Indian Dental Academy: will be one of the most relevant and exciting
training center with best faculty and flexible training programs
for dental professionals who wish to advance in their dental
practice,Offers certified courses in Dental
implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic
Dentistry, Periodontics and General Dentistry.
Diagnosis, treatment planning and radiographic evaluation/ cosmetic dentistry training
1. INDIAN DENTAL ACADEMY
Leader in continuing dental education
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2. Introduction
Rationale for dental implants
Advantages of implant supported prosthesis
Contraindication and implant failures
Patients complaints and expectation
Patients history
Laboratory evaluation
Clinical examination
Diagnostic imaging and techniques
Radiographic interpretation
Diagnostic models
Prosthetic option
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3. Available bone
Division of bone
Bone quality
Treatment option for partially edentulous
Treatment option for completely edentulous
Treatment option for single tooth replacement
Surgical guide
Conclusion
Reference
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4. Thorough patient assessment is prerequisite for
adequate treatment planning
Practioner has to evaluate
Whether implant is indicated
For the patient
In specific oral situation
As comprehensive treatment planning.
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6. Combined effect of no of factors:-
Aging population
Tooth loss related to age
Anatomic consequences of edentulism
Roberts’ et al – 4% strain to skeletal system
maintain bone and helps balance the
resorption and formation phenomenon.
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7. Loss of bone width, height
Keratinized mucosa decreases
Tongue often enlarges
Tongue takes active role in mastication
Decrease neuromuscular control
Prominent mylohyoid , internal oblique ridge,
genial tubercles.
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8. Esthetic consequences of edentulism
Prognathic appearance
Decrease horizontal lip angle
Thin lips
Decrease facial height
Poor performance of removable prosthesis
Psychological aspects of tooth loss
Complex and varied
Minimal to neurocticism
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9. Tooth positioned for aesthetics
Maintainence of bone
Maintainence of occlusal vertical dimension
Development of Proper occlusion
Improved psychological health
Regained proprioception
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10. Increase survival time of the restoration
Improved function, stability, retention and
phonetics
Preserve intact adjacent natural tooth
Improved chewing efficiency
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15. Post head and neck radiation
Osteoporosis
Uncontrolled diabetic
Alcohol , drug abuse, heavy smoker
h/o aggressive periodontits
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16. During initial consultation it is advisable to
have patient elicit his or her complaint,
concerns and treatment request.
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17. Confirms their complaints and expectation
The review of the patient’s medical history is the
first opportunity for the dentist to talk with the
patient
The time and consideration taken at the onset will
set the tone for the entire following treatment
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18. Level of dental disease
Commitment towards its management
Denture history
Additional questions
Age of prosthesis
Reason for tooth loss
H/o periodontal disease
Tooth loss due to trauma
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20. Correct facial proportion
Facial symmetry
Need for cheek and lip support
Facial skeletal classification
Intermaxillary relation
Incisal edge of maxillary centrals
TMJ movement and function
Hypertrophy of facial musculature
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21. Dental examination
Edentulous region
Quantity and quality of mucosa and contour of
underlying bone
Existing prosthesis
Occlusal status and functional examination
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23. Specific criteria
Lip lines
Maxillomandibular relation
Existing occlusion
Crown height space
TMJ status
Existing prosthesis
Natural adjacent tooth
Soft tissue of edentulous site
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24. Evaluated prior to any other segment
Labial position determined with lip in repose
Vertical position evaluated
Maxillary canine is key
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25. Distance between two points
when occluding members are in
contact.
Not a constant position.
Change in OVD may modify
anterior guidance, function and
esthetic
Kois and Phillips , three
situations mandate modification
of OVD
Esthetic
Function
Structural needs of the dentition
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26. Esthetic is related to OVD for incisal edge,
facial measurement and occlusal plane
Function is related for anterior guidance,
canine position and angle of load.
Structural requirements are related to
dimension of teeth for restoration
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27. Mandibular incisal edge should contact lingual
aspect of upper anterior teeth.
Incisal guidance evaluated.
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28. Maxillary occlusal plane
parallel to Camper’s line
Occlusal plane of natural teeth
evaluated in partially
edentulous patient.
