dental implant chapter 2 treatment panning

1. DENTAL IMPLANTOLOGY – CHAPTER TWO -
PREOPERATIVE ASSESSMENT AND TREATMENT PLANNING
Dr. Haydar Munir Salih Alnamer
BDS, FIBMS (Board Certified)

2. INTRAORAL EXAMINATION
After a thorough intraoral examination, the
clinician can evaluate potential implant sites. All
sites should be clinically evaluated to measure
the available space in the bone for the
placement of implants and in the dental space
for prosthetic tooth replacement.

3. The mesial-distal and buccal- lingual dimensions
of edentulous spaces
INTRAORAL EXAMINATION
Dr. Haydar Munir Salih

4. The orientation or tilt of adjacent teeth and their roots
should be noted as well. There may be enough space.

5. HOW MUCH SPACE IS REQUIRED FOR
PLACEMENT OF ONE OR MORE
IMPLANTS?
Dr. Haydar Munir Salih

7. BONE DENSITY (BONE VOLUME & QUANTITY)
Bone density varies substantially from one
anatomic region to another, the failure rate of
implantation is greater for regions with very
low density which result in  low primary
stability,
or regions with very high density  risk of
overheating during drilling

8. A good evaluation of bone density allows the
surgeon to do the following:
1. Select the proper implant diameter.
2. Decide about the optimal drilling sequence, in soft
bone  use of final drill of half depth only with
minimal use of countersink and use of smaller drill
diameter than standard, while in hard (dense) bone
use of oversized drill diameters.
3. Determine the length of healing period.
4. Evaluate occlusal loading capacity of different
implants.

9. BONE DENSITY

10. CLASSIFICATION OF BONE DENSITY
( LEKHOLMS & ZARB )
1. Type I  essentially cortical bone
2. Type II  dense cortico-cancellous bone
3. Type III  sparse cortico-cancellous bone
4. Type IV  thin cortical bone and very sparse
medullary bone

11. CLASSIFICATION OF BONE DENSITY
(LEKHOLMS & ZARB ) 1985

12. MISCH CLASSIFICATION OF BONE
DENSITY 1988

13. BONE QUALITY (STRUCTURE)
Classification of bone quality from biological point of
view (BHP bone healing potential):
1. BHP1  bone with normal bone healing
2. BHP 2  bone with moderately reduced healing
potential (as in moderate smoking 10 Cigarette / day,
controlled diabetes mellitus, etc)
3. BHP3  bone with substantially reduced healing
potential (heavy smoking 20 cigarettes or more/ day,
diabetes mellitus, severe anemia, etc)

16. SOFT TISSUE EVALUATION
Dr. Haydar Munir Salih

17. SOFT TISSUE EVALUATION
Dr. Haydar Munir Salih

18. SOFT TISSUE EVALUATION
Dr. Haydar Munir Salih

19. SOFT TISSUE EVALUATION
Dr. Haydar Munir Salih
Dr. Haydar Munir Salih

20. SOFT TISSUE EVALUATION
Dr. Haydar Munir Salih
Dr. Haydar Munir Salih

21. RADIOGRAPHIC EXAMINATION
A.L.A.R.A. PRINCIPLES
As Long As Reasonably Acceptable

22. RADIOGRAPHIC EXAMINATION
Multiple factors, however, influence the selection of
radiographic techniques for any particular case. Such
factors as cost, availability, radiation exposure, and the
type of case must be weighed against the accuracy of
identifying vital anatomic structures within a given bone
volume and being able to perform the surgical placement
without injury to these structures.

23. AREAS OF STUDY RADIOGRAPHICALLY INCLUDE THE
FOLLOWING:
1. Location of vital structures
2. Bone height
3. Root proximity and angulation of existing teeth
4. Evaluation of cortical bone
5. Bone density and trabeculation
6. Pathology (e.g., abscess, cyst, tumor)
7. Existence of anatomic variants (e.g., incomplete healing
of extraction site)

24. AREAS OF STUDY RADIOGRAPHICALLY
INCLUDE THE FOLLOWING:
8. Cross-sectional topography and angulation (best
determined by using CT and CBCT)
9. Sinus health (best evaluated by using CT and CBCT)
10. Skeletal classification (best evaluated with the use of
lateral cephalometric images)

25. Dr. Haydar Munir Salih

26. Dr. Haydar Munir Salih

28. SURGICAL TREATMENT PLANNING
CONSIDERATIONS

29. THE ANTERIOR MANDIBLE
• It is usually tall enough and wide enough to
accommodate implant placement. Bone quality is usually
excellent, typically the densest of any area in the two
arches.
• Implants should be placed at least 5 mm anterior to the
most anterior portion of the mental foramen, avoiding
the anterior loop of the mandibular canal.

