Essential DIAGNOSTICs of oral IMPLANTs

PRESENTED BY,
Arunraj . D , PG IIIrd YEAR

GUIDED BY,
Dr. N. Gopichander, MDS
(PROFESSOR),
Dr. J.Rameshreddy, MDS (READER)
 Diagnosis of oral implants
• Implant-based rehabilitation approach for an edentulous or partially dentulous
condition requires a series of decisions that are taken to determine whether the
patient is a reasonable candidate for implant therapy.
 General assessment of the patient’s profile

• Medical evaluation - questionnaire

• A patient interview
• Any medical consultations
CLINICAL
ASSSESSMENT OF
DENTAL IMPLANTS
CLINICAL DIAGNOSIS
 Aesthetic assessment (lip lines, tooth position, and other features)
Anterior tooth replacement – primary concern in establishing the esthetic
outcome and long-term stability of the peri-implant tissues.

• In an average smile, 75-100% of the maxillary incisors and the interproximal

gingiva are displayed.
• In a high smile line, additional gingival tissues are exposed.
• Less than 75% of the incisors are exposed in a low smile line.
 Three dimensional clinical evaluation
Available space
Soft tissue ridge support
Periodontal status
Occlusal considerations
 Assessment of available space
• Clinical evaluation of the mesiodistal space involves adequate prosthetic
space assessment so as to reestablish adequate tooth contours.
• If prosthetic space is inadequate, enameloplasty of the adjacent teeth or
orthodontic repositioning must be given consideration.

Rathee, Manu & Bhoria, Mohaneesh. Basics of clinical diagnosis in implant dentistry. Journal of the International Clinical Dental Research
Organization.(2015)
 Assessment of available space
• The implant should be at least 3 mm away from an adjacent implant,
and the diameter of the implant should be selected based on the tooth
to be replaced.
• Based on the above guidelines, for two 4-mm diameter dental implants,
a space of 17 mm is required.
• If three implants are planned, a total space of 24 mm is required.

Rathee, Manu & Bhoria, Mohaneesh. Basics of clinical diagnosis in implant dentistry. Journal of the International Clinical Dental Research
Organization.(2015)
 Assessment of available space
• Clinical evaluation of the buccolingual space, at least 6 mm of bone buccolingually, is
required for the placement of a 4-mm diameter implant and 7 mm for a wider
diameter of 5-mm implant.
• Posterior mandibular dental implant should be planned so that the exit angle of the
screw access points toward the inner incline of the palatal cusp.
• Posterior maxillary implants should be placed so that the exit angle of the screw
access points toward the inner incline of the buccal cusp.

Rathee, Manu & Bhoria, Mohaneesh. Basics of clinical diagnosis in implant dentistry. Journal of the International Clinical Dental Research
Organization.(2015)
Clinical evaluation of available space
 Assessment of available space
• Clinical evaluation of the occlusogingival space can be evaluated under crown height
space availability.
• On clinical examination, the space between the residual ridge and the opposing
occlusal plane should be evaluated.
• If replacing the premolar and molar teeth, a space of 10 mm must exist between
the residual ridge and the opposing occlusion.
• A 7-mm space would be considered the minimum space required.

Rathee, Manu & Bhoria, Mohaneesh. Basics of clinical diagnosis in implant dentistry. Journal of the International Clinical Dental Research
Organization.(2015)
 Evaluation of the soft tissue ridge support
• soft tissue topography is determined by parameters such as contact point position,
crown dimensions, tooth implant distances, and implant diameter.
• Enough space between the implants is needed to allow interdental papilla
reconstruction or at least soft tissue preservation.
• When the space between the dental implants is too close, insufficient blood supply
may result in papilla collapse.
• when the dental implants are placed far apart, unsupported inter-implant papilla
may collapse.

Rathee, Manu & Bhoria, Mohaneesh. Basics of clinical diagnosis in implant dentistry. Journal of the International Clinical Dental Research
Organization.(2015)
RIDGE MAPPING RIDGE ANGULATION
BONE MAPPING

INTRA ORAL
 BONE MAPPING

STENT FABRICATION STENT PLACEMENT

 BONE MAPPING

FILE PLACEMENT SECTIONED CAST

BONE MAPPING

TO DETERMINE BONE WIDTH

BONE WIDTH
BALL BEARING – BONE LENGTH
 FORMULA TO CALCULATE THE DIMENSION OF IMPLANT
PLACEMENT

Actual width of ball bearing = Actual length of implant

Radiographic width of ball bearing Radiographic length of implant
 ASSESSMENT OF PERIODONTAL STATUS
• Gingival biotype – success for implant dentistry.
• It has been suggested that the presence of papilla between the
immediate single tooth implants and the adjacent teeth is correlated
with a thick-flat biotype.
• For thin tissue phenotype variety, minimally invasive or flapless surgery
is more appealing because it minimizes or compromises the blood
supply of the underlying bone and decreases the risk of recession after
implant placement.

