diagnosis and treatment planning materialria

2Diagnosis andTreatment Planning

Hamid Shafie

Diagnosis and treatment planning are themost important parts of the entire implant ther-apy, determining whether the treatment will be asuccess or a failure. Skipping any of the recom-mended steps of the treatment-planning phasecompromises the outcome of the final treatment.

DIAGNOSTIC WORKUP FORIMPLANT OVERDENTURE

1. Perform a radiographic evaluation by utiliz-ing a panoramic x-ray. Determine the magni-fication error of that image, and then deter-mine the height of available bone.

2. Evaluate the existing conventional upper andlower denture to determine if satisfactoryaesthetic, phonetic, and function have beenachieved.

3. If the existing denture is satisfactory, it canbe duplicated with clear acrylic and used fordiagnostic mounting and fabrication of thesurgical guide.

4. Take a bite registration record in centric re-lation for a diagnostic mounting.

5. Mount the duplicated upper and lower den-ture on an articulator.

6. Choose the proper length and diameter forthe designated implant system.

7. Choose the number and location of the im-plants based on the desired attachment as-sembly.

BENEFITS OFDIAGNOSTIC MOUNTING

� Creates a surgical template� Visualizes the relationship of the denture

teeth with anticipated implant positions� Gives the clinician and lab technician a good

idea of the position and final design of thebar

� Creates an index for the position of the finaloverdenture teeth

In patients with a high smile line, a remov-able overdenture will more likely fulfill the pa-tient’s functional and aesthetic demands betterthan an implant-supported fixed bridge. If thepatient’s upper lip support needs to be enhanced,

11

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12 CLINICAL AND LABORATORY MANUAL OF IMPLANT OVERDENTURES

an implant-supported overdenture with a labialflange is the preferred choice of treatment.

If the relationship between the maxilla andmandible is unfavorable, such as class II or classIII, or if excessive inter-ridge space is present,implant-supported overdentures are preferredover fixed bridges supported by implants.

RADIOGRAPHICEVALUATION

Panoramic RadiographThe panoramic radiograph is the most com-mon image used to evaluate implant overden-ture cases. This radiograph produces a single im-age of the maxilla and mandible with all of theanatomical landmarks in a frontal plane. It isvery cost effective and practical, because it canbe generated in most dental offices. The clini-cian can easily identify the gross anatomy of thejaws and opposing landmarks, as well as forman initial assessment of the vertical height ofthe bone. Any pathology within the maxillaryand/or mandibular bone can be detected. Thepatient is exposed to a relatively low radiationdose compared to a CT scan or conventionaltomogram.

However, the panoramic radiograph has sev-eral disadvantages such as overlapping images,distortion of the special relationship amonganatomical landmarks, and magnification er-rors. Also, fine anatomical details cannot be seenas they appear on a CT scan. This radiographusually increases the horizontal dimension byabout 30–70 percent and increases the verticaldimension by about 20–30 percent.

The use of a diagnostic template while takingthe panoramic x-ray can effectively eliminate themagnification error. The diagnostic template isan acrylic base, which has been fabricated overthe study cast.

One or more ball bearings (BBs) should beincorporated into the template using self-curedacrylic. Place the BBs as close as possible to thedesired implant sites (Figure 2.3).

FIGURE 2.1.

DETERMINING MAGNIFICATION ER-ROR OF PANORAMIC X-RAYS

1. Measure the diameter of the ball bearings be-fore incorporating them into the templates(Figure 2.2).

012345678

FIGURE 2.2.

2. Incorporate the ball bearings into theacrylic template utilizing self-cured acrylic(Figure 2.3).

4mm

FIGURE 2.3.

3. Insert the acrylic template in the patient’smouth (Figure 2.1).

4. Take the x-ray image (Figure 2.4).

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DIAGNOSIS AND TREATMENT PLANNING 13

FIGURE 2.4.

