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IMPLANT SITE ASSESSMENT
Transcript of IMPLANT SITE ASSESSMENT
Dr. Ala'a Al-Otaibi - Implants in replacing missing teeth represents one of the most technological advanced forms of dentistry available today.
- It is becoming the first treatment alternative for missing teeth over a conventional fixed or removable prosthesis. - A safe insertion and successful implant treatment need proper planning and careful clinical and radiographic assessment of Anatomic and prosthetic factors to determine the best implant placement sites. the goal of implant dentistry is not the implant but the tooth that is placed. The implant not only needs to be located in an area of a missing tooth but the implant needs to be placed in a way to satisfy restorative, esthetic, biomechanical and functional requirements. A safe insertion and successful implant treatment need proper planning and careful clinical and radiographic assessment of Anatomic and prosthetic factors to determine the best implant placement sites. - Radiography becomes essential to evaluate and select the proper site for implant.
- Clinicians have grown to rely on various imaging modalities to aid them in implant placement.
- Both two dimensional and three dimensional imaging modalities can be used for presurgical implant site assessment. Two dimensional imaging modalities are either conventional or digital GENERAL imaging goal 1. Image the entire region of interest (ROI) 2. View the ROI in at least 2 planes at right angles to each other (3D perspective) 3. Obtain images with maximum detail, minimal distortion and minimal superimposition 4. The diagnostic value of the imaging study must in balance with the cost and risk associated with obtaining the study. IMPLANT SITE ASSESSMENT IMAGING GOALS: - For each implant site the following anatomic considerations may allow the
clinician to determine the best site for the implant and meet the prosthetic goals 1. Determine bone height and width (bone dimensions). 2. Determine bone quality 3. Determine long axis of alveolar bone 4. Identify and localize internal anatomy. Maxilla Mandible 1- maxillary sinuses 2- incisive foramen 3- Tuberosity 4- Floor of the nasal cavity 2- mental foramen
3- mental canal loop 4- Lingual Foramen Lateral Canals. 5. Determine jaw boundaries 6. Pathology detection 7. Transfer of radiographic information Diagnostic Imaging Modalities: I. Two Dimensional II. Three dimensional A. Periapical radiography: B. Panoramic radiography IMPLANT SITE ASSESSMENT IMAGING GOALS: 1. Determine bone height and width (bone dimensions). 2. Determine bone quality 3. Determine long axis of alveolar bone 4. Identify and localize internal anatomy. Maxilla Mandible 1- maxillary sinuses 2- incisive foramen 3- Tuberosity 4- Floor of the nasal cavity 1- mandibular canal 2- mental foramen3- mental canal loop 4- Lingual Foramen Lateral Canals.
5- Lingual Nerve.
5- mylohiod nerve.
6-submandibular gland depression
7- sublingual artery 6. Pathology detection 7. Transfer of radiographic information it is two dimensional radiograph show the body of mandible, maxillary and the lower half of maxillary sinuses.
1- opposing landmark are easily identified.
2- vertical hight of bone initially can be assessed.
3- can be performed with convenience, ease and speed.
4- Gross anatomy of the jaws and any related pathologic findings can be evaluated.
1- Limited in bone quality and mineralization.
2-Misleading quantity of uneven magnification.
3- Limited in depicting the spatial relationship between the structures and the proposed implant site. Advantage:
1- It is a useful in ruling out local bone or dental pathology.
2- identifying critical structure but limited in depicting the spatial relationship between the structures and the proposed implant site.
3- show the location of adjacent tooth.
4- most use for single tooth implant in region of abundant bone width.
1- limited in determining quantity because the image is magnified, distorted and not depict the 3rd dimension of bone width.
2- limited determining bone density or mineralization. B- Computed Tomography:
1. allows the clinician to determine bone quality through the interpretation of the gray scale values known as Hounsfield units, and inspect the topography and thickness of the labial and palatal cortical plates.
2. allows the clinician to assess bone volume, which is essential for adequate fixation and vascularity for bone maturity and maintenance.
3. allows the clinician to appraise any bone defects, which is crucial for planning implant or grafting procedures.
4. Implant Length and Width.
-interactive software tools allow the clinician to identify the “zone” from which ideal implant length and width can be determined. C- Cone Beam Computed Tomography:
1. Determine bone height and width (bone dimensions).
2. Determine bone quality
3. Determine long axis of alveolar bone
4. Identify and localize internal anatomy.
5. Determine jaw boundaries
6. Pathology detection
7. Transfer of radiographic information .
it is currently considered best practice for implant site assessment. Comparing between CT and CBCT in dental implant site assessment:
- Recent study comparing between medical multi-slice CT-multidetector-row helical computer tomography (MDCT) showed that CBCT images of dental structures were superior to those produced by MDCT (Hashimoto K,2007).