Rathee, Manu & Bhoria, Mohaneesh. Basics of clinical diagnosis in implant dentistry. Journal of the International Clinical Dental Research
Organization.(2015)
 OCCLUSAL CONSIDERATIONS
• osseointegrated dental implants are without an intervening periodontal ligament
and the mean axial displacement is noted to be approximately 3-5 μ when
compared to 25-100 μ range of motion of teeth in the socket.
• The range of motion of osseointegrated implants has beenreported to show
deflection in a linear and elastic pattern and movement of the implant under the
load is dependent on the elastic deformation of the bone.

Rathee, Manu & Bhoria, Mohaneesh. Basics of clinical diagnosis in implant dentistry. Journal of the International Clinical Dental Research
Organization.(2015)
 OCCLUSAL CONSIDERATIONS
• The occlusion should be evaluated and organized so that there is
anterior guidance and disclusion of the posterior teeth.
• There should be no contact of the posterior teeth with the nonworking
sides.
• If the canine is compromised, group function is acceptable.

Rathee, Manu & Bhoria, Mohaneesh. Basics of clinical diagnosis in implant dentistry. Journal of the International Clinical Dental Research
Organization.(2015)
 Diagnostic Imaging

• Diagnostic imaging helps develop an

appropriate and precise treatment
plan.

•
The selection of a type of imaging
technique plays a major role in
achieving the required information
with the best dimensional accuracy.

Benson BW Diagnostic imaging for dental implant assessment.Tex Dent J. 1995

 Goals

• To measure bone height and width (bone

dimensions)
• To assess bone quality
• To determine the long axis of alveolar bone
• To identify and localize internal anatomy
• To establish jaw boundaries
• To detect any underlying pathology

Benson BW Diagnostic imaging for dental implant assessment.Tex Dent J. 1995

 Phases of Implant Imaging

The objectives of diagnostic imaging depend on a number

of factors, including the amount and type of information
required and the time period of the treatment rendered.

❖
I: Pre-prosthetic implant imaging
❖
II: Surgical and interventional implant
❖
imaging III: Post- prosthetic implant
imaging.
Misch C. Dental implant prosthetics. St. Louis (Mo.): Elsevier
Mosby; 2015.
 I : Pre-prosthetic implant imaging
The objectives of this phase of imaging include all
necessary surgical and prosthetic
information
• To determine the quantity, quality, and angulations
of bone;
• The relationship of critical structures to the
prospective implant sites;
• The presence or absence of disease at the
proposed surgery sites.

Misch C. Dental implant prosthetics. St. Louis (Mo.): Elsevier

Mosby; 2015.
II : Surgical and interventional implant imaging

The objectives of this phase of imaging are :

• To evaluate the surgery sites during and immediately after surgery,

• Assist in the optimal position and orientation of dental implants,
• Evaluate the healing and integration phase of implant surgery,
• Ensure that abutment position and prosthesis fabrication are
correct.

Misch C. Dental implant prosthetics. St. Louis (Mo.): Elsevier

Mosby; 2015.
III : Post- prosthetic implant imaging

The objectives of this phase of imaging are to

evaluate the long-term maintenance of implant rigid
fixation and function, including the crestal bone
levels around each implant, and to evaluate the
implant complex.

Misch C. Dental implant prosthetics. St. Louis (Mo.): Elsevier

 IMAGING
MODALITI
ES

ANALOG DIGITAL
 IMAGING
MODALITIES

TWO- THREE-
DIMENSION DIMENSION
AL AL
 Imaging Modalities
Periapical radiography

Panoramic radiography

Occlusal radiography

Cephalometric radiography

Computed tomography

Magnetic resonance imaging

Interactive computed tomography

Misch C. Dental implant prosthetics. St. Louis (Mo.): Elsevier

 Periapical Radiography

Periapical radiography
provides a high-
resolution planar image
of a limited region of the
jaws.
Periapical radiographs
may suffer from distortion
and magnification.

