Implant Treatment Planning

Question 1

What should be taken during the pre-implant assessment?

Answer 1

History taking and chief complaint

Patients do they want a fixed or removable solution

Systemic disease and Mhx:

Diabetes status and control

Autoimmune diseases

History of malignancy/head and neck radiotherapy

Medication history

Bisphosphonates

Bleeding disorders (VWD, christmas disease, Factor V Leiden)

Question 2

What causes MRONJ?

Answer 2

Bisphosphonates, pyrophosphates with high affinity for bone.

1st gen: Non-nitrogen

2nd gen: Nitrogen containing (Alendronate, risenodrate, zolendrate)

Question 3

What is the difference between oral and IV bisphosphonates?

Answer 3

Oral is poorly absorbed due to <1% bioavailability

IV is readily available (100%)

Question 4

Is it possible to place implants in patients with bisphosphonates?

Answer 4

Yes, evaluate risks and avoid using in patients on IV BP.

Question 5

What risk factors increase risk for MRONJ from implants?

Answer 5

Females, >65 years of age, smoking, diabetes, immune suppressions, poor OH, mandible position, perio disease

Question 6

What should be examined in the clinical patient examination?

Answer 6

normal 011.

Available keratinized tissue around the implant increase success rate. It is important to have lots of keratinised tissue.

Question 7

What tissue biotype is ideal for implants?

Answer 7

Thick scalloped tissue.

Question 8

How is tissue biotype assessed?

Answer 8

Clinical examination

Bone sounding

Radiographs - CBCT

See if probe can be seen through the gingiva. If it can it is thin.

Question 9

How should implant treatment be adapted to different biotypes?

Answer 9

IA with intact/thick buccal bone uses flapless and immediate implant technique. Loading can be done immediately.

IB with intact/thin buccal bone requires immediate and CTG implant technique. Loading is done early.

II with intact gingiva and dehiscence requires immediate and CTG and GBR implant technique and loading is delayed

III buccal bone with recession and dehisence. Implants are delayed with bone grafting.

Question 10

What should be assessed during the clinical examination?

Answer 10

Tooth examination

Caries

Deficient restorations

Occlusion

Tooth wear

Bruxism evidence

Basic perio exam followed by full perio assessment if there are pockets or 3, 4

Question 11

What is the purpose of the diagnostic wax up?

Answer 11

Tells where the teeth need to go and how they can be arranged.

Should be done before radiographic guides.

Patient wears the radiographic guides during the x ray.

Question 12

What should be looked at during the site specific examination?

Answer 12

Available space

Implant number and position

Occlusal considerations

Type of prosthesis

Question 13

How much available space is required?

Answer 13

Mesio distally 7mm, 1.5mm away from adjacent teeth and 3mm away from another implant.

Wider implants used for molars

Bucco-lingually: At least 1mm of bone present both buccally and lingually.

Implants need to be tilted for favourable connections with the opposing jaw

Occluso-gingival space/interocclusal clearance should allow adequate room for the restoration, adequate room for the placement of the surgical implant. 7 - 10mm space is required ideally.

Question 14

Why is it important to maintain 3mm space between implants?

Answer 14

Interadicular bone won’t get enough blood supply

Question 15

How can over eruption of opposing teeth into interarch space be dealt with?

Answer 15

Enameloplasty if small discrepancies

Orthodontic intrusion

Elective endodontics and crowning

Crowning for a full coverage restoration

Question 16

How deep should implants be?

Answer 16

Ideally 2mm from the apex of the implant to the neuro-vasculature.

For a 10mm fixture 12 - 13mm of bone height is needed.

Question 17

How should vital structures of the maxillary sinus and inferior alveolar bone be treated prior to placing implants?

Answer 17

GBR

Block bone grafting

Maxillary sinus augmentation (Transcrestal and lateral window)

Question 18

What imaging modalities can be used for implant placement treatment planning?

Answer 18

Pre extraction: PA, OPG, CBCT

Pre-implant surgery: CBCT, CT scan

Surgical implant placement: PA

Post implant restoration: PA, OPG (full arch cases)

Implant related complications (PAs, CBCT)

Question 19

What imaging modalities should be used pre-extraction?

Answer 19

PA, OPG, CBCT

Question 20

What imaging modalities should be used pre-implant surgery?

Answer 20

CBCT, CT scan

Question 21

What imaging modalities should be used for surgical implant placement?

Answer 21

PA

Question 22

What imaging modalities should be used post implant restoration?

Answer 22

PA, OPG

Question 23

What imaging modalities should be used for implant related complications?

Answer 23

PAs

CBCT

Question 24

What are the advantages and disadvantages of PAs?

Answer 24

Adv:
Low radiation dose

Minimal magnification

High resolution

Minimal expense

Disadv:

No cross-sectional info

Spatial relations can’t be established

No indication of bone density

Question 25

What are the features of CT scans?

Answer 25

Enables differentiation and quantification of hard and soft tissues

Produces axial images perpendicular to the long axis

3D capability

No magnification

Accuracy enables diagnostic templates to be made

Question 26

What makes CBCT more ideal than CT?

Answer 26

Less radiation and images a larger area. Computer program generates 3D image showing hard and soft tissues.

CT scans offer more contrast resolution

Operates and looks similar to conventional CT scan

Question 27

How is a treatmnet plan formulated for implants?

Answer 27

Collect all data using clinical exam and special tests.

Complete all imaging: PA and CBCT

Look at CBCT or CT scan and see which implant fits with best position length and diameter.