Surgical aspects of implant planning

Question 1

Patient desires / expectations - priorities (4)

Answer 1

• Priorities – functional/fixed/aesthetic
• Smile line
• What is the patient like? Reasonable expectations, understanding/forgiving?
• Understand risks & timescale?

Question 2

Patient desires / expectations - need to discuss (3)

Answer 2

Bridge
Denture
Gap
-don’t assume implants are only option that may satisfy patient’s expectations

Question 3

Relevant medical history - relative contraindications (6)

Answer 3

Bisphosphonates –> ONJ and implant failure
-only absolute contraindication is regarded as IV bisphosphonates/ denosumab
-but oral bisphosphonate is considered high risk for elective surgery
Diabetes (poorly controlled) - 2-3% increased chance of implant failure
Immunosuppressants - affected healing response and ability to deal with bacteria
Steroids - worse healing
Bone disease - osteopetrosis/ Paget’s
-dense bone difficult to drill in to and may overheat when drilling –> necrosis
Radiotherapy - could lead to osteoradionecrosis in that area (above 60-65 Gy)
Also other MH aspects related to general risks of surgery e.g. bleeding tendency

Question 4

Smoking and implants (3)

Answer 4

20%-300% increase in failure risk
Healthy non-smoker - approx 3% failure (97% success)
Therefore, max risk is 9% failure (91% succeed)
Heavy smoking >15 cigarettes/ day
Not absolute contraindication to providing but IS absolute contraindication to providing on NHS
Variation in practitioner acceptance - no-smokers only vs less than 5/day vs less than 15/day

Question 5

Extra-oral clinical examination (2)

Answer 5

a) Facial profile - skeletal pattern

b) Smile line

Question 6

Intra-oral clinical examination (4)

Answer 6

c) Space requirements; horizontal and vertical
d) Access
e) Periodontal status
f) 3D assessment of available bone

Question 7

Class III jaw shape

Answer 7

Mandible fairly square with flat front part

Can be an issue with implants - trying to put teeth too close together

Question 8

Smile line - cervical line (3)

Answer 8

High - upper lip line is above cervical line
Medium - cervical line not exposed, but papillary line visible
Low - upper lip line covers papillary line

Question 9

Space requirements - horizontal (3)

Answer 9

Minimum 3mm between implants
Minimum 1.5mm between implant and tooth
-implant needs to be close to vascularised tissue otherwise bone will necrode
Overall width minimum 7mm (width of a mirror handle)

Question 10

Space requirements - vertical (4)

Answer 10

Screw-retained restoration - 5mm
Cement-retained restoration - 7.5mm
Minimum 15-17mm height for milled bar
Ideal 3mm from ACJ of adjacent teeth

Question 11

Periodontal status (5)

Answer 11

Bleeding on probing
Pathological pocketing
Review previous BPE/ evidence of recession
-history of perio increase risk of peri-implantitis
-active disease contraindicates implant placement

Question 12

3D bone dimensions (3)

Answer 12

Mesiodistal
-issues with ortho: space maintenance for missing laterals (but can torque teeth so roots diverge)
Buccolingual
-critical for whtether implant is feasible in anterior zone
Vertical

Question 13

Assessing buccolingual dimension (3)

Answer 13

Palpate
Ridge map
Get CBCT to assess buccolingual dimension

Question 14

Bone height (3)

Answer 14

IDN - 4mm safety margin (Renton), generally >2mm
Implant loaded over first 10mm length
Nobel Tapered Replace - 8mm+

Question 15

Adjuvants to successful implants (3)

Answer 15

Stents:

• lab made pilot hole
• lab made no palatal contour
• CT guided surgery