Clinical evaluation of the implant patient

1. Clinical Evaluation of the Implant Patient
Diagnostic Imaging for the Implant Patient

2. CONTENT
• Introduction
• Case Types and Indications
• Risk Factors and Contraindications
• Post treatment Evaluation
• Conclusion
Clinical Evaluation of the Implant Patient

3. Dental implants are primarily used to replace teeth in a
partial or complete edentulous patient or to retain
removable prostheses.
The ultimate goal of dental implant therapy is to satisfy the
patient's desire to replace one or more missing teeth in an
aesthetic, secure, functional, and long-lasting manner.
To achieve this goal, clinicians must accurately diagnose the
dentoalveolar condition, as well as the overall mental and
physical well-being of the patient.
INTRODUCTION

4. It is necessary to determine whether implant therapy is
possible, practical, and, perhaps most important, whether it is
indicated for the particular patient who is seeking implants.
•Local evaluation of potential jaw sites for implant placement (e.g.,
measuring available alveolar bone height, width, and spatial relationship)
•Prosthetic restorability are essential considerations in determining
whether an implant(s) is possible.
•Making as assessment of the patient and determining whether that patient is a
good candidate for implants is an equally important part of the evaluation
process.
Along with, the patient evaluation includes identifying factors
that might increase the risk of failure or the possibility of
complications, as well as determining whether the patient's
expectations are reasonable. Perry R. Klokkevold, David L. Cochran,2017

5. Case Types and Indications
1. Complete Edentulous Patients 2. Partially Edentulous Patients
Multiple Teeth Single Tooth

6. Complete Edentulous Patients
These patients can be effectively restored, both aesthetically and
functionally—
• with an implant assisted removable prosthesis,
• or an implant-supported fixed prosthesis.
----used five to six implants in the anterior area of
the mandible or the maxilla to support a fixed, hybrid prosthesis.
-----The design is a denture-like complete arch of teeth attached to a substructure
(metal framework), which in turn is attached to the implants with cylindrical
titanium abutments

7. Another implant-supported design used to restore an edentulous arch is the ceramic-
metal fixed bridge (makes its appearance similar to that of natural teeth.)
Both hybrid and ceramic-metal implant supported
fixed prostheses provide very little lip support and thus may
not be indicated for patients who have lost
significant alveolar dimension.
More problematic for maxillary reconstructions because lip
support is more critical in the upper arch.
some patients, the lack of a complete seal (i.e., spaces
under the framework) allows air to escape during
speech, thus creating phonetic problems.

8. Depending on the volume of existing bone, the jaw relationship,
the amount of lip support, and phonetics, some patients may not be
able to be rehabilitated with an implant-supported fixed prosthesis.
For these patients, a removable, complete-denture type of prosthesis is a better choice
because it provides a flange extension that can be adjusted and contoured to support the
lip, and there are no spaces for unwanted air escape during speech.
This type of prosthesis can be retained and stabilized by two
or more implants in the anterior region of the maxilla or
mandible.
Separate attachments on each individual implant to clips
or other attachments that connect to a bar, which splints
the implants together.

9. Stability of the implant-retained overdenture shows
increased retention and stability over conventional complete
dentures is an important advantage for denture wearers.
Additionally, implant-supported prostheses are thought to
lessen the amount of alveolar bone loss associated with long-
term use of removable prostheses (force bear directly on the
alveolar ridges)
Advantages

10. Partially Edentulous Patients
Multiple Teeth
Partially edentulous patients with multiple missing teeth represent another viable
treatment population for osseointegrated implants, but the remaining natural dentition
(occlusal schemes, periodontal health status, spatial relationships, and aesthetics)
introduces additional challenges for successful rehabilitation.(Lekholm U et al.,1994)

11. The primary challenge with partially edentulous cases is an underestimation of the
importance of treatment planning for implant-retained restorations with an
adequate number of implants to withstand occlusal loads.
Better treatment planning with the use of an adequate number and size of implants,
particularly in areas of poor-quality bone, has solved many of these problems.
Multiunit fixed restorations in the posterior jaw are more likely to experience
complications or failures when they are inadequately supported in terms of the number
of implants, quality of bone, or strength of the implant material .

12. Single Tooth
Patients with a missing single tooth (anterior or posterior) represent another type of
patient who benefits greatly from the success and predictability of endosseous dental
implants
The greatest challenges to overcome with the single-tooth implant restorations were
screw loosening and implant or component fracture mainly in posterior area.
Because of the increased potential to generate forces in the posterior area, the implants,
components, and screws often failed., can be managed by with the use of wider diameter
implants and internal fixation of components.

