implant-based prosthetic rehabilitation requires an understanding of associated anatomical structures. The ultimate predictability of an implant site is determined by the existing anatomy as related to dentition and the associated hard and soft tissues. Meticulous clinical assessment helps in determining the suitability of the potential site for implant placement. The purpose of this article is to present the clinical assessment for dental implants' placement to modulate peri-implant tissue characteristics in individual clinical need.

1. DIAGNOSTIC AIDS IN IMPLANT
SEMINAR
PRESENTED BY- DR. NIKITA CHHABARIYA

2. CONTENTS
• Introduction
• Medical History
• Dental History
• Clinical Examination
• X-Rays
• Template for radiograph
• Template for dental CT
• Radiographic implant template from the implant system
• CT planning
• Study Models

3. INTRODUCTION
• Patient evaluation and treatment planning are crucial steps in implant treatment and
affect the overall success of implant therapy.
• On first visit-
Diagnostic Models
Radiographic Evaluation
Clinical Evaluation
General Condition

4. General And Medical Evaluation
• Age
• Medical problems
• Diabetes mellitus
• Hypertension
• Thyroid disorders
• Bone disorders (like osteoporosis)
• Oral malignancy and osteoradionecrosis
• Liver cirrhosis
• Myocardial infarction
• Pregnancy

5. Oral examination
• Arch form -influences the number and
positions
• Square
• Oval
• Tapering
• Ridge morphology of edentulous region
bone dimensions, positions, and angulations
required for implant placement, and also
reveals the presence of any severe undercut
in ridge morpholo

6. Width of keratinized soft
tissue-
• least 3 mm of attached keratinized
thick marginal soft tissue collar
• non-keratinized thin and mobile soft
tissue is found at the implant site
????
Soft tissue
biotype
Soft Tissue Grafting Procedure

7. Periodontal health of adjacent teeth
Tooth adjacent to the future implant site showing deep periodontal pocket with purulent discharge through a sinus. The
infected pocket is treated first with scaling, curettage and antibiotics until it healed and showed no active infection. The healed
periodontal osseous defect is exposed, cleaned, irrigated with antibiotics and grafted simultaneous to implant placement at the
adjacent site

8. OPPOSING AND ADJACENT TEETH AT OCCLUSAL POSITION
TOBACCO CHEWING

10. DIAGNOSTIC IMAGING :
Imaging objectives : depends on –
Can be organised into 3 phases:
• Pre prosthetic implant imaging
• Surgical & interventional implant
imaging
• Post prosthetic implant imaging
Pre prosthetic imaging :
Objectives :
Identify disease
Determination of bone quality
Determination of bone quantity
Determine implant position
Determine implant orientation

12. MISCH AND JUDY CLASSIFICATION OF BONE AVAILABILITY
Division A (abundant bone)
5 mm or more in width
12 mm or more in height
7 mm or more in length
Less than 30° in angulation
15 mm or less in crown
height.
Division B (barely adequate) bone
2.5–5 mm in width (B+: 4–5 mm; B−:
2.5–4 mm)
b. 12 mm or more in height
c. 6 mm or more in length
d. Less than 20° in angulation
e. 15 mm or less in crown height.
Division C (compromised bone)
0–2.5 mm in width (C-w bone)
b. Less than 12 mm in height (C-h
bone)
c. More than 30° in angulation (C-a
bone)
d. More than 15 mm in crown height
Division D bone (deficient
bone)
severe atrophy,basal bone
loss, flat maxilla, and pencil-
thin mandible, with more
than 20 mm crown height

13. Panoramic radiograph and (B–I) CT scan showing cross-sectional views of the maxilla and the mandible,
showing the Division A bone (adequate bone) for implant placement without any ridge modification or
grafting. (J) The implant-supported, full mouth fixed prosthesis can be seen in the radiograph.

