DIAGNOSIS IN

IMPLANTOLOGY
Case Selection
Initial Information Gathering
 Medical History
 Dental History
 Clinical Examination
 Study Models
 X-Rays
MEDICAL HISTORY
 MEDICAL HISTORY
 First appointment

 2 basic categories
- Past medical history
- Review of the patient’s systemic status

• 6 month drug history

• Pregnancy – elective procedure - contraindicated

 Past medical history

 Diabetes
 Hypertension
 h/o of chest pain
 Persistent cough or cold
 Is the patient aware of any thyroid problem
 h/o of abnormal bleeding after any surgery
‘ extraction or trauma
 h/o of blood transfusion any time in life
 Allergy to any drug
 Smoking habits
 Use of alcohol
 Specific evaluation of the bone
 BONE DISORDERS
 Often influence
decisions in
implantology as
alveolar bone
responds to systemic
bone active agents

 Most common – age-

related -
Osteoporosis

IMPLANT BONE INTERFACE

 THE BONE IN OSTEOPOROSIS
 Microarchitectural
deterioration

 Uncoupling of bone
formation/resorption
process

 Cortical plates –
thinner,

 trabecular bone
pattern more discrete

 and advanced
demineralization
 IMPLICATIONS
 Not a contraindication

 Bone density –

 Greater width of implants, bioactive coats

 Bone stimulation will increase bone density even

with advanced osteoporotic changes
HYPERPARATHYROIDISM
– Not a contraindication in the
absence of bony lesions
 FIBROUS DYSPLASIA
 Fibrous dysplasia – Implant placement
contraindicated in the regions of this
disorder – lack of bone, increased
fibrous tissue

 Problems with rigid fixation and increased

susceptibility to local infection
 PAGET’S
 Paget’s – inability to tolerate a
prosthesis for considerable length of time
– continuous bone remodeling

 Increased osseous vascularity – Fracture

susceptibility

 Implants contraindicated
OROFACIAL X-AMINATION
LOOK FOR PRESENCE OF
ANY GROSS PATHOLOGY
EXISTING PERIODONTAL
STATUS
PROBING
Score the Amount of Bleeding
 Bleeding
Index Chart
MOBILITY OF POTENTIAL
ABUTMENTS
Keratinized gingiva - potential
implant site
INADEQUATE ATTACHED GINGIVA
RESTORATIVE EVALUATION
 Decay

 Teeththat require restorations

and/or endodontic therapy
 AESTHETIC
EVALUATION
PATIENT PROFILE
AND OTHER
AESTHETIC
PARAMETERS
DENTAL FORCE FACTORS
1. PARAFUNCTION
2. POSITION OF THE ABUTMENT IN THE
ARCH
3. MASTICTORY DYNAMICS
4. NATURE OF THE OPPOSING ARCH
5. DIRECTION OF LOAD FORCES
6. CROWN-IMPLANT RATIO
STRESS FACTOR I
 PARAFUCTION

 Repeated sustained occlusion

 Most common cause of rigid implant fixation

during the first year of implant loading

 Complications - Increased frequency in the

maxilla
1. Poor bone density
2. Increase in the moment of force
 NADLER’S CLASSIFCATION –
Causes of nonfunctional tooth contact
LOCAL
SYSTEMIC
PSYCHOLOGIC
OCCUPATIONAL
INVOLUNTARY
VOLUNTARY
LOCAL FACTORS – OCCLUSION
THE VARIOUS HABITS
 BRUXISM
 Vertical, nonfunctional,
horizontal grinding

 Most common oral habit

 Significant excess of
forces

 Gibbs CH et al – A 37-yr
old patient with a long
history of bruxism
recorded maximum force
of 990 psi (Avg – 170lb)
 DIAGNOSIS

 Increase in size of
temporal and
masseter muscles

 Deviation on
opening, limited

 Teeth wear
 IMPLICATIONS
 Classified – mild, moderate, severe

 Forces of bruxism – most difficult to

contend with on a long term basis

 Crestal bone loss, unretained abutments,

fatigue stress fracture of implants
 TONGUE THRUSTING

 Sustained low magnitude forces – lateral in

direction – stress at the permucosal site

 Lingual restoration contour difficult, tongue biting

 Reflect the lip (anterior) or cheek (posterior) –

ask patient to swallow
STRESS FACTOR II
 ABUTMENT POSITION IN ARCH
 Posterior versus anterior

 Implants shorter in the posterior region

invariably due to anatomical limitations
STRESS FACTOR III
 MASTICATORY DYNAMICS
 Age, sex, muscle mass, diet, satus of the
dentition – influence muscle strength –
influence bite force

 In addition, the younger patient needs

additional implant support for the
prosthesis for a longer time. An 80-year
old patient will need implant support or far
fewer years than 20-yr old
STRESS FACTOR IV
 OPPOSING ARCH
 Natural dentition versus prosthesis