Occlusal plane analyzer used
to evaluate pretreatment
condition and assist occlusal
plane correction.
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29. Lip position are evaluated for
Resting lip position
Maxillary high lip line
Mandibular low lip line
Lip position varies with age
Smile line –
Low
Average
High(gummy)
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30. Completely edentulous patient lip position
verified.
Mandibular teeth more visible in middle age
and older patient
Mandibular teeth evaluated during speech
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31. Assessed in vertical, horizontal and lateral
planes.
Improper skeletal position corrected by
orthodontics or surgery
Often effected in edentulous arches
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32. Maxillary arch width decreases 40% in expense
of labial plate – cantilevered force in implant
body.
Long term complete denture patient mimic
class III relation
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33. It is best evaluated with facebow mounted
diagnostic cast
Evaluate if existing occlusion be modified or
maintained.
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34. CHS measured from crest of bone to plane of
occlusion/ incisal region
For FP1 CHS ranges 8 – 12mm
Biological width
Abument height
Esthetic
Hygiene
Removable prosthesis > 12mm
Denture teeth
Acrylic base
Attachments
Hygiene
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36. Help to develop and implement a cohesive
and comprehensive treatment plan for the
implant team and the patient
Organized under three phases
1. Preprosthetic implant imaging
2. Surgical and interventional implant imaging
3. Post prosthodontic implant imaging
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37. PHASES OBJECTIVE
Preprosthetic imaging Identify disease
Bone quantity
Bone quality
Critical structure
Optimum presence of
implant placement
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38. PHASES OBJECTIVE
Surgical and
interventional imaging
Depth of placement
Position and orientation
of implant osteotomy
Evaluate donor or graft
site
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39. PHASES OBJECTIVE
Post prosthetic phase Status and prognosis
Bony changes around
implant
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41. Analog imaging modalities/2D:
1. Periapical radiographs
2. Panoramic radiographs
3. Occlusal radiography
4. Cephalometric radiography
3-D imaging modalities
1. CT
2. MRI
3. CBVT
Digital images can be produced in all the
modalities
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43. Popular form of radiograph
Provides general overview of dentition and jaws.
Disadvantages :
1. Both vertical and horizontal magnification are
present
2. Does not demonstrate bone quality and
mineralization
3. Accuracy depends on patients position
4. Image is 2 dimensional
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45. Bone availability in mid
sagittal region of maxilla and
mandible
Cross sectional image in incisal
and canine region
Check width of bone in
symphysis region and its
relationship between buccal
cortex and roots of anterior
teeth before harvesting bone
for augmentation.
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46. Greek words “tomo”- slice and “graph”-
picture in 1962.
International commision on radiological nits
and measurement.
Types
Linear
Spiral
hypocycloidal
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48. Digital and mathematical imaging technique that
creates tomographic sections
Enables differentiation and quantification of both
soft and hard issues
Density of the structure within the image is
absolute and quantitative and used to differentiate
tissue in the region and the bone quality
Enables evaluation of the proposed implant site
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49. CT imaging software designed to produce life
size images in an easy to read format.
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51. High radiation dose
Cost
Inferior dental canal not always shown well
Beam hardening artifact
Low density structure beyond resolution
The software may not always be available
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52. CBVT permits 3D visualization of dental hard
tissue in a similar manner to multislice CT.
Patient is seating or standing
Cone shaped beam
Image acqisition time varies
Radiation dose is lower
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53. Magnetic properties of hydrogen atoms
Suited for soft tissue
Inferior alveolar nerve appears as black void
within high signal cancellous bone.
Contraindication
Metal foreign bodies
Cardiac pacemakers
1st trimester of pregnancy
claustrophobia
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54. Roots of adjacent tooth
Course of inferior alverior nerve
Floor of nose
Incisal canal
Morphology of maxillary sinus
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55. Identified as narrow radiolucent ribbon
bordered by radio-opaque lines.
Wadi et al found that this line was disrupted or
absent in some cases.
May appear as area of increased density
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56. In buccal cortex in premolar region
In residual ridge may be close to crest of ridge
Loops backward, not always visible
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57. Lies below mylohyoid ridge on lingual aspect
Well demonstrated by tomography, CT, CBVT.
