PART 2 Preoperative Assessment and Treatment Planning 26/11/2015 - PDF document

1/6/2016 PART 2 Preoperative Assessment and Treatment Planning 26/11/2015 LIMU Dr. Rafik M. Alkowafi 55 Preoperative Assessment and Treatment Planning • How many teeth are missing? • What is the degree of bone loss? • Are the remaining teeth in a good position and do they have a long-term prognosis? • What does the patient expect for an end result? • What treatment will result in the best cosmetic outcome? • What is the patient's budget? 1

1/6/2016 Preoperative Assessment and Treatment Planning • Chief Complaint: – The goal of the clinician is to explore, conversationally, the details of the patient’s concerns, desire for treatment, apprehensions, and goals for the desired outcome. – The clinician must assess how realistic the patient’s expectations are. Is the patient looking strictly for a functional replacement, or is there a strong esthetic expectation? – How does the patient’s expectation fit his or her perceived timeline or financial investment? 26/11/2015 LIMU Dr. Rafik M. Alkowafi 57 Preoperative Assessment and Treatment Planning • The evaluation of a patient as a suitable candidate for implants should follow the same basic format as the standard patient evaluation, although some areas require additional emphasis and attention : Medical History . I. Psychological Status . II. Dental History . III. 2

1/6/2016 I. Medical History • The patient’s medical history may reveal a number of conditions that could complicate or even contra- indicate implant therapy. These include: 1. Bleeding disorders; Paget’s disease; A history of radiation therapy in the maxilla or mandible region; Uncontrolled diabetes; Epilepsy that presents with more than one grand mal seizure per month; 2. In addition, there are a host of systemic medical conditions, including steroid therapy, hyperthyroidism, and adrenal gland dysfunction 3. Substance abuse including tobacco and alcohol II. Psychological Status • If the patient cannot come to terms with the possibility of failure, or months of potential discomfort and inconvenience, then he or she is not a suitable candidate for implant therapy . 3

1/6/2016 III. Dental History • It is also vital to evaluate the patient’s chief complaint, as it may have an equal bearing on treatment. For example, the treatment plan recommended to the patient desiring a more secure lower denture will be quite different from the one proposed to the patient seeking a fixed and rigid appliance. Clinical examination I. Extraoral examination: 1 . Facial form. 2. Facial symmetry. 3. Patient’s degree of expression and animation. 4. Patient appearance (e.g., facial features, facial hair, complexion, eye color). 5. Smile line. 6. Incisal edge or tooth display. 7. Buccal corridor display. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 62 4

1/6/2016 Clinical examination II. Intraoral examination: 1. Condition of existing teeth. 2. Pathologic conditions in any of the hard or soft tissues. All oral lesions, especially infections, should be diagnosed and appropriately treated before implant therapy. 3. Patient’s habits. 4. Level of oral hygiene, overall dental and periodontal health. 5. Occlusion, jaw relationship, temporomandibular joint condition, and ability to open wide. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 63 Clinical examination III. Evaluation of the edentulous space or ridge: a. Evaluation of ptential implant sites. All sites should be clinically evaluated to measure the available space in the bone for the placement of implants and in the dental space for prosthetic tooth replacement. b. The height, width, and contour of the edentulous ridge is visually assessed and carefully palpated. c. The presence of concavities/depressions (especially on the labial aspects) is usually readily detected. d. The thickness of the soft tissue can be measured by puncturing the soft tissue with a calibrated probe after administering local anesthetic or carrying out a more detailed ridge mapping. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 64 5

1/6/2016 Clinical examination • Ridge mapping (bone sounding): – Ridge mapping is advocated by some clinicians. – In this technique, the area under investigation is given local anesthesia and the thickness of the soft tissue measured by puncturing it to the bone using either a graduated periodontal probe or specially designed calipers. – The information is transferred to a cast of the jaw, which is sectioned through the ridge. This method gives a better indication ofbone profile than simple palpation. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 65 Clinical examination d. The profile/angulation of the ridge and its relationship to the opposing dentition is also important. e. The distance between the edentulous ridge and the opposing dentition should be measured to ensure that there is adequate room for the prosthodontic components. f. Assessment of the soft tissue thickness, which is important for the attainment of good aesthetics. Keratinized tissue, which is attached to the edentulous ridge, will also generally provide a better peri-implant soft tissue than nonkeratinized mobile mucosa. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 66 6