13. Wide-diameter implants resists tipping forces and thus reduces screw
Loosening and also provides greater strength and resistance to fracture as a
result of increased wall thickness (i.e., the thickness of the implant between the
inner screw thread and the outer screw thread).

14. Aesthetic Considerations
Anterior single-tooth implants present an aesthetic concern for patients
The prominence and occlusal relationship of existing teeth, the thickness and
health of periodontal tissues, and the patient's own psychological perception of
aesthetics all play a role in the aesthetic challenge of the case.
Cases with good bone volume, bone height, and tissue thickness can be predictable in
terms of achieving satisfactory aesthetic results
Achieving aesthetic results for patients with less-than-ideal tissue qualities poses difficult
challenges for the restorative and surgical team.(Beumer J 3rd et al, 1995)

15. Replacing a single tooth with an implant-supported
crown in a patient with a high smile line,
compromised or thin periodontium, inadequate hard
or soft tissues, and high expectations is probably one
of the most difficult challenges in implant dentistry
and should not be attempted by novice clinicians.
Perry R. Klokkevold, David L. Cochran,2017

16. Pretreatment Evaluation
A comprehensive evaluation is indicated for any patient who is being considered for
dental implant therapy.
The evaluation should assess -----
•All aspects of the patient's current health status, including a review the patient's past
medical history, medications, and medical treatments.
•Patients should be questioned about parafunctional habits, such as clenching or
grinding teeth.
•Any substance use or abuse, including tobacco, alcohol, and drugs.
•The assessment should also include an evaluation of the patient's motivations, level
of understanding, compliance, and overall behavior

17. •An intraoral and radiographic examination must be done to determine whether it is
possible to place implant(s) in the desired location(s)
• Properly mounted diagnostic study models and intraoral clinical photographs are
useful parts of the clinical examination and treatment-planning process to aid in the
assessment of spatial and occlusal relationships.
•Once the data collection is completed, the clinician will be
able to determine whether implant therapy is possible,
practical, and indicated for the patient

18. An organized, systematic history and examination is essential to
obtaining an accurate diagnosis and creating a treatment plan
that is appropriate for the patient.
A thoughtful and well-executed evaluation can also reveal
deficiencies and indicate what additional surgical procedures
may be necessary to accomplish the desired goals of therapy
(e.g., localized ridge augmentation, sinus bone augmentation).
Perry R. Klokkevold, David L. Cochran,2017

19. Chief Complaint
The patient's chief concern, desires for treatment, and vision of the successful
outcome must be taken into consideration.
The patient will measure implant success according to his or her personal
criteria. The overall comfort and function of the implant restoration are often
the most important factors, but satisfaction with the appearance of the final
restoration will also influence the patient's perception of success.
Furthermore, patient satisfaction may be influenced simply by the impact that the
treatment has on the patient's perceived quality of life.
Patients will evaluate for themselves whether the treatment helped them to eat better,
look better, or feel better about themselves.

20. With this goal in mind, it is often helpful and advisable to invite patients to
bring their spouses or family members to the consultation and treatment-
planning visits to add an independent “trusted” observer to the discussion of
treatment options.
Ultimately, it is the clinician's responsibility to determine if the
patient has realistic expectations for the outcome of therapy and
to educate the patient about realistic outcomes for each
treatment option.
Perry R. Klokkevold, David L. Cochran,2017

21. Medical History
A thorough medical history is required for any patient in need of dental treatment,
regardless of whether implants are part of the plan.
The patient's health history should be reviewed for any condition that might put
the patient at risk for adverse reactions or complications.
.
Any disorder that may impair the normal wound-healing process, especially as
it relates to bone metabolism, should be carefully considered as a possible risk
factor or contraindication to implant therapy.

22. Appropriate laboratory tests (e.g., coagulation tests for a patient receiving anticoagulant
therapy) should be requested to evaluate further any conditions that may
affect the patient's ability to undergo the planned surgical and restorative procedures safely
and effectively.
If any questions remain about the patient's health status, a medical clearance for
surgery should be obtained from the patient's treating physician.

23. Dental History
 History of recurrent or frequent abscesses, which may indicate a
susceptibility to infections or diabetes?
 Does the patient have many restorations?
How compliant has the patient been with previous dental
recommendations?
 What are the patient's current oral hygiene practices?
If a patient reports numerous problems and difficulties with past dental care,
including a history of dissatisfaction with past treatment, the patient may have similar
difficulties with implant therapy.
It is essential to identify past problems and to elucidate any contributing factors.
The clinician must also assess the patient's dental knowledge and understanding of
the proposed treatment, as well as the patient's attitude and motivation toward
implants.

