Patient evaluation and Surgical

placement of dental implant

Presurgical evaluation of patient

1.General and medical examination:

Age-Usually a patient above the age of 18 years is
considered to be fit for implant therapy.If
the implant is inserted into the adolescent‘s jaw bone
which is still in the growing stage,it may
lead to hindered growth on the side and jaw
disfigurement. The minimum age for implant
placement in girls is considered to 16-17 years
whereas in boys it is 17-18 years
Medical history -
An extensive written medical history is mandatory for
every
dental implant candidate. The review of the patient’s
medical
history is the first opportunity for the dentist to speak
with the
patient.
The two basic categories of information addressed
during the
review of the medical history include the medical history
and a
review of the patient’s systemic health. The dental office
uses a
medical evaluation form to obtain most of this
information of
particular importance is the history of medication usage
including OTC medications, herbs and supplements,
allergies,
and a review of the body systems.
The pathophysiology of the
systems, the degree of involvement, and the medications
being
used to treat the conditions are evaluated. It is important to
review this form with the patient to ensure that
comprehension
is adequate to answer all questions accurately and truthfully
2.Oral examination:
Arch form:In case of either anterioror posterior loading,
the most favorable
implant distribution strategies for the arch models are as
follows: 2,4,5and
2,3,4,5 for longest ellipsoid shape and narrow; 2,4,5 and
2,3,4,5 for shortest
ellipsoid shape and medium width; 1,3,5 and 2,3,4,5 for U-
shaped long and
narrow; 2,3,4,5 and 2,4,5 forU-shaped medium length and
medium width; and
1,3,5 and 2,3,4,5 forU-shaped short and wide.
Length of the edentulous span:
-At least 7mm is required to place a 4mm implant.This
is because at least 1.5mm clearance is required
between the implant and neighboring tooth.
-The recommended clearance between two implants is
3mm.Hence 14mm will be required to restore a space
with two 4mm implants.If there is only 11mm of space
available for 2teeth;then it may better to combine the
implant with a natural tooth and make a tooth-implant
supported prosthesis
Ridge morpology:
1.Ridge height:The height of the bone in anterior
segments can be evaluated clinically.Since the
mandibular basal bone is free of nerves in the
anterior regions;almost all patients will have
sufficient height to place implants.Similarly;the
height of the premaxillary bone can be evaluated
arbitrarily to determine the length of the implant
required.
2.Ridge width: The width of the ridge can be evaluated
clinically by palpation.
The concavity of the anterior maxilla below the ridge crest
should be carefully
evuated to determine bone width.Sometimes there will be
sufficient width at
the crestal region but the bone width below the crestal may
be acutely
decreased due to this labial concavity.
3.Ridge Angle: The angle of inclination of the bone will
determine the
angulation of the implant.Although this can be seen better
with a CBCT ;the
bone mapping procedure provides an idea on the long axis
of the available bone
Soft tissue biotype: Biotype of the patient is the
thickness of the gingiva in the
facio palatal dimension.
Gingival biotype classification:
-Scalloped and thin(<1.5mm)
-Flat and thick(1.6-1.9mm)
Thick biotypes are more common in men than in
women
Width of keratinized soft tissue:This cross-sectional
study is performed to
determine whether an association exists between the
width of keratinized mucosa
and the health of implant-supporting tissues.
Increased width of keratinized mucosa around
implants is associated with lower
mean alveolar bone loss and improved indices of soft
tissue health.
Papilla at the implant site: Distinct papilla is
of great importance for obtaining a favorable
esthetic outcome following implant treatment.
When restoring single missing tooth in the
anterior maxilla, partial or total loss of
interproximal papilla is one of the most
common esthetic complications. Missing
papilla would surely cause cosmetic
deficiency (so-called black triangle), as well as
phonetic problem.
Periodontal health of adjacent teeth:
Periodontitis has negative effect on implant
success. Teeth adjacent to dental
implant plays an important role in deciding
the success or failure of implant.
Maintenance of periodontal health is of
paramount importance for
successful implant therapy
Mouth opening: Patient may represent with
small mouth or limited mouth
opening due to trauma;surgical intervension;
scleroderma;scars or
muscular or TM joint disorder.Limited access
is an important diagnostic
factor when treating patients with dental
implant in posterior region.
Opposing and adjacent teeth are at occlusal position:
Interarch space: If tere is inadequate interarch space in
the anterior region;then a screw retained
crown will become the preferred choice.In this case
the implant has to be placed slightly so the
screw channel can open into the cingulum for anterior
teeth replacement.
If tere is more than 4mm interarch space then the
implants can be restored with cement retained
crowns.
Cusp fossa relationship: If the neighboring teeth have a
cusp fossa relationship the the implant
can be easily restored with the same relationship
Cusp marginal ridge relationship: If the
neighboring teeth have a cusp marginal
ridge relationship;then forces may not be
directed to the centre of the tooth.In
such cases;the implant should be placed
little mesially so that the occlusal
forces are directed along the long axis of the
implant.
Supraeruption of the opposing teeth:
This is a common complication of any
edentulous space left unstored for a long
period of time.
Canine guide occlusion: If the patient has an
existing canine guided occlusal
scheme;then restoring a posterior implant is
easy.However if the canine has to
be replaced;then the occlusal scheme should be
modified such that the anterior
guidance is shared between the canines and
incisrs to reduce force load.
