Diagnosis and Treatment Planning in Implant Dentistry Question And Answers

Dental Implants Diagnosis And Treatment Planning Question And Answers

Oral implants are an alloplastic material or device that is surgically placed into the oral tissue beneath the mucosal or periosteal layer or within the bone for functional, therapeutic, or aesthetic purposes.

Types Of Dental Implants

1. Mucosal insert
2. Endodontic implant (stabilizer)
3. Sub-periosteal implant
4. Endosteal or endosseous implant
   • Plate-form implant
   • Ramus-frame implant
   • Root-form implant
   • Cylindrical implant
   • Theaded implant
5. Transosseous implant

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Implant Design

• Macro Design: Implant length and diameter are directly proportional to its surface area and enable greater bone-to-implant contact.
• Implant Body Shape
  • Cylindrical shaped implants
  • Tapered implants.
  • Pitch, the number of threads per unit length, is an important factor in implant osseointegration.
  • Increased pitch and increased depth between individual threads allow for improved contact area between bone and implant.
  • Implant length, diameter, and thread design along with site parameters like bone quality (density) and quantity determine primary stability.
• Micro Design: Moderately rough surfaces with 1.5 µm improved contact area between bone and implant surface and facilitate adhesion and migration of bone cells onto the implant.

Patient Evaluation

• Patient’s History
  • Chief Complaint: Helps to ascertain problems with present prosthesis and patient expectations.
  • Medical History: A detailed medical history determines past and current diseases, temporary and long-term medication, habits that may be a contraindication for implant placement due to increased risk for patients undergoing the surgical procedure and/or interfere with wound healing and place the patient at higher risk for implant failure.
  • Dental History: History of any existing/past prosthesis and the presumed reason for tooth loss. Patients with periodontal history are at higher risk for potential peri-implantitis leading to late implant failure.

Clinical Examination

• Extra-oral Parameters

1. Evaluate facial proportions and facial symmetry
2. Facial skeletal classification (normal, prognathic, retrognathic)
3. Check the relation of the upper and lower lip to the esthetic plane (line from the end of the nose to the chin)
4. Intermaxillary relation—occlusal vertical dimension (correct, reduced, increased); interocclusal distance in rest (correct with 2–4 mm, reduced, increased)
5. Incisal edge position of the maxillary centrals with respect to mandibular central and occlusal plane
6. Temporomandibular joint movement and function, muscles of mastication.

• Intra-oral Examination: The intra-oral examination comprises:

1. Dental examination including existing restorations and reconstructions, decayed and filed teeth, oral hygiene assessment, periodontal exam, and dental pulp test; detection of malpositioned teeth; midline between upper central incisors corresponding to the philtrum position.
2. Edentulous regions—ridge defects (vertical, horizontal, combined), crown-to-bone relationship (distance between the ideal position of the clinical crowns and the underlying bone), defect compensation with soft and/or hard tissue feasible.
3. Quality/quantity of the mucosa and contour of the underlying bone—any pathologies and pressure spots are recorded and the magnitude of the alveolar ridge resorption is examined. The mucosal quality and quantity with the underlying bone can be assessed by palpation and/or sound.
4. Existing prosthesis—esthetics, fi of the prosthesis, inter/intramaxillary relation, size/form/ position/color of denture teeth.
5. Occlusal status and functional exam—the diagnosis of parafunctional habits (bruxism, clenching) can be deduced from clinical findings of muscular tension and hypertrophy, dental abrasion, attrition, and wear facets.

Diagnostic Aids

• Radiologic Diagnosis
  • Pre-operative radiographs are required not only to evaluate the existing bone quantity but also to identify neighboring anatomic and topographic structures which have to be preserved.
  • Panoramic radiographs are used to evaluate for anatomic landmarks such as mandibular canal, maxillary sinus floor, and mental foramina.
  • Periapical radiographs are however better indicators of crestal bone level or the presence of any periapical pathologies, existing infection at the edentulous site.
  • Computer tomography gives us a three-dimensional view of the anatomic landmarks. Its indications include the need for maxillary sinus augmentation and in computer-aided implant surgery.
• Study Casts
  • The clinical situation is normally analyzed with the aid of study models.
  • The amount of bone resorption in the horizontal and vertical dimensions can be estimated by the ideal placement of the proposed teeth in the set-up in relation to the presenting anatomical situation (‘‘crown to bone relationship’’).

Treatment Planning

• Treatment planning for implants will necessitate the above-mentioned diagnostic aids.
• It is however important to complete all other restorative, periapical, and periodontal pathology management prior to implant placement.

Implant Placement

• A detailed description of the surgical procedures and the associated complication is beyond the scope of this book.
• Briefly, implant placement can be performed as a single-stage procedure or a two-stage procedure.
• In the conventional two-stage procedure, the implant is submerged into bone and soft tissue and left undisturbed for the required healing period.
• During the second stage, the soft tissues are surgically uncovered to complete the restorative process.
• In a single-stage procedure all this is not required as the abutment is left exposed in the oral cavity.
• Immediate placement of implants refers to the placement of implants immediately after extraction in extraction socket in the same sitting.
• The proposed advantages of this type of placement include preservation of crestal bone and better patient compliance.
• However, this cannot be undertaken in the presence of acute infections or any such local contraindicatory factors.

Question 1. Describe peri-implantitis and its management.
Answer:

Peri-Implant Disease

• Diseases of the peri-implant tissues can be broadly classified as peri-implant mucositis and periimplantitis.
• Peri-implant mucositis is a gingivitis-like condition that involves only the soft tissue surrounding the implant. This may be a reversible condition that is largely plaque related in etiology.

Peri-implantitis: It occurs as a result of the extension of inflammation into the deeper structures and is associated with bone loss around the implant. Its clinical features are the presence of inflammation, increased probing depth, bone loss, suppuration, pain, and mobility of the implant.

Management of Peri-implantitis

• CIST Protocol: Cumulative interceptive supportive therapy (CIST) protocol was formulated by Lang et al. 1998 for the management of peri-implant disease. The protocol included four treatment modalities:
  • Mechanical debridement
  • Antiseptic treatment
  • Systemic or local antibiotic therapy
  • Regenerative/resective surgery.