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DIAGNOSIS AND TREATMENT

PLANNING IN ORAL IMPLANTOLOGY

DR. N. KULASHEKAR REDDY

Introduction

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 DIAGNOSIS AND TREATMENT
PLANNING MASTER FLOW CHART
Consultation Chief complaint
Patients goals of treatment

Clinical examination Medical examination

Radiography
Diagnostic models

Diagnosis and treatment plan Periodontics

Operative
Prosthodontics

Goal oriented case presentation Other treatment options

Thoroughly informed consent

Acceptance of treatment plan

Treatment

Maintenance 4
 Prosthodontics

Abutment support evaluation Natural abutment support

New implant abutment support

Evaluation of available bone Quantity

for new implant abut Quality

Choice of implant modality Endosseous Root form

Plate/Blade form
Subperiosteal

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 Rationale for dental implants
 The increasing need and use of implant related treatments
results from the combined effect of a number of factors
including
1. Aging population
2. Tooth loss related to age
3. Anatomic consequences of edentulism
4. Poor performance of removable prosthesis
5. Psychologic aspects of tooth loss
6. Predictable long-term results of implant supported
prosthesis and its advantages
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 The need for additional retention support and
stability or the desire to eliminate a removable
prosthesis are common indications for dental
implants

 Implants are increasingly used to replace single

tooth rather than removing sound tooth structure.

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 Advantages of implant supported
prosthesis

1. Tooth positioned for aesthetics

2. Maintainence of bone

3. Maintainence of occlusal vertical dimension

4. Development of Proper occlusion

5. Improved psychological health

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6. Regained proprioception / occlusal awareness
7. Reduced removable prosthesis size and elimination of
palate or flanges of complete dentures
8. Increase survival time of the restoration
9. Improved function, stability, retention and phonetics
10. Maintenance of muscles Mastication and facial
expression

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 Clinical examination of the
patient
 Medical examination
 Radiographic examination
 Study of diagnostic models

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Medical evaluation of the implant
patients
 Importance of patient interviews with medical history
questionnaires and physical examination

 Laboratories review of tests of interest to implant

dentistry

 Medical and dental implications of common systemic

diseases found in the implant patient

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 Medical history

 The review of the patient’s medical history is

the first opportunity for the dentist to talk with
the patient

 The time and consideration taken at the onset

will set the tone for the entire following
treatment

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 Past medical history

 Review of systemic health

 Medication usage of the preceding six months

and review of the systems of the body

 Questionnaire including all medical areas of

interest to implant dentist

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 Laboratory evaluation

 Routine evaluation of dental patients uncovers

12 to 18% undiagnosed systemic disease

 Includes: Hematocrit evaluation

Complete blood cell count

Bleeding disorder tests

Blood sugar examination

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 ASA guidelines

 Arbitrary guidelines for patients selection for implant

surgery are based on the classification of American
society of anesthesiologists

 This guideline restricts with very few exceptions,

intraosseous implants and implant related graft surgeries
to patients who fall into ASA1 ASA2 categories of the
classification

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 ASA1: patients with no health problems

 ASA2: patients with minor health problems who

respond well to treatment

 ASA3: patients with major health problems with

only partial correction

 ASA3,4,5 – relative to absolutely contraindicated

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 Absolute contraindications to
Implant surgery
1. Recent myocardial infarction
2. Valvular prosthesis
3. Severe renal disorders
4. Treatment resistant diabetes
5. Generalized secondary osteoporosis
6. Chronic to severe alcoholism
7. Treatment resistant osteomalacia
8. Radiotherapy in progress
9. Severe hormone deficiency
10. Drug addiction
11. Heavy smoking habits [>twenty cigarettes a day ]
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 Relative contraindications to
implant surgery
1. AIDS and other sero-positive disorders
2. Prolonged use of corticosteroids
3. Disorders of phosphocalicic metabolism
4. Hematopoietic disorders
5. Buccopharyngeal tumors
6. Chemotherapy in progress
7. Mild Renal disorders
8. Hepatopancreatic disorders
9. Multiple endocrine disorders
10. Psychological disorders , psychosis
11. Smoking habits
12. Lack of understanding and motivation
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Diagnostic imaging and techniques

