection
and postoperative discomfort are greater.
Respiration :
The normal rate the adult varies between 16 to 20 breaths per minute and regular
in rate and rhythm.
24
 A respiratory rate greater than 20 breaths / min requires investigation. Anxiety
may increase this rate, in which case sedative or stress reduction protocols. Indicated
before implant surgery other causes for increased respiration rate are severe anemia,
advanced bronchopulmonary disease and congestive heart failure, all these can affect the
surgical procedure and / or healing response of the implant candidate.

DENTAL HISTORY
Dental history is an important part in evaluation of implant treatment. In the
dental history, extraction dates should be verified to determine if they were performed
within the minimum six month period of time, this could be a relative contraindication.
Also, determine reasons for previous extractions.
Dental history includes information gathered during oral examination. Evaluate
soft tissue condition for health of periodontium, pathology, location of alveolar and
attached mucosa and redundancies. Evaluate remaining teeth condition for caries relative
positions, mobility, plaque, index and presence of calculus. Evaluate edentulous areas for
undercuts, pathology and size and shape of residual bone. Evaluate present occlusion for
interferences, occlusal wear, prematurities, associated muscle tenderness, limited range
of mandibular motion, and evaluate for temporomandibular disorders. Evaluate
parafunctional habits such as bruxism, which can have detrimental long term effects.
The hard and soft tissue should be evaluated as to both quality and quantity. The
radiographs must be evaluated in conjunction with this portion of the clinical
examination to ensure the absence of bony pathology. The complete healing of post-
extraction defects should also be verified by the lack of post extraction defects or
phantoms on the radiograph. The presence of a good trabecular pattern should be
verified.
Presence of tori, should be noted and treatment planned for modification, removal
or both. The soft tissues, especially in the intended area of implantation should be
evaluated for unfavorable frenum, or muscle attachments, presence of disease, or the
presence of attached gingiva. If there is not sufficient equality or quantity of keratinized
tissue at these critical locations, the treatment plan should be modified to include
satisfactory grafting procedure to rectify the situation.

ORAL EXAMINATION

25
 A thorough oral examination should include evaluation of soft tissue conditions,
oral hygiene and periodontal health. Associated structures should be checked, especially
in patients with severe bone resorption, note the position of mental foramina and
neurovascular bundles which may be palpable. Information gathered during the oral
examination, dental history and medical history help determine potential for successful
treatment. Systemic and other conditions should be treated before any implant procedure.
Patients with natural dentition present should have a treatment plan that includes
periodontal management as well as prosthetic treatment for the remaining dentition with
the plan for oral rehabilitation. From a periodontal aspect, attached gingiva management
problems should be addressed. If periodontal problems exist adjacent to the proposed
fixture installation site, the problems should be treated and hopeless teeth should be
extracted prior to implant surgery.
Study models:
Study models, a face bow transfer, and occlusal registration are essential for
treatment planning. The study casts are important for studying the remaining dentition
and residual bone, and for analyzing the maxillomandibular relationship. The mounted
study casts can be helpful to the surgeon for fixture placement can be estimated. In the
angle class II or III situation, the fixture is angled toward the maxillary teeth or residual
ridge this helps prevent prosthodontic problems when fabricating the prosthesis for
proper esthetics and function.
A diagnostic wax-up can be done on the study casts or duplicate study casts.
Proposed fixture installation sites can be checked on the study casts for proper
alignment, direction, location and relation to remaining dentition. A diagnostic wax up
helps to determine the esthetic placement of teeth and potential functional speech
disturbances. After adjustments are completed and the diagnostic wax-up is finished a
resin template can be made from the study casts.
Also, a complete preoperative as well as post operative photographic series of
frontal, profile and intraoral series can be done for the purpose of compression.