5. Measure the diameter of the ball bearings asthey appear in the x-ray image.

6. Use the following formula to calculate the ac-tual height of the alveolar process:

d = Actual diameter of the ball bearingD = Diameter of ball bearing in the

panoramic x-rayH = Height of the bone in the panoramic

x-rayh = Actual height of the bone

Magnification Error: ME = d ÷ Dh = ME × H

PANORAMIC LANDMARKS� Crest of the ridge� Opposing landmarks

Note the opposing landmarks in the mandible(Figure 2.5):

� Anterior: Inferior border of the symphysis� Canine/Premolar Region: Mental foramina� Posterior: Mandibular nerve canal

FIGURE 2.5.

FIGURE 2.6.

Note the opposing landmarks in the maxilla(Figure 2.6):

� Anterior: Inferior border of the nasal cavity� Canine/Premolar Region: Lateral walls of the

nasal cavity and anterior border of the max-illary sinus

� Posterior: Floor of the maxillary sinus

During treatment planning for a mandibularimplant overdenture, this radiograph can pro-vide a fair approximation of the position of themost distal supporting implants. The positionof the mental nerve, the path of the mandibularnerve canal, and the height of the alveolar ridgehave a great influence on the position of mostdistal implants.

The mandibular nerve canal generally ex-tends 3–4mm anterior to the mental fora-men. However, the mandibular nerve may loopforward 6–7mm in some patients. It is recom-mended that you position the center of the dis-tal implant 7mm mesial to the mental fora-men to eliminate any possibility of nerve injury.Note that all anatomical variations are patient-specific.

Occlusal RadiographAn occlusal radiographic image is very helpful inassessing the width of the bone in the mandibu-lar symphysis area. Employ proper techniquessuch as symmetrical positioning of the centralray and the film.

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Make an acrylic base on the lower cast andglue a 5mm diameter ball bearing to the side ofthe acrylic base in the symphysis area. The pa-tient should wear this acrylic base when the im-age is taken. Changes in the diameter of the ballbearing in the radiograph will help the clini-cian determine the magnification error of theradiograph.

Computed Tomography(CT Scan)Since plain films fail to provide data on bonewidth and bone density, clinicians startedutilizing CT scan technology to enhance theirdiagnostic and treatment planning abilities(Figure 2.7).

FIGURE 2.7.

The CT scan creates three-dimensional im-ages of the edentulous arches at 1.00mm inter-vals from left to right around the entire dentalarch in both the mandible and maxilla. The im-ages (cross sections) are sequentially numbered.The clinician has at his or her disposal cross-sectional, panoramic, and occlusal views of theactual osseous topography. This radiographic

technology results in no magnification error, andall of the images have the exact same dimen-sions as the patient’s anatomical structure beingexamined. Therefore, this scan permits precisemeasurement of the bony structure that is rel-evant to the desirable implant locations in allthree planes.

The techniques for producing clinically usefulCT image vary, depending upon the equipmentemployed. However, regardless of the type ofequipment, the thickness of each cut must be1mm or less.

Placing a radioopaque material such as spe-cial barium sulfate teeth as a marker in the di-agnostic guide identifies the desired site for animplant placement (Figure 2.8). This allows theclinician to see the makers on the CT images andevaluate the underlying bony structure.

FIGURE 2.8.

CT analysis of the jaws is normally very ex-pensive; the technique is therefore generally usedonly if additional diagnostic information is nec-essary due to anatomical complexity or otherdiagnostic difficulties. The need to assess accu-rately the position of the inferior alveolar canal,the mental foramen, the contour of the lingualsurface of the mandible, and the floor of the si-nuses are primary indications for using a CTscan during the treatment planning phase forimplant overdenture cases. The advantages ofCT scanning when planning for the placementof dental implants must be balanced against thecost and the amount of the radiation exposureincurred with CT scans.

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JOINT TREATMENTPLANNING

The next phase in the treatment planning pro-cess involves an effective conference amongthe entire implant team, which consists ofthe restorative dentist, surgeon, and laboratorytechnician, along with any number of support-ing members such as the hygienist and the rep-resentative of the implant company.

The crucial factor in building an effective con-ference is to create a team of people, each ofwhom knows his or her job and can perform itwell. Each member of the team must be com-mitted to listening as well as sharing his or herideas and observations. Ideally, the treatmentplanning conference should be done in person.However, it can be conducted via telephone orweb conferencing.

