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Diagnosis & Treatment Planning in Implant Dentistry: part 1

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hello everyone welcome to prosper Hub

and myself Dr Jones now and today we are

going to discuss the topic diagnosis and

treatment planning in in plant industry

so now it's exam time for many

universities and I hope that find their

pgs are preparing well for their exam so

one thing you have to keep in mind is

presentation of your answer is very

important so as I always say include the

content list and don't forget to write

the references at the end of your answer

and also highlight or underline the

important points so that you can grab

the attention of the examiner who is

correcting your paper so for more

details on how to prepare for the exam

and how to study I have done a separate

session on exam preparation I'll give

the link in the description box so I

wish all the best and also good luck and

success for all the exam going pgs

prepare well and do a linear exams so

now getting into the topic diagnosis and

treatment planning and implant in this

industry let us see the content list

attendants include introduction

rationally for implants history

recording extra oral and intraoral

examination and also radiographic

examination the bone assessment

diagnostic caste and surgical templates

the stress treatment theorem implant

processes design treatment planning and

methodology finally conclusion and

preferences so this implant diagnosis

and treatment planning is a very vast

topic so I am discussing here on an exam

point of view only the important

headings that you need to include in

your answer

so before beginning I request everyone

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me at this mail ID so let's start

production proper diagnosis and

treatment planning is the key to any

successful treatment so we know the GPT

definition of diagnosis that is it is a

determination of the nature of a disease

and treatment plan is defined as the

sequence of procedures planned for the

treatment of a patient after diagnosis

so ideally the practitioner evaluates

the diagnosis and then plans for the

sequential treatment prior to any

surgical consultation and what is the

objective of this treatment planning it

is to form an organized documentation of

the patient's pre-treatment conditions

leading to treatment options in

different phases so we have discussed

about the different phases of the

surrounding treatment in case of a full

mouth Rehabilitation that is it consists

of three stages that is the

pre-prosthetic phase the prosthetic

phase and the maintenance phase so once

these treatment phases are determined

then they are completed in a sequence

which is compatible with the patient as

well as the clinicians scheduled and

which is consistent with what it is

clinically appropriate for the patient

so a good wrapper between the patient

doctor a thorough comprehensive written

evaluation and also a multi-phase

treatment planning certainly leads to

successful surgical as well as

prosthetic complex restorative cases

coming to the rationale for implants so

the goal of Modern Dentistry is to

restore the patient to normal Condor

function Comfort Aesthetics speech and

health whether we are restoring a single

tooth or we are replacing several teeth

so the clinical replacement of loss

natural teeth by Osteo integrated

implants has become one of the most

significant advances in restrictive

dentistry and this increased need and

also advantages of these implant

supported processes are as a result of

many factors which can be divided into

four categories they are preservation of

tooth structure preservation of bone

provision for an additional support and

also resistance to disease so we know

the advantages of implant supported

processes like it maintains the bone and

also restores the occlusal vertical

Dimension it improves Aesthetics

phonetics occlusion and also increases

the processes success

and it reduces the size of the processes

when compared to a removable partial

danger like it eliminates the palatal

area and flanges Etc and it improves the

stability and retention of removable processes

processes

thus there is more permanent replacement

and thereby it improves the

psychological health of the patient and

improve health related to diet so these

are the advantages of implant supported prosthesis

prosthesis

this recording of History so this is

designed to provide an accurate profile

of how the patient's quality of life is

being affected by tooth loss so it

consists of mainly three elements that

is the dental history the medical

history and personal history so Dental

history includes identification of all

current problems from the patient's

perspective so it include the functional

issues like unstable or loose danger

inability to masticate efficiently when

there is pain or TMJ disorders

difficulties with speech gagging and

ulceration soreness of mucosa Etc

okay the medical history so a full and

comprehensive review of a patient's

medical history should be undertaken

prior to implant treatment and this

comprises of Vital Signs laboratory

evaluation systemic diseases so Vital

Signs include recording of the blood

pressure temperature pulse respiratory

