CASE SELECTION, DIAGNOSIS

AND TREATMENT PLAN FOR

DENTAL IMPLANT
 CONTENT
• Introduction
• Indication & contraindication for implants
• Diagnosis & treatment planning for implants
• Medical & dental history
• Prosthodontics treatment classification
• Classification of bone density
• Diagnostic aids
• Immediate implants placement
• Indication & contraindication for immediate implants placement
• Protocol for immediate implant planning
• Immediate implant placement technique
• Key elements in immediate implant placement surgery
• Conclusion
• References
 INTRODUCTION
 Proper diagnosis & planning is the key to outcome of any
treatment or therapy.
 Implant-based rehabilitation approach for an edentulous
or partially dentulous condition requires a series of
decisions that are taken to determine whether the patient is
a reasonable candidate for implant therapy.
 The prognosis of implant surgery depends primarily on
the desired prosthetic result.
 Hence, such rehabilitation procedure requires a clear
vision of the end result before the procedure begun.
 INDICATION FOR IMPLANTS
1. Advanced residual ridge resorption, where it is difficult to obtain adequate retention.
2. Where removable partial dentures may weaken the abutment teeth
3. Single tooth replacements where fixed partial dentures cannot be placed OR to avoid
the involvement of abutment tooth.
4. Poor oral muscular co-coordination
5. Low tolerance of mucosa tissue
6. Hyperactive gag reflex elicited by removable prosthesis
7. Patient’s desire & psychological inability to wear the removable prosthesis

Carl E. Misch - Contemporary Implant Dentistry - 3rd Edition (2009)

 CONTRAINDICATION

ABSOLUTE RELATIVE
CONTRAINDICATION CONTRAINDICATION

1. Haematological disorders 1. Pregnancy

2. High dose irradiated patients – 45- 2. Smokers
50 grey of radiation
3. Inability of patient to manage
3. Psychiatric disorder that interfere oral hygiene
with patient understanding.
4. Patient hypersensitive to
4. Debilitating or uncontrolled disease specific components of
where surgery is contraindicated implant.
5. Condition or disease that severely
compromise healing
6. Children below 18 years of age
 DIAGNOSIS & TREATMENT PLANNING
FOR IMPLANTS

PERSONAL HISTORY

• Oral hygiene – Direct effect on the prognosis of therapy

• Habits – Smoking, tobacco chewer, Alcohol - As it directly affects the healing and
osseointegration
• Parafunctional habits like Bruxism – It can induce immense loads on the
prosthesis.
 MEDICAL HISTORY
1. INFECTIVE ENDOCARDITIS - For all invasive procedure follow the antibiotic
prophylaxis.

2. ANGINA PECTORIS –
Unstable Angina – Implant placement should be avoided.
Stable Angina – Implant surgery can be performed with following consideration -
Limit the dose of L.A to 5mL
Follow stress reduction protocol
Patients on stents – use prophylactic antibiotics

Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)

3. HYPERTENSION – Recheck the BP before starting the implant procedure.
Restrict the use of adrenaline
Preferably to use conscious sedation
4. DIABETES MELLITUS – Stress reduction protocol is recommended on
all patients including -
• Early morning appointments,
• Adequate breakfast,
• Pain and anxiety reduction,
• Treatment breaks and possible sedation

 Most common complication during dental procedure is Hypoglycemia which

usually occurs as a result of excessive insulin level due to inadequate food
intake or hypoglycaemic drugs.
 SIGN OF HYPOGLYCEMIA - Weakness, nervousness, tremor ,palpitation or
sweating
5. HYPERTHYROIDISM –

Patients with hyper thyroidism are especially sensitive to catecholamines such as

epinephrine in local anesthetics and gingival retraction cords.
When exposure to catecholamines is coupled with stress (during dental procedures) and
tissue damage (dental implant surgery), an exacerbation of the symptoms of
hyperthyroidism may occur.
The result is termed thyrotoxicosis or thyroid storm.
It is an acute, life-threatening hypermetabolic state clinically presents with symptoms of
fever, tachycardia, hypertension and neurologic and gastrointestinal abnormalities.
6. OSTEOPOROSIS