The leader of this team will be the restora-tive dentist. He or she begins the communica-tion with the patient regarding the patient’s chiefcomplaint and continues that communicationthroughout the treatment process and beyond.The secondary leaders in this process are the sur-geon and the laboratory technician.

ANATOMICALCONSIDERATIONS DURINGDIAGNOSIS ANDTREATMENT PLANNINGPROCESS

Available Bone QuantityBone quantity is one of the most important fac-tors that dictate the treatment plan. The height,width, length, and shape of the available boneshould be assessed.

HEIGHT OF BONE The distance betweenthe crest of the alveolar ridge and opposinganatomical landmarks (e.g., maxilla: floor ofthe sinuses and the nasal cavity; mandible: themandibular nerve canal, mental foramina, andinferior border of the symphysis) determines theheight of the bone. It is advisable to leave 2mm

between the bottom of the implant and border ofthe opposing landmark. The height of the bonecan easily be determined through a panoramicx-ray.

WIDTH OF BONE The distance betweenthe buccal and lingual walls of the alveolar pro-cess determines the width of the bone. It is rec-ommended that at least 1mm thickness of thebone should remain on the buccal and lingualaspects of the implants. Very thin buccal and lin-gual bone plates around the implant will have acompromised blood supply and increase the riskof bone loss. The width of the bone cannot bedetermined by a panoramic x-ray. However, theocclusal x-ray or the CT scan will provide suit-able images for measuring the width of the bone.

SHAPE OF BONE The shape of the alveo-lar ridge influences the clinician’s selection ofthe shape of the implant body (e.g. choosing atapered implant vs. parallel sided screw). Theshape of the bone influences the trajectory ofthe implant, which is not always inline with thepath of insertion of the overdenture. This prob-lem can cause application of destructive forces tothe supporting implants. The shape of the bonecan be modified by bone grafting techniques oralveoloplasty.

LENGTH OF BONE The distance from onepoint of the alveolar ridge to another point in themesio-distal direction determines the length ofthe bone. The mesio-distal distance between thesupporting implants will be determined basedon the design of the attachment assembly.

Misch and Judy described an easy and practi-cal classification for fully edentulous jaws basedon the available bone.

Classification of FullyEdentulous Ridges Based onBone QuantityGROUP A There is minimum bone loss,which translates to less inter-ridge space. Onaverage, the height of the bone in the anteriormandible is more than 20mm, and the width of

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FIGURE 2.9.

the bone is more than 5mm (Figure 2.9). Theheight of the bone in the anterior maxilla is usu-ally more than 15mm, and most of the time thewidth of the bone is more than 5mm. Becauseof small inter-ridge space, patients in this groupare not good candidates for a bar attachmentassembly. Insufficient room is available to fab-ricate a cleansable bar and an overdenture withadequate denture base thickness. Patients in thiscategory are good candidates for hybrid pros-thesis as well as overdenture supported by studattachments.

GROUP B The height and width of the boneis less than group A, which means more inter-ridge space is available. On average, the heightof the bone in the anterior mandible is between15–20mm, and the width is more than 5mm(Figure 2.10). The height of the bone in the an-

width >5 mm12–15

mm

width >5 mm

15–20mm

FIGURE 2.10.

terior maxilla is approximately 12–15mm, andthe width is more than 5mm. Patients in thisgroup can qualify for any kind of implant over-denture. The bone quantity and inter-ridge spaceallow the clinician to utilize any type of attach-ment assembly.

