dental implant

1. Clinical aspect and evaluation of the implant
patient
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2. contents
Introduction
Case types and indications
- edentulous patient
- partially edentulous patient
multiple teeth
single tooth
esthetic consideration
Pretreatment evaluation
-chief complain
-medical history
-dental history
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3. Intraoral examination
Diagnostic study models
Hard tissue evaluation
Radiographic examination
Soft tissue evaluation
Risk factors and contraindications
Medical and systemic health related –issues
Psychological and mental conditions
Habits and behavior consideration
Post treatment evaluation
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4. Case types and indications
 Two types
 1.Edentulous patient
 2.Partially edentulous patient
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5. EDENTULOUS PATIENTS
 Edentulous patient seems to benefit most from dental
implants.
 -------both esthetically and functionally.
 the original design was fixed bone anchored bridge that
use five to six implants in the area of mandible or maxilla
to support a prosthesis.
 Two type of prosthesis
 1.hybrid
 2.ceramicometal fixed bridge
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6. Acrylic(hybrid) Ceramic- metal
fixed bridge
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7. Multiple teeth
Partially edentulous patients with multiple missing teeth
represent another viable treatment population for
osseointegrated implants, but
- the remaining natural dentition .
-periodontal health status
- spatial relationships,
- esthetics
- occlusal schemes
introduces additional challenges for successful rehabilitation
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8. Different variety of implants
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9.  Another difficulty with partially edentulous cases
is an underestimation of the importance of.-
planning for implant-retained restoration
 adequate number of implants to withstand
occlusal load
 For example, one problem that required correction
was the misconception that two implant could be
used to support a multiunit fixed bridge in the
posterior area.
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10.  Another difficulty with partially edentulous cases
is an underestimation of the importance of.-
planning for implant-retained restoration
 adequate number of implants to withstand
occlusal load
 For example, one problem that required correction
was the misconception that two implant could be
used to support a multiunit fixed bridge in the
posterior area.
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11. Esthetic consideration
..
 Anterior single tooth implant plants present some of the same
challenges as the single _ posterior tooth supported by an
implant, but they also are an esthetic concern for patients
 some cases are more esthetically challenging
 due to each individual
 - Smile
 - Display of teeth
 -Prominences
 - Occlussal relation ships

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12. pre-treatment 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,
- The patient's past medical history,
- Medications,
- Medical treatment
. Patients should be questioned about
parafunctional habits, such as clenching or grinding teeth, as
well as 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.
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13. CHIEF COMPLAIN
 What is the problem or concern in the patients own is n
words.
 What is the patients goal of treatment
 It is critical to inquire ,as specifically as possible ,about the
patients expectation before initiating implant therapy and
to appreciate the patients desires and values.
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14. Medical history
Complete medical history should be evaluated.
Either in writing or verbally in interviews.
Patient must be in a reasonably good health.
Any disorder that may impair the normal wound healing
process ,especially as it relates to bone metabolism ,should
carefully consider as a possible risk factor or
contraindication to implant therapy.
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15.  Through physical examination is required if any question
arise about the health status of the patient
 Appropriate laboratory test e.g.
 coagulation test ,if patient is receiving
anticoagulant therapy.
 If any questions remain about the patient's health status,
a medical clearance for surgery should be obtained from the
patient's treating physician.
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16. DENTAL HISTORY
A review of a patient's past dental experiences can be a
Valuable part of the overall evaluation.
-Does the patient report a 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?
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17. The individual's previous experiences with surgery and
prosthetics should bediscussed.
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.
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18. Intraoral examination
 The intr- oral examination is performed to assess the
current health and condition of existing teeth as well as to
evaluate the condition of the oral hard and soft tissues. It
is imperative that no pathologic conditions are 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.
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19.  Additional criteria to consider include
 -The patient's habits,
 -Level of oral hygiene,
 - Overall dental and periodontal health,
 - Occlusion,
 - Jaw relationship,
 - Temporomandibular joint
 - Ability to open wide
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20.  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
 The mesial-distal and buccal-lingual dimensions of
edentulous spaces can be approximated with a periodontal
probe or other measuring instrument.