Groufunction: It may be preferable to convert a
group function to a canine
guided occlusion to protect posterior implants.If
a canine is to be replaced;then
the existing group fucntion occlusion should be
maintained to reduced forces on
the implant.
► 1.General and Medical evaluation :
► Age
► Medical problem
► 2.Oral examination
► Arch form
►
Ridge morphology of edentulous region
► Soft tissue biotype
► Wwidth of keratinized soft tissue
► Pappila at the implant site
► Mouth opening
► Periodontal health of adjacent tooth
3.Diagnostic radiograph
4.Impression and diagnostic cast
preparation
5.Clinical pictures of the edentulous
area
6.Bone mapping
7.Radiographic template fabrication
8.CT planning
9.Surgical guide fabrication
10.Mental foramina position
11.Implant distance from mental foramen ;incisive
foramen;sinus floor and nasal
floor
12.Lip lines
13.Crown height space.
14.Cantelevering of implant prosthesis
15.Direction of force
16.Ideal implant number and position
17.Financial evaluation and management
Vital signs:
#Blood pressure:
► Low blood pressure can also create
issues for dental implant
► surgery. Blood pressure readings of
less than 90 mm Hg systolic
► or less than 60 mm Hg diastolic is
considered abnormal, and elective dental
implant surgery
should be postponed until consultation
with the patient’s physician
Note: If a female patient presents with a
history of a
mastectomy, blood pressure should be
taken on the
arm opposite the side of the mastectomy
to avoid
possible lymphedema. If a patient relates
a history of a
double mastectomy, blood pressure
should be taken on
the ankle (this will usually result in an
elevated blood
pressure reading).
► Pulse
The second vital sign of importance is the pulse. The
pulse represents the force of the blood against the
aortic walls for each contraction of the left ventricle.
The usual location to record pulse is the radial artery
in the wrist. However, other locations, such as the
carotid artery in the neck and the temporal artery in
the temporal region, are convenient to use during
implant surgery or dental treatment. Pulse monitors
are easy to use and are beneficial during surgery or
long prosthetic appointments.
Pulse rate:A decreased pulse rate of normal rhythm
(less than 60 beats/min) indicates a sinus
bradycardia. Naturally, some patients may reach as low
as 40 beats/min, although most patients
become symptomatic with lightheadedness, dizziness,
or can experience syncope with a rate lower
than 40 beats/min. An adult pulse rate lower than 60
beats/min in a nonathlete mandates medical
evaluation before surgical procedures. Patients
receiving betablocker medications may have lower
than normal pulse rates. These patients may be
asymptomatic, but consultation with their
physician should be considered
During implant surgery, inappropriate bradycardia may
indicate a very serious
problem. If thepulse rate of the patient decreases to
less than 60 beats/min and
is accompanied by sweating, weakness, chest pain, or
dyspnea, the implant
procedure should be stopped, oxygen administered,
and immediate medical
assistance obtained. If the resting pulse of the patient is
greater than 60 beats/
min and drops into the 40s or lower, the dental
procedure should be suspended,
even if the patient is asymptomatic, until the pulse
returns closer to the resting rate
An increased pulse rate of regular rhythm (more
than 100 beats/min) is termed
sinus tachycardia. This rate is normal if experienced
during exercise or anxiety.
However, a medical consultation is suggested when
a nonanxious patient has a
resting pulse rate higher than 100 beats/min. In
patients with anemia or severe
hemorrhage, the heart rate increases to
compensate for the depletion of oxygen
in the tissues. Therefore when increased bleeding
during surgery is observed,
evaluate the pulse rate and blood pressure.
Temperature: Special attention must be given to a
prolonged, sustained fever
after surgery sepsis or possible brain abscess could
be present. Very low body
temperatures can also be problematic but can also
result from inaccurate
measurement. If the body temperature is less than
97°F, an alternative method
of testing should be used to verify the reading or at
a minimum the reading
should be repeated. More elderly patients can
have normal body temperatures
that run just higher than 97°F. Low body
temperature can be found in
hypothyroidism.
Respiration:
Respiration is evaluated while the patient is at rest. The
normal rate in the adult varies between
16 and 20 breaths per minute and is regular in rate and
rhythm. Patients with advanced respiratory
conditions including chronic obstructive pulmonary disease
(COPD), CHF, and some forms of
asthma may use accessory muscles in the neck or shoulders
for inspiration, whether before or
during surgery. This is considered a form of dyspnea
(difficultor labored breathing). During dental
implant surgery, the use of intravenous (IV) drugs including
narcotics can cause patients to develop dyspnea
If dyspnea occurs during surgery, it is important to evaluate
the patient’s airway for swelling or
obstruction. The pulse should immediately be evaluated to
rule out the presence of PVCs or
irregularity. This could indicate a more serious condition such
as a MI.
Hyperventilation is the result of both an increased rate and
depth of respiration and may be
preceded by frequent sighs, such as is seen in the anxious
patient. A respiratory rate greater than
20 breaths per minute requires investigation. Anxiety may
increase this rate, in which case
sedatives or stress reduction protocols are indicated before
implant surgery.