Goaz PW, White SC ,Oral radiology: principles and interpretation,2nd ed. St Louis (MO):
Mosby
Goaz PW, White SC, Oral radiology: principles and interpretation,2nd ed. St Louis (MO):
Mosby
Occlusal Radiography

• Shows the widest width of bone versus the width

at the crest
• The degree of mineralization of trabecular bone
is
• not
The determined
spatial relationship between critical
structures, such as the mandibular canal and the
mental foramen, and the proposed implant site is
lost with this projection.

Misch C. Dental implant prosthetics. St. Louis (Mo.): Elsevier

Mosby; 2015.
 Cephalometric radiographs
• Oriented planar
radiographs of the skull.
• A cephalometer, which
physically fixes the
position of the skull with
projections into the
external auditory canal.
• Results in a 10%
magnification of the
image with a 60-inch
focal object and a 6-
•
inch object-to-film
distance. Misch C. Dental implant prosthetics. St. Louis (Mo.): Elsevier
 Cephalometric radiographs
Lateral cephalometric radiography
helps in the analysis of the quality of
the bony site (ratio of compact to
cancellous bone), especially in the
anterior region of the mandible.

The lateral cephalometric view

also can help evaluate
• loss of vertical dimension,
• skeletal arch
• interrelationship, anterior
• crown/implant ratio,
anterior tooth position in the
prosthesis. Misch C. Dental implant prosthetics. St. Louis (Mo.): Elsevier
 Panoramic radiography

Panoramic radiography is a curved plane tomographic

radiographic technique used to depict the body of the
mandible, maxilla, and the lower one half of the maxillary
sinuses in a single image. This modality is probably the most
used diagnostic modality in implant dentistry.

Truhlar RS, Morris HF, Ochi S. A Review of panoramic radiography and its potential use in implant dentistry.
Implant Dent 1993;2:122-30.
 Panoramic radiography
Advantages:
Limitations:
•Easy identification of opposing landmarks
• Initial assessment of vertical height of • Distortions inherent in the panoramic
bone system
• Errors in patient positioning
•Convenience, ease, and speed in
• Does not demonstrate bone quality
performance in most dental • Misleading quantitate because of
offices magnification and no third dimension
•Evaluation of gross anatomy of the jaws • No spatial relationship between
and any related pathologic findings structures

Truhlar RS, Morris HF, Ochi S. A Review of panoramic radiography and its potential use in implant dentistry. Implant Dent
1993;2:122-30.
 Tomography
‘Tomos’- Section- Generation of narrow sections through
an object.
Conventional Tomography is a method that obtains
clearer image of the structures lying within a plane
of interest.

The film and X-ray beam progress with respect to

each other and consequently blurring out structures.

The magnification factor of this imaging technique is stable

in all directions.

Conventional tomography is appropriate for planning single

implant sites or for those within a single quadrant.

Lindh C, Petersson A. Radiologic examination for location of the mandibular canal: A comparison between panoramic radiography and
conventional tomography. Int J Oral Maxillofac Implants 1989;4:249-53.
 Magnetic Resonance Imaging (MRI)
Principle

Paul.C.Lauterbur in
1972

MRI is a technique to image the protons of

the body using magnetic fields, radio
frequencies, electromagnetic detectors, and
computers.
Gray CF, Redpath TW, Smith FW,et al. Advanced imaging: Magnetic resonance imaging in implant dentistry. ClinOral Implants Res
 Magnetic Resonance Imaging (MRI)

Advantages

• No Radiation
• Vital structures are easily
seen
Limitation
s
• Cost
• Technique
• Sensitive
Availability
Uses
• Evaluation of vital structures when
computed tomography is not
• conclusive Evaluation of
infection(osteomyelitis)
Gray CF, Redpath TW, Smith FW,et al. Advanced imaging: Magnetic resonance imaging in implant dentistry. ClinOral Implants Res
2003;14:18–27.
 Computed Tomography
Godfrey
Housfield

The x-ray source is attached

rigidly to a fan-beam geometry
detector array, which rotates 360
degrees around the patient and
collects data.
 Hounsfeild unit

• Three-dimensional digital images, typically

512 × 512 pixels with a thickness
described by the slice spacing of the
• imaging technique.
The individual element called a voxel, referred
• to in Hounsfield units, that describes the
Mah P, Reeves TE, McDavid WD. Deriving Hounsfield • density
units using grey levels in cone beam computed Each voxel contains 12 bits of data
tomography. Dentomaxillofac Radiol 2010;39:323–35.
 Bone Quality - Hounsfeild unit

Bon D D D D D
e 1 2 3 4 5
Hounsfeil
>1250 850- 350- 150- <15
d unit HU 1250 850 350 0

