diagnosis and treatment planning in implants.pptx

DIAGNOSIS & TREATMENT
PLANNING IN IMPLANT
DENTISTRY
Dr. Pritesh P Menge (III MDS)
Department of Prosthodontics
BVDU, Pune.
1

CONTENTS
• PRELIMINARY EXAMINATION
• MEDICAL EVALUATION OF PATIENT
• DIAGNOSTIC IMAGING AND TECHNIQUE
• DIAGNOSTIC CAST AND SURGICAL TEMPLATES
• PREIMPLANT PROSTHODONTICS
• PROSTHETIC OPTIONS IN IMPLANT DENTISTRY
• AVAILABLE BONE AND DENTAL TREATMENT PLANS
• BONE DENSITY
• CONCLUSIONS
• REFERENCES
2

INTRODUCTION
3
 Chief Complaint
 History of Presenting Illness
 Past Dental Problems
 Medical history

MEDICAL EVALUATION
• Patient interview
• Medical history questionnaire
• Physical examination
The first
section
• Lab tests of interest to implant
dentistry
• CBC, BMP, CMP & BDT
The second
section
• Relates medical and dental
implication of the most common
systemic diseases found in
implant patients
The third
section
4
CARL E. MISCH – CONTEMPORARY IMPLANT DENTISTRY 3 EDITION PG -423

FIRST SECTION
5
Of particular note is medication usage within the preceding 6
months, allergies and review of systems of body.
FIRST
SECTION
Patient
Interview
Medical history
questionnaire
Physical
examination
Hands-on
evaluation
Vital signs

EXTRAORAL EXAMINATION
• The facial asymmetry is observed including ears, nose and
eyes.
• If the midline , occlusal plane or smile line of natural teeth or
existing prosthesis is not harmonious the cause should be
determined.
• The submandibular, submental and cervical areas are
palpated for lymphadenopathy or swelling.
• The area between cricoid notch and surprasternal notch is
palpated for hypertrophy of the thyroid gland..
6

INTRAORAL EXAMINATION
• Lips , labial and buccal mucosa, hard and soft palate, tongue
and oral pharynx is examined.
• Any lesions or disease states must be evaluated before implant
procedure.
7

VITAL SIGNS
• BP
• BP too high may contraindicate surgical procedure.
• Pulse
• above 110 and below 60 b/m in a non-athlete – suspects and
warrants a medical consulatation.
• Respiration - 16 – 20 normal range
• Temperature
• 96.8-99.4 F – elective dental procedure ( implant surgery and
bone grafting) is contraindicated in febrile pt.
8
The equipment needed is a thermometer, a sphygmomanometer, and a
watch. Though a pulse can be taken by hand, a stethoscope may be
required for a patient with a very weak pulse.

SECOND SECTION
• Lab analysis include
9
Complete blood
count
Bleeding tests
Biochemical profiles

CBC
BLEEDING TEST
BIOCHEMICAL
PROFILES
 Neutrophil count –
• >2000 – dental procedures without AB
• 1000-2000 – AB coverage
• <1000 – physician referral
 10g/dl – used as minimum baseline for
surgery.
• Normal platelet count - 1.4 – 3.4 lacs/microL
• < 1 lac – bleeding problems during surgery
• < 20,000 – spontaneous bleeding
Biochemical profiles gives current status of
kidneys, liver, blood sugar, electrolyte and AB
balance, Ca levels and monitoring of
hypertension.
10

THE THIRD SECTION -
SYSTEMIC DISEASE AND
ORAL IMPLANTS
• ASA classification
11
ASA 1 A normal healthy pt. without systemic disease
ASA 2 Mild – moderate systemic disease
ASA 3 Severe systemic dis. Which limits activity but is not
incapacitating
ASA 4 Severe systemic dis. Which is incapacitating and constant threat
to life
ASA 5 A moribund pt. not expected to live more than 24 hrs.
Elective implant surgery is not indicated for ASA 4 and 5
patients.
CARL E. MISCH – CONTEMPORARY IMPLANT DENTISTRY 3 EDITION

CLASSIFICATION OF DENTAL TREATMENT
12
• EXAMINATIONS, X RAY, IMPRESSION,
ORAL PROPHYLAXIS, SIMPLE
RESTORATIONS
TYPE 1
• SCALING, ENDO, EXTRACTION,
GINGIVECTOMY, SINGLE IMPLANTS
TYPE 2
• PERIODONTAL SURGERY, ADVANCED
ENDODONTICS, SUB PERIOSTEAL
IMPLANTS, SINUS GRAFT
TYPE 3
• FULL ARCH IMPLANTS,
ORTHOGNATHIC SURGERY, BONE
GRAFT
TYPE 4

