Dental Implants -Part - 1 by Dr

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Dental Implants -part - 1 by Dr. Shahid

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History.:








IMPLANTS MODERATOR: Dr. Neelakamal Sir Presenter: Dr. Shahid

Introduction History And Evolution Of Implants Terminology & Definitions Classifications &Implant Systems Ideal Properties Of Implants Indications & Contraindications Advantages & Disadvantages

Evaluation Of Bone- Divisions & Density Diagnosis & Pt. Selection -History -Examination -Radiographic Assesment -

Study Models Contents:

Part-2 Surgical placement Ossiointegration Healing Period Prosthetic phase Implant

Maintainace Implant Complications & Management Special consideration- full Mouth implants supported, ZygomaImplants Conclusion Future References

Introduction: Dental implants are designed to provide a foundation for replacement of teeththat look, feel, and function like natural teeth. Reconstruction with dental implants has changed considerably. Rather

than merely focusing on the tooth/teeth to be replaced, todays implant practitioners considers a broad and complex

set of interwoven factors before formulating an implant treatment plan.

History Of Implants 1. Ancient Era - 1000 A.D 2. Medieval Period (1000-1799 A.D) 3. The

Foundation Period (1800-1910) The Endosseous Oral Implantology Truly Began In The 19 th Century. 4. PremodernEra ( 1910-1930) 5.The Dawn Of The Modern Era (1935-1978) A.D

History. 2500 BC - Ancient Egyptians - gold ligature. 500 BC - Etruscan population - gold bandsincorporating pontics.

500 BC - Phoenician population gold wire. 300 AD - Phoenician population - Carved Ivoryteeth. 600 AD - Mayan population - Implantation of pieces of shell. Albucasis de Condue ( 936- 1013 A.D) an Arab

surgeon use ox bone to replace missing teeth described the transplantation procedures . .

1700 - John Hunter - Transplanting the teeth. 1911 - Greenfield Irridoplatinum basket

soldered with 24 carat gold.

THE DAWN OF THE MODERN ERA 1935-1978 A.D. The modern era of implant dentistry

most definitely began in the late1930s with the work of Venable, Strock , Dahl , Gershkoff & Goldberg . Venable in 1937

developed the cast Co- Cr- Mo alloy known as Vitallium . 1937 Adams- Introduced submerged implants with ball headscrews. In 1939 Alvin & Strock used the Venable screw type implant .

In 1938 Stock placed the threaded vitallium implant into the extraction socket, the first longterm endosseous implant. It remained firm & asymptomatic for nearly 17 years .

1943 Dahl -sub periosteal type of implant In 1947, Formiggini developed a single helixwire spiral implants made of stainless steel or tantalum. Two ends of the wire were soldered together to form a post

or neck.

Chercheve Modified it by increasing the length of the neck & double helix out of vitallium . In

1950 Lees - design i.e central narrow post with extensions .

1960 Linkow developed blade Implants Late 1970s and Early 1980s - Tatum - custom

blade implants of Titanium alloy. Early 1980s -Tatum - Titanium root form implant

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Hassan Sadek Cairo, Egypt

great informative and educational presentation, it would be very useful as a reference. please sendme this presentation my e mail [email protected]

Reply Like December 30, 2013 at 8:47am2

Santosh Nelogi SDM

good one , can i have ur ppt .please send me on [email protected]

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Manar Magdy Works at Sinai University-Faculty of Dentistry@

please send me this ppt to my e-mail ( [email protected])

Reply Like December 27, 2013 at 4:45am

Manar Magdy Works at Sinai University-Faculty of Dentistry@

very good


dr.hanan alasad (signed in using Hotmail)

nice presentation please send me this ppt to my e-mail([email protected])


Moe Abaza

Please send me this ppt [email protected] , Thanx

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Ankush Rajput Software Developer at Graebert India

Please send me this ppt at [email protected] if possible....it can be more helpful for me ...