ANATOMICAL LIMITS FOR FIXTURE PLACEMENT

Maxillary anterior region.
This region has less bone quality and lower quantity when compared to the
mandibular anterior region. Bone quantity and quality influence success rates, maxillary
success rates are lower due to the bone quality.
26
 In many patients there are anatomical limitations in the maxilla. The nasal cavity
and maxillary sinuses usually interfere with fixture site selection, especially in a patient
with severe bone resorption.
Bone resorption is the maxilla gradually continues after tooth extractions,
resulting in diminishing height and width. As the bone height decreases, the remaining
bone marrows to close approximation with the nasal cavity, maxillary sinuses, and
incisive canal nerve bundle. When the bone resorption is severe, bone availability may
be limited to canine eminence areas, lateral wall of the nasal cavity and medial wall of
the sinus. This area may accommodate longer fixtures, so long as 15 mm, when
positioned to the right and left sides of the nasal cavity. When only 2 fixtures can be
placed, the patient can receive overdenture treatment.
With an adequate amount of bone, six fixtures can be placed to support a fully
anchored prosthesis. The only limitation for placement of fixture is the mid palatine
suture.
A fixture in this area may create forces separating adjacent bone structures and
possibly causing damage to incisive canal nerve and associated blood vessels.
Maxillary posterior region:
Due to the resorption pattern, proximity of sinuses and quality of bone, fixtures
are rarely placed in the maxillary molar areas. In the premolar areas of the maxilla, the
bone is usually thick and spongy. The premolar area usually has adequate bone height
compared to the molar areas and may accommodate fixture between the lateral and
inferior walls of adjacent sinuses. Edentulous patients show a similar pattern for
maxillary resorption from the buccal towards the palatal hence the residual ridge appears
to constrict palatally with continued resorption. If a patient present with a deep palatal
vault and some resorption, remaining bone height may be adequate. It creates the
appearance of flattened maxillary bones. The combination of severe bone resorption and
a low palatal vault creates a difficult situation for implant procedures.
Mandibular anterior region:
The mandibular anterior region between mental foramina usually has adequate
bone for placement of 4 6 fixtures. A minimum of 7 mms from the inferior border of
the mandible to the crestal ridge is needed in this region for adequate fixture length.
Normally the mandibular canal extends five millimeters anterior to the mental foramen
within the body of the mandible. The pathway of the nerve bundle can curve unusually
and posteriorly to exit near the apex of the second premolar.
27
 Damage to the inferior alveolar nerve and artery bundle, which exits as the
mental nerve, results in parasthesia.
The mental foramen can be detected by radiographic analysis but actual location
and size does not change with age and resorption so dissection is essential during
surgery.
In patients with sever resorption; the mental foramen position may be located on
top of the residual alveolar ridge. Occasionally no foramen is found but rather the nerve
is located in the soft tissue above the bone. Edentulous patients show a similar resorption
pattern in the mandible from the facial toward the lingual with a decrease in height, after
years of continued mandibular resorption, fixtures can still be placed directly into solid
cervical bone.
Mandibular posterior region :
Fixture installation in this region can present problems due to the presence of the
inferior alveolar canal. To ensure safety there should be a minimum of one mm clearance
between the fixture apex and the inferior alveolar canal. The canal has a diameter of
approximately 2 or 3 millimeters and its pathway can curve slightly. The canal extends
from the ramus into the body of the mandible at an angle of 150 degrees forward and
downward. The canal then curves anteriorly and is approximately 6 mm below the
second molar apex, transversing one third the body of the mandible. The final pathway
continues and curves between the 1st and 2nd premolar area, opening below the 2nd
premolar apex as the mental foramen.
The pattern of bone resorption is almost the same on both the buccal and lingual
side such that the alveolar bone crest does not appear to change toward the buccal on
lingual direction. However, the pattern of resorption in the crest region can create a
variety of shapes, from a sharp edge to flat and wide. When fixtures are installed into a
sharp edge shaped alveolar crest, first remove the sharp edge with the bone trimmer.
Selection of a shorter fixture might be necessary after bone trimming since the original
length was selected before bone trimming. The inferior alveolar canal position can differ
slightly from patient to patient, so fixture installation above the canal is done carefully to
prevent perforation.

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 DIAGNOSTIC IMAGING AND TECNIQUES
Diagnostic imaging and techniques help to develop and implement a cohesive
and comprehensive treatment plan for the implant team and the patient. The implant team
involves the services or functions of a number of professionals and may include.
Referring dentist
Laboratory technician
Prosthodontist
Periodontist
Oral surgeon
Implantologist
Radiologist
Hygienist

Information acquired from the patients medical and dental history, clinical
examination lab tests, diagnostic casts, diagnostic wax up, diagnostic imaging also
plays a role in developing the patients treatment plan and objectives.
Imaging objectives :
The objectives of diagnostic imaging depend on a number of factors, including
the amount and type of information required and the time period of treatment rendered.
The decision of when the image along with which imaging modality to use depends on
the integration of these factors and can be organized into three phases.
PHASE 1 :- Is Termed As Preprosthetic Implant Imaging
Involves all radiologic examinations along with radiologic examination chosen to assist
the implant team in determining the patients final and compressive treatment plan
Objectives: 1) Necessary surgical and prosthetic information to determine the quantity,
quality and angulations of bone.
2) The relationship of critical structures to the prospective implant sites
3) Presence or absence of disease at the proposed surgery sites.
PHASE 2: Is Termed Surgical And Interventional Implant Imaging
It is focused on assisting in the surgical and prosthetic intervention of the patient.
Objectives : - To evaluate the surgery sites during and immediately after surgery, assist
in the optimal position and orientation of dental implants, evaluate the heating and