Implant placement is not an contraindication, immediate stabilization of

dental implants is a common concern because of decreased trabecular
bone mass.
So implant designs should be greater in width and surface conditions of
implant bodies should be designed to increase bone contact and density.
7. BLEEDING DISORDERS

a. Coagulopathies (Deficiencies of clotting factors)

b. Anemias (Sickle cell, Alpha & Beta Thalassemia)
c. Polycythemia vera
d. Thrombocytopenic purpura
e. Neutropenia
 Tobacco smoke

8. LIFE STYLE RELATED – SMOKING

Decreases
polymorphonuclear
 A nationwide oral health survey established a leukocyte activity
definite association between smoking and poorer
levels of periodontal health.
Lower motility, lower rate of
chemotactic migration, reduced
 Protocol suggest by BAIN – phagocytic activity

The patient is instructed to cease smoking for 2 weeks

before surgery to allow for reversal of increased blood All contributes to a decreased resistance to
viscosity and platelet adhesion. inflammation, infection & impaired wound
healing
 DENTAL HISTORY

1. TMJ & Mouth opening

2. Periodontal parameters
3. Jaw relation
4. Occlusion & Dentition
5. Soft Tissue evaluation
6. Hard Tissue evaluation
TMJ & MOUTH OPENING
• It should be adequately ….??

PERIODONTAL EVALUATION
• Plaque and gingival index
• Pocket depth
• Level of oral hygiene

JAW RELATION
• Severe forms of Class 2 and Class 3 require orthodontic treatment and orthognatic surgery.
OCCLUSION & DENTITION

• Evaluate present occlusion for interference

• Diagnose the parafunctional habit – attrition & wear facets
• Occlusal scheme – Canine Guided Articulation / Group Function
• Evaluate Cusp fossa relationships / Cusp marginal ridge relationship
• Interarch space – if inadequate (less than 4mm) – screw retained prosthesis
if adequate – plan for cement retained prosthesis
• In full mouth construction – interocclusal relation should be recorded with occlusal
rims
SOFT TISSUE EXAMINATION
• Unfavourable Frenum & Muscle attachments
• Presence of any lesions
• Width of Keratinized tissue should be evaluated at the implant site.
• The mucosal quality & quantity with the underlying bone can be assessed by palpation and ⁄
or sounding.
• A thick keratinized mucosa is easier to mould for a papillary-like inter-implant trigonum
than a thin, flappy, non-keratinized ridge tissue.
• Sufficient mucosal thickness helps to hide the abutment margin & better facilitates correct
emergence profile of the clinical crown;
 HARD TISSUE EXAMINATION – BONE
• An assessment of the characteristics of the recipient osseous site is critical as the bone
quality & quantity are the two of the most important factors that determine the fixture
longevity.

• Available bone at the site of implant placement–

I. Height
II. Width
III. Length
IV. Angulation
V. Crown height space / Implant body ratio
WID GTH
T H LEN

Carl E. Misch - Contemporary Implant Dentistry - 3rd Edition (2009)

I. HEIGHT

• Measured from the crest of the ridge to the opposing

landmark.
• 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.
• Greatest height of available bone in the maxillary
anterior - Maxillary canine eminence region
• For implant placement, ideally there should be 8-12
mm height.
II. WIDTH

• It is measured between facial and lingual plates at the crest

• It can be evaluated clinically by palpation.
• BONE MAPPING can also provide the idea of ridge width.
• Edentulous ridges that are greater than 6 mm in width have
demonstrated less crestal bone loss than when minimum
bone dimensions are available.
III. LENGTH

• The 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
IV. RIDGE ANGULATION
• Angle of inclination of bone will determine the angulation of the implant.
• This can better seen with CBCT.