- The lower radiation dose and more user-friendly upright position used for scanning make CBCT the way forward for dental implant treatment planning.
- CBCT measurements were significantly more accurate than those of MDCT. (Al-Ekrish AA, 2011) How? 1- Radiographic stent:
a regular clear acrylic stent made in the lab → CBCT scan done → evaluate the site that already planned by prosthodontist using
native CBCT software → adjust the stent according to CBCT result, and selection of proper implant → use it as a surgical guide II. Produce sterolithographic implant surgical guide: Diagnostic and Planning Software:
- There are many varieties of CBCT related software available, from basic DICOM viewers to very advanced planning modules.
- Some are open platform, meaning that you may plan your case with a variety of different implant systems, others are closed platform,
or specific to one implant manufacturer (nobel biocare)
- Some systems utilise stereolithic fabrication of the surgical guide from the digital treatment plan, and others transform the patient’s
radiographic template into the surgical template. simplant A- SimPlant :
is one of the industry leaders in CBCT guided surgery applications.
1- SimPlant offers a very comprehensive, open platform planning system. It allows for implant planning with almost any implant system.
2- stereolithic surgical guide fabrication, so it is not a SimPlant requirement for the patient to be scanned wearing a radiographic stent.
3- nerve mapping,4- bone density calculation.
5- and even has modules available for graft simulation. AAOMR updates guidelines for dental implant imaging: For the initial evaluation of a dental implant patient, the AAOMR recommends using panoramic radiography, followed by intraoral periapicals to gain supplemental information. The academy discourages the use of cross-sectional imaging including cone-beam CT for initial examinations. However, the AAOMR recommends that the radiographic exam of any potential implant site include cross-sectional imaging orthogonal to the site of interest, and that cone-beam CT be considered the imaging modality of choice for preoperative cross sectional imaging of potential implant sites. The AAOMR also recommends cone-beam CT when clinical conditions indicate a need for augmentation procedures or site development before placing dental implants, and if bone reconstruction and augmentation procedures have been performed prior to implant placement. “There is enough evidence to say that any implant would benefit from cross-sectional imaging.”— Donald Tyndall, 2011 1.Mah JK, Danforth RA, Bumann A, Hatcher D. Radiation absorbed in maxillofacial imaging with a new dental computed tomography device. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 96(4):508‐13. case: a- height of bone.
b- mesiodistal distance.
c- adjacent roots approximation d- but not the buccolingual width - In the same study the authors conclude that both MDCT and CBCT images have a high inter and intraexaminer reliability but are associated with a statistically significant measurement error.
- MDCT is associated with a larger mean absolute error than CBCT, and assessment of implant site dimensions is not adversely affected by minor discrepancies in the plane of orientation of the transverse cross-sectional images.
-As such, the author recommended that the possibility of 1 mm overestimation should be considered when measuring implant site dimensions on MDCT or CBCT images, and correction should be performed accordingly. 1- mandibular canal 5-submandibular gland depression III. Image guided surgery I. Conventional Way (using RG stent) There are two techniques available for making sterolithographic models (Lambrecht JT,1995) :
a- The first technique applies laser technology in which a sterolithographic model is built up, layer by layer, with resin solution. A resin layer is solidified when its surface is struck with the laser.
b- uses a computer-aided milling machine. The implant site assessed by the aid software on CBCT, and stent will made virtually then it is going to sent to CAD CAM system tofabricate the stent according the detail been made on computer. Diagnostic waxup of the planned prosthesis a regular clear acrylic stent made in the lab CBCT scan evaluate the proposal site using native CBCT software adjust the stent according to CBCT result convert it to a surgical guide Advantage:
- Image-guided insertion of dental implants is significantly more accurate than manual insertion. However, the accuracy that can be achieved with manual implantation is sufficient for most clinical situations. (J Brief etal,2005) Disadvantage: Image guided surgery uses virtual x-ray vision, our low radiation dose three dimensional x-ray machine, to implement our virtual surgical plans in real time what is the IGS ? - It's makes surgery less painful and safer because we can make our incisions smaller and more accurately. Is the excessive irradiation exposure of the patient. There is study done in Brazil had shown that most of the dentists in this study prescribe panoramic radiographs in dental implant assessment based on broad coverage and cost. They are not following the American Academy of Oral and Maxillofacial Radiology recommendations regarding cross-sectional imaging. (Sakakura CE,2003) maxillary undercut and bony undercut