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PRE OPERATIVE PRE OPERATIVE EVALUATION OF IMPLANT EVALUATION OF IMPLANT
PATIENTSPATIENTS
Shahnaz KhadarCRI
Contents Contents DefinitionHistoryClassificationIndicationsPretreatment evaluationMedical & Dental historyContraindicationsClinical examinationRadiographic examinationconclusion
Definition Definition Implantation is defined as the insertion of any object or material, such as an alloplastic substance or other tissue, either partially or completely, into the body for therapeutic, diagnostic, prosthetic or experimental purposes.
HISTORYHISTORYCarved bamboo pegs were used 4000yrs
ago in ChinaRoot form metal pegs- Egypt 2000 yrs
backArchaeological museum at Harvard houses
an implant made of shell dating back to 600 AD
Albucasise de condue (1963- 1013) used ox bone , first documented placement of implants.
1809, Maggiolo fabricated gold roots that were fixed to pivot teeth by springs.
•Per Ingvar Branemark - Osseo integration•1965- first titanium dental implant placed in a human volunteer.
X ray of titanium chamber embedded in rabbit femur
Panoramic radiograph of historic dental implants, taken 1978
CLASSIFICATION OF CLASSIFICATION OF IMPLANTSIMPLANTS
Indications Indications Edentuluos patients -implant assisted removable
prostheses -implant supported fixed
prosthesesPartially edentuluos patients
Why implants??Why implants??Maintains boneRestore and maintain occlusal vertical
dimensionsImproves esthetics,phonetics,occlusionImproves masticatory functionImproves psychological health
Pre treatment evaluationPre treatment evaluationChief complaint-Patient’s concernPatient’s expectation
Medical historyMedical historyThorough medical history should be
documented.Review for conditions that might
pose a risk for adverse reactions/complications.
Laboratory tests to rule out conditions that might be contraindication/risk factor.
Medical clearance from treating physician.
ASA PHYSICAL STATUS ASA PHYSICAL STATUS CLASSIFICATIONCLASSIFICATIONASA I - A normal healthy patient without systemic
diseaseASA II- A patient with mild systemic diseaseASA III- A patient with severe systemic disease
that limits activity but is not incapacitatingASA IV- A patient with an incapacitating systemic
disease that is a constant threat to life.ASA V- A moribund patient not expected to
survive 24 hours without operationASA E- Emergency operation
Contraindications Contraindications Medical
• acute infectious diseases – absolute, but temporarily; wait for recovery
• chemotherapy – absolute, but temporarily; reduced immune status
• systemic bisphosphonate medication (≥2 yr)
– risk of bisphosphonate-induced osteonecrosis (BON)
• renal osteodystrophia – increased risk for infection, reduced bone density
• severe psychosis
– absolute; risk of regarding the implant as foreign body and requesting removal despite of successful osseointegration
• depression – relativeNU Zitzman et al Australian Dental Journal 2008; 53:(1 Suppl): S3–S10
• pregnancy– absolute, but temporarily; to avoid additional stress and radiation exposure
• unfinished cranial growth with incomplete tooth eruption
– relative, but temporarily; to avoid any harm to the growth plates, to avoid inadequate implant position in relation to the residual dentition
intraoral
• pathologic findings at the oral soft- and/or hard tissues
– temporarily; increased risk for infection, wait until healing is completed
NU Zitzman et al Australian Dental Journal 2008; 53:(1 Suppl): S3–S10
Increased risk
post head and neck radiation therapy
– reduced bone remodelling, risk of osteoradionecrosis, implant placement 6–8 weeks before or ≥1 yr after radiotherapy
• osteoporosis – reduced bone to implant contact
• uncontrolled diabetes– wound healing problems (impaired immunity, microvascular diseases)
• status post chemotherapy, immuno-suppressants or steroid long-term medication, HIV infection
– wound healing problems, medical advice required
• alcohol and drug abuse, heavy smoking ≥20 cig/d
– wound healing problems, locally reduced vascularization7
• history of aggressive periodontitis
– increased risk to develop peri-implantitis
NU zitzman et al Australian Dental Journal 2008; 53:(1 Suppl): S3–S10
Habits and behavioral Habits and behavioral considerationsconsiderations
◦Smoking & tobacco use *Adversely affects implant success
through its effect on bone metabolism◦Para functional habits * Repeated lateral forces can be
detrimental to osseointegration process.