V. CROWN HEIGHT SPACE (CHS)

• It is vertical distance from the crest of the ridge to the occlusal plane
• It acts as vertical cantilever. So greater the CHS, the greater the moment force or
lever arm with any lateral force or cantilever
• So to counteract it - greater number of implants or wider implants should be inserted
• CHS should be equal to or less than 15 mm under ideal conditions.
 PROSTHODONTICS TREATMENT CLASSIFICATION

FP – FIXED PROSTHESIS, RP – REMOVABLE PROSTHESIS

 BONE DENSITY
Mechanical immobilization and stress distribution.
Bone density is an implant treatment modifier in several ways:
1. prosthetic factors
2. implant size
3. implant design
4. implant surface condition
5. implant number
6. progressive loading

Carl E. Misch - Contemporary Implant Dentistry - 3rd Edition (2009)

 CLASSIFICATION OF BONE DENSITY

LINKOW AND CHERCHEVE

Class I – Ideal bone type consisting of evenly spaced trabeculae with small
cancellated spaces
Class II – Larger cancellated spaces with less uniformity of the osseous pattern
Class III – Larger marrow filled spaces exist between trabeculae

NOTE – Linkow stated that class 3 bone result in loose fitting implant, class 2
bone was satisfactory for implant while class where found to be idal for
implant prosthesis.
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.
MISCH BONE DENSITY CLASSIFICATION

MAPLE WOOD WHITE PINE BALSAWOOD STYROFOAM

 DIAGNOSTIC AIDS

DIAGNOSTIC CAST

• Proper mounting of diagnostic models are helpful

in treatment planning and projecting goals to the
patient pre-operatively.
• They also aid in the retrospective analysis of the
progress of therapy.

Carl E. Misch - Contemporary Implant Dentistry - 3rd Edition (2009)

 DIAGNOSTIC WAX UP

• Techniques used to determine the location, angulation,

and contours of the final prosthesis are initiated by the
completion of a diagnostic wax-up.
• Diagnostic wax-up is completed for the desired contour,
occlusal scheme & esthetic aspects of the final
restoration.
• Procedures vary from being simplistic (single missing
tooth) to rather complex (full-mouth rehabilitation).

Diagnostic wax-up for a partially edentulous patient &

fully edentulous patient.
Carl E. Misch - Contemporary Implant Dentistry - 3rd Edition (2009)
 DIAGNOSTIC & SURGICAL TEMPLATES
 The purpose is to incorporate the patients proposed treatment plan into the
radiographic examination
 Rationale for Using Templates
a. To correlate the positioning of the implant in relation to the available bone
b. Precise placement of implants & prosthesis must be determined
c. Conservation of anatomic structures.
d. Less invasive, flapless surgery, and, therefore, less chance of post operative
swelling
e. Transparency of material which allows seeing through the model
f. Less postoperative strain on dentist and patient

Kola, M. Z., Shah, A. H., Khalil, H. S., Rabah, A. M., Harby, N. M. H., Sabra, S. A., & Raghav, D. (2015). Surgical templates for dental
implant positioning; current knowledge and clinical perspectives. Nigerian journal of surgery, 21(1), 1-5.
TYPES OF DIAGNOSTIC TEMPLATES

1. VACUFORM TEMPLATE

• The proposed restoration on the diagnostic wax-up is coated with a thin film of
barium sulfate. This coating should be done before the fabrication of template.
• On CT examination, restorations become evident but exact position.
• Blend 10% barium sulfate & 90% cold cure acrylic are used to fill proposed
restoration sites in vacuform of diagnostic wax-up However, the precise position
and orientation of proposed implant cannot be identified
• The previous design is modified by drilling a 2 mm channel through the occlusal
surface of the proposed restoration using a twist drill. This corresponds to the
ideal position and orientation of the implant and is identified on CT examination.
2. ACRYLIC TEMPLATE

• Diagnostic wax-up provides an acrylic template.