1/6/2016 Clinical examination A patient with missing maxillary anterior Extensive loss of mandibular bone with teeth in whom the lower incisors nearly marked vertical and horizontal discrepancy touch the soft tissue ridge in centric between the jaws occlusion. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 67 Radiographic examination • Methods of radiographic examination: 1. Periapicals. 2. Occlusal. 3. OPG. 4. Cephalometric. 5. CBCT. 6. CT. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 68 7

1/6/2016 Radiographic examination (CBCT) 26/11/2015 LIMU Dr. Rafik M. Alkowafi 69 Radiographic examination Advantages and Disadvantages of the Various Radiographic Projections 26/11/2015 LIMU Dr. Rafik M. Alkowafi 70 8

1/6/2016 Radiographic examination • Areas of study radiographically include the following: 1 . Location of vital structures: – Mandibular canal. – Anterior loop of the mandibular canal – Mental foramen. – Maxillary sinus. – Nasal cavity. – Incisive foramen. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 71 Radiographic examination 2. Bone height. 3. Root proximity and angulation of existing teeth. 4. Evaluation of cortical bone. 5. Bone density and trabeculation. 6. Pathology (e.g., abscess, cyst, tumor). 7. Cross-sectional topography, bone width and angulation (best determined by using CT and CBCT). 26/11/2015 LIMU Dr. Rafik M. Alkowafi 72 9

1/6/2016 Radiographic examination • Critical measurements specific to implant placement include the following: a. At least 1 mm inferior to the floor of the maxillary sinus and nasal cavity. b. Incisive canal (maxillary midline implant placement) to be avoided. c. 5 mm anterior to the mental foramen. d. 2 mm superior to the mandibular canal. e. 3 mm from adjacent implants. f. 1-1.5 mm from roots of adjacent teeth. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 73 Radiographic examination • Radiographic stent - (can double as surgical stent) acrylic stent with lead beads or ball -bearings (5mm) placed in proposed fixture locations allows more accurate radiographic interpretation also to provide calibration for potential magnification. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 74 10

1/6/2016 Diagnostic casts and photographs • Mounted study models as well as intraoral and extraoral photographs complete the records collection process. • Study models mounted on a semi-adjustable articulator using a face-bow transfer give the clinician a three-dimensional working representation of the patient and provide much information required for surgical and prosthetic treatment planning. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 75 Diagnostic casts and photographs • Elements that can be evaluated from accurately mounted models include the following: 1. Occlusal and arch relationships. 2. Interarchspace. 3. Arch form, anatomy, and symmetry. 4. Pre-existing occlusal scheme. 5. Curve of Wilson and Curve of Spee. 6. Number and position of the existing natural teeth. 7. Tooth morphology. 8. Wear facets 9. Edentulous ridge relationships to adjacent teeth and opposing arches. 10. Measurements for planning future implant locations. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 76 11

1/6/2016 Basic treatment order • A traditional treatment plan may include the following: 1. Examination — clinical and radiographic. 2. Diagnostic setup, provisional restoration, and specialized radiographs if required. 3. Discussion of treatment options with the patient and decision on final restoration. 4. Completion of any necessary dental treatment including: a. Extraction of hopeless teeth. b. Periodontal treatment. c. Restorative treatment, new restorations and/or endodontics as required. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 77 Basic treatment order 5. Construction of provisional or transitional restorations if required. 6. Construction of surgical guide or stent. 7. Surgical placement of implants. 8. Allow adequate time for healing/osseointegration according to protocol, bone quality, and functional demands. 9. Prosthodontic phase 26/11/2015 LIMU Dr. Rafik M. Alkowafi 78 12