IP Annals of Prosthodontics and Restorative Dentistry 2020;6(3):135–139

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IP Annals of Prosthodontics and Restorative Dentistry

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Review Article
Diagnosis for dental implant

Rohit Singh1 , Irfanul Huda1, *, Aaysha Tabinda Nabi2 , Supriya Singh3 , Kumar Anand4
1 Dept. of Prosthodontic, Patna Dental College and Hospital, Patna, Bihar, India
2 Dept. Of Periodontology, Buddha Institute Of Dental Sciences and Hospital, Patna, Bihar, India
3 Awadh Dental College and Hospital, Jamshedpur, Jharkhand, India
4 Dept. of Oral Medicine and Radiology, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar, India

ARTICLE INFO ABSTRACT

Article history: Various factor have been discussed in the literatures that facilitate clinical assessment for dental implant
Received 30-05-2020 selection and placement with consequent hard and soft tissue enhancement around the implant prosthesis.
Accepted 05-06-2020 The sequential process of clinical examination, laboratory tests, radiographic analysis, diagnostic protocols
Available online 24-09-2020 of casts, wax ups. Along with the treatment needs and desires of the patient have to be factored in for the
overall diagnosis and prognosis of implant therapy. A step-by-step methodology has been created to help
the implant practitioner with a checklist that aims to create the optimal plan for each case. 1
Keywords:
Diagnosis © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license
Dental Implant (https://creativecommons.org/licenses/by-nc/4.0/)
& Treatment Planing

1. Introduction are technically demanding. Meticulous attention to detail

is needed for optimal success. As implant options have
Dental implants are one of the options available to replace
proliferated and esthetic expectations have risen, the task
missing teeth 2 in the recent years, dental implant design has
of selecting appropriate implant for each site has become
improved to such an extent that mere integration with the
increasingly important. 4
bone is no longer considered as the only success criteria for
the implants. It is expected that successful implant treatment The success of any surgical implant procedure depends
restores normal function, esthetics, comfort and speech in a on careful selection and preparation of the patient. Imaging
patient.(misch ce. 1999.) 3 is an irrefutable part of preoperative implant assessment
A good dental and medical history is the beginning of to determine feasibility of fixture installment. It is one
any dental treatment planning. The dental history will help of the most accurate means by which the clinician can
in identifying the cause of tooth loss and the reasons why assess the morphologic features of the proposed fixture site,
the patient is seeking replacement. If the patient has lost select implant of appropriate size and evaluate the fixture
his teeth due to periodontal disease, there is a risk that the periodically after its placement. 1,5
patient will develop peri-implantitis, unless his oral hygiene
The assessment includes
and other underlying causes for periodontal disease are not
corrected. The micro-flora associated with failing implants
has been found to be identical to those in chronic adult
periodontitis.[zablotsky mh. 1998). 1. Appraisal of proposed implant site,
The procedures of patient selection, treatment planning, 2. Determination of bone quantity and quality,
implant selection, placement and prosthetic management 3. Assessing inclination of alveolar process,
* Corresponding author.
4. Location of adjacent anatomic structures,
E-mail address: [email protected] (I. Huda). 5. Detect existing pathology

https://doi.org/10.18231/j.aprd.2020.028
2581-4796/© 2020 Innovative Publication, All rights reserved. 135
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2. Initial Consultation Physical limitation; Such limitation may result from