Having a portable pulse oximeter available is always
advisable to measure oxygen concentration. It
is important to keep the oxygen saturation greater than
90%. This may require supplemental
oxygen. There was previous concern regarding oxygen
supplementation in patients with chronic
COPD depressing the hypoxemic drive. Currently the
accepted use of supplemental oxygen in COPD
patients is to keep the oxygen level at their baseline or
greater than 90%. It is important that every
dental office have supplemental oxygen and both a nasal
cannula for routine oxygen
supplementation and a nonrebreather mask to deliver
higher levels of oxygen
Hypoventilation can also occur from IV sedation. However,
the initial evaluation
of a patient that is experiencing hypoventilation with or
without IV sedation
should always be the airway for possible obstruction. If
the airway is clear and
hypoventilation persists, then pharmaceutical reversal of
the sedative agent
should be considered.
Height:The height of the patient should be determined,
especially in an
adolescent patient, to evaluate their growth and
development in the
determination of when dental implants would be
appropriate. Ideally, growth
cessation must occur before implant placement
Weight:
Weight is an important factor when using sedation for
implants procedures, because there exists a
direct correlation between dosage of sedative drugs and
body weight. Additionally, significant
changes in weight (gain or loss) should be evaluated to
assess malnutrition, obesity, or retention of
fluid from either kidney or heart dysfunction. Unintentional
loss of weight may be a sign of
malignancy, diabetes, or various other systemic diseases. A
significant increase in weight may be a
sign of cardiovascular disease such as CHF, hypothyroidism,
or possible systemic diseases. Of
special concern are patients with a history of gastric bypass
because absorption rates of certain
medications may be affected.
Complete blood count:In implant dentistry, CBCs
would be important in
patients with a history of anemia or bleeding
disorders. CBCs are also useful for
patients with chronic renal conditions, which can
cause anemia or those that
have been on recent (<3 months) steroid or
glucocorticoid therapy. Any patient
that received chemotherapy for cancer, cured or
in remission, or history of WBC
disease such as neutropenia (low WBC) or chronic
leukemia (markedly elevated
WBC) would also require a CB
WBC count:From an implant dentistry perspective,
abnormalities in WBC counts
can have significant implications. Inflammatory
processes can be present with
normal WBC counts, but certain types of cells,
when increased, can indicate
ongoing inflammation or possibly infection.
Elevation in band neutrophils or
absolute neutrophil counts (ANCs) usually
indicates a more serious process like
infection or severe inflammation.
RBC count:RBCs are responsible for the
transport of oxygen and carbon dioxide
throughout the
body and for control of the blood pH.
These cells represent the largest segment
of the formed
elements of the blood. The normal RBC
count is higher in men than in women.
Lincreases may
result from polycythemia, smoking,
testosterone use, congenital heart disease,
or Cushing
syndrome. The most common filnding is a
decreased cell count, which usually
indicates anemia.
Hemoglobin:Hemoglobin (Hb) is responsible
for carrying oxygen throughout the
bloodstream. Each Hb protein carries up to
four molecules of oxygen that can be
delivered to various cells in the body. The
normal level of Hb is 13.5 to 18 g/dL
in men and 12 to 16 g/dL in women. The
preoperative threshold of 10 g/dL is
often used as a minimum baseline for
surgery. However, many patients can
undergo surgical procedures safely at 8 g/dL
as long as their anemia has been
chronic and stable
Hematocrit:White and red blood cells are
suspended in serum and make up the
contents of blood.
The hematocrit is the percentage of RBCs in
a given volume of blood. The hematocrit is
a
significant indicator of anemia or blood loss.
Adult males have a normal value of about
42% to 54%
and women 38% to 46%. Values within 75%
to 80% of normal are required before
sedation or general
anesthesia.
Bleeding disorder:
Bleeding disorders are the underlying cause of critical
bleeding episodes in any
type of dental surgery. Blood changes from liquid to solid
through the
coagulation cascade, which is a complex series of steps
that result in a fibrin
clot. The body uses platelets to plug the site of injury, and
clotting factors then
help form the fibrin clot that maintains the platelets in
place.
Bleeding tests-
1.Physical examination-The second method by which the implant
dentist can detect a patient
with a bleeding disorder is the physical examination.The exposed
skin and oral mucosa must be
examined for objective signs. Petechiae, ecchymosis, spider
angioma, or jaundice may be observed
in liver disease patients with bleeding complications. Intraoral
petechiae, bleeding gingiva,
ecchymosis, hemarthroses, and hematomas may be present in
patients with genetic bleeding
disorders. Patients with acute or chronic leukemias how signs of
oral mucosa ulceration,
hyperplasia of thegingiva, petechiae or ecchymosis of the skin or
oral mucosa, or lymphadenopathy.
Macular or nodular lesions could be a sign of the multiple
-
► International Normalized Ratio and Prothombin Time
► Partial Thromboplastin Time
► Bleeding Time
► Platelet Count
► Thrombin Time
► Additional Oral Anticoagulants
Cardiovascular Diseases-
1.HypertensionWith increasing age, the prevalence of
hypertension increases. More than half of people aged
60 to
69 years and approximately three quarters of those age
70 and older are affected with
hypertension. Failure to diagnose and detect
hypertensive patients can result in life-threatening
conditions such as stroke or MI.Because implant dentists
treat a high percentage of elderly patients
and there is such a high prevalence in the general
population, the incidence of treating dental
patients with uncontrolled or undiagnosed hypertension
is very high.