DISEASE SEVERITY
13
ASA II
SEDATION
STRESS
REDUCTION
IV SEDATION
MILD +
ASA III
IV SEDATION
PHYSICIAN
HOSPITAL
IZATION
MODERATE +
ASA IV
POST PONE ALL ELECTIVE
PROCEDURES
SEVERE +

CARDIOVASCULAR DISEASES
14
HYPERTENSION :
INDICATOR – Diastolic in young adults, Systolic in older adults
STRESS REDUCTION PROTOCOL
• Premedication – Diazepam or Flurazepam one night before.
• Early morning appointment, minimizing waiting room time and
short duration of treatment.
• Adequate pain control – preemptive analgesia, profound anesthesia,
postoperative pain control

• ANGINA :
Nitroglycerine tab 0.3 – 0.4 mg or sublingual spray and 100% O2
at 6L/min with pt in semisupine or 45 degree position.
Vasoconstrictors limited to a max of 0.04 – 0.05 mg epinephrine
and conc. >1/100000 should be avoided.
SRP is followed.
 MI :
15
SRP, postpone elective implant procedures for atleast 12
months after MI or hospitalisation for adv. Surgical procedures.

SUB ACUTE BACTERIAL ENDOCARDITIS :
• Postpone elective surgery for 15-18 months after valve
replacement.
• Endosteal implants with adequate attached gingiva.
• CI in pt with limited oral hygiene & multiple endocarditis events.
• Therapeutic bleeding is 2.5-3.5 times high.
16

DIABETES MELLITUS :
ENDOCRINE DISORDERS
• Type 1 – insulin dependent & type 2 – non-insulin dependent.
• Impaired healing, inflammatory gingival changes, periodontal
changes and alveolar Bone loss.
17

THYROID DISORDERS : Use of epinephrine and CNS depressants should be
avoided.
ADRENAL GLAND DISORDER :
18

ERYTHROCYTIC DISORDERS
• Minimum baseline for elective implant surgery is 10 mg/dl.
• Anemia is not a contra-indication.
• Pre and post-operative antibiotics. Aspirin should be avoided.
LEUKOCYTIC DISORDERS
• Most oral implant procedures are CI in acute or chronic
leukemia.
 Neutrophil count –
• >2000 – dental procedures without AB
• 1000-2000 – AB coverage
• <1000 – physician referral
19

LIVER DISORDERS
Management :
1. low risk - no abnormal lab value for CMP, CBC , PTT, and
PT
• Normal protocol is followed
2. Moderate risk - pt with PT < 1.5 times or bilirubin slightly
affected.
• Normal – type 1 & 2, Hospitalisation – type 3 & 4.
• strict attention to hemostasis – collatape, additional
sutures.
3. High risk – PT > 1.5 times, thrombocytopenia, elevated
enzymes
• All elective dental procedures are contraindicated.
• Procedures on pre-existing implant - hospitalisation
20

BONE DISORERS
OSTEOPOROSIS :
• Bone mineral density – 2.5 standard deviations below normal.
• Inc resorption, cortical plates become thinner, trabecular
pattern becomes more discrete and adv. demineralisation occur.
• Not contraindicated, but immediate stabilization of dental
implants is of concern.
• Implant surface characteristics should be selected for poor
quality bone.
21

VITAMIN D DISORDERS :
• Not contraindicated as long as disease is controlled.
HYPERPARATHYROIDISM :
• CI in areas of active bony lesions , implants can be placed after
healing.
FIBROUS DYSPLASIA :
• Rigid fixation of implant and local infection is problematic.
• After condition is corrected long term, the area MAY receive
implant.
22

PAGET’S DISEASE :
• CI in the region.
MULTIPLE MYELOMA :
• Relative CI because of severity of the disease (no treatment).
OSTEOMYELITIS :
• Usually a CI unless etiologic factors are removed and adequate
blood supply is restored.
23

ECTODERMAL DYSPLASIA
• Not a CONTRAINADICATION.
• MAY be placed in preadolescents with function, esthetics and
psychological advantages.
• Alveolar bone continue to grow in transverse and sagittal
plane.
• However vertical growth may result in submersion of the
implants, necessitating prosthetic revision or possible use of
longer abutments.
24