Reply Like October 11, 2013 at 4:12am






Classifications & Implant Systems :

Epiosteal Implant:














Various Implant Systems:

Branemark USA, Inc:

BRANEMARK SYSTEM COMPONENTS :

1978 Bren mark in North America started 2 stage threaded implant placement. After

1980s hollow basket Core vent implant - Screw vent implant - Screw vent implant with Hydroxyapatite -coating implant

with titanium plasma spray

TERMINOLOGY: Implant (GPT 8 ) Any object or material such as an alloplastic substance

or other tissue, which is partially or completely inserted or grafted into the body for therapeutic, diagnostic, prosthetic orexperimental purposes. Dental Implant : A prosthetic device made of alloplastic material implanted into the oral

tissues beneath the mucosal or/ & periosteal layer &/or within the bone to provide retention & support for a fixed or

removable dental prosthesis. A substance that is placed into or / & upon the jaw bone to support a fixed or removabledental prosthesis.

Implantology: Term historically coined as the study or science of planning and restoringdental implants. Implant system (GPT, 1993): Dental implant components that are designed mate together and can

represent a specific concept & inventor. It consists of the necessary parts and instruments to complete the implant

body placement and abutment components. Osseointegration: The apparent direct attachment or connection ofosseous tissue to an inert, alloplastic material without intervening connective tissue.

Classifications & Implant Systems Based on Implant placement within thetissues Epiosteal exp- Subperiosteal Endosteal - Root form Implants - Bladevent/plate form Implant - Ramus frame

Implant Transosteal / Transosseus /Transmandibular/Staple bone implant Mucosal Inserts

Epiosteal Implant It is a dental implant structure that covers almost the entire crestal surface of the

maxillary and mandibular residual alveolar bone under the soft tissue periosteum. It is a dental implant that receives

its primary bone support by resting on the bone. So new bone will grow around the implant. Example- SubperiostealImplant

SUBPERIOSTEAL IMPLANTS first placement Goldberg and Gershkoff (1949). covers thealmost entire crestal surface of ridge, with the four to six posts protruding out through gingiva and on it the complete

denture will be attached . for atrophic mandible. Maxillary subperiosteal implants have higher failure rate and was not

done routinely.

Endosteal Implant: In 1930 Strock placed first. It is a dental implant that extends into the

basal bone for support. Only 1 cortical plate is involve. Root form Plate form Used over a vertical column of bone. -usedfor horizontal column of bone which is flat and narrow facial lingual direction.

ROOT FORM IMPLANTS Advantages: Adaptability to multiple intra oral location. Uniformprecise Implant site preparation. Types of root form implants- Based on surgical procedure Two staged Single staged

Based on surface Press-fit/Non-threaded Screw type/Threaded Hollow basket implant

Blade vent / Plateform implants Introduced by Linkon in (1967). This form of implant uses a

horizontal dimension of base and is flat and narrow in faciolingual dimension. These are one stage system.

Indication: In distal extension cases that offer sufficient depth of bone to avoid damage to maxillary Sinus and themandibular canal. In long inter tooth span, which are not restorable, by fixed prosthodontics. completely edentulous

arches where four implants are used.

Contraindications: As abutments for a removable prosthesis, except in complete arch

overdenture. As a single tooth replacement unless these implants are splinted to at least one and preferably two

adjacent natural teeth. Disadvantages Bone necrosis due to large amount of bed preparation. Fibrous ankylosis ofimplant due to base necrosis from high temperature during implant bed preparation and immediate loading. Difficulty

to prepare a precise slot for blade placement. Large areas of bone lost when these blades are to be removed.

Ramus frame implants Developed by HD Roberts and RA Roberts in 1965. Used to aid in

retention and stability of mandibular full dentures. One piece endosseous implant that uses tripodal mechanical

support in the mandible (the ramii and the bony symphysis ).. It can be bent and shaped without difficulty. IndicationsPatients with h/o mandibular bone resorption. Patients inability to wear dentures. Patients with knife edged ridges,

high labial muscles, mucosal attachments and high convex to flat symphyseal areas with fibrous and flabby tissue.