24. Intraoral Examination
 To assess the current health and condition of existing teeth,
To evaluate the condition of the oral hard and soft tissues.
To find out any pathologic conditions present in any of the hard or soft tissues in the
maxillofacial region.
All oral lesions, especially infections, should be diagnosed and appropriately treated
before implant therapy.
To find out patient's habits, level of oral hygiene, overall dental and periodontal
health, occlusion, jaw relationship, temporomandibular joint condition, and ability to
open wide

25. After a thorough intraoral examination, the clinician can
 Evaluate potential implant sites.
To measure the available space in the bone for the placement of implants and in
the dental space for prosthetic tooth replacement .
The mesial-distal and buccal-lingual dimensions of edentulous spaces.
The orientation or tilt of adjacent teeth and their roots should be noted as well.
.
For these conditions- orthodontic tooth movement may be
indicated.
.

26. Ultimately, edentulous areas need to be precisely measured using diagnostic study
models and imaging techniques to determine whether space is available and whether
adequate bone volume exists to replace missing teeth with implants and implant
restorations.

27. Diagnostic Study Models
Mounted study models are an excellent means of assessing potential sites for dental
implants.
Properly articulated models with diagnostic wax-up of the proposed restorations allow
the clinician to evaluate the available space and to determine potential
limitations of the planned treatment
This is particularly useful when multiple teeth are to be replaced with implants or
when a malocclusion is present.

28. Hard Tissue Evaluation
The amount of available bone is the next criterion to evaluate.
A visual examination can immediately identify
deficient areas
whereas other areas that appear to have good ridge
width will require further evaluation .
Clinical examination of the jawbone consists of palpation to feel for anatomic defects
and variations in the jaw anatomy, such as concavities and undercuts.
If desired, it is possible with local anesthesia to probe through the soft tissue (intraoral
bone mapping) to assess the thickness of the soft tissues and measure the bone
dimensions at the proposed surgical site.

29. Soft Tissue Evaluation
Evaluation of the quality, quantity, and location of soft tissue present in the
anticipated implant site helps to anticipate the type of tissue that will surround the
implant(s) after treatment is completed (keratinized vs. nonkeratinized mucosa).
Areas with minimal or no keratinized mucosa may be augmented with gingival or
connective tissue grafts.
Other soft tissue concerns, such as frenum attachments that pull on the
gingival margin, should be thoroughly evaluated as well.

30. Radiographic Examination
Radiographic assessment of the quantity, quality, and location of available alveolar
bone in potential implant sites ultimately determines whether
 A patient is a candidate for implants
 If a particular implant site needs bone augmentation.
Periapical radiographs, panoramic projections, and cross-sectional imaging, can help
identify vital structures such as the floor of the nasal cavity, maxillary sinus,
mandibular canal, and mental foramen .

31. For implant success and predictability, it is imperative for clinicians to recognize
risk factors and contraindications to implant therapy so that problems can be minimized
and patients can be accurately informed about risks before initiating treatment.
Contraindications for the use of dental implants, although relatively few and often not
well defined, do exist.
Some conditions are probably best described as “risk factors” rather than
“contraindications” to treatment because implants can be successful in almost all
patients; implants may be less predictable in some situations, and this distinction
should be recognized.
Ultimately, it is the clinician's responsibility with the patient to make decisions as to
when implant therapy is not indicated.
Risk Factors and Contraindications

32. Perry R. Klokkevold, David L. Cochran.2017

33. DIABETES
Diabetes and peri-implantitis
Retrospective study of Turkyilmaz ,2010 showed no evidence of diminished
clinical success 1 year after implantation, defined by no bleeding on probing, no
pathological probing depth, and a marginal bone loss of 0.3 ± 0.1 mm in a population of
type II diabetics.
The results in the prospective study of Gomez-Moreno, 2014 found that elevated
HbA1c causes more bone resorption after 3 years.
The bleeding on probing is more often in the poorly controlled population, but the
probing depth is not increased. They concluded that implant therapies for diabetic
patients can be predictable, providing these patients fall within controlled ranges of
glycemia over time, assessed by monitoring HbA1c levels.

