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Examination, Diagnosis, and Case

selection

Contents
Diagnosis
Medical history
Dental history
Oral examination
Radiographic examination
Additional bone evaluation
Consultation

Case selection
Single tooth replacement

objectives
Increase the ability of each candidate to diagnose
and select the suitable cases for implants.
Be able to select the best treatment option predictably.
Give you step by step the best way in single tooth
replacement with implants

indication
Implant is indicated as a treatment option available for
any patient, regardless of sex or age.
The exceptions for this treatment are patients with
chronic diseases, or abnormalities of mucosal
membrans and/or jawbones.
Osseointegrated implant is ideal treatment for patients
unable to wear complete denture.

contraindications
Absolute contraindications for osseointegrated implants
High dose irradiated patients
Patients with psychiatric problems
Hematologic system disorders.

Relative contraindications
Pathology of the hard and soft tissues
Patients with drug, alcohol, or chewing tobacco abuse
Patients with chronic disease such as diabetes or high
blood pressure.

Diagnosis
It is important that the general physical condition of the
patient is checked accurately in order to obtain an overall
health assessment.

Medical history
Dental history
Radiographic study
Study cast
Photographs

All of them are essential in treatment


planning

Medical history
Determine if the patient is currently under
the care of a physician
Determine if the patient has ahistory of
abnormal bleeding tendences.
Determine if the patient is under care for
psychological problems

Dental history
Extraction dates should be verified if they were
within a minimum of three months.

Oral examination
A thorough oral examination should include
evaluation of soft tissue condition

Radiographic examination
Radiographs help determine the quantity and quality
of residual ridge bone
Necessary radiographs include
periapicals
occlusals
orthopantograph
cephalometric
CT-Scan

Fabrication of radiographic splint

Additional bone evaluation

To important points for implant placement:


Biological points
Biomechanical points

Biological points includes:


Consideration of biological width.
Presence of enough and healthy mature bone.
Esthetics consideration

Consideration of biological width.

Biological width formation.


Bone loss of 1.5mm 2.0mm in vertical direction
Bone loss of 1.5 mm in horizontal direction

In response to the micro gab 6 weeks after connection


of the healing abutment
In will control clinical trials

Presence of enough and healthy mature bone.

10-12 weeks after extraction befor stage I


Esthetics consideration

Smile line

Case selection

Case selection
Clinical Findings
Diagnosis
Definition
Thearapeutic Goals
Treatment Considerations
Outcomes Assessment

Treatment Planning
Treatment options

Chief Complaint
I want to have my upper front teeth treated or replaced
and clean the other teeth because I dont want to loss
them

Medical History
Medication: Non
Allergies: Non
Social History: Normal
Head and Neck: Normal
Extra-oral Examination: Normal

Intra-oral Examination:
Bucal Mucosa: Normal
Gingiva: Moderate inflamation
Bucket Depth: 4 5 mm average
Teeth mobility: Grade II &III in the upper arch

Past dental history


Missing teeth:
Amalgam rest. On teeth :
RCT for teeth:
Apicoectomy of tooth:

#1, #15, #29, #30, & 32.


#2, #3, #4, #14, #18, #20, & #21.
#3, #10, #12,#13, & #19.
#10.

Post and core on teeth:

#3, #10, #13 & #19.

Crown and bridge


Single crowns teeth:
4unit PFM bridge on area:
Fistula apical to tooth:
Periodontal surgeries

#10, #13, #19.


#28 - #31.
#9

Diagnosis
Early-onset periodontitis(EOP) OR Aggressive periodontitis
These terms are used to describe deferent forms of clinical
entities which occurs in localized or generalized forms.

Definition
Aggressive periodontitis encompasses distinct types of
periodontitis that affect people who, in most cases otherwise appear
healthy. It tends to have a familial aggregation and there is a rapid
rate of disease progression. Aggressive periodontitis occurs in
localized and generalized forms.

Treatment Planning

Maxilla Option 1
Periodontal treatment that include SRP, antibiotic therapy
and Perio Surgeries if needed.
Extraction of teeth no.#1, #2, #4, #5, #7, #8, #9, #10, #12, #13
&#16.
Fabrication of metal reinforced provisional using teeth
no#3, #6, #11& #14 as abutments extended from tooth #3 to
#14.
Bilateral sinus grafts if needed
Placement of 8 implants ,4 in each side to support 12 PFM
separated FPD.

Mandibular option 1
Periodontal treatment that include SRP, antibiotic therapy
and Perio Surgeries if needed.
Extraction of tooth #19.
Resin bonded bridge to replace tooth #19.
Fabrication of metal reinforced provisional to replace the
existing bridge #28 - #31 to adjust the occlusion.
Placement of implants in area #19, #29& #30.
Crowning of teeth #28 & #31.