MEDICATIONS
BISPHOSPHONATES :
• Invasive dental procedure should be avoided in pt with IV
bisphosphonates.
• Medical consultation – pt on medication for >3 yrs.
• “drug holiday”
IMMUNOSUPPRESSIVE MEDICATIONS :
• Elective implant treatment is contraindicated in pt recieving
active chemotherapeutic medication.
ANTICOAGULANTS :
WARFARIN SODIUM –
INR – 2- 3.5 no need to discontinue anticoagulant.
INR – > 4 Physician consultation, replace with Heparin or Vit D.
ASPIRIN –
If pt is on low dose – <100 mg - no need to discontinue.
If >100 mg then physician consultation for type 3 & 4 procedure
25

DRUG RELATED ADVERSE EFFECTS
Abnormal
bleeding –
aspirin, NSAIDS
Altered host
resistance – AB,
Insulin
Dec stress
tolerance – Beta
blockers , CCB
GI irritation –
Aspirin, AB
Gingival
hyperplasia –
Nifedipine,
phenytoin
Xerostomia –
nearly all drugs
26

LIFESTYLE RELATED FACTORS
SMOKING :
• Not an absolute CI
• Stop for atleast 2 weeks before till
8 weeks after implant placement.
ALCOHOL USE :
• Direct effect on bone – lower bone density, dec. wound
healing, inc. resorption etc.
• Relative CI
CARL E. MISCH – CONTEMPORARY IMPLANT DENTISTRY 3 EDITION PG -423 27

CONTRAINDICATIONS TO IMPLANT
TREATMENT
28
ABSOLUTE
CONTRAINDICATIONS
• Recent MI
• Valvular prosthesis
• Severe renal disorder
• Treatment resistant
diabetes
• Radiotherapy in
progress
• Regional malignancy
• Psychosis
• Blood dyscrasias
RELATIVE
CONTRAINDICATIONS
• Prolonged use of
corticosteroids
• Smoking habit
• Chemotherapy in
progress
• Mild liver or kidney
disease
• Minor endocrinopathy
• Cardiovascular disease
• Connective tissue
disorder
• Drug or Alcohol abuse

RADIOGRAPHIC
EVALUATION
PRE-PROSTHETIC
SURGICAL AND
INTERVENTIONAL
POST-
PROSTHETIC
29

PRE-PROSTHETIC IMPLANT
IMAGING
OBJECTIVES
• Identify disease
• Determine bone quantity
• Determine bone density
• Determine implant position
• Determine implant orientation
30

THE IMAGING MODALITIES CAN
BE SUBDIVIDED INTO –
31
Planar two-
dimensiona
l
PERIAPICAL &
BITEWING
OCCLUSAL
CEPHALOMETRIC
Quasi-
three-
dimensiona
l
X-RAY
TOMOGRAPHY
PANORAMIC
IMAGING
Three-
dimensiona
l
COMPUTED
TOMOGRAPHY
MRI

PERIAPICAL RADIOGRAPHY
• High-resolution 2D planar image of a limited region of the
jaws.
• Lateral view of the jaws and no cross- sectional information.
• Single-tooth implants in regions of abundant bone width.
• Limitations-
• Limited value in determining quantity, third dimension of
bone width and bone density.
• Identifies critical structures but not its spatial orientation.
32

• OCCLUSAL RADIOGRAPHY
• Rarely indicated for preprostheic phase because-
• Does not reveal true BL width of mandible
• No quantitative use.
• Degree of mineralization of trabecular bone is not determined
• The spatial relationship cannot be determined.
33

• Demonstrate cross sectional image
of the alveolus of the mandible and
the maxilla in the midline only.
• Reduced resolution and sharpness
and technique sensitive.
• More accurate for bone quantity
determinations.
• When used with PA radiographs,
spatial relationship between
implant and critical structures can
be determined.
• Can evaluate a loss of vertical
dimension, skeletal arch
interrelationship, anterior
crown/implant ratio and resultant
moment of forces.
34
CEPHALOMETRIC RADIOGRAPHY

PANORAMIC RADIOGRAPHY
• curved plane radiographic image used
to depict the body of the mandible,
maxilla, and the lower half of the
maxillary sinuses in a single image.
• Most used diagnostic modality.
• ADVANTAGE –
• Pathologies and Opposing landmarks
are easily identified.
• The vertical height of bone initially can
be assessed.
• DISADVANTAGE –
• Magnification and distortion.
• Does not demonstrate bone
quality/mineralization,
• Is misleading quantitatively.
• Does not depict spatial relationship.
35

36
A modification of the panoramic x-ray machine has been developed
that has the capability of making a cross-sectioal image of the jaws.