29
integration phase of implant surgery, and ensure abutment position and prosthesis
fabrication are correct.
PHASE 3:- Is Termed Post Prosthetic Implant Imaging
In commences just after the prosthesis placement and continues as long as the implants
remain in the jaws.
Objectives: - To evaluate the long term maintenance of implant rigid fixation and
function, including and to evaluate the implant and to evaluate the implant complex.

30
 IMAGING MODALITIES
Decision to image depends on patients clinical needs.
The imaging modality employed yields the necessary diagnostic information
related to the patients clinical needs. The opinion of a radio- logist may be required for
more complex modalities.
Many imaging modalities have been employed for implant imaging. Some useful
for imaging include periapical, panoramic, occlusal, cephalometric and tomographic
radiography, computed tomography, magnetic resonance imaging and interactive
computed tomography.
Three imaging modalities can be described as either analog or digital and two-
dimensional or three-dimensional. Most dentists are more familiar with analog, 2
dimensional imaging.
Analog imaging modalities :
These are two-dimensional system that employs x-ray film and / or intensifying
screens as the imaging receptors.
Periapical radiography
Panoramic radiography
Occlusal radiography
Cephalometric radiography
Digital 2 Dimensional Imaging :
An image matrix that has individual picture elements called fixed describes it.
Doubled by its width height and pixels Black and white images are optimally dis played.
Digital 3 Dimensional Imaging :
It is described by an image matrix that has individual image / picture elements
called voxels. It is described not only by its width and height and pixels but additionally
by its depth / thickness.
E.g. computed tomograpy, MR.

PREPROSTHEITC IMAGING
The 1st phase of the imaging modality. The global objective of this phase of
treatment is to develop and implement a treatment plan for the patient that enables
restoration of the patients function and esthetics by the accurate and strategic placement
of dental implants.
The specific objectives of preprosthetic imaging are to
31
1) Identify disease
2) Determine bone quantity
3) Determine bone density
4) Identify critical structures at the proposal implant regions.
5) Determine the optimum position of implant placement relative to occlusal loads.

Periapical radiography :
These are images of a limited region of the mandibular a maxillary alveolus.
Periapical radiographs are produced by placing the film intraorally parallel to the body of
the alveolus with the central ray of the x-ray device perpendicular to the alveolus at the
region of interact producing a lateral view of the alveolus.
Drawbacks :
No cross - sectional information is rendered.
Periapical radiographs may suffer from both distance and magnification
In terms of the objectives of preprosthetic imaging periapical radiography is
1) A useful high yield modality for ruling out local bone or dental disease.
2) Of limited value in determining quantity because the image is magnified, may be
distorted and does not depict the third dimension of bone width.
3) Of limited value in determining bone density or bone mineralization.
4) Of value in identifying critical structures, but of little use in depicting the spatial
relationship between the structures and the proposed implant site.
In preposthetic phrase, these films are most often used for single tooth implants in
regions of abundant bone width

Occlusal radiography :
They are planar radiographs produced by placing the film intraorally parallel to
occlusal plane.
Ray is directed perpendicular to film for mandibular image.
Ray oblique to film for maxillary image
Maxillary occlusal radiographs are inherently oblique and so distorted and
therefore have no quantitative use for implant dentistry.
Additionally critical structures such as the maxillary sinuses nasal cavity, nasal
palatine canal are demonstrated, but the implant site is generally last with this projection.