Single tooth replacement

Single tooth replacement


Advantage of using implant to support single crown
over conventional tree unite bridge:
Preservation of tooth structure
predictability
longevity
Preservation of the same occlusion
Less chair time
Less pain and discomfort
No open margin

Disadvantage of using implant to support single crwon


over conventional tree unite bridge
cost
Patient medical history
Clinical set up

Single tooth replacement:


Non aesthetic zone
All the teeth other then the upper anterior
teeth

Aesthetic zone
Upper anterior teeth

Non aesthetic zone

Aesthetic zone

Over denture

introduction

Over 50% of mandible complete dentures


have problem with stability and retention.
Redford
J Dent Res 1996

There are strong clinical evidence that an


over denture should be considered wherever
possible.
It has been shown that attachment retained
over dentures(roots/implants) are within the
current skill level of virtually all general
practitioners.

Advantage of overdenture:
Reduced bone resorption
Better chewing efficiency
Retention of proprioception (root
implant )
Stability of denture
Patient has better control of occlusion
Speaking efficiency

Reduced resorption, better chewing, and speaking


efficiency are all caused by the retention of
proprioception.

Because overchew may traumatized the


ridge.

These advantages are true of over dentures in


general, wither they sit in root copings or
attachments. Regardless of the predictability and
longevity of the roots spurting the copings and or
attachments

Because of the very high success and survival


rate of implants compairing to roots, the use of
implants to support over denturewill eliminates
the disadvantages arises from the generally week
roots and incorporate amore strong and
predictable foundations

Implant options for the Edentulous


patient
Over denture with Retentive Anchor.
Over denture with Bar Attachment.
Fixed Bridge Screw Retained.
Fixed Bridge Cement Retained.

Implant over denture reconstruction:


Appropriate
Affordable
The minimum that will solve the
problem

Adaptable to changing
circumstances:
-additions
-clean ability

Edentulous patients Expectations from


Implant supported prosthesis:
Efficient dental function ( mastication
and speech)
Comfortable (absence of pain during
function)
Aesthetic (natural tooth appearance
soft tissue support
Social confidence
Reduced bone resorption

Chick list:
Extra oral

Fixed

Removable

Lip line

Low

High

Tooth

Little(6)

Distinct>8

display
Facial
support

No need necessary

Intra Oral

Fixed

Removable

Ridge shape

Vertical

Buccal
concavity

<10 mm

>15mm

Inter maxillary distance


Inter max relation

Neutral Skeletal 3

Factor influencing choice of fixed


maxillary prosthesis design:
Adequate available bone and soft

tissue to provide support without


acrylic resin flanges.
-Enough bone volume to support the
correct number of implants.
Enough bone height.
Patients insistence on fixed design.

Reasons to use Removable:


Fewer number of implant required.
Increase buccal and vertical bone loss.
Need for additional lip support.
High smile line.
Speech problem associated with some
fixed prosthesis.

Reasons to use Removable :


ease of hygiene procedure.
ease of repair of prosthesis.
economic issues.
less stress for Bruxer.
ease of future modification.

Advantages of Implant Retained


Over denture:
-Superior Aesthetic dental and facial
tissues
-Oral Hygiene simplified maintenance
-Good masticatory function
-Social confidence

Where it can be used?


Bruxer,both vertical and horizontal.
Fully edentulous.
Partially edentulous.
Cost effective.

The cost of dental implant as compared


to that of conventional strategies
Van der Wijk,
IJOMI 1998;546

Conventional denture in lower


over denture

-mandibular implant over denture vs conventional


denture

.2implant with bar


.4implant with bar
-DiD not compare 2implant w/out bar

Result:

-4Implant +bar vs conventional 7times.


-2Implant +bar vs conventional 4times.
-2Implant with ball attachments 2times.

Concluded the cost effectiveness of dental


implant overdenture would be more
favorable than natural tooth overdenture

Mencske_stern
JPD 1994;543

HOW many implant should be


placed for overdenture?