30. THE ANTERIOR MANDIBLE
Dr. Haydar Munir Salih

31. Dr. Haydar Munir Salih

32. THE POSTERIOR MANDIBLE
limits the length of the implants based on the
position of the mandibular canal that traverses the
body of the mandible in this region. Ideally, the tip
of the implant should be at least 2 mm from the
inferior alveolar nerve (IAN).

35. INFERIOR ALVEOLAR NERVE
REPOSITIONING

36. THE POSTERIOR MAXILLA
•two specific concerns related to implant placement.
• The first is the quality of bone in this area. As previously
discussed, bone quality in the posterior maxilla is
typically the poorest of any area
• The second concern is the proximity of the maxillary
sinus to the edentulous ridge

37. MISCH MAXILLARY POSTERIOR CLASSIFICATION

38. Subantral Option 1: Conventional Implant Placement
The first SA treatment option, SA-1, occurs when there is
sufficient available bone height to permit the placement
endosteal implants after a usual surgical protocol at least
12-mm implant in height is suggested
MISCH MAXILLARY POSTERIOR CLASSIFICATION

39. MISCH MAXILLARY POSTERIOR CLASSIFICATION
Subantral Option 2: Sinus Lift and Simultaneous Implant
Placement
The second subantral option, SA-2, is selected when 10
mm of vertical bone is present the antral floor is elevated
through the implant osteotomy (passive sinus lift/ crestal
sinus lift)

40. (PASSIVE SINUS LIFT/ CRESTAL SINUS LIFT)

41. MISCH MAXILLARY POSTERIOR CLASSIFICATION
Subantral Option 3: Sinus Graft with Immediate or
Delayed Endosteal Implant Placement
The third approach to the maxillary posterior edentulous
region, SA-3, is indicated when at least 5 mm of vertical
bone and sufficient width are present between the antral
floor and the crest of the residual ridge in the area of a
needed prosthodontic abutment

42. ACTIVE SINUS LIFT/LATERAL SINUS LIFT

43. Dr. Haydar Munir Salih
Dr. Haydar Munir Salih

44. MISCH MAXILLARY POSTERIOR CLASSIFICATION
Subantral Option 4: Sinus Graft Healing and Extended
Delay of Implant Insertion
In the fourth option for implant treatment of the posterior
maxilla, SA-4, the subantral region for future endosteal
implant insertion is first augmented. This option is
indicated when less than 5mm remains between the
residual crest of bone and the floor of the maxillary sinus.
There is inadequate vertical bone in these conditions to
predictably place an implant at the same time as the sinus
graft

46. THE ANTERIOR MAXILLA
even though it is the most surgically assessable area, may
be one of the most difficult regions for implant
placement. This area, even when healthy teeth are
present, usually has a thin buccal plate. After tooth loss,
the resorption of the ridge follows a pattern of moving
apically and palatally, only exacerbating an already
tenuous anatomy. The residual ridge anatomy results in a
ridge that is narrow and angulated

47. Dr. Haydar Munir Salih
Dr. Haydar Munir Salih

48. Dr. Haydar Munir Salih
Dr. Haydar Munir Salih

49. SURGICAL GUIDE
Dr. Haydar Munir Salih
Dr. Haydar Munir Salih

50. Dr. Haydar Munir Salih
Dr. Haydar Munir Salih

51. Dr. Haydar Munir Salih Dr. Haydar Munir Salih

52. Dr. Haydar Munir Salih
Dr. Haydar Munir Salih

54. KEY IMPLANT POSITIONS
1. Cantilevers on the prosthesis should be reduced and
preferably eliminated; therefore the terminal abutments in
the prosthesis are key positions.

55. KEY IMPLANT POSITIONS
2. Three adjacent pontics should not be designed in the
prosthesis

56. KEY IMPLANT POSITIONS
3. The canine and first molar sites are key positions,
especially when adjacent teeth are missing.
4. An arch is divided into five segments. When more than
one segment of an arch is being replaced, a key implant
position is at least one implant in each segment