32
 It shows the widest width of bone i.e. versus the width at the rest, which is where
diagnostic information is needed most. The degree of mineralization of trabecular bone is
not determined from this projection, and the spatial relationship between critical
structures such as the mandibular canal and the mental foramen and the prepared implant
site is lost with this projection. Is a result occlusal radiographs are rarely indicated for
diagnostic preprosthetic phases in implant dentistry.
Cephalometric radiographs :
These are oriented planar radiographs of the skull. The skull is oriented with
respect to the x-ray device and the image receptor using a cephalometer, which
physically fixes the position of the skull with projections into the external auditory
canal.
This radiograph demonstrates a cross sectional image of the alveolus of both
the mandible and the maxilla in the midsagittal plane. The cross sectional view of the
alveolus demonstrate the spatial relationship between occlusion and esthetics with the
length, width Angulation is more accurate for bone quantity determinations, unlike
panoramic or periapical images.
Drawback. :
This technique is not useful for demonstrating bone quality and only
demonstrates a cross sectional image of the alveolus where the central rays of the x-ray
device are tangent to the alveolus.
Panoramic radiography :
It is a curved plane tomographic radiographic technique used to depict the body
of the mandible, maxilla and the lower and half of the maxillary sinuses in a single
image. This modality is probably the most utilized diagnostic modality in implant
imaging it is not the most diagnostic. This radiographic technique produces an image of a
section of the jaws of variable thickness and magnification. The image reception has
traditionally been x-ray film but may be a digital storage phosphor plate or a digital CCD
reception.
Panoramic images offer the following advantages.
1) Opposing landmarks are easily identified.
2) The vertical height of bone initially can be assessed
3) The procedure is performed with convenience, case and speed in most dental offices.
4) Gross anatomy of the jaws and any related pathologic finding can be evaluated.
Drawbacks :
33
 Traditional panoramic radiograph is a high yield technique for demonstrating dental and
bone disease. However panoramic radiography
(1) Does not demonstrate bone quality / mineralization
(2) Is misleading quantitatively because of magnification and because the third
dimension, cross sectional view, is not demonstrated.
(3) Is of some use in demonstrating critical structures but of little use in depicting the
spatial relationship between the structures and dimensional quantitative of the
implant site.

Tomography
It is a generic term, formed from the Greek words tomo(slice) and graph (picture)
that has adapted in 1962 by the INTERNATIONAL COMMISSION ON
RADIOLOGIC UNITS AND MEASUREMENTS.
Body section radiography is a special x-ray technique that enables utilization of a
section of the patients anatomy by blurring regions of the patients anatomy above and
below the region of interest.

34
 PROSTHODONTIC CLASSIFICATION
TYPE DEFINITION
FP 1 Fixed prosthesis, replaces only the crown, looks like a natural tooth.

Fixed prosthesis, replaces the crown and a portion of the root, crown
FP 2 contour appears normal in the occlusal half but is elongated on hyper
contoured in the gingival half.

Fixed prosthesis, replaces missing crowns and gingival color and

FP 3 portion of the edentulous site, prosthesis most often uses denture teeth
and acrylic gingiva, but may be preordain to metal.

Removable prosthesis, over denture supported completely by implant.

RP 4 Removable prosthesis, over denture supported by both soft tissue and

implant.

RP 5

Patient should not be encouraged to accept a fixed prosthesis if a removable

prosthesis can predictably satisfy the patients needs and desires.
But if adequate natural or implant abutment situations exist, than the present oral
conditions or the needs and desires of the patient must be altered. In other words either
the mouth must be modified to place implants in the correct anatomic positions or the
mind of the patient must be modified to accept a different prosthesis type and its
limitations.
In 1989, Misch reported five prosthetic options available in implant dentistry.
The first three options are fixed prostheses (FP). They may replace partial or total
dentitions and may be cemented or screw retained. These options depend on the
amount of hard and soft tissue structures replaced common to all fixed options is the
inability of the patient to remove the prosthesis.

35
 Two types of final restorations are removable (RP), they depend on the amount of
implant support, not the appearance of the prosthesis.

Fixed prostheses :
FP 1
Is a fixed restoration and appears to the patient to replace only the anatomic
crowns of the missing natural teeth.
Since minimal loss of hard and soft tissue the volume and position of the residual
bone often permit ideal placement of the implant in a location similar to the root of a
natural tooth.
Most often desired in the maxillary anterior region. However, the width and / or
height of the crestal bone is frequently lacking, augmentation is often required before
implant placement to achieve a natural looking crown in the cervical region because
there are no interdental papillae in edentulous ridges, gingivoplasty is required after the
abutment is positioned to improve the interproximal gingival contour. Ignoring this step
causes open black triangular spaces (where papillae should usually be present).
FP 2
Appears to restore the anatomic crown and portion of the root of the natural
tooth. The volume and to topography of the available bone dictate a different vertical
implant placement compared with the FP 1 prosthesis, which is more apical compared
with the cementoenamel junction of a natural root. As a result the incisal edge is in the
correct position, but the gingival third of the crown is over extended usually. Apical and
lingual to the position of the original tooth. These restorations are similar to teeth
exhibiting gingival recession and periodontal bone loss. If the high lip line and low lip
line do not display the cervical regions, the longer teeth are usually of no consequence.
Does not require as specific an implant position in the incisal or distal position
because the cervical contour is not displayed during function .The implant position may
be chosen in relation to bone width angulation, or hygienic considerations rather than
truly esthetic demands.
On occasion implant may even be placed in an embrasure between 2 teeth. Place correct
facio lingual position so that hygiene direction of force and not compromised.
FP 3
Fixed restoration that appears to replace the natural teeth crowns and a position of
the soft tissue. As with the FP 2 prosthesis, the original available bone height has