Mah P, Reeves TE, McDavid WD. Deriving Hounsfield units using grey levels in cone beam computed tomography. Dentomaxillofac
Radiol 2010;39:323–35.
 Denta Scan

Commercially available desktop interactive software program

Comprehensive assessment of the bone pre-operatively for implant surgery.
It is a computed tomography (CT) software program
Permits imaging in three planes i.e. cross-sectional, axial and
panoramic.
Advantages : Assess bone volumes and density, make direct
measurements, manipulate the images to simulate implant placement or
bone grafting procedures, as well as can view the images in all the three
planes at the same time.
Chandel S, Agrawal A, Singh N, Singhal A. Dentascan: A Diagnostic Boon. Journal of dental sciences and
Cone Beam CT
Cone Beam
Volumetric
tomography

The use of CBCT technology

in clinical practice
provides a number of
potential advantages for
maxillofacial imaging
compared with conventional
CT. As most CBCT units
can be adjusted to scan small
regions for specific
diagnostic tasks, hence, the
size of the irradiated area is
reduced as the primary x- ray
beam is collimated to the area
of interest thus, the radiation
dose is minimised.
 Uses
• Determination of the available bone height, width, and relative quality.

• Determination of the 3D topography of the alveolar ridge.

• Identification and localization of vital anatomical structures such as the inferior

alveolar nerve, mental fora- men, incisive canal, maxillary sinus, ostium, and
floor of the nasal cavity.

• Identification and 3D evaluation of possible incidental pathology.

• Fabrication of CBCT-derived implant surgical guides.

• Communication of the diagnostic and treatment planning information to all

members of the implant team.

• Evaluation of prosthetic/restorative options through implant software

applications.
BONE LENGTH
BONE WIDTH
 Advantages and Limitations

Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed tomography in implant dentistry: The International Congress of
Oral Implantologists consensus report.Implant Dent.2012;21:78–86.
 FOV (Field of View)
The dimensions of the field of view (FOV) or scan volume able to be covered
primarily depend on the detector size and shape, the beam projection
geometry, and the ability to collimate the beam.

Larg Mediu Small/ Stitche

 Available Models of CBCT
3D Accuitomo 80/170; J. Morita Mfg Corp, Kyoto,
Japan
Galileos; Galileos Comfort/Compact Sirona
Dental
Systems
GmbH,G
ermany
GXCB-500 HD/GXDP-700 S; KaVo 3D Gendex Dental Systems,
eXam Hatfield, PA/KaVo Dental
Systems,Germany
CS 9000 3D/9000 C 3D/9300/9300 Carestream Dental, Atlanta,
Select/ GA
9500
NewTom 9000/3G QR srl,/Cefla Dental
Group,Italy

Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed tomography in implant dentistry: The International Congress of
Oral Implantologists consensus report.Implant Dent.2012;21:78–86.
 Interactive CT (ICT)

ICT is a technique that was

developed to bridge the gap in
information transfer between the
radiologist and the
practitioner. This technique
enables the radiologist to
transfer the imaging study to the
practitioner as a computer file
and enables the practitioner
to view and interact with the
imaging study on a personal
computer.

Ritter L, Reiz SD, Rothamel D, et al. Registration accuracy of three-dimensional surface and cone beam computed
tomography data for virtual implant planning. Clin Oral Implants Res 2012;23:447–52.
 Galileos Implant Software

• Colour visualisation of the nerve

• Canal Depiction of the bones in all dimensions
• Easy to use
• The implant can be ideally adapted to fit the patient’s anatomy
 Planmeca Romexis

Helps in planning treatment and evaluation of implant

placement using realistic implant, abutment and crown models.
This software thus allows to import and superimpose a soft-
tissue scan and crown design with CBCT data for implant
planning.
Spector L. Computer-aided dental implant planning. Dent Clin North Am 2008;52:761-75.
 SIMPLANT
• Cost-effective, user-
friendly and uniquely
compatible with the
brands and equipment
that clinicians already
know and use.

• Compatible with over

10,000 implants from
more than 100 brands,
as well as all DICOM
compatible (CB) CT
scanners and major
optical and intraoral
scanners.
Spector L. Computer-aided dental implant planning. Dent Clin North Am 2008;52:761-75.
 Noble Guide Software

The ideal implant placement can be determined based on bone quantity and
quality, critical anatomical structures and prosthetic needs. NobelClinician
warns you when implants are placed too close to annotated nerves or tooth roots.
Spector L. Computer-aided dental implant planning. Dent Clin North Am 2008;52:761-75.
 Radiographic Templates and Visualisation
Radiographic templates are typically fabricated by duplicating the existing
or proposed restoration or waxing on a dental cast, duplicating the
diagnostic cast, and fabricating a separate template based on the wax-up.