COMPUTED TOMOGRAPHY
• Digital and mathematical 3D imaging technique that creates
tomographic sections.
• It enables differentiation and quantification of soft and hard
tissues in the same image.
• 3d bone model and interactive treatment planning.
• Fulfills all 5 radiologic objectives of pre-prosthetic phase.
• But given their cost and high radiation dose their use is often
limited to more complex cases.
37

38
Medical
Cone beam
technology

INTERACTIVE COMPUTED TOMOGRAPHY
• Bridge the gap in information transfer between the radiologist
and the practitioner.
• Most important feature - dentist and radiologist can perform
electronic surgery.
• Implant placement can be visualized before surgery.
• Enables the determination of bone quality at the proposed
implant site.
40

Impression
is made and
cast is
poured
Diagnostic
wax-up
done
Radiopaque
template is
fabricated
Pt wears it
during scan
Teeth
postion is
transfered
PROCEDURE
Achieving relative parallelism and spacing between
implants and executing the plan is difficult.
41

MAGNETIC RESONANCE IMAGING
• 3D imaging technique that is antithesis of CT images.
• No radiation and useful for identifying vital structures.
• Not useful in characterizing bone mineralization or as a high-yield
technique for identifying bone or dental disease.
• Secondary imaging technique.
42

43
Diagnostic cast mounted at
accurate centric relation and
VD on a semi-adjustable
articulator helps to determine :
• Ridge relationship
• Occlusal scheme
• Position of potential natural
abutment
• Soft tissue morphology
• Inter arch space
• Arch form
• Opposing dentition
• Number of missing teeth
• Condylar guidance
DIAGNOSTIC CASTS

• It is also used for
• Diagnostic wax up.
• For making a second surgical cast in which mock
surgery can be carried out.
• Estimate underlying bone by bone mapping.
• Fabricate templates
44

DIAGNOSTIC TEMPLATE
• Template is made on diagnostic waxed up stone cast using
clear acrylic or plastic vacuum formed sheet
• The proposed restoration are either coated with barium
sulphate or holes are drilled in the occlusal surface of
restoration and filled with gutta-percha or reamers.
• These act as radiographic markers and proposed implant sites
can be evaluated radiographically.
45

RADIOGRAPHIC MEASUREMENT TEMPLATE
46
The distortion factor of film and actual bone
dimensions are calculated by the formula
rs/5 = rm / x
rs = x –ray ball bearing measurement
rm = x –ray bone measurement
5 = actual ball bearing measurement
x = actual bone measurement

LABORATORY STEPS FOR RADIOPAQUE TEMPLATE
47

TYPES OF BARIUM SULPHATE RADIOPAQUE
TEMPLATES
48

SURGICAL GUIDE TEMPLATE
• To establish a logical continuity between diagnosis, prosthetic
planning, and surgical phases, use of a transfer device is
essential.
• It ensures accurate positioning of implant in mesiodistal,
buccolingual and axial relationship as planned.
• 2 types
• Acc. to type of material used in the fabrication,
• The amount of restriction (drill guidance) associated with the
template.
49

ACC TO AMOUNT OF RESTRICTION
51

ADVANCED SURGICAL GUIDANCE
CAD-CAM
surgical
guides
Navigation
technique
• Using virtual
planning of
implant
positions.
• No modification
is possible
during surgery
• Provides no drill
guidance but
provide real-
time feedback.
• Therefore
modifications
are possible.
52

PRE-IMPLANT
PROSTHODONTICS
54
OVERALL
EVALUATION
PRETREATMENT
PROSTHESIS
SPECIFIC
CRITERIA

OVERALL EVALUATION
1) maxillary anterior tooth position
2) Occlusal vertical dimension
3) mandibular incisal edge
4) maxillary posterior plane
5) mandibular posterior plane
55

• Maxillary anterior tooth position
56

• Existing Occlusal
vertical dimension
1) Subjective method
a) Esthetics
b) Resting interocclusal
distance
c) Closest speaking space
2) Objective method
a) facial measurements
b) Radiographic method
57