GROUP C Patients in this group demonstratesevere resorption of the alveolar process. Theheight of the bone in the anterior mandible isapproximately 10–15mm, and the width of thebone in this region is almost 5mm (Figure 2.11).The height of the bone in the anterior maxillais less than 10mm, and the width of the boneis less than 5mm. This means that patients haveexpansive inter-ridge space. These patients gen-erally are not good candidates for a stud attach-ment assembly since the expansive inter-ridgespace translates into longer teeth and denturebase. This space will increase the chance of lat-eral dislodgement of the prosthesis if the over-denture is supported by small and short studattachments. Bar attachments are strongly rec-ommended for this group of patients. However,exceptional situations mandate use of stud at-tachments for these types of patients. (Refer toChapter 5, “Stud Attachments.”) In some cases,alveolar ridge augmentation, ridge expansion,or sinus lift may be necessary.

width ~5 mm10–15

mm

width ~5 mm

10–15mmFIGURE 2.11.

GROUP D Patients in this group demonstratecomplete resorption of the alveolar process, aswell as part of the basal bone. Generally, theheight of the bone in the anterior mandible is

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less than 10mm, and the width of the bone isless than 5mm (Figure 2.12). The height andwidth of the bone in the anterior maxilla isseverely deficient. Any overdenture treatmentfor patients in this group requires advanced bonegrafting procedures to accommodate implantslonger than 10mm length and 4mm in diameter.The other approach to accommodate patientsin this group is to utilize shorter implants withexpansive surface area instead of subjecting thepatient to the bone grafting procedure. The en-dopore implant has been designed with a poroustitanium surface and a tapered body and can beused in most of the group D patients with com-promised bone quantity. (Refer to Chapter 12.)

Classification of EdentulousRidges Based on Bone QualityA direct correlation exists between the primarystability of the implants and the bone quality.This is a very important factor if the patient hasbeen treatment planned for immediately-loadedoverdenture.

Since most of the implant overdenture pa-tients are over 50 years of age, the issue of bonequality plays a roll in the prognosis of the treat-ment. Most people in this age group, especiallywomen, experience some level of osteoporosis.Generally, in osteoporotic patients, a physiolog-ical reduction of the trabecular bone can be ob-served. The most accurate way to determine thebone quality is by assessing the bone during the

surgical steps or when the clinician starts drillingthe osteotomy.

Misch described a simple classification fordifferent bone quality osteotomy (Figure 2.13):

� D1: Thick, compact bone� D2: Thick, porous, compact bone with a

highly trabecular core� D3: Thin, porous, compact bone surround-

ing a loosely structured cancellous bone� D4: Loose, thin, cancellous bone

FIGURE 2.13. (Photo courtesy of Dr. Elianedos Santos Porto Barboza)

D1: THICK, COMPACT BONE This typeof bone usually can be found in the symphysispart of the mandible (Figure 2.14).

Advantages� Provides good primary stability for the im-

plants� Expansive implant bone interface� Use of short implants is possible� Overdenture can be loaded immediately


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Disadvantages� Reduced blood supply� Difficult implant bed preparation, which can

cause overheating� Extra step of tapping the bone is required

to eliminate the possibility of the pressurenecrosis

D2: THICK, POROUS, COMPACT BONEWITH A HIGHLY TRABECULAR COREThis type of bone can be found in the anteriorand posterior portions of the mandible as well asthe palatal aspect of the anterior maxilla (Figure2.15).


Advantages� Provides good primary stability� Easy implant bed preparation� Overdenture can be loaded immediately� Good blood supply, which means shorter

healing time and faster osseointegration

Disadvantages� None

D3: THIN, POROUS, COMPACT BONESURROUNDS A LOOSELY STRUCTU-RED CANCELLOUS BONE This type ofbone can be found in the facial aspect of theanterior maxilla, posterior maxilla, posteriorportion of the mandible, and the remaining

bone after the osteoplasty of the D2 bone (Fig-ure 2.16).


Advantages� Good blood supply

Disadvantages� Possibility of unwanted widening of the os-

teotomy, which can leads to poor primary sta-bility

� Reduced implant bone interface

D4: LOOSE, THIN CANCELLOUS BONEThis type of bone can be found in the poste-

rior maxilla as well as the remaining bone afterosteoplasty of the D3 bone (Figure 2.17).


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Disadvantages� Poor primary stability� Reduced implant bone interface

REFERENCES ANDADDITIONAL READING

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sten, C. H. J.ten, C. H. Jtemplates ftemplatesQuintesseQuintess

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