36
decreased natural resorption or osteoplasty at the time of implant placement. To place the
incisal edge of the teeth in proper position for esthetics, function, lip support and speech,
the excessive vertical dimension to be restored requires teeth are unnatural in length.
However unlike the FP 2 prosthesis, the mandibular lip line during smiling or a low
mandibular lip line during speech.
As a result the patient will display the longer teeth, which look unnatural. In FP 3
the restored gingival color and contour give the teeth a more natural appearance in size
and shape and mince the interdental papillae region. The addition of gingival tone
acrylic or porcelain for a more natural appearance is often indicated because bone loss is
common.
The maxillary FP 2 or FP 3 is often extend to the tissue so that speech is not
impaired access next to reach implant abutment is provided. The mandibular restoration
may be left above the tissue, similar to a sanitary pontic. This facilitates oral hygiene in
the mandible especially when the implant perimucosal site is level with the floor of the
mouth and the depth of the vestibule. FP 2, FP 3 restoration usually has greater crown
implant routes compared with FP 1.
The biomechanics of force distribution in implant-support prostheses is
qualitatively different than when natural teeth serve as abutments. The essential
difference is caused by the periodontal ligament, which permits micromovements,
compared to the osseointegrated implant, which has none. This article describes the
principles force distribution as applied to diagnosis and treatment of implant-supported
prosthese.
Principles of force distribution :
The character of force distribution between members of a system depends on the
relative stiffness/deflection of each member. (Weinberg R, personal communication).
However, there is a paradox concerning the role of rigidity and deformation (flexibility)
when comparing tooth-supported and multiple-implant-supported prostheses. There are
structural differences between the two entities and the supporting medium (ie,
periodontal ligament versus osseointegration), which are diametrically opposed
physiologically. The former has the maximum flexibility of any portion of the system
whereas the latter, by definition, has none.
The prostheses of both systems are considered stiff. A fixed prosthesis is usually
permanently cemented to the natural teeth, forming one stiff structural unit. however, the
vertical elements of each system have opposing characteristics. The implant-abutment-
37
prosthesis interfaces introduce minute degrees of flexibility as the result of retaining
screw deformation. These factors have a profound effect on the concepts offorce
distribution when systems are compared and introduced the risk of clinical failure when
teeth and implants are combined in support of prosthesis without an understanding of
these fundamental differences.
Character of force distribution :
A scientific analysis of force distribution is statistically indeterminate because of
variable factors that prevent quantifying measurements. For instance, cortical and
medulary bone have different elasticities. The attaching screws have much more
deflection (flexibility) than the prosthesis framework. The relative intimacy of interface
fit of the prosthesis to the abutments will alter force distribution. Cantilever force
application and the geometric location of the fixtures further alter force distribution
patients.

CONCLUSION :

Implant dentistry is now a fast developing field which has a wide area of
application. Though an expensive affair it is a treatment option that most patients opt for.
To assure a definite treatment plan with no loopholes it is essential to examine the patient
thoroughly. Not only does the dental history play a vital role, the medical history too is
equally important .
Implants can be utilized in both dentulous and edentulous individuals regardless
of age or sex. It can be used to replace a single tooth or more. It may also be used to
support a fixed prosthesis or a removable one. Implants have their boons and banes.
Management of surgical procedures as well as the bone overload encountered with the
use of implants is sometimes a tricky task .
Since implants are being so widely used many new modifications have been made in
the implant systems to render a problem free implant treatment. Thus the conventional
dentures of today are being compensated for implant supported prosthesis.

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REFERENCES :

1.Implant Prosthodontics Clinical and Lab Procedures Stwen :

Fredrickson. Gress
2. Principles and Practice of Implant Dentistry
Adam Weiss and Charles M.Weiss
3. Dental Implants a Guide for the General Practitioner
Michael Norton
4. Contemporary Implant Dentistry
Carle Misch
5. Osseointegration and Occusal Rehabilitation
Sumiya Hobo
6. Dental Implants Principles And Practice
Charles A. Babbush
7. Treatment Planning
Michael J Engleman.

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