2.Angina pectorisThe major concern for the implant clinician is
the precipitation or management of the actual
angina attack. Precipitating factors are exertion, cold, heat, large
meals, humidity, psychological
stress, and dental-related stress. All of these factors cause
catecholamine release, which in turn
increases the heart rate, blood pressure, and myocardial oxygen
demand.The dental emergency kit
should include nitroglycerin tablets (0.3–0.4 mg) or sublingual
nitroglycerin spray, which are
replaced every 6 months because of their short shelf-life. During
an angina attack, all dental
treatment should be stopped immediately. Nitroglycerin is then
administered sublingually, and
100% oxygen is given at 6 L/min, with the patient in a
semisupine or 45-degree position
Congestive Heart FailureCHF is a pathophysiologic state in
which an abnormality in cardiac function is responsible for
failure of
the heart to pump blood in adequate volume to meet the
needs of the metabolizing tissues. CHF
patients are very susceptible to intraoperative cardiovascular
morbidity issues. Stress reduction
protocol and strict monitoring should be followed. CHF
patients should be positioned in the most
recumbent position in which they can breathe comfortably
and efficiently.
Usually, the more upright the
patient is, the easier it is for
the patient to
breathe. Oxygen
supplementation (≈2 L/min)
during implant procedures is
highly recommended to
minimize the possibility of
hypoxia. The use of nitrous
oxide in these patients is not
advised
subacute Bacterial Endocarditis and Valvular Heart
DiseaseBacterial endocarditis is an infection of the heart valves
or the endothelial surfaces of the heart. The
infection is the result of the growth of bacteria on damaged or
altered cardiac surfaces. The
microorganisms most often associated with endocarditis after
dental treatment are alpha-hemolytic
Streptococcus viridans and less frequently staphylococci and
anaerobes. The disorder is serious,with a
mortality rate of approximately 11%.38 Dental procedures
causing transient bacteremia has been shown
to be an etiologicalfactor of bacterial endocarditis.
Patients with gingivitis and certain cardiac conditions
are at highest risk. The guidelines suggested prophylactic
antibiotics only for dental procedures that
involve manipulation of gingival tissue and bleeding.
Antibiotics are not recommended for routine
anesthesia through noninfected tissues or placement or
adjustment of removable prosthodontic or
orthodontic appliances
Endocrine Disorders-
1.Diabetes MellitusStudies have shown that hyperglycemia
has a negative effect on bone metabolism,reducing bone
mineral density,affecting bone mechanical properties, and
impairing bone formation, leading to
poor bone microarchitecture.There is a direct correlation
between implant osseointegration and
glycemic control.Osseointegration is more predictable in
anatomic areas with abundant cortical
bone, which is why the mandible has shown a greater bone
formation
2.Thyroid DisordersThyroid disorders are the second
most common endocrine problem, affecting
approximately 1% of
the general population, principally women.The
majority of patients in implant dentistry are
women, a slightly higher prevalence of this disorder
is seen in the dental implant practice.
Abnormalities in the anterior pituitary gland or the
thyroid can result in disorders of thyroxine
production. Excessive production of thyroxine results
in hyperthyroidism.
Symptoms of this
disorder include increased pulse rate, nervousness, intolerance
to heat,excessive sweating,
weakness of muscles, diarrhea, increased appetite, increased
metabolism, and weight loss.
Excessive thyroxine may also cause atrial fibrillation, angina,
and CHF.
XerostomiaXerostomia (dry mouth) may directly or indirectly
have effects on dental implants. A decrease in
salivary flow is also accompanied by a change in its
composition. An increase in mucin and a
decrease in ptyalin result in a more viscous and ropy saliva.
Plaque formation is increased, and the
reduced antibacterial action of the saliva results in a favorable
environment for bacteria growth.
Dental implants are not contraindicated in patients suffering
from xerostomia. Case reports have
been documented with successful implant placement with no
increase in failure rate. However,
with the lack of saliva, implant patients may be susceptible to
more oral lesions and the possibility
of irritation from tissue-borne implant prostheses.
PregnancyElective dental implant surgery procedures are
contraindicated for the pregnant patient.
Not only is the mother the responsibility of the dentist, but
so is the fetus. The
radiographs or medications that may be needed for implant
therapy and the increased
stress are all reasons the elective implant surgical procedure
should be postponed until
after childbirth. However, after implant surgery has
occurred, the patient may become
pregnant while waiting for the restorative procedures,
especially because modalities may
require 3 months to 1 year of healing. Periodontal disease is
often exacerbated during
pregnancy.
 All elective dental care, with the exception of dental prophylaxis,
should be
deferred until after the birth. The only exceptions to this are caries
control or
emergency dental procedures. In these instances, medical clearance
should be given for
all drugs, including anesthetics, analgesics, and antibiotics to be
administered to the
patient. In most cases, physicians will approve the use of lidocaine,
penicillin,
erythromycin, and acetaminophen (Tylenol). Aspirin,
vasoconstrictors (epinephrine), and
drugs that cause respiratory depression (e.g., narcotic analgesics) are
usually
contraindicated. Diazepam (Valium), nitrous oxide, and tetracycline
are almost always
Hematologic SystemErythrocytic (Red Blood Cell) Disorders-
1.Polycythemia- Polycythemia is defined as an increased
concentration of Hb in
body. It is either the result of increased RBC production or can
it be caused by
reduction in plasma volume. Most cases of polycythemia are
the result of other
underlying medical conditions or medications and referred to
as secondary
polycythemia. Because of the higher viscosity of the blood in
polycythemic
patients, an increased possibility of stroke, MI, or pulmonary
embolism may
occur..