• This is modified by a thin coating of barium sulfate, and a hole
drilled the occlusal surface of proposed restorations followed
by filling this hole by gutta-percha.
• This provides radiopacity of the proposed restoration on CT
examination
• Precise position and orientation of proposed implant may be
identified by radiopaque plug of gutta-percha.

Kourtis, S. (2018). A New Type of Radiographic Template for Presurgical Radiographic Examination in Implant
Restorations. J Dent Oral Disord, 4(1), 1084.
3. TEMPLATE FABRICATED WITH
RADIOPAQUE DENTURE TEETH

• These radiopaque denture teeth are specifically

manufactured for implant imaging purposes and are
used for the diagnostic wax–up and subsequently
are incorporated into the template.
• If acceptable, it may be modified into a surgical
template at a later stage.
• This serves to transfer these findings to the patient
at the time of surgery.
 CLASSIFICATION OF RADIOGRAPHIC
IMAGING TECHNIQUES

 The Goal of radiographic imaging in implant dentistry is to acquire the most practical and
comprehensive information that can be used for the various phases of implant treatment.

PHASE 1 - PRESURGICAL & DIAGNOSTIC IMPLANT IMAGING

• It involves all past radiologic examinations and new radiologic surveys chosen to assist the
implant team in determining the patient’s final comprehensive treatment plan.

Objectives of Preprosthetic Imaging

• Identify pathology
• Determine bone quality
• Determine bone quantity
• Determine ideal implant position
• Determine ideal implant orientation
PHASE 2 - THE SURGICAL AND INTRAOPERATIVE IMPLANT IMAGING
• It focused on assisting in the surgical and prosthetic intervention of the patient

PHASE 3 - POSTPROSTHETIC IMPLANT IMAGING

• This phase commences just after the prosthesis placement and continues indefinitely.

Phase 1 Phase 2 Phase 3

• Pre surgical implant • Surgical or • Post prosthetic implant
imaging intraoperative imaging imaging
• It helps in treatment • It assists in surgical • It helps in maintenance
planning intervention plans
• It helps in evaluating
the osseointegration

Carl E. Misch - Contemporary Implant Dentistry - 3rd Edition (2009)

 TYPE OF IMAGING MODALITIES

Carl E. Misch - Contemporary Implant Dentistry - 3rd Edition (2009)

PERIAPICAL RADIOGRAPHY

• Evaluation of small edentulous spaces

• Alignment and orientation during surgery
• Recall and maintenance evaluation
ORTHOPANTOMOGRAPHY (OPG)

• It is the most utilized diagnostic element in implant dentistry.

• It offers many advantages:
1. Easy identification of opposing landmarks
2. Initial assessment of vertical height of bone.
3. The procedure is performed with convenience, ease and speed.
4. Gross anatomy of the jaws and any related pathologic findings could be evaluated
CONE BEAM COMPUTED TOMOGRAPHY (CBCT)

1. 3 dimensionally the available bone can be evaluated

2. Density of available bone
3. It produces a highly detailed, distortion-free image.
4. It helps in precisely locating vital structures and evaluating
alveolar ridge topography.
5. Pathology in relation to implant site
6. Evaluation of remaining teeth present
7. They can be used to fabricate CAD-CAM generated
precise surgical stents. FIG - Cone-beam computed tomography reformatted
images. A, Axial. B, Coronal. C, Sagittal
 SURGICAL PROTOCOLS FOR
IMPLANT PLACEMENT

• The surgical placement of implants can be performed by using a flapless

approach or alternatively raising a full-thickness mucoperiosoteal flap for
implant insertion.
Conventional surgical implany placement
• It involves raising a full-thickness flap,ensuring adequate visibility and access to
the alveolar ridge, as well as identification of anatomical landmarks and vital
structures.
• Using a surgical guide may assist in optimal placement.