 Implants> Conventional fpd>soft tissue

borne prosthesis

 Time period of prosthesis wear

STRESS FACTOR V& VI
Stress multipliers
DIRECTION OF LOAD

Axial Vs lateral forces

All stresses occur in coronal

half of alveolus. Excessive –
Crestal bone loss
CROWN HEIGHT
EVALUTION
 CROWN HEIGHT
 Crown height – lever with lateral force

 Ideal – CI ratio = 1

 Crow height inversely proportional to

implant height as resorption progresses
 SUMMARY

•Identify sources of additional force on the

implant system

•Magnitude, duration, direction, type, and

magnification effects

•Treatment planned to negate them

 LISTING OUT THE DIAGNOSTIC
AIDS

 Casts and mounts

 Wax ups
 Stents
 Radiographs
DIAGNOSTIC CASTS AND
MOUNTING
Study Model
Impressions
Take Two Sets
CENTRIC RECORD
Two Sets of Mounted Models
One Set of Models is kept as an
Original Record

The Other Set may be equilibrated

and Waxed Up
 CASTS MOUNTED ON A
SEMIADJUSTABLE IN CRP

 Premature contacts

 Edentulous ridge relationships to

adjacent teeth and opposing arch

 Position of potential abutments including

inclination, rotation, extrusion, spacing,
parallelism and esthetic considerations
4. Tooth morphology and overall condition

5. Direction of forces in future implant site

6. Present occlusal scheme

7. Edentulous soft tissue angulation, length,

width, locations, permucosal esthetic
position, muscle attachments nd
tuberosities
8. Interarch space

9. Overall occlusal curve of Wilson and Spee

10. Arch relationships

11. Opposing dentition

12. Potential future occlusal schemes

13. Number of missing teeth

14. Arch location of future abutments

15. Arch form and symmetry

WAX UP IN VIEW
WAX UP IN VIEW
DIAGOSTIC STENTS
FABRICATION
FROM WAX UPS
FROM EXISTING PROSTHESIS
Purpose of diagnostic templates
 Assess position and angulation of prosthetic
component

 Plan implant placement and angulation based

on the same

 Determine favorable crown contours

 Also used as surgical template in some

situations
 EVALUATION OF
AVAILABLE BONE AND
DIAGNOSTIC AIDS
USED
EVALUATION OF
AVAILABLE BONE

QUALITY AND QUANTITY

 CLINICAL
 ON THE DIAGNOSTIC CAST
 RADIOGRAPHIC
 QUANTITY
Length of the edentulous span

Height of available bone

Buccolingual width
DIVISIONS OF AVAILABLE
BONE
Progress of Bone Loss

W- > 5mm

A H - > 10-13 mm
L - > 7 mm
< 30 degree angulation
CL ratio <1

Abundant bone
Progress of Bone Loss

W- 4 - 5mm

B H - > 10-13 mm
L - > 12 mm
< 20 degree angulation
CL ratio <1

Barely sufficient bone

Progress of Bone Loss

W- > 2.5 -4mm

B-w H - > 10-13 mm

L - > 7 mm
< 30 degree angulation
CL ratio <1
Progress of Bone Loss
zz
zzzz
C-w Unfavorable
Angulation >30
CL ratio >/= 1

Compromised bone
Progress of Bone Loss

C-h
Progress of Bone Loss

D
Severe atrophy

Deficient bone
 QUALITY
Density of available bone
 MISCH JUDY BONE DENSITY
CLASSIFICATION
 D1 – DENSE CORTICAL BONE

 D2 – THICK DENSE TO POROUS CORTICL

BONE ON CREST AND COARSE TRABECULAR
BONE WITHIN

 D3 – THIN POROUS CORTICAL BON ON

CREST AND FINE TRABECULR BONE WITHIN

 D4 – FINE TRABECULAR BONE

 D5 – IMMATURE NONMINERALIZED BONE

SIGNIFICANCE OF RIDGE
ASSESMENT
FAILED IMPLANT
PRESERVATION OF VITAL
STRUCTURES
Clinical Ridge
Assessment
By Observation
INADEQUATE MESIODISTAL
WIDTH
INADEQUATE BUCCOLINGUAL
WIDTH
 by
by
Palpation
Palpation
By Ridge mapping near the Crest of
the Ridge
1.75mm
By Ridge mapping
more Apically
3 mm
Ridge Height
Assessment
 Using
a Boley Gauge on
the base of the
Nose
and on the Ridge
 TRANSFERING RIDGE
MEASUREMENTS TO THE
DUPLICATED CAST
DIAGNOSTIC IMAGING
 SUCCESSFUL IMPLANT
IMAGING
Individualized to the needs of the patient
and must recognize that the imaging as
well as the implant process is
prosthetically driven. Because the ultimate
objective of fixture placement is a
functional, aesthetic and maintainable
restoration, imaging must provide a
database that facilitates the safe
placement of adequately sized fixtures in
appropriate positions.
 IMAGING OBJECTIVES
 PHASE I –
Objectives
1. Determine quantity, quality and
angulation of bone
2. Relationship of critical structures to
proposed implant sites
3. Presence or absence of disease
 PHASE II – Surgical and interventional
 IMAGING MODALITIES

DIGITAL ANALOG
RADIOGRAPHIC IMAGING
IN RIDGE ASSESMENT

Quantitative- analog
imaging
IOPA
 INFORMATION YIELD IN IOPA
RADIOGRAPHY

 Details of region under investigation – vital

structures

 Periodontal and endodontic status of teeth

 Residual roots and pathology

 FALLBACKS
 Distortion and magnification

 Does not depict the third dimension of

bone width

 Little value in determining bone density

 Spatial relationship not discernible

DENTAL PANAROMIC
TOMOGRAPH
 ADVANTAGES
 The most utilized diagnostic modality in
implant dentistry.

