DIAGNOSTICS IN DENTAL IMPLANTOLOGY

Dr.K.V.Pratheep

Definition
An instrument or a technique used in medical diagnosis.

Objectives of diagnostics in dental implantology

Determine the quantity, quality, and angulation of bone. The relationship of critical structures to the prospective implant sites. The presence or absence of disease at the proposed surgery sites.

 to estimate the length and width of the implant to be inserted, the appropriate number of implants, the location and orientation, and the possible need for additional treatment before implant placement, like bone augmentation procedures and to estimate the prognosis.

Diagnostic aids
Diagnostic casts. Diagnostic imaging

Diagnostic imaging and techniques

Based on ALARA(as low as reasonably achievable) principle. so selection of imaging technique itself should be a part of radiation protection measures.

Types of imaging
Analog / two dimensional. -periapical radiography. -occlusal radiography. -cephalometric. -panoramic. Three dimensional. -conventional tomography. -computed tomography. -magnetic resonance imaging.

Periapical radiograph

Periapical radiography
Advantages : provide required contrast and delineation of objects. High resolution. Low cost. minimal distortion.

 limitations: limited imaging area. no facio-lingual dimension. not accurate in determining bone density. possibility of image elongation or foreshortening.

Panaromic radiography
Advantages : Broad overview. Accidental pathologic findings possible. Sinus , nerve canals visualized. Height measured with accuracy if magnification factor known. Can be a only radiographic investigation if bone width can be assessed clinically.

Limitations: Cant depict bone width. Increased chances of distortion. Maxillary anterior most distorted.

Zonography
a modification of the panoramic x-ray machine that makes cross-sectional image of the jaws. This technique enables the appreciation of spatial relationship between the critical structures and implant site and quantification of geometry of implant site. tomographic layers are relatively thick (5mm thick).

Conventional tomography
Conventional film- based tomography is designed to obtain clear images of structures lying within a plane of interest . used for accurate assessment of alveolar bone height, width and inclination. can assess both the quality and quantity of the bone. gives information regarding the spatial relationship of vital structures .

Conventional tomograph

Computed tomography
multiple thin axial slices are obtained through jaws and then the data are reformatted with special software packages to produce crosssectional and panoramic views.

 Advantages : Minimal superimposition Facial-lingual dimension Uniform magnification Accurate measurements Moderate cost radiation exposure is moderately low.

 Disadvantages: Less image definition than plain films special training for interpretation sensitive to technique errors

Conebeam computed tomography

 Cone-beam computed tomography (CBCT) is accomplished using a rotation in which a pyramidal- or cone-shaped xray beam is directed towards an area x-ray detector on the other side of the patients head. Multiple 2D projection images are acquired for a field of view (FOV) selected according to the region of interest (ROI).

 There are four components to CBCT image acquisition: 1) X-ray generation, 2) Image dtection, 3) Image reconstruction, 4) Image display

Advantages: Rapid scan time: Because CBCT acquires all projection images in a single rotation. Image accuracy:CBCT imaging produces images with sub-millimeter isotropic voxel resolution ranging from 0.4 mm to as low as 0.09 mm. Reduced patient radiation dose compared to conventional CT. Interactive display modes.

Disadvantages: increased susceptibility to movement artifacts. lack of appropriate bone density determination.

Treatment planning softwares

Noble guide

 Simplant :

Diagnostic casts
Assist in implant site selection. To discuss treatment plan with other members of implant team and lab. Permanent record for medicolegal purpose. Patient motivation. Assess number of missing teeth. Inter arch space. existing occlusal relationship. Arch form Symmetry. Occlusal wear and force direction.

Bone mapping

Diagnostic templates
Vacuform template. Acrylic template. Template with radio-opaque denture teeth.

Assessment of available bone

Available bone describes the volume of bone in the edentulous area considered for implant placement. It is evaluated based on-height. -width. -length. -angulation.

Height
c

L=H/M-c-s
H

L
s

 Implant outlines on a transparent plastic templates are larger thanoriginal implants by a factor of 1:1.13

Width
Buccolingual dimension of the available bone. Minimum of 0.5 mm of bone should be present on each side of the implant at the crest. ie., 4mm diameter implant requires more than 5 mm of crestal bone width. Width determined by osteometer , bone mapping,or by tomographic readings.

Osteometer

Mainz measuring device

Length
Refers to the mesio-distal length of available bone. It is limited by adjacent teeth or implants.

Bone angulation
Represents the root trajectory in relation to the occlusal plane. Bone angulation does not remain constant after tooth loss. For eg., Labial undercuts and resorption after tooth loss often mandate a greater angulation of implant.

Classification of available bone

Mish and Judy in 1985. Based on the amount of available bone for endosteal implantation in regard to bone height,width and length.

 Division A: (abundant bone) >12mm height. >5mm width. >7mm length. <30 degrees of angulation. <15mm crown height. ideal for FP1 prosthetic option.

 Division B: (adequate bone) >12mm height. Width B+ 4 to 5mm B-w 2.5 to 4 mm >6mm in length. <20 degrees of angulation. <15mm crown height.

Division B treatment options

FP 2 or FP3

Div B FP 1

 Division C: (compromised bone) < 12mm height C-h < 2.5mm width C-w > 30 degrees of angulation >15mm of crown height.

Division C Treatment options

Division C-w: -osteoplasty C-h shorter textured implants, RP-5 prosthesis to reduce cantilever forces. Division C-h: -sub periosteal -disk design -ramus frame -transosteal

 Division D: -basal bone loss. -flat maxilla. -pencil thin mandible. > 20mm crown height.

Conclusion

Reference
Carl e.misch 3rd edition. IChariton NO. Daffner RH, GehweilerJA etal. Panoramiczonographyoffractures of the facial skeleton.AJR 1981; 137:109112. Littleton JT. Tomography: Physical principles and clinical applications. Williams and Wilkins, Baltimore, 1976. DelBalso AM, Greiner FG, Licata M. Role of diagnostic imaging in the evaluation of the dental implant patient. Radiographics 1994; 14(4):699 719. White SC, Heslop EW, Hollender LG, Mosier, KM, Ruprecht A, Shrout MK. An official report of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91(5):498511. Truhlar RS, Morris HR, Ochi S. A review of panoramic radiography and its potential use in implant dentistry. Implant Dent 1993; 2(2):12230.