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58. Extends anteriorly from mental foramen
Some studies have shown life threatening
complication caused by profuse bleeding
Usually poorly demonstrated on conventional
radiograph
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59. Funnel shaped hole between two halves of
maxilla
Contains nasopalatine nerve and descending
palatine artery
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60. First paranasal sinus to develop
Don’t extend beyond apex of upper canine
Visualized as air filled space on r/g
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61. Prosthetic criteria in absence of
patient
Implant site selection
Bone resorption
Diagnostic set up – used for
surgical template or provisional
restoration
Permanent record
Motivation
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62. Centric relation and occlusal contact
Natural abutment and its orientation
Interarch distance
Wear facets
Arch form and symmetry
Arch relationship
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63. In 1989 Misch, reported five prosthetic options
FP1
FP2
FP3
RP4
RP5
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64. FP1- bone augmentation required
difficult to achieve when 2
adjacent teeth missing
FP2- implant position chosen in
relation to bone width, angulation
or hygienic consideration.
Implant should be placed in correct
F-L position to ensure contour
hygiene and direction of forces not
comprised.
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65. FP3 – Two approaches
Hybrid restoration of denture teeth and acrylic and metal
substructure
Porcelain metal restoration.
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67. RP 4 – completely supported by implant, teeth
or both.
5-6 implants in mandible
6-8 implants in maxilla
RP5 – combine implant and soft tissue support
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68. In 1985 Misch and Judy established four basic
divisions of available for implant dentistry in
maxilla and mandible which follow the natural
resorption phenomena represented by
Atwood.
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69. Describes the amount of bone in the edentulous
area considered for implantation
Measured in: height
width
length
angulation
crown-implant body ratio
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70. Available bone height is measured from the crest of the
edentulous ridge to opposing landmark
Maxillary sinus
mandibular canal
Nares
Inferior border of mandible
Maxillary canine offers greater height
Mandibular first premolar present reduced height
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71. Minimum height of available bone for
endosteal implants is in part related to the
density of the bone
Once the minimum height is established for
each implant design and bone density, width
is more important than additional length
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72. Measured between facial and
lingual plates at the crest of the
potential implant site
Minimum bone thickness is in the
midfacial and midline contour of
the crestal bone
4 mm implant requires >5mm
width allow predictable blood
supply around the implant
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73. Mesio- distal length of available bone in the edentulous
area is often limited by the adjacent teeth or implant
Depends on the width of the bone
For a 5mm width minimum 7mm length is sufficient
If width is less than 5mm, a 3.2 mm implant is placed
In narrower ridge it is better to place 2 small implants
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74. Ideally it is aligned with the forces of occlusion
and is parallel to the long axis of the restoration
Represent root trajectory in relation to roots
Rarely does the available bone angulation
remain constant after the loss of teeth specially
in the anterior edentulous maxilla
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75. Here the teeth are angulated most to the occlusal forces
Accepted bone angulation in wider ridges is 30degrees
In the posterior mandible, the submandibular fossa
mandates greater angulation as implants are placed
more distally
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76. 2nd PM region 10 ° angulation to the horizontal
1st M – 15 degrees
2nd M – 20 to 25°
Limiting factor of angulation of force between
body and abutment is correlated to the width
of the bone
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77. Impacts the appearance of the final prosthesis
and the amount of moment of forces on the
implant and the surrounding crestal bone
Crown height measured from the occlusal
plane to the crest of the ridge
Implant body is measured from the crest to the
apex
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78. • >crown Height >moment of
force
• As the crown implant ratio
increases more number of
implants or wider implants
should be Inserted to
counteract the increase in
stresses
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79. Division A
Division B
Division C
Division D
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80. Forms soon after the tooth extraction
Abundant bone volume remains for few years
Interseptal bone height decreases and crestal bone
width decreased by 30% within the first 2 years
There is abundant bone in all dimensions
Width >5mm
Height >10-13mm
Mesiodistal length > 7mm
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81. 4 to 5mm implant can be placed
In A plus bone 7mm Implant can be placed
Angulation of load doesn’t excced 30 ̊
Crown implant ratio less than 1
Restored with division A root form implants
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82. Width of the available bone first decreases at
the expense of facial cortical plate
25% decrease in bone width in first year, 40%
decrease in one to three years
Division B once reached may remain for more
than twenty years
Offers sufficient available bone height
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83. Depending on available bone width division B
can be further classified into
- 4-5mm
- B minus width [B-w] 2.5 to 4mm
Crown implant ratio less than one
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84. Three treatment option:-
Osteoplasty
Narrow implant
Augmentation
In order to select the proper approach the final
prosthesis must be considered.
