Dental Implant Treatment Planning for New Dentists Starting Implant Therapy
100
Dental Implant Treatment Planning for New Dentists Starting Implant Therapy
100eBook
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Product Details
| ISBN-13: | 9781546221104 |
|---|---|
| Publisher: | AuthorHouse |
| Publication date: | 01/26/2018 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 100 |
| File size: | 13 MB |
| Note: | This product may take a few minutes to download. |
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CHAPTER 1
Implant Treatment planning
In planning dental implants the first step is deciding which patients would be good candidates for implant therapy. The medical history for patients are first reviewed to identify any uncontrolled systemic conditions that can be able to affect dental implant placement. Next, to select the right patient cases, a comprehensive exam involving a clinical exam and radiographic exam utilizing full mouth x-rays and panorex are completed. CT Scans should also be obtained if necessary to view vital structures or for more comprehensive treatment planning especially with multiple implants.
Typically, for single teeth replacements around premolars and molars, Panoramic x-rays to evaluate vital structures such as the maxillary sinus, mental foramen and inferior alveolar nerve are necessary. Periapical x-rays can provide a focused view of the implant site. CT Scans can also be utilized to give a better understanding about the bone height, density and width, as well as to allow the anatomy in the area to be visualized. These scans give a three dimensional view of the bone in the implant site and are essential for treatment planning especially for more complex dental implant cases. CT scan imaging does offer a number of advantages even with single tooth dental implant placement by giving a better preoperative visualization of the bone in the dental implant site prior to dental implant placement.
A preliminary dental implant examination allows for assessment of the patient's oral condition, so that all teeth that should be treatment planned for dental implants can be readily visualized. It will also allow the ability to evaluate other teeth in the mouth so that the appropriate restorative options can be chosen, and disease conditions that might hamper the success rate of dental implants can be identified and treated prior to dental implant therapy.
The overall benefit that can be gained from this examination is also that it helps develop a comprehensive course of action that incorporates all treatment needs of a patient during the treatment planning phase.
Inter-occlusal and inter-arch space can be evaluated, condition of adjacent teeth, as well as other treatment needs of the patient can also be identified.
The need for periodontics, restorative, prosthodontics, orthodontics, endodontics, and oral surgery is also determined, and the sequence to start therapy is decided. Examination starting from a periodontal evaluation, occlusal analysis, endodontic, and restorative planning should be completed prior to dental implant therapy. Orthodontic assessment and therapy should be completed if needed prior to initiating dental implant therapy unless otherwise recommended by an orthodontist.
For example, if a patient needs or still has braces on their teeth to correct for extensive spacing or crowding in the arch, collaboration should occur between treating dentists to determine when and where would be ideal to place the dental implant. In addressing spatial concerns, a team approach to dental implant placement is recommended. The team usually comprises orthodontists, implant surgeons and restorative dentists who make decisions about when and where to place the dental implants. Spatial deficiencies and diastemas can be corrected using orthodontics, enamelplasty or restorations prior to placement and restoration of dental implants.
Preliminary Dental Implant Examination:
During the initial dental implant assessment, comprehensive restorative and periodontal examinations are completed to assess the condition of adjacent teeth and screen for dental diseases and other pre-existing conditions.
The approach to dental implants especially in the anterior zone is now more of a restoration driven dental implant placement rather than a surgical guided one with dental implants placed in sites that allow the most optimal restorative outcome rather than an emphasis on only where there is adequate bone for implant placement. As a result, the goal of the current approach is to utilize additional techniques such as bone augmentation in other to create more favorable sites for dental implant placement rather than placing implants in situations that present possible restorative complications.
This is particularly important especially when treatment planning and restoring anterior dental implants. A multi-disciplinary approach to dental implant placement is often the goal. If potential complications such as deficient space or inter arch distance, crowding, staining, wear, or caries in adjacent teeth, they should be addressed, and periodontal and endodontic disease that are detected in adjacent teeth should be noted and treated. These conditions when noted during treatment planning are treated by the general dentist if within scope of care, or referred to specialists as needed.
As a dentist that is starting to place dental implants, recommendation is usually made to start placement in the areas of the mouth typically not in the esthetic zone but still accessible such as mandibular and maxillary premolar areas, as well as first molar areas for first implant placement. As level of expertise increases, the anterior zone becomes a viable area for dental implant placement and restoration. However, if your first implant surgery is in the anterior zone, with careful dental implant planning and therapy, you can still be able to get a successful result.
SEQUENCE OF DENTAL IMPLANT TREATMENT PLANNING:
As part of the preliminary examination, impressions for study models are made, allowing fabrication of a diagnostic wax-up by a dental laboratory. This will allow for visualization of potential end results, and provide a guide for achieving successful esthetic outcomes. This can also provide a stent if Ct guided stent is not being utilized.