34. Aguilar-Salvatierra ,2015, started to evaluate 2 years after insertion of dental implant
and found that the number of patients suffering from peri-implant inflammation
increases with elevated HbA1c values. The population was divided into well-controlled
(HbA1c 6–8 %), moderately controlled (HbA1c 8–10 %), and poorly controlled (HbA1c
>10 %), but there was no healthy control. They concluded that patients with diabetes
can receive implant‐based treatments with immediate loading safely, providing they
present moderate HbA1c values.
.

35. Diabetes and implant survival
Naujokat et al , 2016 in a systematic review mentioned 18 publications with data.
Short period study covers 7 studies with observation time up to 1 year (6 prospective, 1
retrospective studies)
Longer periods study included 4 prospective, 1 cross-sectional, and 6 retrospective studies.
In the short-time group, 5 of the studies had a healthy control group
The result for implant survival in diabetics is 100 to 96.4 %, which does not differ from
the healthy control (Dowell et al, 2007, Alsaadi et al, 2007, Oates et al, 2014, Erdogan
et al ,2014, Ghiraldini et al, 2015)
The 2 studies without control group report a 100 % survival rate 4 months and 1 year
after implantation [Turkyilmaz et al, 2010, Khandelwal et al, 2011].

36. The time periods in the long-time group differ from 1 year up to 20 years and
are very heterogeneous
Among 4 prospective, 6 retrospective, and 1 cross-sectional study, Seven studies
compared the diabetic survival rates to healthy population, and results are equivocal.
Survival rates of diabetics are similar to healthy control: 95.1 vs. 97 %, 97.2 vs. 95 %, 92 vs.
93.2 %, and 97 vs. 98.8 % [Morris et al,2000 , Anner et al 2010, Busenlechner et al. 2014].
On the other hand, there are 2 studies reporting relative risk for implant failure in diabetic
patients elevated to 4.8 and 2.75, respectively [Daubert et al, 2015, Moy et al , 2005].
Studies without a healthy control present survival rates from 100 to 86 % [Aguilar-
Salvatierra, et al, 2015], 97.3 and 94.4 % after 1 and 5 years [Peled, et al , 2003],
and 91 to 88 % after 5 years [Olson et al, 2006], which are comparable to survival rates in
healthy individuals.

37. There was a large improvement in implant survival in the type II diabetic patients
when chlorhexidine (CHX) (95.6 %, 4.4 % failures) was used at the time of
implant placement, as compared to when CHX was not used (86.5 %, 13.5 %
failures)(Naujokat et al, 2016)
This difference in survival (9.1 %) was large enough to be considered clinically
significant but was not found in the non-type II diabetic patient.
For the non-diabetic group, survival increased only slightly when CHX was used (94.3
%, 5.7 % failures), compared to when CHX was not used (91.8 %, 8.2 % failures)
[Olson et al, 2000].

38. ACTIVE CANCER THERAPY
Both ionizing radiation and chemotherapy disrupt host defense mechanisms and
hematopoiesis.
In 3% to 35% of patients who undergo head and neck radiation, spontaneous and
traumatic osteoradionecrosis ensues.(Marx RE, Johnson RP,1987)
Mucositis and xerostomia resulting from radiation damage to mucosa and salivary
glands, respectively, contribute also to a poor oral environment.
Cytotoxic anticancer drugs induce rapid granulocytopenia, followed by
thrombocytopenia. Myelosuppression occurs often from a multiple drug regimen.
In addition to bone marrow toxicity and immunosuppression, anticancer
agents cause gastrointestinal toxicity and skin reactions.

39. PSYCHIATRIC DISORDERS
In general, any type of psychological abnormality can be considered a
contraindication to dental implant treatment because of the patient's
uncooperativeness, lack of understanding, or behavioral problems.
Physiologically, there is no reason to suspect that implants could not become
osseointegrated in these patients.
However, the patient's ability to tolerate the number and type of treatment appointments
required for implant placement, restoration, and maintenance could be problematic. All
psychological conditions have the potential to be absolute contraindications to implant
treatment depending on the severity of the condition.
The exception might be individuals who demonstrate good cooperative behavior with only
mild psychological or mental impairment.
The clinician should take great care before accepting a mentally or psychologically
impaired individual for treatment with implants.

40. BISPHOSPHONATE TREATMENT
Bisphosphonate related osteonecrosis of the jaw (BRONJ) which was first published in
the literature in 2003 is a severe side effect of bisphosphonate therapy [Marx RE
J Oral Maxillofac Surg. 2003 Sep; 61(9):1115-7).
The prevalence and incidence remains uncertain.
In general, the risk of BRONJ is between 1 in 10,000 and 1 in 100,000
but may increase to 1 in 300 after an oral surgical procedure.
Patients may be considered to have BRONJ if they have all of the following criteria.
•Current or previous treatment with a bisphosphonate
• Exposed bone in the maxillofacial region that has persisted for more than eight
weeks
• No history of radiation therapy to the jaws.