AnemiaAnemia is the most common hematologic
disorder. Almost all blood
dyscrasias may at one time or another be associated
with anemia. Anemia
is not a disease entity; rather, it is a symptom complex
that results from a
decreased production of erythrocytes, an increased rate
of their
destruction, or a deficiency in iron. Some anemias are
associated with
abnormal bleeding. During extensive surgery, the
increased bleeding may
cause a decreased field of view for the clinician and
possible postoperative
issues.
 Most often iron-deficiency anemia and other vitamin
dependent
anemias are associated with increased bleeding. Bone
maturation and
development are often impaired in the long-term anemic
patient. A faint,
large trabecular pattern of bone may even appear
radiographically, which
indicates a 25% to 40% loss in trabecular pattern. Therefore
the initial
quality of the bone required to support the implant can be
affected
significantly.
3.Platelet DisordersWhen treating patients with any
hematologic disease, a medical consultation and
clearance is
warranted, including those with current or past
history of reduced or elevated platelet counts
because many times there may be an associated
platelet dysfunction, which could lead to issues
with perioperative and postoperative bleeding. The
patient’s physician should be presented with a
comprehensive summary of the proposed
procedure, medications to be prescribed, and the
extent
of anticipated bleeding.
Digestive SystemLiver Disease (Cirrhosis)-
Cirrhosis of the liver is characterized by irreversible
scarring and is usually
caused by excessive alcohol intake, viral hepatitis B
and C, and certain
medications. Although patients with advanced
disease can present with jaundice
and itching, the diagnosis is usually confirmed by
liver biopsy and blood tests.
Cirrhosis may cause excessive bleeding, mental
confusion, kidney failure, and
accumulation of fluid in the abdomen (ascites).
Cirrhosis is irreversible,and
transplantation is becoming the most successful
treatment for advanced disease
states.
Patients with cirrhosis have several significant issues that
can affect
dental treatment, including dysfunctional synthesis of
clotting factors and the
inability to detoxify drugs. Hemostatic defects of liver
disease cause not only
reduced synthesis of clotting factors but also an abnormal
synthesis of fibrinogen
and clotting proteins, vitamin K deficiency, enhanced
fibrinolytic activity, and
quantitative and qualitative platelet defects.
Bone DiseasesDiseases of the skeletal system and
specifically the jaws often influence decisions
regarding
treatment in the field of oral implants. Bone and
calcium metabolisms are directly related.
Approximately 99% of the calcium in the body is
held in the bones and teeth. Calcium equilibrium
is influenced by several different processes in the
body, which then could directly affect bone
health.
PTH as the most important influence on calcium by
impacting the storage of calcium on
bones. Even though vitamin D is important for small
intestine absorption of calcium, the renal
tubules inthe kidneys reabsorb 95% of the calcium. In the
elderly there is increasing evidence to
support that lower levels of vitamin D have the most
influence on calcium levels.There exist many
diseases that directly affect the dental implant treatment.
1.OsteoporosisThe most common disease of bone metabolism the implant cli
will encounter is osteoporosis,
which is an age-related disorder characterized by a decrease in bone mass, in
microarchitectural deterioration, and susceptibility to fractures. Underprepar
the
osteotomy site (or use of osteotomes) will result in the implant having more b
the implant
interface. Although not contraindicated, immediate stabilization of dental imp
a common
concern because of decreased trabecular bone mass. Healing periods and imp
surface
characteristics should be selected for poorerquality bone
2.Vitamin D Disorders (Osteomalacia)-
Osteomalacia results in softer than normal bones and is
directly
related to calcium deficiencies. Lack of vitamin D is the
most
common cause of osteomalacia. Treatment for
osteomalacia
is usually successful, with radiographic changes seen
months
after treatment. There are no known reports of implant
complications in osteomalacia patients; however, there is
no
contraindication as long as the disease is not active and
well
controlled.
3.OsteomyelitisOsteomyelitis is an infection with or without
inflammation of the bone. Most always the infection
is caused by a bacteria or fungi entering the bone. Open
wounds or recent surgery around a bone
are the most common sources, but an abscessed tooth is
also a potential source for the infection.
The radiographic appearance is a poorly defined,
radiolucent area with isolated fragments of bone
(sequestra) that can exfoliate or become surrounded by
bone (involucrum). Implant placement in
surgical sites that have been previously affected with
osteomyelitis leads to an increased morbidity.
Because of the lack of vascularity, endosseous implants
have a greater chance of bone loss,
infection, and failure.
Radiographic Evaluation
Periapical radiograph: Periapical radiography (digital),
one of the most commonly used
radiographic modalities in dentistry, has many
advantages, such as high resolution, low radiation,
convenience, and image modification via digital software
capability. However, the implant
clinician must understand the inherent disadvantages of
this radiologic technique when used in oral
implantology
Periapical radiographs have many inherent
disadvantages, most notably
providing only a 2D image of a 3D object. The
inability to determine the buccallingual bony
dimensions is a major shortcoming with respect to
implant
treatment planning. These radiographs are of little
value in determining
quantity and quality of bone, identifying vital
structures, and depicting the
spatial relationship between structures within
proposed implant sites. In
summary, periapical radiographs should be limited to
an initial evaluation of a
proposed implant site, intraoperative evaluation, and
postoperative assessment.