Ho, C. C. (2021). Surgical Protocols for Implant Placement. Practical Procedures in Implant Dentistry, 173-180.
Implant Positioning - “Prosthodontically Driven”

Determining the size and length of the implant is based on the analysis
of the bony anatomy
Mesio-distal position: The implant should not be closer than 1.5 mm to
an adjacent tooth and not closer than 3.0 mm to an adjacent implant.
Bucco-lingual/palatal position - The aim is to have sufficient bony
envelope surrounding the implant with at least 1.5 mm bone on the
labial side & 1 mm on the palatal
Apico-coronal position: The implant shoulder is positioned 3 mm
apical to the emergence of the future restoration. Placing the implant
too shallow may lead to metal show-through of componentry, and too
deep may lead to adeep peri-implant pocket.
• The surgeon should perform the osteotomy in an atraumatic technique, ensuring no
overheating of the bone, which may cause necrosis of the bony ridge.
• This should be achieved by cooling the drills with fluid irrigation, as well as the use of
an intermittent pumping motion whereby drills are inserted intermittently so bone is not
constantly under pressure and heat generation.
• Drill sequence: Depending on the diameter and length of the implant chosen (Drill
speed ranges from 600 to 1500 rpm)
• Use of thread former/screw tap: In cases of dense
bone it may be necessary to form threads within the
bone to lessen the insertion torque.
• These thread formers are normally used at 25 rpm,
and need to be reversed back once to depth.
• Inserting implant: The implant is inserted at a speed
of 20–25 rpm and cover screw is placed
 IMMEDIATE IMPLANTS PLACEMENT

• According to international congress of oral implantology , immediate implants

is defined as placement of dental implant at the time of tooth extraction, into
the extraction socket
• Concept was described by SCHULTE & HEIMKE in 1976
• It is now becoming a common strategy to preserve bone.
• On one hand, it shortens treatment time and can improve esthetics because the
soft tissue envelope is preserved
 INDICATIONS

Block and kent, 1991 summarized the indications & contraindication-

1. Traumatic loss of teeth with a small amount of bone loss
2. Tooth lost because of gross decay without purulent exudates or cellulites
3. Inability to complete endodontic therapy
4. Adequate soft tissue health to obtain primary wound closure.
5. Tooth which are compromised by dental trauma, root fractures/root fissures,
endodontic complications, root resorptions,etc
6. It is limited to sites with 3 or 4 alveolar walls with a minimum of
circumferential defect.
7. Presence of at least 3 to 5 mm of residual bone beyond the apex and a
minimum bone height of 10mm for primary implant stability.
 CONTRAINDICATION

1. Lack of adequate bone apical to the tooth being extracted

2. Presence of granulation tissue
3. Local bone infection
4. Poor anatomical configuration
5. Adverse location of vital structure
 PROTOCOL FOR IMMEDIATE IMPLANT
PLANNING

EOA proposed the 5 triangle concept in 2014

1. Presence of a buccal plate,

2. Primary stability,
3. Implant design
4. Filling of the gap between the buccal plate and the implant,
5. Tissue biotype.
 IMMEDIATE IMPLANT
PLACEMENT TECHNIQUE

Step 1: Clinical and Radiographic Examination

Step 2: Atraumatic Tooth Extraction
Step 3: Curetting the Extraction Socket
Step 4: Evaluating the Extraction Socket for Remaining Walls
Step 5: Immediate Implant with Bone Graft
Step 6: Temporary Abutment and Crown Placement
 KEY ELEMENTS IN IMMEDIATE IMPLANT
PLACEMENT SURGERY
 Delicate starting with a pilot drill; because of the hardness of the palatal wall,
there is a risk to slip into the socket and perforate the buccal bone plate.