 Help to develop and implement a cohesive and

comprehensive treatment plan for the implant team
and the patient

 Organized under three phases

1. Preprosthetic implant imaging

2. Surgical and interventional implant imaging

3. Post prosthodontic implant imaging

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 Surgical and interventional implant
imaging
 Focused on assisting in the surgery and prosthetic
intervention of the patient
 Objectives :
1. To evaluate the surgical sites during and immediately
after surgery
2. Assist in optimal position and orientation of implant
3. Evaluate healing and integration phase of surgery

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Post prosthodontic implant imaging

 Commences just after prosthesis placement and

continues as long as implant remains

 Objectives

1. To evaluate long-term maintenance and rigid

fixation

2. Function

3. Crestal bone levels and health of implant

complex
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Preprosthetic implant imaging

 Includes all past and new radiological

examinations to determine comprehensive
treatment plan

 Requires surgical and prosthodontic information

to determine the quality quantity and angulation

of bone

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 Imaging modalities
1. Periapical Radiography
2. Panoramic
3. Occlusal
4. Cephalometric
5. Tomography
6. Computed tomography
7. MRI
8. Interactive computed tomography
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 Analog imaging modalities/2D:
1. Periapical radiographs
2. Panoramic radiographs
3. Occlusal radiography
4. Cephalometric radiography

 3-D imaging modalities

1. CT
2. MRI
3. ICT
 Digital images can be produced in all the modalities

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 Preprosthetic imaging
 Evaluation includes
patient history
clinical examination
Radiographic examination
 Objectives : Identification of disease
Determining bone quality, quantity
Identification of critical
structures at proposed site
Determining optimal positioning of
implants relative to occlusal loads
(Implant position and orientation )
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 Periapical radiography
 Useful for single implants in region of greater bone width.

 Useful for ruling out local bone and dental disease

 Limited value in determining bone density and

mineralization

 Of limited value in determining quantity as it is only a two

dimensional magnified image

 Critical structures are detected but provides no

information on spatial relation

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 Occlusal radiography
 Is rarely indicated

 Maxilla- inherently oblique and distorted hence of

no quantitative use

 Mandible- because it is an orthogonal projection it is

less distorted than maxillary occlusal

but produces an oblique and distorted image

of the alveolus hence it is of little use in
implant dentistry
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 Cephalometry
 It is an oriented planar Radiograph of the skull hence a useful
tool
 Lateral cephalograph: produces a cross section of image of
Mandible and maxilla in incisal and canine region
 Useful as it demonstrates the geometry of alveolus in the
anterior region and lingual plate angulation
 Gives spatial information when clubbed with periapical
radiography
 Not useful for demonstrating bone quality
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 Panoramic Radiography
 Most used however not most diagnostic for
quantitative imaging
Advantages :
1. Opposing landmarks easily Identify
2. Vertical height of Bone initially can be assessed
3. Speed and ease of procedure
4. Gross anatomy, pathological findings can be

evaluated
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Disadvantages :

1. Both vertical and horizontal magnification are

present

2. Does not demonstrate bone quality and

mineralization

3. Misleading quantitatively because of

magnification

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 Tomography
 Body section Radiography is a special x-ray technique
that enables the visualization of a section of the patients
anatomy by blurring the regions of patients anatomy
above and below the section of interest

 Types : linear

circular

spiral

hypocycloidal

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 High quality complex motion tomograms
demonstrate the alveolus