Transosteal implants / Mandibular Staples/ Transcortical implants A dental implant thatpenetrates both cortical plates and passes through entire thickness of the alveolar bone. indicated in atropic anterior

mandible, where root form implants further compromises the strength of the jaw.

Advantages: Stock implants usually fits all mandibles. No special preoperative surgical or

preprosthetic preparation Short time required with minimal armamentarium Immediate wearing of denture with early to

limited function and chewing Stability adequate Adequate high success rate.

Mucosal inserts These are attachments in dentures to provide added stability and retention

. This technique was introduced by Dahl in 1943 ,modified by Lew 1957,Izikowitz 1961, Trainin 1962, Cronin 1970 . In

1973 Wein & Judy introduced a newly designed mucosal inserts that had more satisfactory design and health .

Advantagenous for providing retention Complete maxillary dentures . Distal extensionpartial dentures. Large bulb obturator. Usually 14 inserts are used for dentures. Disadvantages Retention is not

adequate Soreness due to ridge resorption

Other Classifications Based on Surface characteristics: Titanium plasma- sprayed Coating

Sand Blasting- Surface Etching Laser Induced surface roughening Hydroxyapatite coating Depending on function

Cosmetic cannot withstand masticatory forces Semifunctional can withstand along with mucoperiosteal. Functionalcan withstand masticatory load and transfer to bone

Based on Faundation : Implant supported Implant assisted Based on Retention of

prosthesis: Removable Fixed- screw retained, cement retained

PARTS:

Various Implant Systems Branemark system Developed from the pioneering work of Prof.

Per-Ingvar Branemark who introduced the term osteointegration . ( 1960)

33 Branemark USA , Inc Advantages ADA full acceptance (edentulous) and provisional

acceptance for all other uses. Longest documented research. Relatively simple surgery. Excellent educationavailability. Disadvantages Some sponsors do not allow general practitioners to take surgery course . Most expensive

system. Has only pure titanium implants.

BRANEMARK SYSTEM COMPONENTS FIXTURE pure titanium with

machined threads . The top of the fixture has hexagonal design & threads .. The apical portion tapered with four vertical

notches. COVER SCREW- seals the coronal potion of fixture during the interim period.




FRIALIT Implant system:

ITI Implant System:

Other popular cylindrical endosseous dental implant systems :

Core-Vent (CORE-VENT Corp.):

Interpore IMZ:

Steri OSS Denar Corp:

Stryker Precision Stryker Inc:

Ideal Properties of implants:

Indications :

General Medical Contraindications :

Relative Contraindications:


Intraoral Contraindications:




BONE EVALUATION :



ABUTMENT - -made of titanium in a cylinder shape. the apical portion has hexagonalshape to fit the coronal portion of fixture. ABUTMENT SCREW insert through the abutment & threads into the fixture to

connect the two components. GOLD CYLINDER- made of Au , Pl, Pd. It is machined to fit the coronal portion of the

abutment. It becomes integral part of final prosthesis. GOLD SCREW inserted through the gold cylinder & threads

into the abutment screw to connect the gold cylinder & abutment.

FRIALIT Implant system 1n 1974 Dr. Willi Schulte developed Frialit 1 also known asTubingen Implants Worlds first root analog system. Advantages Optimum stabilization of the implant abutment

interface. Anti-rotational connection between the abutment and the implant. Clear and secure positioning of the

abutment on the implant. No possibility of screw breaking or loosening. Minimum risk of soft tissue perforation.

ITI Implant System International team of implantology Types Hollow cylinder, Hollow screw Solid

screw Single stage and 2 stage versions Advantages: The microgap between the primary and secondary componentsis supragingival good peri -implant hygiene. The construction of the implant body is such that no second stage

surgery for uncovering it is required.