 To avoid this problem, two techniques have been proposed:

1. Round bur technique
2. Trepan technique

Amine, M., El Kholti, W., Laalou, Y., Bennani, A., & Kissa, J. (2018). Immediate implant placement: a review.
J Dent Forecast. 2018; 1 (2), 1013.
1. ROUND BUR TECHNIQUE - It is indicated in cases of immediate implantation without or
with minimal tissue loss.

 The drilling is initiated with a small round bur about 1/3 of the apex on the palatal wall of the
socket.
 The drilling is then carried out keeping a palatal direction with respect to the tooth axis.
 However, it would be not possible to recover the bone
 And it must be completed by a grafting material in cases of residual space greater than 2mm.
2. TREPAN TECHNIQUE

It allows better axis implant control with recovery of

the bone for further filling
During implant site preparation, the drilling should
extend beyond the socket to optimize the implant
primary stability.
In the cases of an apical lesion, drilling should be
performed beyond this lesion in order to remove
infected tissue and to achieve a reliable anchorage in
the healthy tissue.
 Reduces the
number of
surgical
Decreased procedures. Osseointegrati
treatment on is more
time. favorable

High patient
satisfaction – Width and
Immediate height of
psychological
advantage Implant alveolar bone
Placement - are preserved.
Advantages

Preservation Provide
of the soft better
tissue drape esthetics

Decreased Improve
need for Implant
bone positioning
augmentation
 DISADVANTAGES

1. Site morphology - mesiodistal and buccolingual dimensions are usually much different from the
implant diameter.
2. Surgical technique is more complicated – difficulty in preparing the osteotomy site due to bur
movements
3. Difficulty to predict the final position of the implant ( in case of multirooted teeth).
4. Anatomic limitations - It is often necessary to deepen the osteotomy 2 to 4 mm apical to the
existing extraction socket to obtain primary stability.
5. Lack of primary closure – inadequate soft tissue coverage
6. Persistence of acute/chronic pathology like residual bacterial, excudate which lead to implant
failure
 CONCLUSION

 Implants have become the treatment of choice in most of the situations when missing teeth
require replacement
 The treatment planning for an implant restoration is unique regarding the number of
variables that may influence the therapy.
 With appropriate diagnosis and treatment planning, the use of endosseous oral implants
enjoys good prognosis.
 REFERENCES
1. Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)
2. Carl E. Misch - Contemporary Implant Dentistry - 3rd Edition (2009)
3. Gowd, M. S., Shankar, T., Ranjan, R., & Singh, A. (2017). Prosthetic consideration in implant-supported prosthesis: A review
of literature. Journal of International Society of Preventive & Community Dentistry, 7(Suppl 1), S1.
4. Begum, Shaesta & Peeran, Syed. (2021). 66. Diagnosis and Treatment planning-Dental Implants. Essentials of Periodontics
and Oral Implantology.
5. Ho, C. C. (2021). Surgical Protocols for Implant Placement. Practical Procedures in Implant Dentistry, 173-180.
6. Ebenezer, V., Balakrishnan, K., Asir, R. V. D., & Sragunar, B. (2015). Immediate placement of endosseous implants into the
extraction sockets. Journal of pharmacy & bioallied sciences, 7(Suppl 1), S234.
7. Amine, M., El Kholti, W., Laalou, Y., Bennani, A., & Kissa, J. (2018). Immediate implant placement: a review. J Dent
Forecast. 2018; 1 (2), 1013.
8. Swathi, K. V. (2016). Immediate implants placement-A review. Journal of Pharmaceutical Sciences and
Research, 8(11), 1315.
9. Kola, M. Z., Shah, A. H., Khalil, H. S., Rabah, A. M., Harby, N. M. H., Sabra, S. A., & Raghav, D. (2015). Surgical templates
for dental implant positioning; current knowledge and clinical perspectives. Nigerian journal of surgery, 21(1), 1-5.
10. Kourtis, S. (2018). A New Type of Radiographic Template for Presurgical Radiographic Examination in Implant
Restorations. J Dent Oral Disord, 4(1), 1084.
THAN
K YOU