◦Substance abuse * Psychological problems , non
compliance * Impaired organ function
Dental Dental historyhistoryOral hygiene status and
practicesCompliance with past dental
recommendationsPrevious experience with
surgery and prostheticsAttitude and motivation
towards implants
Clinical Clinical examinationexamination
Facial proportionsFacial symmetryFacial convexityLip and cheek supportIntermaxillary relationLip length and incisal show
Intraoral Intraoral examinationexaminationInfections , lesions and
pathologic conditionsOverall dental &
periodontal healthOcclusionJaw relationTMJ conditionMouth opening
Soft tissue evaluationSoft tissue evaluationQuality( keratinized/ non keratinized)
Quantity Location Frenum attachments
Hard tissue evaluationHard tissue evaluationClinically and radiographically
Palpate for anatomical defects, concavities and undercuts
Intraoral bone mapping
Evaluation of implant sitesEvaluation of implant sitesAlveolar bone Atleast 1.0 to 1.5mm of bone around implantInterdental space
Buccolingual width > 6mm
Interocclusal space
Diagnostic study modelsDiagnostic study modelsEvaluate space availableDetermine potential limitations of planned
treatmentUseful while replacing multiple teeth or in case
of malocclusion.
Radiographic examinationRadiographic examinationQuality, quantity and location and volume of alveolar
boneIdentify vital structures: floor of nasal cavity, maxillary
sinus, mandibular canal, mental foramenRadio opaque markers can be used to evaluate
relation of alveolar ridge to existing teeth
Misch’s classification of bone density
INDICATIONS ADVANTAGES LIMITATIONSPERIAPICAL RADIOGRAPHY
Small edentulous spaces, alignment and orientation during surgery
Low radiation dose ; inexpensive
Minimal site evaluation; distortion & magnification
OCCLUSAL RADIOGRAPHY
none Evaluation of pathology
Does not reveal true buccolingual width:Difficulty in positioning
CEPHALOMETRICRADIOGRAPHY
Used with other radiographs for anterior implants
Low magnification;Height/width in anterior region
Limited to midline; reduced sharpness & resolution
PANORAMIC RADIOGRAPHY
Commonly used Initial assessment of vertical bone height;Gross anatomy & pathology evaluation
Distortion; does not demonstrate bone quality
COMPUTED TOMOGRAPHY
Determination of bone density; vital structure location; determination of pathology
Negligible magnification; high contrast image; 3D;Various views
Cost; technique sensitive
Laboratory testsLaboratory testsComplete blood count WBC- 4,000 to 11,000 cells/mm3
RBC- 4-6 million/mm3
Platelet- 1,50,000- 4,00,000cells/mm3
MCV- 80-100 fL MCHC- 32 to 36 g/dL hemoglobin- 11- 16 g/dLProthrombin time- INR (normal range- 0.8 to 1.2)Glycemic control- HbA1c (4 to 6%)Thyroid function tests- T3- 60 to 175 µg/dl T4- 4-11 ng/dl
Conclusion Conclusion The success and predictability of
dental implants have changed philosophy and practice of dentistry.
However, proper pre treatment evaluation, and a treatment plan are imperative for its success.
Reference Reference Contemporary implant dentistry, 3rd ed,
Carl E MischCarranza’s clinical periodontology, 10th ed.Phillips’ science of dental materials, 11th
ed, AnusaviceShenoy VK. Single tooth implants:
Pretreatment considerations and pretreatment evaluation. J Interdiscip Dentistry2012;2:149-157.
Internet