38 Other popular cylindrical endosseous dental

implant systems

39 Core -Vent (CORE-VENT Corp.) Advantages Extensive implant options Extensive

Prosthodontics options Simple surgery Lower cost Good education High popularity Sells "Branemark" clone at lower

cost Disadvantages Complexity of options (both surgical and prosthodontic) requires good organization

40 Interpore IMZ Advantages ADA provisional acceptance for all uses. Relatively simple surgery

Moderate cost Good education Provides simulated periodontal ligament intramobile eIement - IMZ) if desired Pioneerin research on hydroxylapatite coating for faster integration Tissue recession on HA coating leaves polished surface

Disadvantages Intramobile element (IMZ) requires replacement on annual basis

41 Steri OSS Denar Corp Advantages Prosthodontics acceptability good Company will replace

implants that fail Simple surgery Good education Moderate cost Disadvantages Suggests very low hand piece rpm

(300 rpm), can get higher rpm if desired

42 Stryker Precision Stryker Inc Advantages Moderate cost Relatively simple surgery

Hand auger ostectomy is kind biologically Mechanical retention good Disadvantages Fair prosthodontic acceptability

Education availability fair Prosthodontic esthetics can be difficult because of some head designs Lacks ADA

acceptance

Ideal Properties of implants According to Branemark, 1969 & Brunski, 1988 : It should be

biocompatible (Not produce foreign body reaction / response). Non-allergenic. Non-carcinogenic. Should be

sterilizable . Resistant to strain. It should be able to moulded to specifically required forms. It would be ideal for the

implant to be integrated with surrounding bone and soft tissues. Inserted with atraumatic surgical technique. Placed

with initial stability Not functionally loaded during the healing period of 4 to 6 months.

Indications Patients who are unable to wear removable dentures and have adequate bone for

replacement of dental implants. Complete or partial edentulism . Painful / loose dentures. Bone resorption leading to

lack of stability of denture. Posterior edentulism where FPD is not possible. Orthodontic skeletal anchorage( micro

/mini implants). Cranio and maxillofacial defects either- Congenital Acquired

General Medical Contraindications Absolute Contraindications : Systemicdiseases such as developing cancer and Aids. Even HIV positive patients should not to be considered. Cardiac

diseases patients with heart valve replacements and recent infarcts. Deficient hemostasis and blood dyscrasias.

Disorders involving erythrocytes Anemia. Anticoagulant medication or any medication leading to impaired

hemostasis. Psychological diseases may carry potential risks. Uncontrolled infections.

Relative Contraindications Diabetes. Irradiation of the Jaws. - Specifically if the jaw hasbeen exposed to irradiation over the level of 50 Gy . (Sennerby & Rasmusson 2001, Lekholm Periodontology 2000, Vol.

33, 2003) Hyperbaric oxygen treatment preceding implant therapy, the failure rate can be reduced from 60% to about

5% . ( Cochrane Library, Issue 1, 2006. Granstrom 1992) Reports have indicated a lower risk for failures if the pre-

operative irradiation has been less than 40 Gy and carried out two years or more prior to the implant placement.

Chemotherapy. If the implants are placed during medication or if the chemotherapy is given in combination with

irradiation higher failure rates have been indicated. (Wolfhardt et al 1996)

Smoking. If the patient stops smoking during the healing period, implants survival rate may

improve. (Bain 1996) Misuse of alcohol and drugs patients suffering from severe osteoporosis have been treated with

implants without developing any negative results in the long term. Robert A. Jaffin, INT J ORAL MAXILLOFAC

IMPLANTS 2002;17:816819) Friberg et al Clinical Implant Dentistry and Related Research,January2001,Sennerby &

Rasmusson 2001

Intraoral Contraindications No Pathologic conditions should be present. All Oral lesions,

including periodontal inflammation should be treated. Unfavorable intermaxillary relationships. Pathologic conditions

in alveolar bone. Pathologic alterations of Oral mucosa. Xerostomia- reduced salivary flow rate is a relative

contraindication for oral implantology. (Matukas 1998) Macroglossia. Unrestored teeth and poor oral hygiene.