 Both jaws in one shot

 Ease of availability and speed of the

procedure, cost factor

 Magnification error of approximately 1.3,

good indicator of bone height
Panoral views are subject to magnification
and distortion
BALL BEARING STENT – WAX
BALL BEARING STENT -
ACRYLIC
Place the Ballbearing directly over the
Centre of the Ridge
With 5 mm ball bearings in place
 Horizontal Width of
Ballbearing on Panoral X-ray
= 6.2 mm

Menu <
Magnification Ratio = 1.24
 Mesio-distal Space on
Panoral X-ray = 7.4 mm
7.4 / 1.24
7.4 / 1.24 = 5.92 mm
Vertical Height
Vertical Height 6.4 mm
Bone Height on X-ray = 20
Available vertical height
20 / 1.28 = 15.6 mm
 OTHER APPLICATIONS OF
PANOROGRAPHIC X RAY IN
IMPLANT DIAGNOSIS
 Pathology in
relation to teeth

 Related
Anatomical
structures
 PITFALLS
 Distortion

 Does not demonstrate bone quality

 No cross sectional views

 Spatial relationship
 OTHER ANALOG IMAGING
MODALITIES
 Occlusal radioraphs

Used in conjunction with

periapical radiography
Buccolingual bone width
 OTHER ANALOG IMAGING
MODALITIES
 Lateral Ceph

Evaluates – facial profile,

jaw relation, width of
bone in midline

 Conventional Tomograph
Cross sectional, distorted,
multiple exposures
COMPUTED TOMOGRAPHY
IN RIDGE ASSESSMENT

Qualitative and quantitative- digital

imaging
 AXIAL SECTIONS

RECONSTRUCTED INTO 3-D

IMAGES
 ABOUT CT
 Three dimensional imaging

 Axial slice thickness – 0.25 mm

 Image can be reformatted or processed in

all three planes
 ABOUT CT
 Density of the structures within the image
is absolute and quantitative

 Most useful when it comes to imaging the

posterior mandible

 Variables - bone ht, width, density, implant

angulation, future prosthesis outline and
angulation.
A REFORMATTED CT IMAGE IN
THE CORONAL PLANE
 DETERMINING BONE DENSITY
USING CT
 HOUNSIELD UNITS – X-ray attenuation
measurement of voxels

 Voxel – Volume element of the image

(512*512*0.25)

 HU range -1.024 to +3.071 (-1.024 – air)

BONE DENSITY AND HU
DENSITY HOUNSFIELD UNITS

D1 >1250

D2 850-1250

D3 350-850

D4 150-350

D5 <150
ROLE OF MRI IN IMPLANT
IMAGING
 Secondary imaging technique

 Kircos LT – “Complex tomography fails to

differentiate the IAN in 60% of the implant cases
and CT fails to differentiate the IAN in 2% of the
implant cases

 Failure to differentiate the canal may be caused by

osteoporotic trabecular bone and poorly corticated
inferior alveolar canal

 MR visualizes the fat in trabecular bone and

diferentiates the canal and neurovascular bundle
from the adjacent trabecular bone
NEWER DIGITAL IMAGING
MODALITIES

TACT, iCAT, ConeBeamCT.

TUNED APERTURE COMPUTED
TOMOGRAPHY
 Can selectively examine small sections without
exposing the entire axial plane

 Isolate images to certain depth

 Ability to accommodate movement between

exposures

 Flexibility to adjust contrast ad resolution

 In office system

 Significantly lower
radiation
CONEBEAM CT
 CBCT
 Cone shaped x ray beam rather than a
conventional linear fan

 2 dimensional array of detectors

 Compact, relatively low radiation

Fan Beam Cone Beam
 CONCLUSION
 Today’s clinician has a variety of
diagnostic modalities at his disposal. But
to date no modality has been deemed
perfect.So the clinician has to carefully
weigh the pros and cons of each
modality.Our constant Endeavour as a
clinicians is to provide our patients with
predictable, functionally and esthetically
sound treatment which is not at all
possible without a good diagnosis.
 REFERENCES
 DENTAL IMPLANTS-the art and science
by Charles a. babush.
 CONTEMPORARY IMPLANT
DENTISTRY by Carl e.misch
 JPD VOLUME 59 YEAR 1988
 DCNA- IMPLANT IMAGING
THANQ