41. Intravenous administration leads to a higher drug exposure than the oral route,
osteonecrosis related to oral bisphosphonate therapy is less common than that of
related to intravenous forms such as zolendronate which is also more potent than
oral bisphosphonates.(Ruggiero SL, et al 2009)
This higher incidence of alendronate associated osteonecrosis of the jaw may be
related to the frequent presciription of alendronate, or can be explained by its dose,
potency, half-time, and absorption related factors --- Marx RE et al,2007
As oral bisphosphonates are less bio-available than intravenous formulations, they
are used for long terms . Longer duration (for more than two years) has been
associated with an increased risk of oral BRONJ. Otto S et al 2011.

42. Dental implant therapy, as well as other surgical procedures, should be avoided in
individuals who have been treated with intravenous (IV) bisphosphonate therapy and
carefully considered with caution in patients treated with oral bisphosphonate
therapy, particularly those with a history of more than 3 years of use.

43. OSTEOPOROSIS
Osteoporosis is a condition of universal reduction in bone mass in which
resorption overtakes deposition, with no other abnormality.
An examination of dental clinical studies on this osteoporosis reveals little
effect of this disease on implant success..
Friberg et al 2001, placed 70 implants in the jaws of 14 patients with osteoporosis.
This group achieved 97% success in both maxilla and mandible after 3-year follow-
up.
Taking the aforementioned reports into consideration, osteoporosis alone does
not affect implant success

44. SMOKING
Nicotine attenuates red blood cell, fibroblast, and macrophage proliferation,
increases platelet adhesion, and induces vasoconstriction via the release of
epinephrine; this leads to a lack of perfusion and compromised healing.
In addition, smoking promotes expression of inflammatory mediators
(e.g., tumor necrosis factor- and PGE2), and impairs polymorphonuclear
neutrophil chemotaxis, phagocytosis, and oxidative burst mechanisms.
It also increases matrix metalloproteinase production (e.g., collagenase and
elastase) by polymorphonuclear neutrophils.

45. Retrospective analysis of 2194 implants placed in 540 subjects and found that failures
occurred in 11% in smokers versus 5% in nonsmokers, a significant difference.
The maxilla showed the greatest failure disparity between smokers and nonsmokers:
18% versus 7%, respectively.
(Bain CA, Moy PK,1993)
De Bruyn and Collaert, 1994, also described a negative impact of smoking on implants
in a retrospective study of 452 fixtures in 117 patients; the failure rate in the maxilla 3-36
months after loading was 9% in smokers and 1% in nonsmokers. With no
mandibular differences.

46. Bain and Moy,1993, suggested a protocol without reliance on research-based data,
hypothesized that stopping smoking 1 week prior to surgery would allow
reversal of platelet adhesion, blood viscosity, and short-term effects of nicotine.
In order to allow osteoblastic bone healing and adequate osseointegration
to occur, they recommended tobacco abstinence until 8 weeks after fixture
placement.
In 1996, Bain, performed a prospective investigation on 223 implants in 78
patients. The group of subjects that followed a smoking cessation protocol exhibited
a lower failure rate (12%) than the group that continued to smoke (38%).

47. Weyant,1994, did not find a correlation between implant failure and tobacco use,
but smoking appeared to increase the frequency of peri-implant soft tissue
complications.
A retrospective study by Minsk et al 1996 in 380 patients with 1262 implants also
showed no relationship.

48. Kumar et al,2002 looked at initial osseointegration before loading in 461 patients
with 1183 surface-modified ITI SLA implants.
In their retrospective study, they found successes of over 98% in both smokers
and nonsmokers.
The maxilla and mandible did not differ statistically with respect to failures.
Nonsmokers and smokers did not exhibit variation in bone quality.
Even Bain et al,2002 observed that surface-modified implants may resist
effects of smoking. In a metaanalysis of 2274 dual acid-etched Osseotite implants
(Biomet, Inc., Warsaw, IN), they found 3-year cumulative successes of 98.4% in nonsmokers
and 98.7% in smokers.
Machine-surface fixtures failed more often, but no success differences occurred between
nonsmokers (92.8%) and smokers (93.5%) for these implants either.