accident, facial burns, malignancies or congenital defects.
The initial consultation is the first assessment process thus
allowing for the completion and reviewing of medical and 2.1. Extraoral examination
dental history questioners and preliminary evaluation of
patient, emotionally and psychologically. In gathering the Extraoral examination allows for evaluation of facial
patient’s history in which the patient’s profile is recorded in symmetry, skeleton profile, facial contours, and patient’s
which age, sex, occupation status is noted down. Then the speech, etc.
chief complaint is recorded in the patient’s words.
While taking the medical history special attention 2.2. Intraoral examination
should be given to whether the patient has the ability to Intraoral examination is visual as well as palpation process.
physically and emotionally sustain all the procedures that Intraoral soft tissue is examined for any pathology.
may be required in the implant therapy including surgery, Evaluation of tongue and para functional habits should be
a variety of anesthetics, pain control drugs and prosthetic examined along with lateral and frontal tongue thrust and
rehabilitation. History of uncontrolled medical conditions factors of force. Muscle attachment on buccal or lingual
like diabetes, hypertension, and record of drug allergies, and aspect of natural teeth or implant site should be evaluated.
information on any drugs patient may be consuming should
be noted down
2.2.1. Bone evaluation
Past dental condition with a history of periodontal Usual method of doing this is by means of radiographs. The
disease, caries, trauma, change in occlusion or smile, any types of radiographs used depends on number of implants
oral pathology or smoking habits should be noted down. to be placed, location in jaws. Another method less used is
If there is a history of change in occlusion then minor palpation.
changes from missing tooth, major occlusion discrepancies Intraoral palpation can be used to evaluate the following:
or changes in tm joint should be examined and recorded.
The consultation appointment allows an opportunity to 1. Sharpness of crest, it often indicates the presence of
get to know the patient and can also be utilized as knife edge ridges
a screening process of patients in whom the clinician 2. Depth of vestibule
establishes whether he can fulfill the patient’s expectations
and establish a long-term successful relationship.(mills. Ridge relationship: plays an important role in determining
Edward j, 2002). 2 the type of prosthesis that can be fabricated and occlusion
Comprehensive diagnostic examination. The patient’s plays an important role in manner in which forces are
initial signs are documented like blood pressure, pulse directed to implants at bone implant interface. The best
and respiration and pertinent aspects of medical history observation of this relationship is accomplished from
is further investigated by screening radiographs. Including mounted diagnostic casts to the articulator.
panoramic and a full set of periapical x-rays are taken.
Medical history; The medical history is an essential 2.3. Periodontal evaluation
part of the diagnostic process and may have a direct Periodontal evaluation includes periodontal charting,
bearing on the treatment plan and prognosis. 3 The medical periodontal disease, classification and documentation of the
history usually completed in the first visit, it becomes location of quantity of keratinized attached gingiva. Bone
an important factor in establishing rapport and gaining loss, i.e. Vertical or horizontal defect should be carefully
confidence. Leading questions concerning past medical mapped on the chart any gingival recession on maxillary
experience may reveal the patients level of pain tolerance, or mandibular teeth should be examined. Oral prophylaxes
and further astute questioning will also reveal factors such of patient should be inspected for plaque or calculus. The
as adaptability to change. patient should be radiographically and clinically evaluated
Health information; Anatomical abnormalities This with a comprehensive periodontal examination.
may include severly resorbed alveolar ridges, congenital
deformities like diminutive maxilla or mandible, undercut, 1. Intra oral and extra oral photographs should be taken
tori, exoestosis, enlarge tongue and salivary gland. Age pre-operatively, intra-operatively and post operatively
Patient under 18 may not be candidates for implant 2. Diagnostic study models are helpful in treatment
replacement because their dental arches are not fully planning an projecting goals to the patient pre-
developed. operatively. They also aid in this retrospective analysis
Systemic illness; These may reflected in poor tissue of the progress of therapy.
tone, low pain threshold, slow healing, sensivity to pressure, 3. Pre-operative radiographic analysis is one of the most
tissue fragility and xerostomia. critical aspects of the clinical evaluation
 Singh et al. / IP Annals of Prosthodontics and Restorative Dentistry 2020;6(3):135–139 137

