implants, pretreatment evaluation

1. PRE OPERATIVE EVALUATIONPRE OPERATIVE EVALUATION
OF IMPLANT PATIENTSOF IMPLANT PATIENTS
Shahnaz Khadar
CRI

2. ContentsContents
Def init ion
Hist ory
Classif icat ion
I ndicat ions
Pret reat ment evaluat ion
Medical & Dent al hist ory
Cont raindicat ions
Clinical examinat ion
Radiographic examinat ion
conclusion

3. DefinitionDefinition
Implantation is defined as the
insertion of any object or material,
such as an alloplastic substance
or other tissue, either partially or
completely, into the body for
therapeutic, diagnostic, prosthetic
or experimental purposes.

4. HISTORYHISTORY
Carved bamboo pegs were used
4000yrs ago in China
Root form metal pegs- Egypt 2000
yrs back
Archaeological museum at
Harvard houses an implant made
of shell dating back to 600 AD
Albucasise de condue (1963-
1013) used ox bone , first

5. •Per Ingvar Branemark
- Osseo integration
•1965- first titanium dental
implant placed in a human
volunteer.
X ray of titanium chamber embedded
in rabbit femur
Panoramic radiograph of historic
dental implants, taken 1978

7. CLASSIFICATION OF IMPLANTSCLASSIFICATION OF IMPLANTS

8. IndicationsIndications
Edentuluos patients
-implant assisted removable prostheses
-implant supported fixed prostheses
Partially edentuluos patients

9. Why implants??Why implants??
Maintains bone
Restore and maintain occlusal vertical
dimensions
Improves esthetics,phonetics,occlusion
Improves masticatory function
Improves psychological health

10. Pre treatment evaluationPre treatment evaluation
Chief complaint -
Pat ient ’s concern
Pat ient ’s expect at ion

11. Medical historyMedical history
Thorough medical history should be
documented.
Review for conditions that might pose a
risk for adverse reactions/complications.
Laboratory tests to rule out conditions
that might be contraindication/risk
factor.
Medical clearance from treating
physician.

12. ASA PHYSICAL STATUSASA PHYSICAL STATUS
CLASSIFICATIONCLASSIFICATION
ASA I - A normal healthy patient without systemic
disease
ASA II- A patient with mild systemic disease
ASA III- A patient with severe systemic disease
that limits activity but is not incapacitating
ASA IV- A patient with an incapacitating systemic
disease that is a constant threat to life.
ASA V- A moribund patient not expected to
survive 24 hours without operation
ASA E- Emergency operation

13. ContraindicationsContraindications
Medical
• acute infectious diseases
– absolute, but temporarily; wait for
recovery
• chemotherapy
– absolute, but temporarily; reduced
immune status
• systemic bisphosphonate medication
(≥2 yr)
– risk of bisphosphonate-induced
osteonecrosis (BON)
• renal osteodystrophia
– increased risk for infection, reduced
bone density
• severe psychosis
– absolute; risk of regarding the
implant as foreign body and
requesting removal despite of
successful osseointegration
• depression – relative
NU Zitzman et al Australian Dental Journal 2008; 53:(1 Suppl):
S3–S10

14. • pregnancy
– absolute, but temporarily; to avoid
additional stress and radiation
exposure
• unfinished cranial growth with
incomplete tooth eruption
– relative, but temporarily; to avoid
any harm to the growth plates, to
avoid inadequate implant position in
relation to the residual dentition
intraoral
• pathologic findings at the oral soft-
and/or hard tissues
– temporarily; increased risk for
infection, wait until healing is
completed
NU Zitzman et al Australian Dental Journal 2008; 53:(1
Suppl): S3–S10

15. Increased risk
post head and neck radiation therapy
– reduced bone remodelling, risk of
osteoradionecrosis, implant
placement 6–8 weeks before or ≥1 yr
after radiotherapy
• osteoporosis – reduced bone to implant contact
• uncontrolled diabetes
– wound healing problems (impaired
immunity, microvascular diseases)
• status post chemotherapy, immuno-
suppressants or steroid long-term
medication, HIV infection
– wound healing problems, medical
advice required
• alcohol and drug abuse, heavy
smoking ≥20 cig/d
– wound healing problems, locally
reduced vascularization7
• history of aggressive periodontitis
– increased risk to develop peri-
implantitis
NU zitzman et al Australian Dental Journal 2008;
53:(1 Suppl): S3–S10