In terms of the objectives of presurgical imaging, periapical
radiography is:
► a useful high-yield modality for ruling out local bone or
dentaldisease;
► limited value in determining quantity because the image
ismagnified, may be distorted, and
does not depict the third dimension (bone width);
► limited value in determining bone density or
mineralization(the lateral cortical plates prevent
accurate interpretation and cannot differentiate subtle
trabecular bone changes); and
► has poor ability in depicting the spatial relationship
betweenthe anatomic structures and the
proposed implant site
Panoromic radiograph:Panoramic radiography is a curved plane
tomographic
radiographic technique used to depict the body of the mandible,
maxilla, and
the maxillary sinuses in a single image. Its convenience, speed,
and ease have
made this type of radiography a popular technique in evaluating
the gross
anatomy of the jaws. However, the implant clinician must
understand the
inherent fundamental limitations characteristic of this type of
radiograph.
Although panoramic radiographs have historically
been the gold standard in
evaluating potential implant sites, many
disadvantages are associated with
these types of radiographs. A lower resolution
prevents evaluation of the fine
detail that is required for the assessment of
osseous structures and anatomy.
The magnification Iiln the horizontal and vertical
planes are nonuniform; thus
linear measurements are inaccurate. Often the
image has superimposition of
real, double, and ghost images, which result in
difficulty in visualizing anatomic
and pathologic details
The true positions of important vital structures,
which
are crucial in dental implant treatment, are not
easily seen or incorrectly
depicted. Therefore panoramic radiographs have
value for initial evaluation;
however, caution should be exercised when using
these types of radiographs for
the sole determinant of implant placement because
they predispose the implant
clinician to many surgical, prosthetic, and medical-
legal complications
MRI:Magnetic resonance imaging (MRI) is a cross-
sectional imaging technique
that produces images of thin slices of tissue with
excellent spatial resolution.
Use in oral implantology:In oral implantology,
because of the imaging artifacts associated with
CBCT scans, MRI is a possible alternative for the
postoperative evaluation of dental implants,
especially if associated with a neurosensory
impairment.
CBCT:Today CBCT imaging has become the gold
standard for dental implant
treatment planning. However, many implant
clinicians lack the background and
knowledge in evaluating and treatment planning
with CBCT, thus predisposing to
possible complications. Therefore the implant
clinician must have a thorough
understanding of inherent disadvantages of CBCT
scans, together with
knowledge of applied head and neck anatomy,
anatomic variants, incidental
findings, and pathologic conditions with respect to
implant treatment planning
Applied Anatomy for Dental ImplantsSurgical
Anatomy of the Maxilla and MandibleThe surgical
anatomy of the maxilla and mandible provide the
foundation
required to safely insert dental implants. The anatomy
is also a requisite
to the understanding of complications that may
inadvertently occur
during surgery, such as injury to blood vessels or
nerves, as well as
postoperative complications such as infection.
This information also
provides the operator with the confidence needed
to deal with these
complications. This chapter addresses those issues
important in the field
of oral implantology.
Arterial Supply to the Maxilla-
1. Mandibular portion: deep auricular, tympanic, middle
meningeal, and inferior alveolar arteries
2. Pterygoid portion: deep temporal, lateral pterygoid,
medial
pterygoid, and masseteric arteries
3. Pterygopalatine portion: posterior superior alveolar,
descending palatine, and sphenopalatine arteries
4. Infraorbital portion: anterior and middle superior
alveolar,
palpebral, nasal, and labial arteries anterior and middle
superior
alveolar, palpebral, nasal, and labial arteries
Muscle Attachment to the Mandible-
1.Lingual or Medial Attachments-
► Mylohyoid Muscle
► Genioglossus Muscle
► Medial Pterygoid Muscle
► Lateral Pterygoid Muscle
► Temporalis Muscle
2.Buccal or Facial Muscle Attachments-
► Mentalis Muscle
► Buccinator Muscle
► Masseter Muscle
Available Bone and Dental Implant Treatment
PlansImplant SizeImplant Width (Diameter)-
Manufacturers describe the root form implant
in dimensions of width and length (e.g., Hahn 4.3 mm ×
16.0 mm). The
implant length corresponds to the height of available
bone. Therefore this
text refers to root form implant height or length. The
width of a root
form implant is most often related to the diameter and
mesiodistal length
of available bone. Most root form implants have a round
cross-sectional
design to aid in surgical placement; therefore the
diameter of the implant
corresponds to the implant width.
Implant Height (Length)-
The height of the implant also affects its total surface area.
A cylinder root form implant 3 mm
longer provides a 20% to 30% increase in surface area. The
minimum height for long-term survival
of endosteal implants is in part related to the density of
bone. The denser bone may accommodate
a shorter implant (i.e., 8 mm), and the least dense, weaker
bone requires a longer implant (i.e.,
12 mm). After the minimum implant height is established
for each implant design and bone density,
the width is more important than additional length
Measurement of Available BoneAvailable Bone HeightThe
height of available bone is measured from the crest of the
edentulous
ridge to the opposing landmark. The anterior regions are
limited by the
maxillary nares or the inferior border of the mandible.