2.4. Bony anatomy of implant site and its evaluation may be indicative of temporomandibular joint arthropathy
and neuromuscular imbalance of the head and neck.
The skeletal profile has both esthetics as well as well-
functional ramifications. The patient should be evaluated
aesthetically while inspecting the edentulous arch. Skeletal 3.2. Plain film radiography
profile classification relating the maxilla and the maxillary It is still the most widely used modality for pre and
arch to the mandible and the mandibular arch is done postoperative implant assessment. Both periapical and
with visual inspection mounted study models and by occlusal radiographs are known to provide the best image
cephalometric radiographs. Mounted study models can details with minimal geometric distortion of all the available
assist in properly evaluating the arch form as well as inter modalities. (frederiksen nl. 1995).
arch relationship. The arch geometry impacts the position of
dental implants., thus impacting the way the implants relate 3.3. Periapical radiograph
to each other in an anteroposterior direction In a V shaped
arch would land more easy to place implants with a great Provide detailed information regarding the dimensions in
anterior posterior ratio than a u-shaped arch or an arch with length and height of available bone in small sections.they
straight anterior ridge. are indicated for single tooth replacement, but it is difficult
to locate the inferior alveolar canal in the first molar
2.5. Smile analysis region and correct positioning of film is difficult in
edentulous region. They do not give information regarding
All aspects of patient’s smile should be analyzed and the buccolingual dimension and this modality is limited by
the patient’s esthetics, expectations should be documented its 2d nature. 2
preoperated digital photographs can be utilized to evaluate
and document the pretreatment smile. (chee w 2006) the 3.4. Occlusal radiograph
maxillary anterior teeth should show when the patient
smiles. The anterior arrangement of teeth including teeth Usually used in conjunction with the periapical radiographs
sizes as well as the positions in the arch should be and they show the buccolingual width between the extremes
documented. of buccal and lingual cortical plates.
While analyzing the smile, the implantologist should
look for any spaces, length of clinical crowns any recessions 3.5. Disadvantages
flaring teeth, attrition and shade of the teeth preoperative and
check the feasibility of creating the golden proportions of a 1. It fails to show the medial and lateral extent of cortical
pleasing smile postoperative. bone delineating the alveolar process as it displays only
the extremes of the cortical plate.
2. This modality is limited by its 2d nature.
3. Occlusion
The patient should be examined for the changes in occlusion 3.6. Panoramic radiograph
due to the missing teeth. There may be premature contacts
or major occlusal discrepancies due to trauma to occlusion. They display image slices through the jaws by producing
The patient’s existing occlusion should be evaluated. In a single image of the maxilla and mandible and their
conjunction with the development of the treatment plan supporting structures in a frontal plane they display
it is also necessary to create a diagnostic wax-up to anatomic structures like nasal cavity, maxillary sinus,
determine spatial relationship (mesial, distal, buccal, and inferior alveolar canal and mental foramen and indicated
lingual) as well as the alignment and parallelism of the when multiple implant placements are planned.
implants to be placed. In the edentulous space the tooth
or teeth are fabricated using a base plate The diagnostic 3.7. Disadvantages
wax-up is duplicated into a stone model and a surgical
The resolution is lesser when compared to intraoral
template is fabricated to assist the surgeon in proper
radiograph.
alignment, parallelism and direction of implants. The cuspid
relationship as well as posterior tooth contact in centric as
well as eccentric relationship should be documented. (chee 1. A 10-20% image magnification occurs, which is non
w and jivraj s. 2006.) uniform. This magnification is undesirable for both
implant selection and implant site assessments.
2. Geometric distortion and overlapping of images of
3.1. Temporomandibular joint teeth can occur.
The temporomandibular joint’s movement should be 3. Overlapping of anterior region by vertebral column
thoroughly examined. Alteration in mandibular movement occurs.(reiskin ab. 1998).
138 Singh et al. / IP Annals of Prosthodontics and Restorative Dentistry 2020;6(3):135–139