16. Habits and behavioral considerationsHabits and behavioral considerations
◦ Smoking & tobacco use
*Adversely affects implant success through
its effect on bone metabolism
◦ Para functional habits
* Repeated lateral forces can be detrimental
to osseointegration process.
◦ Substance abuse
* Psychological problems , non
compliance
* Impaired organ function

17. Dental historyDental history
Oral hygiene status and
practices
Compliance with past dental
recommendations
Previous experience with
surgery and prosthetics
Attitude and motivation
towards implants

18. Clinical examinationClinical examination
Facial proportions
Facial symmetry
Facial convexity
Lip and cheek support
Intermaxillary relation
Lip length and incisal show

19. Intraoral examinationIntraoral examination
Infections , lesions and
pathologic conditions
Overall dental & periodontal
health
Occlusion
Jaw relation
TMJ condition
Mouth opening

20. Soft tissue evaluationSoft tissue evaluation
Quality( keratinized/ non
keratinized)
Quantity
Location
Frenum attachments

21. Hard tissue evaluationHard tissue evaluation
Clinically and radiographically
Palpate for anatomical defects,
concavities and undercuts
Intraoral bone mapping

22. Evaluation of implant sitesEvaluation of implant sites
Alveolar bone
Atleast 1.0 to 1.5mm of
bone around implant
Interdental space
Buccolingual width >
6mm

23. Interocclusal space

24. Diagnostic study modelsDiagnostic study models
Evaluate space available
Determine potential limitations of planned
treatment
Useful while replacing multiple teeth or in case
of malocclusion.

25. Radiographic examinationRadiographic examination
Quality, quantity and location and volume of alveolar
bone
Identify vital structures: floor of nasal cavity, maxillary
sinus, mandibular canal, mental foramen
Radio opaque markers can be used to evaluate
relation of alveolar ridge to existing teeth

26. Misch’s classification of bone density

27. INDICATIONS ADVANTAGES LIMITATIONS
PERIAPICAL
RADIOGRAPHY
Small edentulous
spaces, alignment and
orientation during
surgery
Low radiation dose ;
inexpensive
Minimal site
evaluation; distortion
& magnification
OCCLUSAL
RADIOGRAPHY
none Evaluation of
pathology
Does not reveal true
buccolingual width:
Difficulty in
positioning
CEPHALOMETRIC
RADIOGRAPHY
Used with other
radiographs for
anterior implants
Low magnification;
Height/width in
anterior region
Limited to midline;
reduced sharpness &
resolution
PANORAMIC
RADIOGRAPHY
Commonly used Initial assessment of
vertical bone height;
Gross anatomy &
pathology evaluation
Distortion; does not
demonstrate bone
quality
COMPUTED
TOMOGRAPHY
Determination of
bone density; vital
structure location;
determination of
pathology
Negligible
magnification; high
contrast image; 3D;
Various views
Cost; technique
sensitive

28. Laboratory testsLaboratory tests
 Complete blood count
WBC- 4,000 to 11,000 cells/mm3
RBC- 4-6 million/mm3
Platelet- 1,50,000- 4,00,000cells/mm3
MCV- 80-100 fL
MCHC- 32 to 36 g/dL
hemoglobin- 11- 16 g/dL
 Prothrombin time- INR (normal range- 0.8 to 1.2)
 Glycemic control- HbA1c (4 to 6%)
 Thyroid function tests- T3- 60 to 175 µg/dl
T4- 4-11 ng/dl

29. ConclusionConclusion
The success and predictability of dental
implants have changed philosophy and
practice of dentistry.
However, proper pre treatment
evaluation, and a treatment plan are
imperative for its success.

30. ReferenceReference
Contemporary implant dentistry, 3rd
ed,
Carl E Misch
Carranza’s clinical periodontology, 10th
ed.
Phillips’ science of dental materials,
11th
ed, Anusavice
Shenoy VK. Single tooth implants:
Pretreatment considerations and
pretreatment evaluation. J Interdiscip
Dentistry2012;2:149-157.