49. HUMAN IMMUNODEFICIENCY VIRUS
Patients with an immuno compromising disease, such as human immunodeficiency
virus (HIV) infection or acquired immunodeficiency syndrome (AIDS), are not good
candidates for implants when their immune system is seriously impaired.
Patients with very low or undetectable viral loads and normal (T cell counts)
immune function may be candidates for implant therapy
Without the presence of severe immuno suppression or bleeding disorders, HIV
status does not lower implant success.

50. Harrison et al, 2002 conducted a prospective, blind, controlled study on
wound infection and orthopedic implants in HIV-positive and negative subjects.
With no preoperative contamination, the incidence of wound infection failed to differ
between patient groups.
In regard to intraoral implants, Fielding et al,1990 presented successful osseointegration
and function after 4 years in HIV-positive patients with CD4 counts of 200 cells/mm3 at
the UCLA Symposium on Implants in the Partially Edentulous Patient.
A case report demonstrated 18-month functional success of an immediate dental implant
in an HIV-positive patient with CD4 counts less than 200 cells/mm3; a regimen of
amoxicillin was given postoperatively.---- Rajnay et al, 1998

51. Post treatment Evaluation
Periodic post treatment examination of implants, the retained prosthesis,
and the condition of the surrounding peri-implant tissue are important
components of successful treatment.
Several parameters are available to evaluate the condition of the prosthesis,
the stability of the implants, and the health of surrounding periimplant
tissues after implant integration and prosthetic restoration.
Intraoral radiographs should be taken at the time of placement (baseline), at
the time of abutment connection (to confirm seating and serve as another
baseline), at the time of final restoration delivery (loading), and subsequently
to monitor marginal or periimplant bone changes.

52. Conclusion
Today, clinicians are able to predictably replace missing teeth with endosseous dental
implants. Whether missing a single tooth, several teeth, or all teeth, many patients
can be candidates for dental implant therapy.
It is important for clinicians to recognize factors that influence implant success. In
addition to the quantity, quality, and location of available bone, the patient's health,
risk factors, and contraindications must be assessed.
Patients should be informed about risk factors and provided with treatment options
both with and without dental implants. Periodic evaluation, good oral hygiene, and
regular maintenance are important aspects of care for the long-term success and the
prevention of complications with dental implants.

54. Diagnostic Imaging for the Implant Patient

55. CONTENT
Introduction
Standard Projections
Cross-Sectional Imaging
Interactive “Simulation” Software Programs
Patient Evaluation
Clinical Selection of Diagnostic Imaging
Conclusion

56. Comprehensive and accurate radiographic assessment is a crucial aspect of dental
implant treatment planning to evaluate bone quality, quantity, and anatomic
structures in relation to the proposed implant sites.
Traditionally, implant clinicians have relied on two-dimensional conventional
radiograph modalities in implant dentistry, with the discovery of computed
tomography (3D) a new era in all phases of the radiographic imaging survey of
implant patients has become available.
.
Introduction

57. Goal of radiographic imaging in implant dentistry is----
To acquire the most practical and comprehensive information
that can be used for the various phases of implant treatment.
The implant team must assess each individual patient on which
imaging modality should be used, and the decision should be
based on sound and practical information.

58. Phase 1 Imaging in implant dentistry
Phase 1 is termed presurgical implant imaging-----
• involves all past radiologic examinations and new radiologic surveys
• to assist the implant team in determining the patient’s final
comprehensive treatment plan.
The objectives of this phase of imaging include all necessary surgical
and prosthetic information to determine-----
• The quantity and quality of bone
• Identification of vital structures
• Proposed implant sites
•Presence or absence of disease.

59. Phase 2 Imaging in implant dentistry
Phase 2 is termed the surgical and intraoperative implant imaging
phase
Focused on assisting in the surgical and prosthetic intervention of
the patient.
The objectives of this phase of imaging are to evaluate-----
• The surgery sites during and immediately after surgery,
•Assist in the ideal position and orientation of dental implants,
•Ensure that abutment position and final prosthesis fabrication are
correct

60. Phase 3 Imaging in implant dentistry
Phase 3 is termed the post prosthetic implant imaging.
This phase commences just after the prosthesis placement
and continues indefinitely.
The objectives of this phase of imaging are to access
•the long-term maintenance,
•integration, and function of the implants, which includes
the evaluation of the implant complex and surrounding
crestal bone levels.