MANDIBULAR INCISAL EDGE POSITION
• Evaluated on diagnostic casts
• Steep incisal guidance – problems in anterior single tooth implant.
• If existing guidance is shallow , it may be necessary to plan
recontouring or prosthetic restoration of posterior teeth.
Existing occlusal plane
• Should have harmonious occlusion with max intercuspation and
canine or mutually protected occlusion
• Can be corrected by odontoplasty, endodontic therapy, or crowns
• Should be parallel to camper’s plane with proper curve of
occlusion
58

MISCH’S OCCLUSAL ANALYZER
59

SPECIFIC CRITERIA
It includes 10 elements
1) Lip lines
2) Maxillo-mandibular relationship
3) Existing occlusion
4) Crown height space
5) TMJ status
6) Extraction of hopeless or guarded exisiting teeth
7) Existing prosthesis
8) Arch form
9) Natural tooth adjacent to implant site
10) Soft tissue evaluation of edentulous state
60

LIP LINES
61
• Maxillary lip line
• Mandibular lip line
• Lower lip line is assessed during pronunciation of S sound
or sibilants
• Some patients may expose entire anterior mandibular teeth
and gingival contours .

Maxillo mandibular arch relationship
• Implants are often placed lingual to the original incisal
position resulting in vertical cantilever and inc. moment of
force.
• Improper skeletal relationship can be modified by orthodontic
or orthognathic surgery.
• In long term edentulous patients pseudo class III is often seen.
• This requires proper positioning of the implant for esthetic
results
62

CROWN HEIGHT SPACE(CHS)
• Measured from the crest of bone to plane of occlusion of
posterior teeth and incisal edge of anterior.
• CHS is a vertical cantilever and hence a force magnifier
• For FP-1 : 8-12mm ; removable prosthesis : >12mm.
Excessive CHS –
Shorten cantilever length, min. BL offset, inc. diameter and no. of
implants, removable prosthesis removed at night. and splinting.
63

TMJ
• No abnormal signs or symptoms should be present
• Normal mouth opening – 40 mm
64

ARCH FORM
• Three forms square ,tapering ,ovoid
• Tapering arch form requires greater number and width of
implant.
• The arch form is critical element when anterior implants are
splinted together and support a posterior cantilever.
• In implants, two arch forms are considered, first of residual
ridge edentulous bone which determines A-P spread and
second of the replaced teeth position.
65
• The cantilevered posterior section should not exceed
2.5 times the A-P spread.
• Tapered arch form provide favorable A-P spread.

NATURAL TEETH ADJACENT
TO IMPLANT SITE
Natural teeth to be used as abutment
• Mobility – if mobile should not be splinted to implant
• Crown height
• Crown root ratio – ideal crown root ratio is 1 : 1.5
• Position – no tipping , rotation , extrusion should be present
• Endodontic and periodontal status
• Caries
• Root configuration and root surface area
Soft tissue assessment
• Soft tissue at the implant site should be well keratinized -
thickness of 2-3 mm.
66

OTHER FACTORS
• Soft Tissue Attachments
• Muscle and frenal attachments at region of implant placement
should be evaluated
• Mandibular Movements
• Movements in all the directions should be evaluated
• Abnormal movements result in increased forces on the
implants
• Should be treated before implant placement
67

Difference in movements between implant and natural
tooth
68

Guidelines for joining natural tooth to implant
69

Evaluation of Stress Factors
• Stress factors evaluated are
• Parafunction
• Bruxism ,clenching ,tongue thrust result in greater stresses
• Masticatory dynamics
• Vary depending on age, sex, dental status and muscle mass
• Greater biting force exerts increased forces on implants
• Opposing arch
• Natural teeth in opposing arch exert greater forces on implants
• Position of implant abutment
• Forces are greater on posterior abutment
70

Arch length
• Arch length should be evaluated as it will determine the
no of implants that can be placed
• It should be kept in mind that
• 2 implants should be separated by 3mm
• Implant and natural teeth by 1.5mm
71

Manual Palpation
• With thumb and fingers the edentulous area should be
palpated to get general overview of available bone and soft
tissue
• A sharpened periodontal probe can be used to measure soft
tissue thickness after anaesthetizing the tissue
72