3.8. Cephalometric radiograph 4. It automatically calculates bone height and width in a

specified region.
It displays an image of the skull and facial bones in the mid-
5. The information provided is a life size image, which
saggital plane.
is highly desirable for ease of measurements.(brookssl
1. It provides more accurately the information on 1993).
inclination, height and width of alveolar bone
at the midline, when compared to panoramic 4.2. Disadvantages
radiographs.(frederiksen nl.1995).
It is an expensive modality.
It provides information regarding the relationship of the
jaws when image is taken with teeth in occlusion. Position
and relationship of mental foramen, nasal fossa and 1. An expert radiologist required to interpret the image.
maxillary sinus to the adjacent structures can be assessed. 2. High radiation dosage when compared to conventional
radiographic technique.
3. Patient’s head position must remain constant
3.9. Disadvantages
throughout the entire imaging process of about
1. 6-15% image magnification occurs which leads to 15-20 min.
measurement errors of implant site.
2. Image resolution is less when compared to intraoral
4.3. Recent advances in computed tomography
radiographs (potter bj, shrout mk 1997.
1. Cone beam ct is a relatively newer modality. It
3.10. Digital radiography uses a conical beam and reconstructs the image in
any direction using special software. It gives all the
It was first introduced in 1987 and became popular very
information of a ct but, at 1/8th the radiation dose.
soon. In this modality, the conventional film has been
2. Microtomograph, another modification of ct is
replaced by a ‘charged couple device’ (ccd).
especially useful in acquiring serial sections of bone-
1. It allows rapid acquisition of images. implant interface. (senner 2003).
2. Postacquisition enhancement is possible. 3. Multislice helical ct offers higher accuracy of images
3. Ease of storage, retrieval and transmission of images when compared to ct. 5
to remote site from the database. (vandre rh, 1995).
4.4. Periodontal treatment phase
4. Disadvantages
The periodontal treatment phase is directed towards
1. Digital radiography lacks the resolution of film obtaining optimal health for the patient’s periodontium
radiography. as well as potential implant sites. The patients with
2. It has a much smaller active image area (17 × 26 mm) periodoniitis. Root planning and scaling indicated. Osseous
when compared to iopa film (32 × 41 mm). surgery may be indicated for deeper osseous defects.
3. There are very few studies on the use of this technique Mucogingival surgery can be done during the initial
for presurgical site evaluation. periodontal phase to obtain adequate attached keratinized
gingiva. Esthetic periodontal surgery can be performed to
4.1. Computed tomography enhance tissue contours. In an atrophied maxilla a soft tissue
Considering the new age tool, it blends the concept of thin graft is considered following itmplant insertion.
layer radiography (tomography) with computer synthesis of
image. It was first applied successfully in implantology in 4.5. Edentulous ridge
the 1980s. In computed tomography (ct), multiple thin axial
slices at small distances are obtained through the jaws and The edentulous area present in the patient’s mouth is further
data is reformatted with special software package to produce evaluated. Classification of is described by misch and judy
cross-sectional, panoramic and 3d images. describing edentulous ridge as division—a bone is greater
The ct always images entire arch, and normally is not than 5 mm in width and over 10 mm in length. It is adequate
used for single tooth replacements. in all dimensions and root form implants are usually the
implant of choice. Division-b bone is between 2.5 mm and
1. It can determine bone density in any region of the jaw. 5 mm in width. A division c ridge is and either lacking in
2. The 3d image helps in accurately locating the vital height (c-h) or have inadequate width (c-w) to place a root
structures. form implant. The division-d ridge is severely atrophied and
3. Operator has an access to full range of contrasts. is the most challenging to restore prosthetically.
 Singh et al. / IP Annals of Prosthodontics and Restorative Dentistry 2020;6(3):135–139 139

4.5.1. Implant dentistry: a multidisciplinary approach References

Dental implants are one of the options available to replace 1. Mehrotra G, Iyer S, Verma M. Treatment planing the implant Patient.
missing teeth. The long-term success of any dental implant Int J Clin Implant Dent. 2009;1(1):12–21.
treatment is influenced by several factors including patient 2. Shaheen ZA, Rehana Z. Diagnosis and Treatment planning for Implant-
factors, preventative measures used by the patient, esthetics, Supported Fixed Prosthesis. J Interdiscip Dent. 2013;17(1):47–52.
3. Diagnosis and Treatment planning for Implant-Supported Fixed
surgical factors, periodontal factors, restorative factors and Prosthesis: J. Dhaka National Med. Coll Hos. 2011;.
mechanical factors of the implant system. Dental implants 4. S SE. Essentials of Periodontology; 2013.
are placed and restored by specialists as well as general 5. Singh T, Singh R, Singh R, Singh JP. Hypohidrotic Ectodermal
Dysplasia: A Felicitous Approach to Esthetic and Prosthetic
dental practitioners with differing levels of training in dental
Management. J Interdisciplinary Dent. 2013;3(2):140–5.
implantology. Therefore, it becomes very important for the
main clinician in charge of the implant patient to be aware
of the multidisciplinary approach that is required to ensure Author biography
long-term implant success. 3
Rohit Singh Senior Lecturer
5. Conclusion
Irfanul Huda Reader
Long-term success of dental implant treatment is dependent
on good case selection, detailed patient assessment and Aaysha Tabinda Nabi Reader
implementation of a multidisciplinary approach
Supriya Singh Senior Lecturer
6. Source of Funding
Kumar Anand Reader
None.

7. Conflict of Interest Cite this article: Singh R, Huda I, Nabi AT, Singh S, Anand K.
Diagnosis for dental implant. IP Ann Prosthodont Restor Dent
None. 2020;6(3):135-139.