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21.  The orientation or tilt of the adjacent teeth and their roots
should be noted as well. There may be enough space in the
coronal area for the restoration but not enough space in the
apical region for the implant if roots are directed into the
area of interest.
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22. How Much Space Is Required for
Placement of One or More Implants?*
 Alveolar Bone
 Assuming an implant that is 4 mm in diameter and 10 mm
long, the minimal width of the jawbone needs to be 6 to 7
mm, and the minimal height should be 10 mm (minimum of
12 mm in the posterior mandible, where an additional
margin of safety is required over the mandibular nerve).
This dimension is desired to maintain at least 1.0 to 1.5
mm of bone around all surfaces of the implant after
preparation and placement
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23.  Interdental Space
 Edentulous spaces need to be measured to determine
whether enough space exists for the placement and
restoration with one or more implant crowns. The minimal
space requirements for the placement of one, two, or more
implants . The minimal mesial-distal space for an implant
placed between two teeth is 7 mm. The minimal mesial-
distal space required for the placement of two standard-
diameter implants (4.0-mm diameter) between teeth is 14
mm.
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24. The required minimal dimensions for wide-diameter or narrow-
diameter implants will increase or decrease incrementally
according to the size of the implant. For example, the
minimal space needed for the placement of an implant 6
mm in diameter is 9 mm (= 7 mm + 2 mm). Whenever the
available space between teeth is greater than 7 mm and
less than 14 mm, only one implant, such as placement of a
wide-diameter implant, should be considered. The
placement of a wide-diameter implant should be
considered. Two narrow-diameter implants could be
positioned in a space that is 12 mm. However, the smaller
implant may be more vulnerable to implant fracture
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25. 25

26.  Interocclusal Space
 The restoration consists of the abutment, the abutment
screw, and the crown (it may also include a screw to secure
the crown to the abutment if it is not cemented). This
restorative "stack" is the total of all the components used to
attach the crown to the implant.
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27.  The dimensions of the restorative stack vary slightly
depending on the type of abutment and the implant-
restorative interface (i.e., internal or external connection).
The minimum amount of interocclusal space required for the
restorative "stack" on an external hex-type implant is 7 mm.
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28. Diagnostic Study Models.
Mounted are an excellent means of assessing potential sites
for the dental implants. Properly articulated models with
diagnostic wax-up of the proposed restoration allows the
clinician to evaluate the available space and - 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.
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29. Hard Tissue Evaluation.
 The amount of available bone is the next criteria to
evaluate
 Wide variation in jaw anatomy is encountered ,and is
therefore important to analyze the anatomy of dento
alveolar region of interest both clinically and radio
graphically
 . A visual examination can immediately identify deficient
areas whereas other areas that appear to have good ridge
will require further evaluation .
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30.  Clinical examination of the jawbone consist of palpation
to feel for anatomic defects and variation 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
dimension at the proposed surgical site.
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31. The spatial relationship of the bone must be evaluated in a
three-dimensional view because the implant must be placed
in the appropriate position relative to the prosthesis.
It is possible that an adequate dimension of bone is available
in the anticipated implant site but that the bone and thus
the implant placement might be located too lingual or too
buccal for the desired prosthetic tooth replacement
."' Bone augmentation procedures may be necessary to facilitate
the placement of an implant in an acceptable prosthetic
position despite the availability of an adequate quantity of
bone (i.e., the bone is in the wrong location).
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32. 32

33. Radiographic examination
 . Radiographic assessment of the quantity, quality, and
location of available alveolar bone in potential implant
sites ultimately determines whether the patient is
icandidate for implants and if a particular implant site
needs bone augmentation. Appropriate radiographic
procedures, including
 periapical radiographs,
 panoramic projections,
 tomographic cross-sectional imaging
 , it will help to identify vital structures such as the floor
of the nasal cavity, maxillary sinus, mandibular canal, and
mental foramen.