73
PRE-TREATMENT PROSTHESIS
• Serves to
• Improve hard and soft tissues
• Evaluate soft tissue support
• Reestablish proper OVD
• Evaluate proper tooth position
• Phonetics and esthetics can be evaluated
• Evaluate patient attitude

PROSTHETIC OPTIONS IN
IMPLANT DENTISTRY
FP-
1
FP-
2
FP-
3
RP-
4
RP-
5
74

FP-1
• Fixed restoration that replace only the anatomical crowns of
the missing natural teeth.
• Usually loss of hard and soft tissues has been minimal.
• Permit ideal placement of the implant.
• Desired most often in the maxillary anterior region.
75

FP-2
• Restore the anatomical crown and a
portion of the root of the natural
tooth.
• Available bone are more apical
compared with the cement-enamel
junction of a natural root.
• Different vertical implant placement
compared with the FP-1 prosthesis.
• Incisal edge is in the correct
position, but the gingival third of
the crown is overextended.
• Implant position in relation to bone
width, angulation, or hygienic
considerations rather than purely
esthetic demands (compared with
the fp-1 prosthesis).
• Problematic in patient with high lip
line.
76

FP-3
• Replace the natural teeth crowns and a portion of the soft
tissue.
• The available bone height has decreased by natural resorption
or osteoplasty.
• More natural appearance in size and shape and mimic the
interdental papillae region.
• 2 approaches depending upon the inter-arch space present -
• Hybrid restoration - more
• Porcelain restoration - less
77
The FP-2 or FP-3 restoration has greater crown heights, so a greater
moment of force is placed on the implants. As a result, additional
implants or shorter cantilever lengths should be considered.

RP-4
• Completely supported by the implants or teeth.
• A low-profile tissue bar or superstructure that splints the
implant abutments.
• Same appearance as an fp-1, fp-2, or fp-3 restoration but a
more lingual and apical implant placement.
• 5-6 implants in mandible and 6-8 implants in maxilla
78

RP-5
• Removable prosthesis combining implant and soft tissue
support similar to traditional overdentures.
• Pre-treatment implant denture.
• Lower cost and failure rate.
• Bone resorption with RP-5 restorations may occur 2 to 3 times
faster than conventional prosthesis.
• Relines and occlusal adjustments every few years are common
maintenance requirements
79

• Describes the external architecture or the quantity of bone
present in edentulous area considered for implants.
• It is measured in terms of
• Bone height
• Bone width
• Bone length
• Bone angulation
• Crown height space
80
AVAILABLE BONE AND
DENTAL TREATMENT PLANS
CARL E. MISCH – CONTEMPORARY IMPLANT DENTISTRY 3 EDITION PG -

Height
• 11-12mm height
• Influenced by density of bone, implant site and skeletal
anatomy.
• Once the minimum implant height is established for each
implant design and bone density, the width is more important
than additional length.
Width
• Width is measured between the facial and lingual plates at the
crest
• Minimum should be 6mm 81

• Length
• Minimum MD length for 4mm diameter implant is 7mm.
• 1.5mm from adjacent tooth and 3mm from adjacent implant.
• Angulation
• Represents root trajectory in relation to occlusal plane
• Depend upon the width of the bone. Narrow – 200 and wide – 25o
• Crown height
• Its measured from the occlusal plane to the crest of the ridge
• It acts as a vertical cantilever
82

• Based on these five characterstics, in 1985 Misch and Judy
gave a classification of available bone
• DIVISION A
• DIVISION B
• DIVISION C
• DIVISION D
83

DIVISION A(ABUNDANT BONE)
• Division A abundant bone forms soon after the tooth is
extracted.
• Consists of abundant bone in all directions
• Dimensions
• Width>6mm
• Height>12mm
• Length>7mm
• Angulations<25 degrees
• CHS<15mm
84

Treatment options :
• Decrease in treatment costs and number and complexity of
surgeries are significant benefits.
• Division A root forms or wider and longer implants can be used.
• The implant designs may be one or two stage, have variable
design, and have a full range of prosthetic options for the final
restoration i.e. FP1-3 and RP4-5
• In case of less CHS it may require osteoplasty or contradict
superstructures placed highly above the tissues
85
CARL E. MISCH – CONTEMPORARY IMPLANT DENTISTRY 3 EDITION PG

DIVISION B (BARELY SUFFICIENT BONE)
• Available bone first decreases in width
• Dimensions
• Width - 2.5mm-6mm
• Height>12mm
• Length>6mm
• Angulations <20 degrees
• CHS<15mm
86

