Implant Planning and Placement

Question 1

What is a dental implant?

Answer 1

Screw that is placed into the maxilla or mandible, that replaces the root of a tooth.

Coronal restoration placed within the screw to replace the missing tooth.

Question 2

What is osseointegreation?

Answer 2

A direct functional and structural connection between a load bearing dental implant and living organised bone

Question 3

What are the two stages of osseointegration?

Answer 3

Primary osseointegration
- implant is anchored in bone due to frictional forces provided between osteotomy and dental implant design features

Secondary osseointegration
- The process of a functional connection between bone and a dental implant. Living bone grows onto the surface of a dental implant.

Question 4

Describe the healing process following implant insertion?

Answer 4

Osteoclasts will remove the bone that is damaged during the placement of the implant

Then osteoblasts will create new bone during secondary healing in osseointegration.

Question 5

What are the supra-crystal soft tissue differences between tooth and an implant?

Answer 5

Tooth- more fibroblasts, less collagen.
- Collagen fibres orientated perpendicular to root surface.

Implant- less fibroblasts, more collagen.
- collagen fibres orientated parallel to implant crown.

Question 6

What are the sub-crystal differences between tooth and implant?

Answer 6

Tooth- anchored to bone via periodontal complex.
- capable of physiological adaptation
- Resilient tissue attachment.

Implant- anchored to bone by direct functional contact.
- No physiological adaptation
- Rigid connection.

Question 7

What materials are used for dental implants?

Answer 7

Titanium- pure type 4 titanium, produces titanium dioxide.

Titanium Zirconia- increased strength compared to Ti

Ceramic- Yttrium stabilised Zirconia.

Question 8

Under what circumstances with you want to use bone level and tissue level implants?

Answer 8

Bone level- aesthetic areas
Tissue level- used posteriorly

Question 9

What might an implant’s surface be treated with before placement?

Answer 9

Sand blasting
Acid etch
Plasma spray

Question 10

What are the advantages and disadvantages of implant surface treatments?

Answer 10

Advantages- good for osseointegration

Disadvantages- Peri-implantitis occurs, recession, microbes can accumulate on the surface of the implant.

Question 11

What are the primary aims of a dental implant?

Answer 11

Replace missing teeth with aesthetic, functional and predictable restoration

Low rate of complications during healing and maintenance period

Long term stability

Question 12

Describe the process of patient assessment for an implant?

Answer 12

C/O
HPC
Motivation
Medical history
Dental history
Social history
Age/skeletal maturity

Mouth level
- E/O and I/O

Site level

Question 13

What aspects of the presenting complaint would you want to address?

Answer 13

Will implants address the patients presenting complaint?

What is the patient’s expectations?

Are they realistic?

Can you achieve them with implants?

Question 14

What aspects of the patient’s medical history would you want to know?

Answer 14

ASA classification

Meications
- SSRI’s
-PPI’s
-Bisphosphonates
-Steroids

Radiotherapy

Poorly controlled diabetes

Cardiovascular disease

Question 15

What aspects of social history would you want to know?

Answer 15

Are they a smoker?
- implants more like to fail and increased risk of peri-implantitis.
- More cigarettes you smoke, the more likely they are to fail.

Question 16

Why are implants in a smoker more likely to fail?

Answer 16

Vascularity
Fibroblast/osteoblast function
PMN function

Question 17

What aspects of dental history would you want to know?

Answer 17

Regular attender?
Motivation
OH status
WHat treatment has the patient accepted in the past?
Bruxism?

Question 18

Does age matter with implant placement?

Answer 18

All implants should be placed after cessation of growth.

Question 19

What are the risks involved in placing an implant in a patient who is not skeletally mature?

Answer 19

Infra-occlusion- bone will continue to grow over the implant but the implant will stay fixed in place.

Suboptimal aesthetics

Occlusal disharmony

Implant fenestration

Question 20

Extra-orally, what would you want to examine?

Answer 20

Smile line
Skeletal relationship
Presence of incisal cants
Presence of gingival cants
Width of aesthetic zone

Question 21

What depicts a high, medium and low smile line?

Answer 21

High- greater than 2mm gingivae on show
Medium- less than 2mm gingivae on show
Low- lip covers greater than 25% of tooth.

Question 22

Intra-orally, what would you want to examine?

Answer 22

Gingival phenotype

Bone crest to contact point

Restorability of adjacent teeth

Infection at local site

Width of edentulous span

Anatomy of implant site

Question 23

What gingival phenotype is advantageous?

Answer 23

Thick and low scalloped.

It is not advisable to have a thin and high scalloped biotype because there is a high risk fo aesthetic failure.

Question 24

Why is bone crest height to contact point height so important?

Answer 24

it determines the presence of adjacent papilla.

Question 25

What bone crest to contact point distance is advantageous?

Answer 25

less than 5mm to contact point.

If it is greater than or equal to 7mm- this is not good.

Question 26

How might infection at the implant site influence the implant itself?

Answer 26

Will affect survival and success of dental implants.

Important to determine if the infection is acute or chronic.

Question 27

What aspects of the restorative status of adjacent teeth would you need to take into consideration?

Answer 27

Risk of recession with subgingival restoration margins on adjacent teeth

Risk of suboptimal aesthetics if trying to match a restored tooth with another restored tooth

Question 28

Why is width of edentulous space important to analyse?

Answer 28

Toot wide- challenge to fill the space, will leave spaces, not look aesthetic if you have to use larger teeth

Too narrow- risk of damage to adjacent teeth, risk of necrosis of bone between teeth and implants, aesthetic concerns.

Question 29

What aspects of the anatomy of implant site would you want to analyse?

Answer 29

Are the soft tissues intact?

Assessment of available bone-
- horizontal or vertical bone deficiency?

Question 30

What relevant anatomy in the maxilla would you need to be aware of for implant placement?

Answer 30

Maxillary sinus
Nasal flor
Nasopalatine canal
Infra-orbital nerve

Question 31

What mandibular anatomy would you need to be aware of for the placement of implants?

Answer 31

Inferior alveolar canal
Mental foramen
Incisive canal
Lingual perforating vessels
Submandibular fossa

Question 32

How much mesio-distal distance is required between the implant and adjacent teeth?

Answer 32

1.5mm on each side

This lowers the risk of damage to adjacent teeth
Lowers the risk of bone necrosis and soft tissue defect between implants and teeth

Question 33

What can be used to check for mesido-distal orientation?

Answer 33

Intra-operative radiographs

Question 34

How much bunco-palatal distance is required for an implant?

Answer 34

You want at least 2mm of buccal and palatal bone on either side of the implant.

Question 35

How is the pico-coronal element positioned?

Answer 35

Planned relative to the proposed gingival margin position
- 2mm apical to the ACJ.

Question 36

What aids are used for implant planning?

Answer 36

Study models
Diagnostic wax up
Surgical template
Essex (provisional)
Clinical photographs
CBCT
Surgical guide