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34.  In addition to the absolute dimensional measurement of
the alveolar bone, it is important to determine whether the
volume of bone radiographically (as well as clinically) is
located in a position to allow for the proper position of the
implant to facilitate restoration of the tooth/teeth in
proper esthetic andfunctional relationship with the
adjacent and opposing dentition. The best way to evaluate
the relationship of available bone to the dentition is to
image the patient with a diagnostically accurate guide
using radiopaque markers that accurately represent the
proposed prosthetic contour.
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35. The best way to evaluate the relationship of available bone
to the dentition is to image the patient with a
diagnostically accurate guide using radiopaque markers
that accurately represent the proposed prosthetic contours .
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36. 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 inucosa). For some cases, depending on the
clinician's view of keratinized tissue, evaluation may
reveal a need for soft tissue.
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37. Risk factor and contraindications
Contraindications for the use of dental implants, although
relatively few and often not well defined, do exist.
Some conditions are probably best describe as "risk factors"
rather than "contraindications" to treatment because
implants can be successful in almost all patients; implants
may be less predictable insome 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.
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38. conditions Risk factor contraindications
Medical and
Systemic Health-
Related Issues
-Diabetes (poorly
controlled)
-Bone metabolic disease
(e.g., osteoporosis)
-Radiation therapy (head
and neck)
-Immunosuppressive
medication
Immunocompromising
disease (e.g., HIV,
AIDS)
?? –Possibly
?? -Probably
Yes
?? –Probably
?? -Possibly
Relative
Relative
Relative
Relative
Relative
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39. conditions Risk factor contraindications
Psychologic and
Mental Conditions
Psychiatric syndromes
(e.g., schizophrenia,
paranoia)
Mental instability (e.g.,
neurotic, hysterical)
Mentally impaired;
uncooperative
Irrational fears; phobias
Unrealistic expectations
No
No
No
No
No
Absolute
Absolute
Absolute
Absolute
Absolute
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40. conditions Risk factor contraindications
Habits and
Behavioral
Considerations
Smoking; tobacco use
Parafunctional habits
Substance abuse (e.g.,
alcohol, drugs)
Intraoral
Examination
Findings
Atrophic maxilla
Current infection (e.g.,
endodontic) Periodontal
disease
Yes
Yes
?? –Possibly
Yes
Yes
?? -Possibly
Relative
Relative
Absolute
Relative
Relative
Relative
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41. Diabetes mellitus
 Poorly controlled diabetics often have impaired wound
healing and a predisposition to infections, whereas diabetic
patients whose disease is well controlled experience few, if
any, problems There is concern about the predictability of
implants in patients with diabetes. Several studies have
reported moderate failure rates in diabetic patients, with
implant
 Success ranging from 85.6%, to 94.3'%,.',1',-1'A prospective
 study demonstrated 2.2% early failures and 7.3% late
failures in diabetic patients.'.
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42. Bone metabolic disease
 Osteoporosis is a skeletal condition characterized by
decreased mineral density.
 The two main classifications are
 Primary (three types)
Primary osteoporosis has been attributed to
Menopausal related changes (type-I)
Age-related(type-II)
Idiopathic (type-III)
Secondary osteoporosis has been attributed to different
diseases and conditions, including
alcoholism, malnutrition, and smoking.
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43.  All the various types of osteoporosis fundamental problem
of decreased bone MINERAL DENSITY
 this lead to improper implant osseointegration
Interestingly, there is a trend in aging, 50 years and
postmenopausal women to decrease progressively through
bone demineralization at a rate of 1%-2%
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44. Immune compromise and immune
suppression
Individuals undergoing chemotherapy or taking medication
that impair healing(e.g., steroids) are not good candidates
for implant therapy because of the effects on normal
healing.
 A lowered resistance to infection may also be problematic
for e.g HIV pts.
 A past history of chemotherapy or immunosuppressive
therapy may not be problematic if the patient has recovered
from the side effects of treatment.
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45. Radiation therapy
.rtes as low as 60.4% in the irradiated
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46. Psy chologic and mental conditions
patient's ability to tolerate the number and type of
treatment appointments required for implant placement,
restoration, and maintenance could be problematic.
All psychologic conditions have the potential to be absolute
contraindications to implant treatment depending g on the
severity of the condition.