• Treatment options:
1) Modify the narrower div B bone to div A by osteoplasty
However after osteoplasty the ridge ht. should not become <10 mm.
2) Insert a narrow diameter(3.25mm) division B root form
• In this case the bone angulation should be<20
• Also the available bone height should be atleast 12mm to ensure
adequate surface area for narrow diameter implants
• For single tooth replacement – max lateral or mand incisor.
3) Ridge augmentation
• In cases where osteoplasty will result in ridge height less than 10mm,
ridge augmentation instead should be done 87

DIVISION C (COMPROMISED BONE)
• Deficient in one or more dimensions
• Resorption first occurs in width .The bone is called C-w
• Then in height. The bone is called C-h
• Dimensions
• 0 to 2.5 mm width (C-w bone)
• <12 mm height (C-h bone)
• > 30 degrees of angulation (C-a bone)
• > 15 mm CHS
88
CARL E. MISCH – CONTEMPORARY IMPLANT DENTISTRY 3 EDITION PG - 190

TREATMENT OPTIONS :
• Subperiosteal implants (C-h and C-a bone in mandible)
• Transosteal implants (C-h bone anterior).
• Disk design implants (posterior mandible or anterior maxilla)
• Ramus frame implants (C-h bone, completely edentulous
mandible)
89

In general, Division C-h presents less favorable biomechanical
factors, and additional implants or teeth, cross- arch
stabilization, soft tissue support, and an opposing removable
prosthesis need to be considered for long-term prognosis.
• Osteoplasty (C-w bone) before implant insertion
• Root-form implants
• Augmentation procedures
90

DIVISION D (DEFICIENT
BONE)
• Long-term bone resorption may result in the complete loss of
the alveolar process, accompanied by basal bone atrophy with
>20mm CHS
• Dimensions -
• Severe atrophy
• Basal bone loss (flat maxilla and pencil thin mandible)
• 20 mm crown height
91

TREATMENT OPTIONS:
• Any treatment without augmentation will
result in poor outcome.
• If implant failure occurs, the patient may
become a dental cripple
92
The goal of every dentist should be to educate and treat the
patient before reaching a Division D bone condition.

BONE DENSITY
• Refers to the internal structure or the quality of the bone
• Greater bone density means
• greater strength of bone
• Improved mechanical immobilization of implant during healing
• Better distribution of stresses
93

CLASSIFICATION OF BONE DENSITY
Linkow and Chercheve
• Class I – Ideal bone type consisting of evenly
spaced trabeculas with small cancellated
spaces
• Class II – Larger cancellated spaces with less
uniformity of the osseous pattern
• Class III – Larger marrow filled spaces exist
between trabeculas
94

Lekholm and Zarb
Quality 1: composed of homogenous compact bone.
Quality 2: thick layer of compact bone surrounding a core of
dense trabecular bone.
Quality 3: thin layer of cortical bone surrounding dense
trabecular bone of favorable strength.
Quality 4: thin layer of cortical bone surrounding a core of low
density trabecular bone
95
135

MISCH
D1: Dense cortical bone
D2: Thick dense to porous cortical bone on crest and course
trabecular bone within.
D3: Thin porous cortical bone on crest and fine trabecular bone
within.
D4: Fine trabecular bone
96

• Implant treatment is influenced by bone density.
• In case of decreased bone density following modifications can be done
• Increase the no of implants
• Increasing the width of implants in case of D4 bone
• Cantilever length should be shortened or eliminated
• Narrow occlusal tables
• Removable rather than fixed prosthesis
• Coatings on implant body to increase the surface area e.g.HA
coatings in case of D4 bone
• Progressive loading to gradually increase the occlusal loads and
density of bone
• Reduction of parafunctional forces 97

CONCLUSION
98
Dental implants have become one of the most exciting and
rapidly progressing treatment modality since the past decade.
The success and longevity of dental implants however depends
on a broad and complex set of interwoven factors. Thus a
detailed step by step approach towards proper diagnosis and
treatment plan formulation is of paramount importance

REFERENCES
• Carl E Misch :Dental implant prosthetics
• Charles A .Babbush :Dental implants principles
and practice
• Hobo:Ichida:Garcia : Osseointegration and
occlusal rehabilitation
• Igor J Pesun :Fabrication of guide for radiographic
evaluation and surgical placement of implants :J
Prosthet Dent:1995:73:548-52
99

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