Advantages Reduce the stress on the remaining teeth by offering independent support and

retention. Preserve natural teeth by avoiding the need to cut down adjacent teeth for conventional bridgework. Preserve

bone that results in loss of jaw height and the appearance of aging. Long-term data suggests that implants last longer

than conventional bridgework. Implants will allow to chew better and speak more clearly. Implant restorations are very

natural appearing and easy to clean and maintain.

Disadvantages A surgical procedure is necessary for implant placement. There may be

insufficient bone for implant placement. This may necessitate bone grafting and additional expense. While implant

fixtures (roots) have a 95% success rate, a porcelain crown placed on the implant may still fracture with time. Initial

implant expense may be costly but in the longterm is actually more cost-effective

Evaluation of Bone Divisons & density

BONE EVALUATION Available bone : is the amount of bone in the edentulous area considered

for implantation. it is measured in : width height length angulation crown : implant

Available bone height : crest of edentulous ridge to opposing landmarks . Max- Maxillary

canine Min.-Mandibular 1 st pre-molar Minimum bone height long term survival - 10 mm Height requirementdepends on bone density .

Available bone width : once adequate height is available for implants width is the primary

criteria width facial & lingual plates at the crest Can be measured directly using bone callipers. ridge mapping By









BONE QUALITY: Lekholm and Zarb (1985) classified the bone quality into four classes :











Dental evaluation::




subtracting the sum of facial and palatal mucosal thicknesses from the width of the entire alveolar ridge, effective bone

width can be calculated ( Spiekermann 1987).

Available bone length : length mesio distal for bone > 5 mm wide : min m - d : 7 mm

narrower ridge 2 / more implants of smaller diameter Available bone angulation : Ideally it is aligned with the forces

of occlusion & is parallel to the long axis of prosthodontic restoration. Premolar region-10* 1 st Molar -15* 2 nd Molar-

20-25* For Wider ridge 30* is acceptable.

CROWN : IMPLANT : Affects appearance of the final prosthesis & the amount of momentforce on the implant & surrounding bone during occlusal loading. as the C: I increases the number of implants & / or

wider implants should be inserted to counteract the increase in stress. Most ideal 1 : 2 More common 1 : 1.5

Minimum requirement 1 : 1

Divisions of available bone : By Mish & Judy ( 1990) Division A (Abundant bone) Dimension

> 5mm width > 10-13 mm height > 7 mm length < 30 degree angulation Crown / implant ratio < 1 Treatment options:Division A root form implant

Division B (Barely sufficient bone) : Adequate bone height, but reduced bone width

Dimensions 2.5 5 mm width > 10 13 mm height > 12mm length < 20 degree angulation Crown / implant ratio < 1

Treatment Options Osteoplasty , Division A root form Augumentation, Demanding aesthetics Great force factors

Narrow Implant Division B root form, Plate form.

Division C (Compromised bone) Unfavourable in : Width , Height , Length Angulation > 30 o

, Crown / implant ratio > 1 T/t options: Osteoplasty / Augumentation Fixed prosthesis endosteal or ramus frame or

transosteal implants.

Division D (Deficient bone): severe atrophy Dimension: Severe atrophy Basal bone lossFlat maxilla Pencil thin mandible T/t options: Augumentation

BONE QUALITY: Lekholm

and Zarb (1985) classified the bone quality into four classes Q1: Dense homogenous cortical bone with a small

trabecular bone Q2: Large, dense layer of cortical bone surrounding dense trabecular core Q3: Thinner layer of cortical

bone around dense trabecular core Q4: Thin cortical layer surrounding low-density trabecular bone.