61. Types of Imaging Modalities----
A)two-dimensional imaging techniques
• Periapical radiography
• Panoramic radiography
• Occlusal radiography
Three dimensional imaging techniques
• CT
• CBCT
• Interactive CT

62. Three dimensional imagine techniques are quantitatively
accurate, and three-dimensional models of the patient’s
anatomy can be derived from the image data and used to
produce stereo lithographic surgical guides and prosthetic
frameworks

63. Periapical Radiography
The paralleling technique is generally preferred in implant dentistry because of less
distortion and magnification.
Direct exposure projections do not use
intensifying screens, so intraoral
radiographs offer the highest detail and
spatial resolution of all radiographic
modalities

64. •One of the most significant recent advances in dental radiology is the advent of digital
technology.
• Film is replaced by a sensor that collects the data.
•The analog information interpreted by specialized software, and an
image is formulated on a computer monitor.
•The resultant image can be modified (in various ways, such as gray scale, brightness,
contrast, and inversion.)
•Compared with conventional radiographs, the most current digital systems have
significantly less radiation (50%-65% approx)(Wenzel A, Grondahl H-G:,1995) with
superior resolution.(Van der Stelt PF,2005)

65. Advantages of Digital Intraoral Radiograph
very low radiation dose,
images have high resolution and can be modified
in various ways.
Color images may be formed for enhancement of
evaluation and density readings.
Ensuring accurate measurements.( Most
computer software programs are now available to
allow for calibration of magnified images)

66. Disadvantages
• Distortion and magnification
• Minimal site evaluation
• Difficulty in film placement
• Technique sensitive
• Lack of cross-sectional imaging

67. In phase 1 and 2 imagine cases to evaluate----
Small edentulous spaces,
 Alignment and orientation of the implant during surgery
Confirmation that the implant is not invading an adjacent tooth
root or mandibular canal during surgery are major benefits of
periapical images.
Abutment and Prosthetic Component Imaging
When evaluating for transfer impressions
along with two-piece abutment component
placement, radiographs should be taken to
verify complete seating.
A slight angulation may allow a slight gap to
remain unnoticed.

68. In Post prosthetic Imaging (Phase 3 imagine )
•Act as a baseline for future evaluation of component fit verification and for
marginal bone level evaluation.
•May be used to verify the absence of cement (in cement retained crown)
•In recall and maintenance Imaging
Follow-up or recall radiographs should be taken after 1 year of
functional loading and yearly for the first 3 years. (Borg et al
2000)
Multiple studies have shown that in the first year, marginal
bone loss ( upto1.2 mm) and a higher rate of failure are seen.

69. Occlusal Radiography
Advantages
• Evaluation for pathology (sialiths)
Limitations
• Does not reveal true buccolingual width in mandible
• Difficulty in positioning
Indications
• None

70. Panoramic Radiographs
Panoramic radiographs are often used in the evaluation of the
implant patient because they offer several advantages over
other modalities. Truhlar et al, 1993.
Panoramic radiographs deliver low radiation doses ( Effective
Dose 20μSv) to provide a broad picture of both arches and thus
allow------
• Assessment of longer edentulous spans
•Angulations of existing teeth and occlusal plane
• Assessment of Important anatomy in implant treatment
planning (such as the maxillary sinus, nasal cavity, mental
foramen, and mandibular canal)

71. Limitations
• Distortions inherent in the panoramic system
• Errors in patient positioning
• Does not demonstrate bone quality
• Misleading measurements because of magnification (approx 25%)
• No spatial relationship between structures
Because of magnification and distortion errors, panoramic radiographs should
not be used for detailed measurements of proposed implant sites.

72. Computed Tomography
The CT scan was invented by Sir Godfrey Hounsfield, an electrical engineer, in 1972.
In dentistry, CT scanners were introduced in the 1990s and replaced two
dimensional radiographic modalities .

74. Typical dental views reconstructed from a MSCT scan include a
scout view as well as axial , panoramic , and cross-sectional views of the jaws.
Appropriate axial slices
through the alveolar
ridge of interest are
selected as scout
views.

75. Computed Tomography
Advantages
• Negligible magnification
• Relatively high-contrast image(the ability to distinguish two objects with small
density differences)
• Various views
• Three-dimensional bone models
• Cross-referencing
Limitations
•CT scanning is the significantly higher radiation (Effective Dose 920μSv)
delivered to the patient
• Cost

76. With the U.S. Food and Drug Administration’s approval of cone-beam technology,
there exists the ability to provide more accurate diagnostic images along with a
fraction of the radiation exposure with conventional CT and adherence to the
ALARA principle.(Winter A, Pollack A,2005)
Cone-Beam Computed Tomography