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85. FP1 requires augmentation
RP4, RP5 requires osteoplasty
Disadvantage of division B root form implants
Twice stress concentrated at crestal bone
Lateral loads 3 times
Emergence profile less esthetic
Angle of load less than 20 ̊
Two implants required
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86. Available bone is deficient in one or
more dimensions [W, L, Ht, ANG,
CR/I ratio]
W may be less than 2.5
Ht maybe less than 10mm
Cr/I ratio may be >or equal to one
Angulation may be greater than or
equal to 30
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87. Division C is most commonly present in
posterior maxilla and mandible
C-w resorbs to C-h as fast as A to B occurs
C-h eventually leads to division D
Division C prosthetic treatment is complicated
and greater complications are seen during
healing prosthetic design and maintenance.
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89. Osteoplasty converts C-w to C-h
Augmentation requires greater block bone
Subperiosteal implants show more predictable
results in mandibular arch
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90. There Is complete loss of alveolar bone with
basal bone atrophy
Most difficult to treat In implant industry
If implant failure occurs the patient may
become a dental cripple unable to wear any
prosthesis
So benefits must be carefully weighed against
risks before treatment
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91. Available bone is particularly important in
implant dentistry and describes the external
architecture or volume of edentulous area
considered for implants
Multiple independent groups have reported
higher failure rates in poor quality bone
compared to a higher quality bone
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92. Bone classification schemes related to implant dentistry
Linkow in 1970
- Class 1 bone structure
- Class 2
- Class 3
Class 3 results in loose implants,
Class 2 is satisfactory for implants
Class 1 is ideal for implants
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93. Lekholm and Zarb in 1985, gave four bone
qualities found in the anterior region of the jaw
-Quality 1: homologous compact bone
-Quality 2: thick layer of cortical bone surrounding a core of
dense trabecular bone
-Quality 3: thin layer of cortical bone surrounding dense
trabecular bone of favorable strength
-Quality 4: thin layer of cortical bone surrounding low density
trabecular bone
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94. In 1988 Misch extended the four bone density
groups independent of the region of jaws based
on macroscopic cortical and trabecular bone
characteristics
Suggested implant design, surgical protocol,
healing, treatment plans loading time for each
bone density types.
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95. D1: dense cortical
D2: thick dense to porous cortical
bone on the crest and coarse
trabecular bone within
D3: thin porous cortical bone on the
crest and fine trabeculae within
D4: fine trabecular bone {almost no
crestal or cortical bone}
D5: immature non mineralized bone
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96. Bone density determined by
- tactile sense during surgery
- general location and
- radiographic evaluation
Tactile D1: drilling into oak on maple
D2: drilling into white pine/ spruce
D3: drilling into balsa
D4: drilling into Styrofoam
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98. Periapical or OPG are not beneficial
D2 D3 changes are not quantifiable
More precisely determined by tomography
especially CT
Most critical region of bone density is the crestal 7-
10mm of bone
When bone density varies from crest to apex,
crestal 7-10mm determines the treatment plan
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99. CT Bone quality in Hounsfield units
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100. Numerous classifications have been proposed
for partially edentulous arches
The Kennedy classification is most commonly
used
The implant dentistry bone volume
classification may be used to build on the four
classes of partial edentulism described in the
Kennedy Applegate system
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101. By using this classification the doctor is able to
convey the dimensions of the bone available in
the edentulous area and also indicate the
strategic position of the segment to be restored
The Implant dentistry classification for
partially edentulous patients also includes the
same 4 available bone volume divisions
discussed for the edentulous area
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102. Other intradental edentulous regions not responsible
for the Kennedy Applegate class determination are not
specified within the available bone section of the
Misch- Judy system if implants are not considered in
the modification region
However if the modification segment is also included
in the treatment than it is listed followed by available
bone division it characterizes
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110. A history of edentulous classification primarily
includes the Classification of Kent and Louisiana
Dental school
This classification treats all regions of the
edentulous arch in similar fashion and does not
address regional variations
The classification was for ridge augmentation
with hydroxyapatite and a conventional denture