14. Division B

15. Division C-w
Division C-h bone

16. The subperiosteal implant can be preferred over the endosseous root form implant to avoid problems
such as mandibular fracture in the Division D ridge. (A) Subperiosteal implant (B) placed on the deficient
mandibular ridge (C) to support denture. (D) Post-loading radiograph .
Courtesy: Terry D Whitten, DDS

17. Radiographic examination
Extraoral technique
• Periapical
• occlusal
Intraoral technique
• Panoramic Radiographs
• Lateral cephalography
• Tomography
• Magnetic resonance image

18. Periapical radiograph
• Paralleling technique –
McCormack 1920
• Provide – minimum distortions,
better resolution, anatomical
truer view
• Length and height
• Single tooth

19. Occlusal radiograph
• Buccolingual width – extreme boundaries of buccal and lingual cortical plane,
but not necessary in horizontal plane.

20. Cephalometric
• Used as tomogram or section of mid sagittal
region of the maxilla and mandible.
• Vertical height , width and angulation of the bone
at midline
• loss of vertical dimension
• Skeletal arch interrelationship
• Anterior crown implant ratio
• Anterior tooth position in prosthesis
• Resultant movement forces
Help to
evaluat

21. Panoramic
Radiographs
• Single image of maxilla and mandible and supporting structure in frontal
plane.
Advantages
• Opposing landmarks are easily identified
• Vertical dimension of bone can easily
assessed
• Relatively low radiation dose exposer
• Convenience, easy and fast
• Gross anatomy and pathological finding.

22. PANORAMIC DISTORTION
Vertical component- x-ray source as a
focus
Horizontal component - Rotation centre
of the beam as the focus
Distance from the patient arch
from the film
Depend
s
Panoramic beam is angled below the
edentulous arch- width of bone
increase towards the base-
overlapping and increase in vertical
dimension.
Object film distance
Horizontal dimension is
unreliable

23. HOW TO IDENTIFY THE PERCENTAGES OF DISTORTION ?????

24. PANORAMIC LANDMARKS-
Crest of ridge
Opposing landmarks
Maxilla
• Inferior and lateral piriform apertures
• Floor and borders of maxillary sinus
Mandible
• Inferior borders of symphysis
• Mental foramina and ant. Loops of mandibular canals
• Mandibular canal

25. ZONE OF SAFETY
• 530 Misch 1980- 1989Crawford 324
• Neurovascular bundle.
• Mesial to middle half of first molar- 100%

26. Tomography-
The dental
CT scan
gives an
idea about
Accurate three-dimensional measurement of available bone (buccolingual,
mesiodistal, and bone height)
Bone- density at the implant site , ridge morphology, angulation
Any osseous defect, if present
Three-dimensional view of the complete jawbone
Three-dimensional paths and architecture of vital structures like the
mandibular canal, nasal cavity and its floor, sinus cavity and its floor, etc.
Implant simulation for accurate implant selection and its three-dimensional
placement orientation for the best possible future prosthesis
Volume of the graft required, if any grafting procedure like sinus grafting,
block grafting, etc. needs to be performed.

27. CONVENTIONAL TOMOGRAPHY-
• Slices image – in predetermined plane.
• Determine – bone quality and quantity
• Xray sources move in one direction while
film in another direction.
• Plane other then section projected are
blurred.
• Types : linear , complex , spiral

28. COMPUTED TOMOGRAPHY
• Hounsfield 1942. digital & mathematical imaging
technique
• produces digital data
• 3 dimensional axial images

29. • the imaging data are acquired
from the entire volume at
once (one revolution) in CBCT
• CBCT scanners can provide
multiple reconstructions,
including sequential
panoramic, cross-sectional,
sagittal, and other type of
images of the proposed
implant sites or sites.
• alveolar bone height and
width estimates
• Cross-sectional images
identify undercuts and
anatomic concavities in the
alveolar bone.