 Enables quantification of the geometry of the

alveolus

 Spatial relationships of critical structures and

quantity of bone determined

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 Computed tomography
 Enables differentiation and quantification of both soft
and hard issues
 Produces axial images of the patients anatomy
perpendicular to the long axis of the body
 Provides a unique means of post imaging analysis of
proposed surgical or implant sites by reformatting the
Image data to create tangential and cross sectional
Tomographic images of the implants site

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 Density of the structure within the image is absolute
and quantitative and used to differentiate tissue in the
region and the bone quality

 Enables evaluation of the proposed implant site

 Dentascan imaging provides programmed

reformation, organization and display of the imaging
study but the images may not be of true size

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Dentascan

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Bone quality in Hounsfield units

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Interactive computed tomography
 Enables the radiologist to transfer the imaging study to
the clinician as a computer file and the clinician can
view and interact with the study on his own computer

 Clinician and the radiologist can perform electronic

surgery (ES) by selecting and placing simulated root
from implants

 Presently the most accurate imaging technique for

Implant imaging and surgery

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 Magnetic resonance imaging
 It is quantitatively an accurate technique with exact
tomographic sections and no distortion
 Secondary imaging technique after complex tomographs ,
computed tomographs and interactive computed
Tomography fail
 Example: failure to differentiate inferior alveolar canal
 MRI is not a high yield technique for estimating bone
mineralization or for identification of bone disease

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 Diagnostic models
 Help to evaluate several prosthetic criteria in the
absence of the patient

 Assist with implants site selection and angulation

requirements during the surgical phase

 Sagittal templates are designed from diagnostic

casts or after diagnostic waxup of desired prosthesis

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 Serve as permanent record of pretreatment
conditions for dento-legal issues

 Diagnostic casts and pretreatment setup useful

for motivation

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 Uses of diagnostic casts
 Diagnostic casts provide
1. Centric relation position and occlusal contacts
2. Edentulous ridge relationship of opposing arches
3. Position of natural abutment and orientation
4. Structure and wear facets of abutments
5. Direction of forces In future implants sites
6. Present occlusal schemes, balancing or working
contacts visualized

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7. Edentulous soft tissue characteristics
8. Interarch space
9. Overall curve of Wilson and curve of Spee
10. Arch relationships
11. Opposing dentition
12. Potential future occlusal schemes
13. Arch location of future abutment

14. Arch form and symmetry

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Pre implant prosthetic considerations

 Resemble those done in traditional dentistry with

certain modifications
1. Existing occlusion
2. Existing occlusal plane and orientation
3. Interarch space
4. Existing VDO
5. Maxilla mandibular arch relationships
6. TMJ status

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7. Existing prosthesis

8. Arch from

9. Implant ideal permucosal position

10. Missing teeth location and number

11. Lip line at rest and during speech

12. Mandibular flexure

13. Soft tissue support

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 Triangle of bone
Earlier concept :

 Immediate implant placement

after extraction showing fragile
buccal plate of bone

 If the implant follows the

socket site it perforate the
buccal cortical plate of bone and
leads to poor prognosis

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Current proposed concept by
Scott
•When The proposed triangle
of bone is placed over the
cross sectional image it is
seen that the base of the
triangle demarcates the
widest available bone
•Implant should bisect the
triangle of the bone
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 As the implant is placed parallel to the
trajectory of bone an angulated transmucosal
abutment is necessary to enable correct
restoration of the tooth and good esthetics.
 The final Prosthetic crown with good
emergence profile, increased thickness of
buccal cortical plate replaces the natural tooth
in its original position

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 Advantages
 Greater volume of bone

 Placement of longer fixture

 Bicortical stabilization

 Proper emergence profile

 Better long term prognosis

 Parallel to the trajectory of bone

 Support from lateral forces of occlusion

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57
 DIAGNOSIS AND TREATMENT
PLANNING IN ORAL IMPLANTOLOGY

 DR. N. KULASHEKAR REDDY

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 Prosthetic options in implant
dentistry
 In 1989
Misch,
reported
five
prosthetic
options