Classification (Misch 1990) : D1 - Thick, dense compact bone Site : Anterior segment of the

atrophic edentulous mandible Thick lateral aspects of anterior mandible Advantages : Provides good primary stability

for the implants. More implant bone interface approximately 80%. Because of this use of shorter implants is possible.

It is highly mineralized and able to withstand greater loads.

5. Ensures excellent bone stability even after trauma. 6. Threaded Titanium implants when

placed into D1 bone, proved to be very predictable over long term period with a success rate of above 94%. ( Adell

1981, Babbush 1986) Disadvantages: Low Vascular supply compared with other bone categories and healing phase

is longer. Bone height is often short and so crown to implant ratio is increased . Difficult implant bed preparation and

may require greater burr revolutions ( up to 2000 rpm). Healing time is 5 months and immediate loading can be done

D2 Bone : Thick porous compact bone with coarse trabecular core. Site: Anterior and

posterior segment of the mandible. Anterior maxillary segment ( palatal aspect). Advantages: Provides immediate

stability and long term survival. Osseointegration is very predictable. The intrabony bleeding helps control over heating

during preparation. The percentage of contact at bone implant interface is 70%. The excellent blood supply and rigid

initial fixation permit adequate bone healing within 4 months. Progressive loading is important.

D3 Bone: Thin porous compact bone with coarse trabecular core. Site: Anterior (Facial

aspect) and posterior segments of the maxilla, posterior segments of the mandible, Condition following osteoplasty of

D2 bone Advantages: Good blood supply. Disadvantages Difficult implant bed preparation (widening). careful to avoid

lateral perforations of the cortical bone.

The rotations of the drill may have to be reduced to less than 1000 rpm to improve thetactile sense of the bone preparation. 3. Because of reduced implant bone interface, more number of implants may be

necessary. Time period of healing - 6 months. Extended gradual loading should be done.

D4 Bone: Fine trabecular bone Site: Maxillary tuberosity, condition following osteoplasty of

D3 Bone. Advantages: None. Disadvantages: Has very little bone density and little or no crestal cortical bone. Difficult

implant bed preparation. The bone site is easily distorted resulting in reduced initial stability of the implant.

Reduced implant bone interface, so optimum usage of available bone is necessary.

Number of implants to be placed is increased. Obtaining rigid fixation for the implant is very difficult. Up to 8 months of

undisturbed healing is suggested.

Diagnosis & Patient Evaluation

Evaluation of the patient for implant therapy: -Includes medical, dental and diagnostic

evaluation. Medical evaluation : The placement of an implant is basically a surgical procedure, the patients should be

evaluated if she/ he is fit to undergo surgery. Medically compromised patients who are unfit for surgical therapy are

contraindicated for implant therapy. Eg : endocrine disorder, cardiovascular disorder etc

Factors that affect the prognosis of implant prosthesis include-: Diabetes Arteriosclerosis

Renal diseases Endocrine imbalances Malnutritional effects Diseases of the CNS Smoking Age Motivation

Dental evaluation: Dental history will involve an oral examination, a radiographic examination and a

diagnostic evaluation. The oral examination should include routine assessment of hard & soft tissues. A dental &

periodontal evaluation will elicit information on the presence of caries, periodontal diseases & oral hygiene status.

EXTRA ORAL EXAMINATION: - Smile line -Smile symmetry -Incisal edges in relation to

Lower lip - Functional analyses - examination of the temporomandibular joints, muscles of mastication and occlusal

relationships. If functional disturbances of the masticatory system are present, recreate functional harmony by

selective grinding or fabrication of night guard.

INTRA ORAL EXAMINTION : Inspection of the oral cavity - Mucosal situation ( such as width

of attached gingiva) -Possible existence of pathological changes -Extent of bone resorption -Presence of lesions /

abscess : Inter arch space : Ideal inter arch space : 7 mm posterior 8 10 mm anterior Tooth Mobility oral hygiene

habits & periodontal health

Intraoral bidigital palpation - available bone mass (width), contour of the alveolar processand thickness of mucosa. Measurement of Mucosal thickness: to evaluate the width of available bone. The needle is

inserted through the mucosa to the bone surface and a rubber stop marks the position of the depth.