Usually the anterior
regions of the jaws have the greatest height, because the
maxillary sinus and
inferior alveolar nerve limit this dimension in the posterior
regions. The
maxillary canine eminence region often offers the greatest
height of
available bone in the maxillary anterior
54 In the posterior jaw region, there
is usually greater bone height in the maxillary first
premolar than in the
second premolar, which has greater height than the molar
sites because of
the concave morphology of the maxillary sinus floor.
Likewise the mandibular
first premolar region is commonly anterior to the mental
foramen and
provides the most vertical column of bone in the posterior
mandible.
After adequate height is available, the next most significant
criterion affecting long-term survival
of endosteal implants is the width of the available bone.
Root form implants of 4-mm crestal
diameter usually require a minimum of 7 mm of bone width
(4.0 mm + 2.0) mm buccal + 1.0 mm
lingual) to ensure sufficient bone thickness and blood supply
around the implant for predictable
survival. These dimensions provide more than 1.5 mm of
bone on the buccal side and at least 1.0
mm on the lingual side. When measuring necessary bone
width, always determine the true
diameter of the implant at the crest module, because many
implant systems base the diameter on
the root area of the implant, not the neck area.
Available Bone LengthThe mesiodistal length of available bone
in an edentulous area is often limited by adjacent teeth
or implants. As a general rule the implant should be at least 1.5
mm from an adjacent tooth and 3
mm from an adjacent implant. This dimension not only allows
surgical error but also compensates
for the width of an implant or tooth crestal defect, which is
usually less than 1.4 mm. As a result,
if bone loss occurs at the crest module of an implant or from
periodontal disease with a tooth, the
vertical bone defect will not spread to a horizontal defect and
cause bone loss on the adjacent
structure
 As a result,
if bone loss occurs at the crest module of an implant or from
periodontal disease with a tooth, the
vertical bone defect will not spread to a horizontal defect and
cause bone loss on the adjacent
structure.Therefore in the case of a single tooth replacement,
the minimum length of available
bone necessary for an endosteal implant depends on the width
of the implant. For example, a 5-
mm-diameter implant should have at least 8 mm of mesiodistal
bone, so a minimum of 1.5 mm is
present on the buccal and 1.0 mm on the lingual. A minimum
mesiodistal length of 7 mm is usually
sufficient for a 4-mm-diameter implant
Available Bone AngulationBone angulation is the fourth
determinant for available bone. The initial
alveolar bone angulation represents the natural tooth
root trajectory in
relation to the occlusal plane. Ideally it is perpendicular
to the plane of
occlusion, which is aligned with the forces of occlusion
and is parallel to
the long axis of the prosthodontic restoration.
 The incisal and occlusal
surfaces of the teeth follow the curve of Wilson and curve
of Spee. As such
the roots of the maxillary teeth are angled toward a
common point
approximately 4 inches away. The mandibular roots flare, so
the anatomic
crowns are more lingually inclined in the posterior regions
and labially
inclined in the anterior area compared with the underlying
roots.The first
premolar cusp tip is usually vertical to its root apex.
Divisions of Available Bone-
1. Division A (Abundant Bone)
2. Division B (Barely Sufficient Bone)
3. Division C (Compromised Bone
4. Division D (Deficient Bone)
Division A Dimensions-
•Width > 7 mm
•Height > 10 mm
•Mesiodistal length > 7 mm
• Angulation of occlusal load (between occlusal plane
and implant body) <
25 degrees
•CHS ≤ 15 mm
• Prosthesis:
•Fixed: FP-1 likely, possible FP-2
• Removable: RP-4 or RP-5
Division B Dimensions-
► 2.5 to 7 mm wid
► B+: 4 to 7 mm
► B−w: 2.5 to 4 mm
► Height > 10 mm
► Mesiodistal length > 6 mm
► Angulation < 20 degrees
► CHS < 15 mm
► Prosthesis:
► Fixed: most likely FP-2 or FP-3
► Removable: RP-4 or RP-5
Division C Bone Dimensions-
• Width (C−w bone): 0 to 2.5 mm
•Height (C−h bone):
•Angulation of occlusal load (C−a bone): >30 degrees
•CHS: >15 mm
•Prosthesis:
•Fixed: most likely FP-2 or FP-3
•Removable: ideally RP-5 because of increased CHS
Division D Bone-
• Severe atrophy
Basal bone loss
Flat maxilla, flared maxillary anterior
Pencil-thin mandible
• >20-mm crown height prosthesis
• Fixed: FP-3
•Removable: ideally RP-5 because of increased CHS
CT Determination of Bone DensityD1:
>1250 HU
D2: 850 to 1250 HU
D3: 350 to 850 HU
D4: 0 to 350 HU
D5: <0 HU
CT Determination of Bone Density-

D1: >1250 HU
D2: 850 to 1250 HU
D3: 350 to 850 HU
D4: 0 to 350 HU
D5: <0 HU
Fig:Cone beam computed tomography
determination of bone density inside and
outside of implant
surgical spacerequirements:

1.From adjacent tooth: 1.5mm –to prevent excess interproximal

bone loss
2.From adjacent Implant: 3mm –to prevent excess interproximal
bone loss
3.From buccolingual bone: 1mm
4.From buccopalatal bone: 2mm
5.From gingival margine: 3mm apical to GM for appropriate
crown profile.
6. From inferior alveolar nerve: 2mm
7.From mental foramen : 5mm –to avoid anterior loop of mental
nerve.