Specifically, the potential size of the planned implant restoration can be visualized with the wax up, allowing the dentist to evaluate if there is adequate or excessive amount of space for the implants that are treatment planned. It will also allow the dentist to evaluate the potential length of the restoration in comparison to adjacent teeth especially for teeth that have been extracted for a number of years. They can be able to provide guidance such as whether increasing the ridge height or width would be needed and referral for block or particulate bone grafting is needed prior to implant placement. Usually alginate impressions can be taken for preliminary study casts as well as a bite registration which is also provided to the dental lab, for more complex cases a face bow transfer and models mounted on semi adjustable articulators are needed.
The diagnostic wax up would also be a good guide for determining the best restorative option for patients. For example, if the patient would be better served with over dentures versus fixed prosthetic restorations on the implants due to loss of bone and supporting tissues. The wax up would give a guide of the potential optimal option so that a choice can be made to ensure the right restoration is utilized. It will also allow decisions such as whether single implant restorations or splinted implant bridges would be the better option when multiple implants are being placed.
The articulated diagnostic wax up also allows dentists to be able to choose abutments based on the inter-occlusal space present, and assess whether angled abutments, custom or standard abutment would be necessary. The diagnostic wax-up can also be utilized to fabricate temporary restorations as well as provide a template for a surgical guide for dental implant placement.
Surgical guides aid in restoration driven dental implant placement. These guides allow the placement of dental implants in optimal positions, not just based on the anatomic characteristics of the bone, but they also in positions that allow cosmetic restorative outcomes. They also facilitate optimal positioning and angulation of implants in bone.
Preparing for implant surgery is a major process for a dentist. It involves not only preparing the patient, but also the operatory and surgical staff for the procedure. Having taken preliminary impressions, the next step will involve sending the models to the dental laboratory for a diagnostic wax-up and surgical stent fabrication. Once the wax-up is approved and the surgical stent is ready, the next step would be to schedule the implant surgery and get prepared for the surgical therapy. For dentists that are just starting placement of dental implants, use of surgical stents are highly recommended.
Types of Surgical stents:
Surgical stents can be either fixed or variable. Variable position stents include those that are made with vacuumed formed acrylic and other materials over duplicate casts made from diagnostic wax-up. It takes into consideration the mesio-distal position of implant site as well as the width of the site.
Fixed stents do not allow for variation of the implant position from the one already planned. Most fixed stents utilize a 3D scan of the bone at the implant site, and help transmit this information to the optimal position in the mouth for implant placement. They usually are in the form of plastic, metal tubes and channels made in acrylic resins that determine the position of the dental implant prior to dental implant placement.
More recently advanced techniques have been used for fabrication of surgical stents, and the design concepts for surgical stents can be classified further as non limiting stents, partially limiting stents and completely limiting stents.
Nonlimiting stents provide the surgeon only with the ideal position of the implant restoration based on the diagnostic wax-up. It does not take into consideration angulation of the drill, therefore there is significant flexibility in the implant position. It also does not take into consideration site related factors such as presence of concavities in bone. Examples of non-limiting stents can include vacuum formed matrix with access holes that will place the dental implant in an optimal restorative position
Partially limiting stents involve direction of the initial drill using a surgical guide and completing the rest of the surgery free hand. Fabrication of these stents involve to creation of a radiographic template which is converted to a surgical guide. The problem with these stents is that there is again a concern with ability to completely limit the angulation of drill. Most surgeries in the United States are performed using partially limiting stents due to cost effectiveness.
Completely limiting stents create limits in angulation in the bucco-lingual and mesio-distal directions and control depths of burs by having stops on the drills. Two types exist, cast based stents and also CADCAM surgical guides.
The cast based technique combines analog technique done with bone sounding and periapical radiographs. The root is trans-positioned to the cast using imaging software, and a laboratory sleeve is converted in part with wires that produce a frame work around teeth. Polyvinylsiloxane is what forms the superstructure of the stent.
Fabricating CAD/CAM based surgical guides involve 4 steps:1) Fabrication of the template, 2) completion of CT Scan, 3) Implant planning using interactive software and 4) Fabrication of stereolithographic drill guide which will be used for surgery.
CAD/CAM stents are considered to be the most accurate stents that currently exist. They promote use of flapless technique by allowing three dimensional visualization of the site so that adequate preoperative planning can be performed. They also allow pre-surgical master cast production so that provisional restorations can be created facilitating using of immediate dental implant placement and restoration but they are not completely without inaccuracy.
A study conducted on 61 placed dental implants using free hand technique with no surgical guide, tube, channel and Guided CAD/CAM stents found that while CAD/CAM stents had the least mesio-distal error, they were not as accurate as would have been desired in the bucco-lingual direction and tended to err towards implant placement to the palatal aspect.