Diagnostic methods:

Timing of implant radiography:

Radiographic diagnosis:







:





Diagnostic casts or study model analysis:




Bibliography:

Diagnostic methods A primary determinant for the long term success of the endosteal implants

is the best possible anchorage in the bone. Before attempting any implant treatment. Analysis of appropriate and

adequate radiographs. Analysis of mounted study models.

Timing of implant radiography Time in months Radiographic procedures Treatmentplanning -1 Periapical, panoramic, cross sectional tomography, CT, Cephalometry Surgery (fixture placement) 0 Films

only for the correction of problems. Healing 0-3 Films only for the correction of problems Remodelling 4-12 Periapical,

panoramic Maintenance (without problem) 13+ Periapical, panoramic (follow up every three years) Problem present

(any time) Periapical, panoramic, cross sectional tomography

Radiographic diagnosis Peri apical radiographs: Intra oral radiographs provide valuableinformation concerning - The mesiodistal dimension, bone height . To determine whether implant treatment can be

performed after bone augmentation, if available bone volume is less. Any residual pathology.

Disadvantages : It cannot provide information about the buccolingual dimension of the

bone and whether implant treatment can be performed. 2. Limited value in determining bone density as a lateralcortical plates prevent accurate interpretation. 3. Little use in depicting the spatial relationship between the critical

structures and the proposed implant site

Occlusal radiograph: Can provide information about the cortical and cancellous bone

structure in edentulous jaw segments i.e., bone quality. It provides the 3 rd dimension in combination with otherradiographs to clarify the existence and localization of root tips, cysts, tumors etc. The disadvantage is that it shows the

widest width of the bone (at the base), rather than the width at the crest where diagnostic information is needed most.

Panoramic radiograph: General view of both jaw & bone condition Jaw relationship.Location of landmarks-

Advantages : 1. The opposing landmarks are easily identified. 2. The vertical height of bonecan be assessed. 3. Procedure is performed with convenience and speed. Gross anatomy of the jaws and any related

pathologic findings can be evaluated. Disadvantages : Produces vertical magnification of up to 10 % and horizontalmagnification of up to 20 %. 2. Does not demonstrate bone quality. 3. Does not provide spatial relationship betweenthe critical structures and the implant site.

Overcoming the shortcomings Use of diagnostic templates that have 5mm ball bearings

or wires incorporated around the curvature of the dental arch when the radiograph is taken can enable the clinician todetermine the amounts of magnification in the radiograph. These metal spheres appear radio opaque in the film.

Because their diameter is known, it is easy to calculate the true bone height. (Spiekermann 1987)

Lateral cephalometric radiograph : Demonstrates a cross sectional image of the alveolus

of both the mandible and the maxilla in the midsagittal plane. Is more accurate for bone quantity determinations unlikepanoramic or periapical images. Magnification ranges from 6% to 15%. Provides information on bone availability in the

region of premaxilla and symphysis of the mandible.

Computed tomography : CT enables differentiation of both hard tissues and soft tissues. Tomographic sections

produced are of best image quality due to less disturbing ghost shadows from adjacent structures. CT enablesidentification of disease, identification of critical structures at the proposed region determination of bone quantity,

quality determination of the position and orientation of dental implants.

Evaluation of Mischs bone density using CT number or Hounsfield unit : Each CT imageproduced has 2,60,000 pixels and each pixel has a CT number or Hounsfield unit (HU) related to the density of thetissues within the pixel Higher the CT number, denser is the tissue. D1 : >1250 HU D2: 850 HU - 1250 HU D3: 350 HU

850 HU D4:



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Dental Implants -Part - 1 by Dr