Fig: (A) The figures show the ideal range of implant diameters which should be selected for replacing any
maxillary or (B) mandibular tooth
Surgical Armamentarium-
1.Instrument to Incise Tissue-
• Scalpel/Surgical Blades
2. Instruments to Reflect Tissue
3. Instruments to Grasp Tissue
• Adson forceps (pickups)
• Allison forceps
4. Instruments to Remove Bone/Tissue
• Rongeur forcep
• Surgical burs
• Bone file
4. Instruments to Retract Tissue-
• Mirror
• Weider tongue retractor
• Seldin retractor
• Minnesota retractor
• Misch “Spoon” cheek and tongue retractor
• Sinus graft cheek retractor
5. Instruments to Hold Mouth Open
• Bite block
• Molt mouth prop
• Orringer retractor
• Suctions/Aspirators
• General surgical suction
• Fraser suction
• Yankauer tonsil aspirator
6. Instruments to Hold Drapes
• Towel clamp
7. Handpieces/Motors
• Surgical motor console
• Piezosurgery unit
8. Osteotomes
• Pointed
• Progressive osteotomes
9. Sinus Curettes
• Membrane curettes
Pre-Implant Placement Protocols-
Flap Design-
Prior to the placement of implants, the underlying bone and osteotomy site
must be exposed for implant osteotomy preparation and insertion.
1.Full-thickness flap: The most common technique includes a
mucoperiosteal flap, which may involve the buccal, lingual, and crestal areas.
2.Flapless: This technique does not reflect the crestal soft tissue. Instead, a
core of keratinized tissue (the size of the implant crest module diameter) is
removed over the crestal bone. The implant osteotomy is then performed in
the center of the core of the exposed bone. This protocol requires no sutures
around the healing abutment after implant placement.
Surgical Approaches-
Freehand surgery:
This may include the flap or flapless technique, with the clinician placing the
implant with the diagnostic information available (i.e., position of adjacent
teeth, radiographs). Freehand surgery may include the use of nonlimiting
surgical templates,which allow the surgeon the dimensional variability in
implant location because the template will indicate the position of the final
prosthesis; however, it will not specifically guide the placement of the
implant.
Guided:
This type of surgery, which may be performed flap or flapless, guides the
osteotomy from a digitally designed and printed surgicaltemplate.
Bone supported: The template rests on the alveolar bone and this
technique requires the reflection of a full thickness flap.
Tissue (mucosa) supported: The template is supported by the soft
tissue. This type of template is most commonly used with a flapless
technique.
Tooth-supported: This is the most accurate technique and includes
placement of the template directly on the natural teeth for support.
Osteotomy Preparation-
Osteotomy Preparation-
• Irrigation: copious amounts of 0.9% NaCl
• Irrigation solution temperature: refrigerate before use
• Drilling technique: graduated protocol (more drills)
• Intermittent (bone dancing)
• Drilling speed: D1, D2 bone is 1500–2000 rpm; D3, D4 bone is ∼1000 rpm
• Drilling time: greater drilling time, greater heat generation
• Drilling pressure: minimize pressure, never allow rotations per minute to
decrease from excess pressure
• Insertion torque: 35-45 N/cm
 Fig:Number of steps in the preparation of
Fig:Irrigation should use 0.9% NaCl
the osteotomy is related to the bone
density
Generic Drilling Sequence-
Step 1: Pilot Drill
With most surgical systems, a 1.5-mm or 2.0-mm surgical pilot drill is used
to initiate the osteotomy. Pilot drills are end-cutting starter drills used to
most commonly initiate an osteotomy in the center of the ridge in a
mesiodistal and buccolingual dimension. The osteotomy should be
completed with a reduction handpiece (e.g., 16:1 or 20:1 high-torque
handpiece) and an electric motor at a preferred speed of 2000 rpm (i.e., for
D1 and D2 bone) and >1000 rpm (i.e., for D3 and D4) under copious
amounts of chilled saline irrigant. The osteotomy is made no greater than 7
to 9 mm deep in the bone . The rationale for preparation of only 7 to 9 mm
is if the angulation is determined to be nonideal, then it is easier to modify.
Fig:Pilot drill. (A and B) With most surgical systems, the first drill includes a
pilot drill with an approximate diameter of 1.5 mm.
Step 2: Position Verification-
Once the initial osteotomy is prepared, it is assessed for ideal
position. If incorrect, the osteotomy location may be
“stretched” to the proper location by a side-cutting Lindemann
bur. This bur makes the hole oblong toward the corrected
center position. After the new position is obtained, it should be
deepened 1 to 2 mm beyond the depth of the initial osteotomy.
This will prevent the second surgical bur from entering the first
nonideal implant osteotomy. Ideal final implant positioning
should be a minimum of 1.5 mm from an adjacent tooth, 3.0
mm from another implant, and 2.0 mm from a vital structure Fig:Position verification
such as the inferior alveolar canal or mental foramen.
Step 3: Second Twist Drill-
The second drill used is approximately 2.5 mm in diameter, and is an
end-cutting twist drill required for the initial osteotomy to the required
depth. The osteotomy location and angulation are reassessed at this
point. A slight correction of position or angulation with a Lindemann
drill may be completed;however, it should ideally be accomplished after
the first drill.
Fig:(A and B) Second twist drill is used to widen the osteotomy to allow for
larger diameter drills.