The exception might be individuals who demonstrate good
cooperative behavior with only mild psychologic or mental
impairment. The clinician should take great care before
accepting a mentally or psychologically impaired individual
for treatment with implants.
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47. Habits and behavior consideration
Patients have a variety of habits and behaviors that may
increase the risk of failure for implants.
- Smoking,
- Clenching or grinding of teeth,
- Drug
-Alcohol abuse
are among the most well-known habits that should be
identified because of the increased risk for implant failure
or complications.
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48. Smoking and Tobacco Use.
Moderate to heavy smoking has been documented to result in
higher rates of early implant failure and adversely affect
the long-term prognosis of dental implant restorations.
The mechanisms of action responsible for higher implant
failures associated with smoking are not understood.
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49. Smoking is a known risk factor for osteoporosis and thus
may adversely affect implant success through its effect on
bone metabolism.
Smoking cessation may improve the success rate of implants.'
Ina meta-analytical review, Bain et dl." found that implants
with an altered surface microtopography (Osseotite, acid-
etched surface) seemed to lessen significantly the adverse
affects of smoking on implant success.
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50. Para functional Habits.
Parafunctional habits, such as clenching or grinding of teeth
(consciously or unconsciously), has been associated with an
increased rate of implant failure.
Repeated lateral forces (i.e., parafunctional habits) applied
to implants can be detrimental to the osseointegration
process, especially during the early healing period.
Patients with known par functional habits should be
advised about an increased risk of complications or failures
as a result of their clenching or grinding.
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51. Many consider it to be a contraindication to implant
treatment, especially in the case of a short-spars, fixed
partial denture or a single-tooth implant.
If implants are planned for a patient with para functional
habits, protective measures should be employed, such as
creating a narrow occlussal table with flat cusp angles,
protected occlusion, and the regular use of occlussal guards
51

52. Substance Abuse.
. Drug and alcohol abuse should be considered a
contraindication for implant therapy for reasons similar to
the psychologic problems discussed earlier. Patients with
drug or alcohol addictions can he irresponsible and
noncompliant with treatment recomendations.
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53. Post treatment evaluation
Periodic examination of implants, the retained prosthesis,
and the condition of the surrounding periimplant tissue is
all important part of successful treatment.
Aberrations and complications can often be treated if
discovered early, but many problems will go unnoticed by
the patient.
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54. Thus, periodic examination is essential to discovering problems
early. Several parameters are available to evaluate
-The condition of the prosthesis
, - The stability of the implant(s),
- The health of surrounding periimplant tissues after
implant integration and prosthetic restoration.
Many of these clinical measures are adaptations from dental
and periodontal examination methods, such as
-Clinical inspection,
-Probing, and
-Radiographic examination.
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55. CLINICAL EXAMINATION
The clinical examination includes
- visual inspection
- probing.
VISUAL EVALUATION
visual evaluation of the tissue
color
contour
consistency,
PERIIMPLANT PROBING, AND RADIOGRAPHIC IMAGES
are some of the ways to evaluate implants in the post treatment phase. Soft
tissues can e visually inspected for signs of inflammation or swelling. They can
also be palpated to detect areas of edema,
tenderness,
exudate,
suppuration.
Periimplant probing anbe used to assess the condition and level of hard and soft
tissues surrounding implants.
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56. Per implant probing
Periodontal probing around natural teeth is very useful to assess
the health of periodontal tissues, the sulcus or pocket depth, and the
level of attachment.
However, using a periodontal probe around implants may not
provide comparable results." Clinicians should use caution when
evaluating periimplant probing because these measures cannot
be interpreted the same as probing depths around teeth.
Because of distinct differences in the surrounding tissues that
support teeth compared to those that support implants, the
probe inserts and penetrates differently.
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57. Around teeth, the periodontalprobe is resisted by the health of the
periodontal tissues and, perhaps most importantly, by the
insertion of supracrestal connective tissue fibers into the
cementum of the root surface.