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1. FP1 FP2 FP3:
depend on amount
of hard and soft
tissue structure
replaced

2. Common to all FP
is the inability of
the pt. to remove
the prosthesis

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RP4 RP5:
depend on
amount of
implant support
not the
appearance of
the prosthesis

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 Divisions of available bone

 The prosthetic needs and desires of the patient should

be first determined and if natural teeth are in proper
position to serve as abutment support they are
evaluated with traditional methods

 If no tooth is present In the area of the abutment the

implant ideal and optional positions are determined

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 Once this has been accomplished the most important
element in the implant design is available bone
 In 1985 Misch and Judy established four basic
divisions of available for implant dentistry in maxilla
and mandible which follow the natural resorption
phenomena represented by Atwood.
 The four divisions were later expanded to six

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 Available bone

 Describes the amount of bone in the edentulous area

considered for implantation
 Measured in: height
width
length
angulation
crown-implant body ratio

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 Available bone height
 Available bone height is measured from the crest of the
edentulous ridge to opposing landmark such as the
Maxillary sinus or the mandibular canal in the posterior
mandibular region

 In the anterior region it is limited by the nares in the

maxilla and the inferior border of the mandible

 It is maximum in the maxillary canine region and less in

the mandibular first premolar region

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 Minimum height of available bone for endosteal
implants is in part related to the density of the bone
 Once the minimum height Is established for each
implant design and bone density, width is more
important than additional length
 For every one mm increase in diameter, surface area
increases by 20 to 30%

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 Available born height initially estimated by OPG

 Minimum bone height for endosteal implants for

long-term success is 10mm

 Height minimum can be decreased in very dense

bone

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 Available bone width

 Measured between facial and lingual plates at

the crest of the potential implant site

 Once height is available the primary criterion

affecting long-term survival of the endosteal
implant is width of the available bone

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 Minimum bone thickness is in the midfacial and
midline contour of the crestal bone

 4 mm implant requires >5mm width allow

predictable blood supply around the implant

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 Available bone length

 Mesio- distal length of available bone in the

edentulous area is often limited by the
adjacent teeth or implant

 Length of the available bone depends on

the width of the bone

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 For a 5mm width minimum 7mm length is
sufficient

 If width is less than 5mm, a 3.2 mm implant is

placed

 In narrower ridge it is better to place 2 small

implants

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 Available bone angulation

 Ideally it is aligned with the forces of occlusion and is

parallel to the long axis of the restoration
 Rarely does the available bone angulation remain
constant after the loss of teeth specially in the anterior
edentulous maxilla
 Here the teeth are angulated most to the occlusal forces
 Accepted bone angulation in wider ridges is 30degrees

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 In the posterior mandible the mandibular foramen
mandates greater angulation as implants are placed
more distally
 2nd PM region 10 ° angulation to the horizontal
 1st M – 15 degrees
 2nd M – 20 to 25°
 Limiting factor of angulation of force between body and
abutment is correlated to the width of the bone

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 Crown implant body ratio
 Impacts the appearance of the final prosthesis
and the amount of moment of forces on the
implant and the surrounding crestal bone
 Crown height measured from the occlusal plane
to the crest of the ridge
 Implant body is measured from the crest to the
apex

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•>crown Height
>moment of force
•As the crown implant
ratio increases more
number of implants or
wider implants should
be Inserted to
counteract the
increase in stresses

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 Divisions of available bone

 Division A
 Division B
 Division C
 Division D

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 Division A –abundant bone
 Forms soon after the tooth extraction

 Abundant bone volume remains for few years

 Interseptal bone height decreases and crestal bone

width decreased by 30% within the first 2 years

 There Is abundant bone in all dimensions

 4 to 5mm implant can be placed

 In A plus bone 7mm Implant can be placed

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 Division B-barely sufficient bone
 As bone resorbs the width of the available bone first
decreases at the expense of facial cortical plate
 That is 25% decrease in bone width in first year, 40%
decrease in one to three years
 Division B once reached may remain for more than twenty
years depending on available bone height
 Depending on available bone width division B can be
further classified into
- 4-5mm
- B minus [Bw] 2.5 to 4mm 82
Division C-compromised bone