rate Etc and the laboratory evaluation

where we evaluate the glycemic index the

blood sugar level the total blood count

and differential count the pro thrombin

time that is to avoid bleeding

complication during surgery

Etc and then General SLS systemic

conditions needs to be assessed so most

of the conditions are relative

contraindication and some of them turn

out to be absolute contraindications for

dental implants so some of the relative

contraindications are active

malignancies bleeding disorders cardiac

complications infections like HIV

radiotherapy Etc and some of the

absolute contraindications include age

below 17 years that is the implant

retards the bone growth of the

surrounding area and so it should not be

used especially in patients under an

active growth period and smoking and

radiation and leukemic patients Etc

based on the medical conditions we can

classify the patient as per the ASA

classifications that is the American

Society of anesthesiologists physical

status classification so the AC

classification groups the patients into

five groups and here the implant therapy

can be done for asa1 patients that is

with no health problem and asa2 that is

patients with minor health problems who

respond well to treatment any patient

whose health condition is in the

category as A3

or higher should be carefully screened

for relative contraindications or

absolute contraindications usually the

electro implant surgeries are not

indicated for ASA 4 or 5 patient and in

case of Asa 3 patient Preparatory

measures have to be taken before treatment

treatment

in the personal history where you can

assess the oral hygiene as per oral

hygiene is a relative contraindication

for dental implants then tobacco usage

again it affects the prognosis of

implant therapy and it can lead to

failure of implant because it directly

affects healing and also integration and

then parafunctional Habits Like bruxism

plunging Etc so patients with drug

system are again relative

contraindications and these para

functional habits induces immense load

under processes so all these should be

assessed in personal history recording

next coming to extra oral examination

where we evaluate the facial symmetry

skeletal profile facial Condors TMJ

patients speech and coordination lymph

nodes Etc so I'm not discussing in

detail about this as we have already

discussed this in our case history session

session

coming to intraoral examination so

intraoral examination is visual as well

as palpation process

so we have to assess the oral hygiene

then intraoral soft tissue should be

checked for any pathology and the arch

form so mounted study models can assist

in properly evaluating the arch form as

well as the interaction relationship so

the arch geometry impacts the position

of dental implants that is in a v-shaped

arch it would be more easier to place

implants with a greater AP spread ratio

than a U-shaped Arch or an arch with

straight anteater Ridge then comes a

residual Ridge form where we assess the

ridge height Ridge width the angle of

Rich Etc

and then the tongue along with muscle

attachment should be assessed and

interact space is again important

because if there is an inadequate

interact space then a screw retain Crown

will become the Preferred Choice and if

there is more than 4 mm in Rod space

then implants can be restored with

cement retained crumbs

then existing occlusion and occlusal

plane is evaluated so if the patient is

having a canine guided occlusal scheme

and we have to restore the canine then

this occlusal scheme can be modified

such that anterior guidance is shared

between canines and incisors to reduce

the force load similarly if the patient

is having a group function it is

preferable to convert that group

function to a canine guided occlusion in

order to protect the posterior implants

then comes the vertical dimension of

occlusion so in case of improvement of

Aesthetics or function or when there is

a structural needs of Dimension we need

to modify the vertical dimension of

occlusion during implant treatment and

finally the periodontal evaluation so

periodontal charting and classification

and documentation of the location of

quantity of keratinized attached in Java

should be done and also bone loss that

is vertical or horizontal defect should

also be carefully mapped on this chart

so these are the items under intraoral examination

examination

coming specifically to the clinical

examination of the implant site so here

we examine the length of the Evangelist

plan which is specially important in

partially even less conditions so

generally we know that there should be

1.5 mm clearance between an implant and

a neighboring tool and a 3mm gap between

two implants so in order to place a four

millimeter diameter implant at least

there should be 7 mm space this is

because there should be 1.5 mm clearance

on both sides between implants and the

neighboring teeth

next comes the rich characteristics also

under this we assess the ridge height

Ridge width Ridge angle and also quality

of soft tissue on the ridge so the soft

tissue on the ridge that is the gingival

biotype the gingival Zenith the gingival

line angle Etc is assessed and also the

width of the keratinized mucosa can be