A stent which mimics the desired tooth setup is constructed and radiographic markers usually made of
gutta percha or another radio-opaque material placed within it
Kopp KC, Koslow AH, Abdo OS. Predictable implant placement with a diagnostic/surgical template and advanced radiographic imaging. J Prosthet Dent 2003;89:611–
5.
 Materials for Radiographic stent

Ball Bearings Gutta Percha Radiopaque

teeth/Resin
Israelson H, Plemons JM, Watkins P, et al. Barium-coated surgical stents and computer-assisted
 Stick ’n scan technology

•
•
•

•
•
• To determine the accuracy and effectiveness of digital panoramic radiographs for pre-
operative assessment of dental implants.

• 86 patients (221 implants) and calculated the length of the planned implant based on the
distance between a selection of critical anatomical structures and the alveolar crest using the
scaling tools provided in the digital analysed the magnification rate.
RESULTS:

Magnification rate of the width and length of the inserted implants, seen in the
digital panoramic radiographs, was 127.28 ± 13.47% and 128.22 ± 4.17%,
respectively.
The magnification rate of the implant width was largest in the mandibular anterior part
and there was a significant difference in the magnification rate of the length of implants
between the maxilla and the mandible
There is no significant difference between the planned implant length and actual
inserted implant length according to the clarity of anatomical structures (P < 0.05).

CONCLUSIONS:

Digital panoramic radiography can be considered a simple, readily available and

considerably accurate pre-operative assessment tool in the vertical dimension for
dental implant therapy.
Determination of the dental implant length using panoramic radiography is a reliable
technique to prevent neurosensory complications. However computed tomography
or cone- beam computed tomography based planning of dental implants may be
required for borderline cases

An implant proximity more than 1 mm to the mandibular canal is safe and predictable for
dental implant planning in mandibular posterior region on panoramic radiographs.
RECENT ADVANCES
 Double Scan Protocol

The procedure is based This template is then

on the modified to add the
use of a partial complete prosthetic
radiographic information, and a
template with second CBCT is made
radiopaque only to the template.
markers for initial cone
beam
computer tomography
(CBCT) allows 3D virtual prosthetic information
This Modification
to be applied in regions where teeth will be extracted.

Alejandro Lanis, Miguel Padial-Molina, Rami Gamil, Orlando Alvarez del Canto, Computer-guided implant surgery and immediate loading
with a modifiable radiographic template in a patient with partial edentulism: A clinical report, In The Journal of Prosthetic Dentistry,
Volume 114, Issue 3, 2015, Pages 328-334,
 Double Scan Protocol

The use of modifiable radiographic

templates as part of a double scan
protocol appears to be a predictable
method of applying 3D prosthetic virtual
 Non-ionizing real-time ultrasonography

Suitable signal-to-noise, a dynamic

range of 80 dB for large soft tissue
contrast.

Application of ultrasound gel and the

use of gel- based stand-off pads.

The limitation of ultrasound imaging

is that structures within bone could
not be seen, such as the inferior
alveolar nerve.

Additionally, a medium is required

for sound transmission.
Chan H-L, Wang H-L, Fowlkes JB, Giannobile WV, Kripfgans OD. Non-ionizing real-time ultrasonography in implant and oral surgery: a
feasibility study. Clin. Oral Impl. Res. 00, 2016; 1–7
 Non-ionizing real-time ultrasonography
This pilot study demonstrates the feasibility of ultrasound to evaluate multiple
important oral and dental anatomical structures.
Ultrasound Realtime CBCT Merged

Chan H-L, Wang H-L, Fowlkes JB, Giannobile WV, Kripfgans OD. Non-ionizing real-time ultrasonography in implant and oral surgery: a
feasibility study. Clin. Oral Impl. Res. 00, 2016; 1–7
Radiation Safety
 Selection Of A Radiographic Method
Indications for the most frequently used imaging modalities in implant dentistry
are proposed based on clinical need and biologic risk for the
patient.
 SUMMARY
• Proper evaluation of bone and the soft tissue- success in implant dentistry
• Selection of an appropriate imaging modality should be made based on the
type and number of implants, location of the implant, and surrounding
anatomy.
• As in the case of all imaging techniques, appropriate selection criteria must
be applied before selecting one which is most suitable for each patient.
THANK YOU..!!