 Available bone is deficient in one or more dimensions

[W, L, Ht, ANG, CR/I ratio]
 W may be less than 2.5
 Ht maybe less than 10mm
 Cr/I ratio may be >or equal to one
 Angulation may be greater than or equal to 30

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 Resorption of the available bone occurs in width then
height therefore division B resorbs in width though
height is still present until it becomes inadequate for any
design
 This is C minus width [Cw]
 Process continues and available bone height is
decreased [Ch]
 Moderate to average atrophy may be used to describe
the clinical condition of division C

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 Division C is most commonly present in posterior maxilla
and mandible

 Cw resorbs to Ch as fast as A to B occurs

 Ch eventually leads to division D

 Anatomical landmarks are usually not present so greater

surgical skill is required

 Division C prosthetic treatment is complicated and

greater complications are seen during healing

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Division C: Treatment options

1. Osteoplasty
2. Root form implants
3. Subperiosteal implants
4. Augmentation procedures
5. Ramus frame
6. Transosteal implants

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 Division D- deficient bone
 There Is complete loss of alveolar bone with basal
bone atrophy
 Most difficult to treat In implant industry
 If implant failure occurs the patient may become a
dental cripple unable to wear any prosthesis
 So benefits must be carefully weighed against risks
before treatment

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 Bone density: a key determinant
for clinical success

 Available bone is particularly important in implant

dentistry and describes the external architecture or
volume of edentulous area considered for implants
 Multiple independent groups have reported higher
failure rates in poor quality bone compared to a
higher quality bone

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 Ant. Mandible greater density hence greater success
rate than ant. max
 Posterior mandible lesser success than ant. Mand
 Posterior Max poorest bone quality so least success
 Posterior region of mouth have less dense bone
compared to anterior region both in Max and mand

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 Bone quality
Bone classification schemes related to implant dentistry

 Linkow in 1970

- Class 1 bone structure

- Class 2

- Class 3

 Lekholm and Zarb in 1985, gave four bone qualities

found in the anterior region of the jaw

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- Quality 1: homologous compact bone
- Quality 2: thick layer of cortical bone
surrounding a core of dense
trabecular bone
- Quality 3: thin layer of cortical bone surrounding
dense trabecular bone of favorable
strength
- Quality 4: thin layer of cortical bone surrounding
low density trabecular bone

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 In 1988 Misch extended the four bone density groups
independent of the region of jaws based on macroscopic
cortical and trabecular bone characteristics
 Dense and/ porous cortical bone are found on the outer
surface of bone and Include the crest of an edentulous
ridge
 Coarse and fine trabecular bone are found within the
outer shell of cortical bone and occasionally on crestal
surface of edentulous residual ridge

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 These four macroscopic differences of bone
arrangement, from the most dense to least are as
described by Frost
 The regional location of the different densities of
cortical bone are more consistent than the highly
variable trabecular bone

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 Misch classification of bone quality

 D1: dense cortical

 D2: thick dense to porous cortical bone on the crest and
coarse trabecular bone within
 D3: thin porous cortical bone on the crest and fine
trabeculae within
 D4: fine trabecular bone {almost no crestal or cortical
bone}
 D5: immature non mineralized bone
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 Bone density determined by
- tactile sense during surgery
- general location and
- radiographic evaluation
 Tactile D1: drilling into oak on maple
D2: drilling into white pine/ spruce
D3: drilling into balsa
D4: drilling into Styrofoam

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 Bone density based on general
location in %
Bone Ant max Post max Ant mand Post mand

