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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
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
BONE DISORDERS
Often influence decisions in implantology as alveolar bone responds to systemic bone active agents
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
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
PROBING
RESTORATIVE EVALUATION
Decay
Teeth
AESTHETIC EVALUATION
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
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
BRUXISM
DIAGNOSIS
Teeth
wear
IMPLICATIONS
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
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
DIRECTION OF LOAD
Axial Vs lateral forces
All stresses occur in coronal half of alveolus. Excessive Crestal bone loss
CROWN HEIGHT
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
CENTRIC RECORD
One Set of Models is kept as an Original Record The Other Set may be equilibrated and Waxed Up
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
8. Interarch space
WAX UP IN VIEW
WAX UP IN VIEW
DIAGOSTIC STENTS
FABRICATION
Assess position and angulation of prosthetic component Plan implant placement and angulation based on the same
QUANTITY
Length of the edentulous span Height of available bone Buccolingual width
Abundant bone
B-w
C-w
zzzz
Unfavorable Angulation >30 CL ratio >/= 1
Compromised bone
Deficient bone
QUALITY
Density of available bone
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
FAILED IMPLANT
By Observation
by by Palpation Palpation
1.75mm
3 mm
DIAGNOSTIC IMAGING
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
IOPA
Details of region under investigation vital structures Periodontal and endodontic status of teeth Residual roots and pathology
FALLBACKS
Does not depict the third dimension of bone width Little value in determining bone density
Spatial relationship not discernible
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
Menu
<
7.4 / 1.24
Vertical Height
PITFALLS
Distortion
Occlusal radioraphs
Lateral Ceph
AXIAL SECTIONS
RECONSTRUCTED INTO 3-D IMAGES
ABOUT CT
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.
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)
D5
<150
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
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
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