evaluated with a balloon test or eye

dentist so ideally where it should be

covered with keratinase mucosa in order

to have a good Peri implant health and

if you want to know about the balloon

test or write in test you can comment

below this video

so careful palpation of the ridge can

detect any presence of concavities and

another procedure to determine the

thickness or width of the alveolar bone

is called as Rich mapping or bone

mapping for this we use bone calipers so

here first the area that needs to be

examined should be anesthetized and then

the bone caliper tips

so these bone caliper tips should be

pierced through the soft tissue such

that the tips hit the facial as well as

the lingual cortical bone and then the

reading is measured on the scale in this

gauge so this procedure is repeated at

various locations and all the

measurements can be transferred to the cast

cast

so this gives an idea about the

approximate Ridge width as well as a

rough estimation of the rich Contour

and this ensures that the diameter of

the inertia screw implant does not

exceed the dimensions of available book

coming to the key vertical parameter and

treatment planning for Implant

Restorations that is the crown height

space so this is defined as the distance

from the occlusal plane to the crest of

the alveolar Ridge in case of posterior

region and distance from incisal Edge of

the arch to the alveolar Ridge in case

of anterior region so this Crown height

space influences the type of processes

the material choices and also the

surgical technique that we need to follow

so in order to provide a sufficient room

for the prosthetic components adequate

space should be present between edangels

Ridge and opposing dentition and ideally

for cement retain processes a to 12 mm

Crown height spaces needed and screw

rate in registration generally require

lesser CHS compared to the cement retain

processes because it can screw directly

onto the implant body so this ideal

measurement that is 8 mm it consists of

2 mm of occlusal material Space 4

millimeter minimum abutment height for

retention and two millimeter above the

is greater than 15 mm we say it is an

excessive CHS so we know that Crown

height with a lateral load may act as a

vertical cantilever called as the

vertical offset and it's a magnifier of

stress at the implant to Bone interface

so this can be corrected either by

surgical methods to increase the bone

height before implant placement or

stress reduction method to the support

system and processes so we can include

steps like shortening the cantilever

length minimizing offset load increasing

the number of implants or diameter of

the implants and design implants to

maximize the surface area so in these

ways we can reduce the stress in case of

excessive ground height space

this is the inadequate PHS Which is less

than 8 mm so an inadequate a crown

height space may be due to skeletal

discrepancies like deep bite or a

reduced occlusal vertical Dimension from

iteration or vibration and also maybe

due to supraorruption of the opposing

teeth so this can result in a shorter

abutment less area for cement retention

increased flexibility of metal and

processes compromised strength

anesthetics because of the reduced bulk

of the restorative material and also can

result in poor hygiene conditions so we

can do either osteoplasty before implant

placement in order to increase the crown

height space and if the available space

is inadequate due to over eruption of

opposing teeth depending upon the extent

of available space minimal enameloplasty

orthodontic intervention Collective

Endodontics and Crown can be indicated

radiographic examination so many

emerging modalities have been reported

to be useful for dental implant therapy

which includes IPA OPG CT cbct MRA Etc

so all these radiographic examination is

of utmost importance in Implant

Dentistry as the bone in the proposed

implant site is our primary concept so

Bond should be visualized in all

possible Dimensions so that accurate

data can be gathered and also Geo

Anatomy can be visualized before implant placement

placement and

and

post-operatively also Advanced Imaging

studies can show the failure of an

inductious implant also integrate or an

improper placement of implant and

violation of important structures so

these radiographs are actually used to

evaluate the width and height of

available bone density of the available

Bond the surrounding vital structures

and its relation to the implant site any

pathology in relation to the implant

site and also for evaluating the

remaining dentition

now the use of radiographic extensor

templates have become a mandatory

diagnostic exercise for all in plant

cases so what is the need for this

radiographic template this is to

correlate the position of the implant in

relation to the available bone so that

we can determine the ideal or the

precise location of our implant final

tooth position and the processes so many

radio opaque materials have been used in

fabricating these templates and they

include barium sulfate gatta Pacha

amalgam lead foil metal sleeves or beads

Etc and in some cases these radiographic

templates can be converted into surgical

templates for use during implant

placement and usually we make a

conventional temporary partial denture