D1 0 0 6 3

D2 25 10 66 50

D3 65 50 25 46

D4 10 40 3 1

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 Radiographic bone density

 Periapical or OPG are not beneficial

 D2 D3 changes are not quantifiable
 More precisely determined by tomography especially CT
 Most critical region of bone density is the crestal 7-
10mm of bone
 When bone density varies from crest to apex, crestal 7-
10mm determines the treatment plan

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CT Bone quality in Hounsfield units

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 Influence of bone density on
treatment plan
 Bone density modifies implant treatment plan in
several ways
1. Prosthetic factors
2. Implant size
3. Implant design
4. Implant surface condition
5. Implant number
6. Progressive loading

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 Classification and treatment plan for
partially and completely edentulous arches

 Numerous classifications have been proposed for partially

edentulous arches
 These include classifications proposed by, Cummer, Kennedy and
Bailyn.
 The Kennedy classification however is taught in most American
dental schools
 The Kennedy classification is difficult to use in many situations
without certain qualifying rules

 The eight Applegate rules are used to help clarify the system

102
 The Implant dentistry bone volume
classification
 This classification was given by Misch and Judy and
builds on the four classes of partial edentulism described
in the Kennedy Applegate system
 By using this classification the doctor is able to convey
the dimensions of the bone available in the edentulous
area and also indicate the strategic position of the

segment to be restored

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 The Implant dentistry classification for partially edentulous
patients also includes the same 4 available bone volume
divisions discussed for the edentulous area

 Other intradental edentulous regions not responsible for the

Kennedy Applegate class determination are not specified within
the available bone section of the Misch- Judy system if implants
are not considered in the modification region

 However if the modification segment is also included in the

treatment than it is listed followed by available bone division it
characterizes

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 Classification of completely
edentulous arches

 A history of edentulous classification primarily includes

the Classification of Kent and Louisiana dental school
 This classification treats all regions of the edentulous
arch in similar fashion and does not address regional
variations
 The classification was for ridge augmentation with
hydroxyapatite and a conventional denture

112
 The divisions of bone are the basis of the
classification of the completely edentulous patient
presented by Misch

 It organizes the most common implant options of

prosthodontic support for the completely edentulous
patient

 Its objective is to communicate the volume of bone

and its location

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 Each edentulous jaw is divided into three regions

1. Right posterior section extending from the mental

foramen to the retromolar pad

2. Left posterior section extending from the mental

foramen to the retromolar pad

3. Anterior region between the mental foramen [1st PM

to 1st PM]

4. In the maxilla rt and lt posterior regions from where

max. sinus determines the ht of available bone

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 The classification of the edentulous arch is then
determined by the division of bone in each section of
the edentulous arch

 The three areas are evaluated independently

 Hence there may be 1,2, or 3 different divisions of

bone

 The term type Is used in this edentulous classification

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 Type 1

 Division of bone is similar in all three anatomic

segments
 Four different categories present
 Type 1 division A: abundant bone in all three regions
 Type 1 division B: adequate born in all three sections
 Type 1 division C-w: inadequate bone width
 Type 1 division C-h: inadequate bone height
 Type 1 division D

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 Type 2

 Posterior sections are similar but different

from anterior segment

 Described by two division letters following

type 2

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 Type 3
 Posterior section of maxilla/mandible differ from each
other
 It is less common
 Seen more in the maxilla
 Anterior bone volume listed first then right posterior
then left posterior segment
 Anterior section usually determines the treatment plan

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Diagnostic templates and surgical
guide templates

 Diagnostic Radiographic templates

 Purpose: to incorporate the patients proposed

treatment plan into the radiographic examination

 This requires that the treatment plan be developed

prior to the image and procedures

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 Ideally mounted diagnostic casts, a diagnostic wax-up, agreement
between the clinicians on the number and location of proposed in
dental implants and prior authorization of the proposed treatment
by the patient makes the diagnostic template a very useful tool and
many times determining factor in the final treatment plan of the
patient