In evaluating the effect of surgical guides on dental implant surgery, it was found that most errors occurred in the position and angulation of the surgical guide, and that the surgeon's prior experience as well as the size of the site where the most important factors to creating errors that affected accuracy of dental implant placement using surgical guides.
Advantages of Fixed Surgical Stents:
1) Simplicity. Better ease of implant placement.
2) Minimizes errors in angulation and positioning for dental implants.
3) More precision in the location of dental implants.
4) Allows visualization of potential restorative outcome during dental implant placement.
5) For anterior cases reduces risk of getting a poor esthetic result by direct guidance of implant position in comparison to adjacent teeth.
6) Allows avoidance of placement of implant into unfavorable positions such as in locations with concavities.
7) Accuracy. Especially for fixed positioned stents using 3D CT imaging, (completely limiting stents) they are able to prevent surprises during surgical therapy that would have resulted in changes in position of the dental implant to compensate for the bone changes. By showing the potential position of the dental implant restoration with regard to the existing bone in the site, unfavorable changes in bone density and bone width, and defects in bone can be identified and addressed prior to the surgical visit.
Required characteristics Surgical stents:
1) Easy to place and remove from mouth.
2) It should be rigid and stable and stay in position during surgery drilling.
3) It should allow placement and removal of bite blocks if they are being used for the surgical procedure without obstruction.
4) It should not interfere with tissue reflection and also allow visualization of the surgical site where the surgery is being performed.
Restorative Temporization during implant integration:
Types of temporary restorations to utilize prior to permanent implant restorations include removable partial dentures, complete dentures, nesbite type removable restorations, Essix retainer type removable restorations, maryland bridges and also immediately loaded temporary restorations on dental implants. The type of permanent restoration to utilize is often determined in this early planning stage prior to dental implant placement to ensure optimal esthetic and functional outcomes.
For single tooth molar extractions, typically, most patients do not require provisionalization prior to dental implant placement because of the location in the mouth, but occasionally some highly esthetic conscious patients might want a temporary restoration fabricated to replace the missing posterior tooth while the implant is osseo-integrating. In such cases, nesbite type removable restoration that rest on adjacent teeth would be the best option available, although acrylic partials, retainer type devices and Maryland bridges are also viable options.
In the anterior areas of the mouth, the goal is to provide temporization which is both functional as well as esthetic. A number of factors are involved in treatment planning dental implants in the esthetic zone in the mouth. These factors include the location of the midline, the size of adjacent teeth, and the potential size of the implant restoration, the shade of adjacent teeth, the presence of excessive or deficient periodontal tissue as well as spacing or crowding of teeth.
Temporization in the anterior zone is extremely important. Most patients will state a clear aversion to not having anterior temporary restorations even for a short period of time. Options for temporization of the partially edentulous anterior zone include removable acrylic partial dentures, Maryland bridges supported by adjacent teeth, Nesbyte type partials replacing single teeth, temporary restorations placed on the implants without occlusal loading on the dental implant, and permanent restoration of the dental implants with functional loading of the dental implant.
Keeping up with a need for esthetics in the maxillary anterior zone, the one stage technique with immediate restoration of dental implant with temporary or permanent restorations is done more frequently in this area of the mouth. The goal has been to provide patients with esthetic functional restorations while minimizing the wait time to receive their implant restorations. In the absence of significant bone loss requiring bone or soft tissue grafting, or replacement of endodontically and periodontally infected teeth, it is the recommended protocol in the esthetic zone, with success rate comparable or slightly higher than the two staged technique in the area.
(Continues…)
Excerpted from "Dental Implant Treatment Planning"
by .
Copyright © 2018 Dr. Nkem Obiechina.
Excerpted by permission of AuthorHouse.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Introduction, v,
Chapter 1: Implant Treatment planning, 1,
Chapter 2: Assessment of conditions that can affect dental implant placement, 15,
Chapter 3: Dental Implant Components and Protocols for Dental Implant surgery, 20,
Chapter 4: Delayed and Immediate Dental Implant placement, 28,
Chapter 5: Site preparation prior and during Dental Implant placement, 37,
Chapter 6: Bone and Soft tissue augmentation procedures prior to dental Implant placement, 42,
Chapter 7: Preparation and Steps for Dental Implant Surgery, 45,
Chapter 8: Dental Implant Uncovering and Second Stage Implant Surgery, 56,
Chapter 9: Selecting Dental Implant abutments and Impression techniques for Fixed Implant restorations, 59,
Chapter 10: Cemented versus Screw retained dental implant restorations, 67,
Chapter 11: restorative Options for Edentulous patients (Overdentures and Fixed restorations), 70,
Chapter 12: Dental Implant Complications, 76,
Chapter 13: Dental Implant maintenance, 81,
Chapter 14: Conclusion, 86,
References, 89,