These fibers, unique to teeth, are the primary source of resistance to
the probe.' There is no equivalent fiber attachment around
implants. Connective tissue fibers around implants generally run
parallel to the implant or restorative surface and do not have
perpendicular or inserting fibers
. The primary source of resistance to the probe around all implant
will differ depending on the conditions surrounding the implant.'-
,," At noninflamed sites, the probe will be resisted by the most
coronal aspect of connective tissue adhesion to the implant. At
inflamed sites, the probe tip consistently penetrates farther into
the connective tissue until less
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58.  The value of periimplant probing periodontal probing and
offers very
 by comparison.
 Probing around implant can measure the level of the
mucosal margin relative to a fixed position ofthe implant or
restoration and the depth of tissue around the implant. -
probing depth is often a measure of the - surrounding
connective tissues
58

59. Microbial Testing
. Studies have demonstrated the development ofmucosal
inflammation in response to the accumulation, of bacterial
plaque
Likewise, evidence micobiota of inflamed periimplant site,
harbors the same periodontal pathogens, as those observed
in diseased periodontal pocket .
However, there is no evidence to prove that periodontal
pathogens cause periimplant disease, and the pathogenesis
of inflammatory disease around implants has not been
defined.
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60. Stability measures
Two techniques that have been as noninvasive ways of
evaluating implant stability
- Impact resistance (e.g., Periotest)
- Resonance frequency analysis.(RFA)
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61. - Impact resistance , (Periotest)
 The Periotest (Gulden, Bensheim, Germany) is a non-
invasive, electronic device that provides an objective
measurement of the reaction of the periodontium to a
defined impact load applied to the tooth crown.
 The test value depends to some extent on tooth mobility
but mainly on the damping characteristics of the
periodontium.
 Detection of horizontal mobility may be a significant
advantage for use of the Periotest because it is much more
sensitive horizontal movement than similar detection by
other means, such as manual assessment.''
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62. Resonance frequency analysis
 RFA is another noninvasive method used to measure the
stability of implant .52 This method uses a transducer that is
attached to implant or abutment.
 A steady-state signal is applied to the implant through the
transducer, and a response ‘measured .
 The RFA value is a function of the stiffness of the implant in
the surrounding tissues. The stiffness influenced by the implant,
the interface between the implant and bone, and soft tissues as
well as the surrounding bone. Additionally, the height of the
implant or abutment above the bone will influence the RFA
value. . An increase in a value indicates increased implant
stability, whereas decrease indicates loss of stability.
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63. RADIOGRAPHIC EXAMINATION
 Intraoral radiographs should be taken at the time of placement
(baseline), at the time of abutment connection (confirm seating
and serve as another basclinei. and subsequently to monitor
marginal or periimplant bone changes.
 periapical radiographs have excellent resolution and provide
adequate details for evaluating bone support around implants if
taken at a perpendicular direction.
 The limitation of periapical radiographs is that they arc difficult
to standardize, and great variability is inherent in the
acquisition process.
 However, periapical films are relatively simple, inexpensive,
and readily available in the dental office.
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64.  The objective of the radiographic examination is to
 - measure the height of bone adjacent to the
implant(s) presence and quality of bone along the
length of the implant any radiolucent lesions around the
implant.
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65. Oral hygiene and implant maintenance
The long-term success of dental implants likely requires the
maintenance of healthy periimplant tissues because the soft
tissue "seal" around implants is best when the surrounding
mucosa is not inflamed.
For this reason, good oral hygiene and regular professional care are
essential to maintaining implants.
The importance of good oral hygiene should be stressed even before
implants are placed, and oral hygiene instructions for plaque
control should begin as early as possible.
The patient's ability to maintain good oral hygiene should be
monitored and reinforced at each visit, and the patient should
be given instructions specific to individual needs.
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66. conclusion
Dental clinicians can now predictably replace missing teeth with
endosseous dental implants. Most patients, whether missing a
single tooth, several teeth, or all their teeth, can be candidates
for dental implant therapy. However, many factors influence
the outcome; the clinician must consider the quantity,quality,
and location of available bone; the patient's mental and
physical health; and risk factors and contraindications. Patients
should be advised about risk factors and provided treatment
options both with and without dental implants. Periodic
evaluation, good oral hygiene, and regular maintenance are
important aspects of care for the long-terra
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