78. An important feature of the various CBCT units is the field of view (FOV) describing the
extent of the imaged volume. CBCT units are typically categorized as large FOV (greater
than 15 cm), medium FOV (8 to 15 cm), and limited FOV systems (less than 8 cm).
Large FOV units image a more extensive anatomic area, deliver a higher radiation
exposure to the patient, and produce lower-resolution images . Conversely, limited
FOV units image a small area of the face, deliver less radiation, and produce a
higher-resolution image.
field of view (FOV)

79. Interactive “Simulation” Software Programs
Implant treatment planning can be greatly enhanced by the use of specialized software
In addition to measuring the quantity and quality of bone in potential implant sites, these
programs use CT (MSCT or CBCT) scan data to simulate placement of implant and
restorations.
The length, width, angulations, and position of implants can be “simulated” in the desired
positions and evaluated relative to other structures in three dimensions
In cases of alveolar ridge deficiency or defects, or when sinus bone augmentation is
indicated, the additional bone volume needed can be evaluated and quantified. The
restoration of the implants can also be simulated and the distribution of mechanical
forces onto the implant and adjacent bone predicted.

80. Software programs specialized in implant treatment planning, such as SIM/Plant
(Materialise/Columbia Scientific, Glen Burnie, Maryland), can acquire information
directly from CBCT or CT scan data.

81. InVivo5 planning software (Anatomage, San Jose, California) acquires data directly
from CBCT or CT scan DICOM (Digital Imaging and Communications in Medicine)
files without the need for reformatting.

83. Indications for Computed Tomography–Guided Surgical Guides
Surgical guides are very helpful in the precision and accuracy of implant placement.
With surgical guides patient and treatment planning time increased and additional
expense along with radiation exposure, which may outweigh the clinical benefits in
certain cases.
Some of the most common indications include----
• The clinician’s early learning curve
• Proximity to vital anatomic structures
• Implant position that is crucial to the planned restoration
•Multiple implants in an esthetic region.

84. Preimplant Evaluation: Diagnosis and Treatment Planning
The first part of the preimplant evaluation is the assessment of the edentulous area in
question for bone quantity and quality.
Most proprietary software available today allows the implant dentist to evaluate the
area of interest in multiple reconstructions in many different planes, including cross-
section, axial, panoramic, sagittal, and three dimensional.

85. From these reconstructions, a series of interactive tools is available, including
measurement tools, bone density, angulation (restorative spaces), virtual teeth, and
vital structure outlining (inferior alveolar nerve).

86. Preimplant Evaluation: Site Evaluation with Implants
After the quantity and quality of bone are evaluated, special software programs allow the
implant dentist to actively place implants in areas of interest and allow for selection--
•Implant brand
•Type
•Dimensions along with prosthetic abutments that are selected from special libraries.
These features allow for the placement of multiple implants that are precisely parallel, thus
allowing for fabrication of a surgical template to be used for the surgical placement of the
implants.
if the implant needs to be placed at an angle, the angle can easily be determined and the
final abutment selected even before the surgery.

87. Immediate Loading Prostheses
The newest technological advancement in CT-guided surgery is the fabrication of a
provisional prosthesis that is immediately inserted at the time of surgery.
After the virtual treatment plan is created by the implant team, computer-generated
stereolithographic surgical guides are fabricated by the manufacturer from the virtual
treatment plan.
A dental laboratory then uses the fabricated surgical guides and mounted study casts
to interim or final prostheses to be inserted after implant placement.
Some software companies have allowed for the fabrication of provisional and final
restorations to be completed from the Pre surgical workup .

89. Clinical Selection of Diagnostic Imaging
Screening Radiographs
The American Academy of Oral and Maxillofacial Radiology,2000, recommends
panoramic radiography as the initial evaluation of the dental implant patient,
supplemented with periapical radiographs as needed.
Fabrication of Radiographic and Surgical Guides
Cross-Sectional Imaging
The American Academy of Oral and Maxillofacial Radiology , 2000, recommends that
radiographic examination of any potential implant site should include cross-sectional
imaging orthogonal to the site of interest.
Intraoperative and Postoperative Radiographic Assessment

90. Conclusion
Many radiographic projections are available for the evaluation of implant placement,
each with advantages and disadvantages.
The clinician must follow sequential steps in patient evaluation, and radiography is an
essential diagnostic tool for implant design and successful treatment of the implant
patient.
Selection of appropriate radiographic modalities will provide the maximum diagnostic
information, help avoid unwanted complications, and maximize treatment outcomes
while delivering an “as low as reasonably achievable” radiation dose to the patient.