30. Magnetic resonance imaging ( MRI ) :
MRI visualizes the fat in the bone & differentiates – inf alv canal & neuro vascular
bundle – adjacent trabecular bone
Is not useful in characterizing bone mineralisation / in identifying bone / dental
disease

31. DIAGNOSTIC CAST
• To evaluate the patient’s opposing tooth/teeth, their
overeruption, buccal or lingual inclinations, the drifting of
adjacent teeth, ridge form, etc.
• To fabricate a radiographic template (using radiograph or
CT scan), which is used for accurate planning of the implant
• To fabricate the surgical stent for accurate implant
placement
• For the fabrication of an interim prosthesis after implant
insertion

32. DIAGNOSTIC MOUNTING-
occlusal
relationship-
Interarch and
interdental
Edentulous ridge
relationship to
adjacent teeth and
opposite arches
Tooth position Tooth morphology
Direction of forces in
future implant site
Present occlusal
scheme
Interarch space
Occlusal curve of
spee and Wilson
Arch relationship Opposing dentition
Existing occlusion No. of missing teeth
Arch location of
future abutment
Arch form
Parallelism of
abutment

33. EXISTING OCCLUSION
• The relationship of centric occlusion to centric relation is to be noted because.
• Of potential need of occlusal adjustments to eliminate deflective tooth
contacts.
• Evaluation of their potential noxious effects on the existing dentition.
• For planned restoration.
• Correction may involve one or more of the procedures.
1. Selective odontoplasty
2. Restoration with the crown (with or without Endodontic therapy)
3. Extraction of the offending tooth.

34. EXISTING OCCLUSAL PLANE ORIENTATION
• Aids to evaluate the needed changes.
• Pretreatment diagnostic wax up.
• Occlusal plane analyzer.
Following changes can be seen in opposing dentition
• Drifting
• Tilting
• In partially edentulous ridge more facial resorption may
require implant insertion more medial in relation to the
original central fossa of the natural dentition.

35. CROWN HEIGHT SPACE.
Type of
restoration
Anterior Posterior
Fixed 8-10
mm
7 mm
removable 12 mm. 12 mm
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences;
2004 Sep 20.

36. BONE MAPPING PROCEDURE
• To estimate the underlying bone volume
• Patient is anesthetized  needle is inserted through the overlying
mucosa over the crest and facial and lingual aspects to measure its
thickness.

37. • The edentulous region of the diagnostic cast is sectioned perpendicular to the ridge.
• The diagnostic cast cross-section is shaded with a pencil to represent the tissue thickness observed while probing.
• The remaining cross-section of the cast roughly estimates the available bone volume under the soft tissue.
• Alternatively, a bone caliper with sharp beaks may be used to penetrate the soft tissues at a known height.
• Once the calipers are inserted, bone width can be measured by the calibrated instrument.

39. radiographs show some degree
of magnification; thus the
template with calibrated metal
balls should be used in
radiographic planning of the
implant case, to exactly
calculate the percentage of
magnification in the
radiographic image.
Template for radiograph

40. TEMPLATE FOR DENTAL CT
gutta-percha or self-cure acrylic mixed with barium sulphate can be used in the
template

41. ACRYLIC TEMPLATE

43. Manual surgical guide fabrication

44. Computer-assisted surgical guid
• (A) Edentulous maxillary ridge.
• (B) Implant planning using implant simulation software.
• (C) A surgical guide simulation is done using software.
• (D) The finally planned CT images are exported to the CAD/CAM
system, which fabricates an accurate soft tissue supported surgical
guide.
• (E) Surgical guide is seated over the edentulous ridge and immobilized
using fixation screws.
• (F) The special drill guide sleeves are used to prepare the implant
osteotomies through the surgical guide.
• (G) Clinical and
• (H) radiographic views immediately after implant insertion

45. Treatment prostheses -
• To improve hard and soft tissue
• To evaluate aesthetic and hygiene
consideration
• To determine vertical dimension
• Evaluate psychologic health and attitude
• To determine condition of the patient
management.

46. Conclusion
• Comprehensive treatment with osseointegrated implants
begins with patient evaluation and selection. A thorough
healthy history, review of systems, and physical assessment
should be performed.

47. References
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2004 Sep 20.
• Buser D, Belser U, Wismeijer D. ITI Treatment Guide, Vol 1: Implant
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Quintessence. 2007.
• Mehrotra G, Iyer S, Verma M. Treatment planning the implant patient. Int
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• Bryington M, De Kok IJ, Thalji G, Cooper LF. Patient selection and
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