That is Controversial and no


supporting evidence for it

Criteria for overdenture


Analysis:
.resorption pattern of mandible
.interarch space
.nature of opposing occlusal tables
.number of implant required to provide
support
.types of attachment to be used
.occlusal concept and load transfer to
implant

Peri _implant mucosal aspects of ITI


implant supporting overdenture
A five _year longitudinal study

Mericska_stern,COIR
1994:9_14

That is also controversial

IMPLANT SUPPORTING OVER


DENTURE IN ELDRLY PATIENTS MAY
BE MAINTAINED WITH HEALTHY
PERI IMPLANT TISSUES OVER
5YEARS IRRESPECTIVE OF THE
PRESENCE OR ABSENCE OF
KERATINIZED MUCOSA

Attachments for over denture are


generally classified as:
Studs and bars
Which attachments should you use

There are four consedrations:


How much inter occlusal space is there
Do you need to splint the abutments
The nature of oposing dentitoin
cost

Factors related to success and failure


rates in a multicenter study of over
denture supported by Branemark implant
Hutton,Jemt
IJOMI 1995;33

Conclusions:
.mandibular overdenture faillures 3,3%
.maxillary overdenture faillures 27%
.cast bar with parallel sided or oval shape

.4implant in maxilla
.1-4 retention clips
.extension bars

Reasons for fails:


1-cast bar with parallel sided or oval shape
2-4 implant only in maxilla
3-(1-4)retentive clips with extension bars

A 5-year Prospective Multicenter


Follow Up Report on Overdenture
Supported by Osseointegrated
Implant
Jemt,IJOMI

1996;11:291

Maxillary overdenture Survival


Rate:
Enquist

1988

81%

Jemt

1992

83%

Hutton

1995

72%

Jemt

1996

72%

Denture problems:
.reduced stability
.insufficient retension
.impaired load bearing capacity

Most Popular Attachments:


.Bar and clip
.Stud attachment
.Magnet

Photoelastic stress pattern produced


by implant retained over denture:
Kenny,R
JPD 1998;559

Conclusion:
.Ball /o_ring attachments transferred

less stress to implant than the bar clip


attachments when the photoelastic
model can subjected to a posterior
vertical load

Attachment guide lines:


.2 implant :6 prosthetic movements-bar with
o_ring
.3 implant :3-6 prosthetic movements -bar
with o_ring
.4 implant :2-3 prosthetic movements Hader
bar or Dolder bar attachments
.5-6 implants Hybrid case depend on APspread

Four implant overdenture:


Joint implant mucosal_supported
Allows ease of rotation
Resilient attachment
.full palatal coverage
cast metal framework

six implant over denture:


.primarily implant supported
.no rotation
.no fulcrum line
.metal frame work
.palate open

Attachment used with a minimum


number of implant are dependent on
the soft tissue and the relative
movements that may be allowed by
different support ,these attachments
should be durable and easily replaced

Prosthetic Components
less is better
The more components the more Surgical
and Diagnostic error

Treatment Planning:
.patient desires
.smile line /aesthetic demands
.condition of remaining /opposing dentitions
.occlusion/bruxer/smoker
.mounted models/wax up
.dental scan
.evaluation_surgeon/restorative

Diagnostic Phase:
.clinical examination
.occlusal analysis(bruxer)_mounted
diagnostic casts
.provisional wax up _final tooth position
.radiographic stent with marker
.dentascan _analyze with simplant
.modification of diagnostic stent for surgery
.fixture installation

Diagnosis:
.smile line:high/low
.tissue:thin /thick
.implant/implant
.implant/tooth (contact area greater
than 5mm,nice gingival papilla for
aesthetic reason)
.inter proximal height bone

Preoperative Evaluation:
.opposing occlusion
.number of teeth to be replaced
.implant size /number
.implant arrangement
.bone quality/quantity

Clinical determinants:
.phonetics
.musculature support _lip
.ease of hygiene _extent of
cantilevering
.trial tooth set up

Diagnostic wax up determinants:


.physiologic occlusal vertical dimension
.maxillomandibular relationship
.tooth form
.embrasure determination

Surgical Templates
Are they necessary?
Transfer of prosthetic parameters
.soft tissue emergence profile
.arch form
.vertical dimension-----lead to ideal
placement
.occlusal plane

Implant Restoration :Achieving


Optimal Occlusion AND Esthetics in
Implant Dentistry
Hebel,K.J Prosth Dent 1997;28
.Due to increase in implant survival
rates,the issue of retrivability has not
been as clinically significant

Single Missing Tooth

Treatm ent options


.resin retained fixed partial denture
.fixed partial denture
.removable partial denture
.implant supported single crown

Resin Retained FPD Advantages:


.less tooth preparation
.fixed prosthesis
.short treatment time
.low cost

Resin Retained FPD Disadvantages:


.risk of debonding
.risk of sensitivity
.technique sensitivity
.longevity

Removable Partial Denture


Advantages:
.cost
.familiar

Removable Partial Disadvantages:


.removability
.caries risk
.periodontal risk
.bulk
.speech
.chewing

Fixed Partial Denture Advantages:


.predictability
.familiar

Fixed Partial Denture Disadvantages:


.caries risk
.periodontal risk
.endodontic risk
.maintenance
.esthetic risk