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111. The divisions of bone presented by Misch are
the basis of the classification of the completely
edentulous patient
Its objective is to communicate the volume of
bone and its location
Each edentulous jaw is divided into three
regions
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113. Division of bone is similar in all three
anatomic segments
Four different categories present
Type 1 division A: abundant bone in all
three regions
Type 1 division B: adequate born in all
three sections
Type 1 division C-w: inadequate bone
width
Type 1 division C-h: inadequate bone
height
Type 1 division D
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114. Posterior sections are similar but different from
anterior segment
Described by two division letters following
Type 2
Common in
mandible
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115. Two main treatment
option
Osteoplasty in anterior
section then treated as
Type2 A,C
Augmentation the
treated as Type 1 B
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116. Posterior section of
maxilla/mandible differ from
each other
It is less common
Seen more in the maxilla
Anterior bone volume listed
first then right posterior then
left posterior segment
Anterior section usually
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118. Inadequate bone volume
Inadequate intra tooth space
Observable mobility of adjacent tooth
Time frame
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119. Decreased risk of caries, endodontics
Improved ability to clean
Less risk of porcelain fracture
Decreased cold or root contact sensitivity
Maintenance of bone
Decreased risk of abutment tooth loss
Psychological need of patient
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120. Crest module and abutment connection that
decrease force to abutment screw are indicated.
Antirotational feature
Titanium alloy
Threaded implant design
If facial bone thickness less than 1.4mm bone
loss may result in implant failure
1.5- 2 mm from adjacent tooth and 1.5mm from
lateral width of ridge
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121. Implant replacing maxillary premolar is
positioned under buccal cusp
Care should be taken of canine root, implant
placed parallel to canine root
Second premolar apices may be located over
mandibular neurovascular canal or maxillary
sinus.
First molar M-D dimension is 8 to 12mm, if
4mm implant placed 4-5 mm cantilever on
marginal ridge
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123. Most challenging restoration
Factors influencing treatment
Patient compliance
Patient desire
Treatment time
Age
Esthetics
Soft tissue drape
Bone height and width
M-D space
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124. Implant placed 1.5mm from adjacent tooth
Midcrestal position of edentulous site should
be 2mm below the CEJ of adjacent teeth
Interproximal bone scalloped 3mm more
incisal then midcrestal bone
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125. To establish logical continuity between
diagnosis, prosthetic planning and surgical
phase
Dictates implant placement that offers best
combination of
Support
Esthetics
hygiene
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126. 1. Rendered to be stable and rigid in correct position
2. If the arch treated has remaining teeth the
template should fit over and around enough teeth
to stabilize it in position
3. When no remaining teeth are present the template
should extend onto unreflected soft tissue regions
[tuberosity, palate, retromolar pad]
4. In this way it can be used after the soft tissues
have been reflected from the implants site
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127. Other requirements include
Size
Surgical asepsis
Transparent
Ability to revise the template as required
Should relate to ideal facial contour
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128. Until recently, no method existed to transfer an
ideal implant position to surgical guide
Innovative developments in software
technology and manufacturing techniques have
been applied
These technologies allow accurate position of
implants by forcing the drills into steady
position
Flapless technique
Less operative time
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130. Surgical guidance can be classified in two
categories
Computer-aided manufacturing of guides
Navigation technique
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131. Laser sintering
Streolithography
Layer of liquid polymer is
deposited and cured by
computer driven laser
3D printers to fabricate
guides
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133. Despite benefits associated with implant
therapy, a more predictable outcome seems to
be with conventional therapy
Need for discriminating patient assessment
and comprehensive treatment plan that
includes different option with pretreatment
necessities.
Practitioner’s role to give honest treatment
recommendation based on his/ her
specialization and experience.
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134. Contemporary implant industry , Carl E Misch,
third edition
Fundamentals of implant dentistry, Weiss and
Weiss
Implants in restorative dentistry, Scortsessi
Australian dental journal 2008;53 : S3-S10
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135. Thank you
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