and then the proposed implant positions

are marked on the occlusal surface and

then two millimeter Hollow channels have

to be created in these marked positions

and these channels are filled with Gutta

parcha and then assessing it

radiographically and many digital tools

from many implant manufacturers have

been developed which is used as an

alternative to these radiographic

templates one such is the simplan

software from materialize so here they

use the virtual teeth function for short

irangular spans and single tooth

replacement so here the clinician can

design the replacement teeth via the

computer program without the fabrication

of a radiopic template

next coming to Bone assessment so after

the radiographic evaluation we have to

analyze the quantity and quality of the

available bone to determine the suitable

site for Implant placement so we have to

assess the length that is a major distal

Dimension the width of the

buckle-lingual dimension and also the

depth of the available bone that is from

the Ridge Crest to the nearest

anatomical landmark so we can classify

the bone as per the divisions of bone by

Mission Judy that is called as the ABCD

classification where division a that is

the Abundant bone which is five

millimeter wide and greater than 10 mm

length where root form implants are

usually indicated and division B that is

barely sufficient bone that can be

barely sufficient height or barely

sufficient width then C that is a

compromised bone either compromised in

height or compromised in width and

finally the D the deficient bone where

you have to do augmentation procedures

for Implant placement so in this say the

quantity of the bone can be assessed

next the bone quality can be assessed by

bone density classification so the bone

is divided into five section depending

upon the type of bone that is D1 as

dense cortical bone D2 dense to porous

cortical bone on the crest and coarse

trabecular bone within D3 thin porous

cortical bone under Crest and fine

trabecular bone within D4 is completely

fine trabecular bone and D5 it's a

mature or non-mineralized bone so among

these the two bone is considered as one

of the best implant beds D1 that is a

dense cortical bone can get overheated

during placement and it's associated

with failure and D2 and D3 bone has got

the best load transfer D Phi Bond it's

not suitable for Implant placement as it

is immature and non-mineralized and in D

for bone implant can be placed by

packing the trabecular spaces with graft materials

materials

and bone density is considered to be a

key determinant in treatment planning

implant design surgical approach healing

time and type of loading during

next coming to the assessment of the

available bone height or depth that is

the distance from the crest of edangels

Ridge to the anatomical landmarks so

ideally there should be an adequate

safety margin of approximately two

millimeter that is between the buy

calendar of implant and neurovascular

structures and the anatomical structures

to be considered before planning the

implant length are in maxilla the flow

of mensillary sinus and floor of nose in

mandible mental foramen roof of inferior

alveolar Canal submandibular fossa and

also the adjacent tooth Roots so these

landmarks can be outlined directly on a

periapical or a panoramic radiograph to

clearly indicate the amount of available

bone height

coming to the phasing requirements or

the implant positioning guidelines so

these guidelines should be used When

selecting an implant size and also by

evaluating the mesial distal space for

Implant placement so as we have already

said the implant should be at least 1.5

mm away from the adjacent teeth so there

should be 1.5 mm Gap here and implant

should be at least 3 mm away from the

adjacent implant so 3 mm should be

between two implants and greater than

one millimeter bone should be present on

the facial and the lingual aspect of the

implant that means the implant should be

placed in the center of the ridge so

that there is adequate cortical bone

both buccali and lingually and this

cortical bone prevents future hard and

soft tissue precision

here you can see that in order to

restore an eventual space with the two

four millimeter implants we need at

least 14 mm of space that is 1.5 between

the implant and the natural teeth 3 mm

between the implants and the four

diameter of each implant so total of 14

mm space is needed now coming to the

need for this spacing so allowing a 1.5

mm of Crystal bone India approximately

will allow for proper development of the

healthy papilla and also we can develop

proper contacts and Condors in the

restoration and it allows for an

adequate width of soft tissue between

implants and adjacent teeth and also for

the prosthetic components not to impact

on each other for the effective cleaning

of the processes by the patient and to

develop a harmonious occlusion and

finally to allow for at least one amount

of space from the implant to the

adjacent root so this is the need for guidelines

next we are going to discuss diagnostic

caste and surgical templates which will

be continuing in our next session

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YouTube Transcript:
Diagnosis & Treatment Planning in Implant Dentistry: part 1