 The prosthetic imaging procedure enables evaluation of the

proposed implant site at the ideal position and orientation identified
by radiographic markers incorporated into the template

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 The precision of CT enables use of a complex and
precise diagnostic template

 Although CT can accurately identify the available bone

height and width for a dental implant at the proposed
implant site the exact position and orientation of the
implant which many times determines the actual length
and diameter of the implant is often dictated by the
prosthesis

 As such a diagnostic template use during imaging is

most beneficial
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 The services of the proposed restorations and exact position and
orientation of each dental implant should be incorporated into
the diagnostic CT template

 They’re basically two designs

 One produced by a vacuum form reproduction

 And other, processed acrylic reproduction of the diagnostic wax-

up modified by coating the processed restorations with a thin film
of barium sulfate and filling a hole drilled through the occlusal
surface of the restoration with gutta percha

128
 The surfaces of the proposed restoration then become
radiopaque in the CT examination and the position and
orientation of the proposed implant is identified by the
radiopaque plug of gutta percha within the proposed
restoration
 Another designed involves filling the proposed
restoration site in the vacuum form of the diagnostic
template with a blend of 10% Barium sulfate and 90%
cold cure acrylic, the CT appearance of the proposed
restoration matches the density of enamel and dentin of
natural teeth

129
 A 2mm hole through the occlusal surface of the
proposed restoration can be drilled at the ideal position
and orientation of the proposed implants site with a twist
drill
 This results in a natural tooth like appearance of the
proposed restoration in the CT examination that all the
surfaces of the restoration activated along with a 2mm
radiolucent channel through the restoration, which
precisely identifies the position and orientation of the
proposed implant

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 Surgical templates
 Diagnostic templates can be modified and used as
surgical templates
 Typical modification of a diagnostic template to produce
a surgical template does not incorporate the precision of
the results of ICT or ES
 CADCAM stereotactic templates can be produced from
CT examinations that have used ICT to develop a three
dimensional treatment plan for the patient for the
position and orientation of dental implant

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 The surgical guide template is fabricated by the
restoring dentist after the presurgical restorative
appointment, once the final prosthesis optional
abutment number and location, occlusal scheme, and
implant angulation have been determined
 It offers the best combination of support for the
repetitive forces of occlusion, aesthetics ,and hygiene
requirements

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 Requirements
1. Rendered to be stable and rigid in correct position
2. If the arch treated has remaining teeth the template
should fit over and around enough teeth to stabilize it
in position
3. When no remaining teeth are present the template
should extend onto unreflected soft tissue regions
[tuberosity, palate, retromolar pad]
4. In in this way it can be used after the soft tissues have
been reflected from the implants site

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5. The ideal angulation implant insertion should be
determined on the diagnostic wax –up and the
template should relate this position during surgery
6. Other requirements include size, transparency and
ability to revise the template as required
7. It should relate the ideal facial contour
8. The angulation of the osteotomy can also be
determined with the template

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 Bone mapping
 Even experienced implant surgeons can be misled by the
apparent buccolingual dimension of the max. Or mand
residual ridges
 Ridge mapping allows the implant surgeon to determine
the thickness of the residual bone before a
mucoperiosteal flap is reflected during surgery
 Wilson caliper ( exact up to + or – 1 mm), Spoerlein
caliper ( exact up to + or – 0.5 mm) are used

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 Ridge mapping technique Involves a series of measurements with a
caliper.
 The points of the caliper penetrate the mucosa until the surface of
the bone has reached
 A mm scale near the handle of the caliper will give a reading of
ridge thickness
 Recently sonographic imaging has been used successfully, requires
no local anesthesia also renders exact information on the location of
mental foramina and maxillary sinus

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Conclusion

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 References

 Contemporary implant industry , Carl E Misch,

second edition

 Fundamentals of implant dentistry, Weiss and

Weiss

 Implants in restorative dentistry, Scortsessi

 JPD 1992 vol 67 pg 358

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