Basics of clinical diagnosis in implant dentistry

Abstract

Implant-based prosthetic rehabilitation requires an understanding of associated anatomical structures. The ultimate predictability of an implant site is determined by the existing anatomy as related to dentition and the associated hard and soft tissues. Meticulous clinical assessment helps in determining the suitability of the potential site for implant placement. The purpose of this article is to present the clinical assessment for dental implants' placement to modulate peri-implant tissue characteristics in individual clinical need.

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S13© 2015 Journal of the International Clinical Dental Research Organization | Published by Wolters Kluwer - Medknow
INTRODUCTION
Implant-based rehabilitation approach for an edentulous or
partially dentulous condition requires a series of decisions that
are taken to determine whether the patient is a reasonable
candidate for implant therapy. Every effort should be made
to preserve the natural tooth through restorations. Clinical
evaluation to assess the suitability of the candidate for dental
implant is a vital phase of treatment planning before implant
surgery. The prognosis of implant surgery depends primarily
on the desired prosthetic result.[1] Hence, such rehabilitation
procedure requires a clear vision of the end result before
the procedure begun. Clinical evaluation for dental implant
placement requires overall condition assessment that resembles
traditional dentistry. When a clinician evaluates the prosthetic
need of patients, an orderly sequence is required regardless of
the current status of the dentition. In other words, whether the
patients are partial dentate or edentate, consistent approaches
to evaluate before the management are beneficial.[2,3]
Clinical diagnosis
Various factors have been discussed in the literatures that
facilitate clinical assessment for dental implant selection and
placement with consequent hard and soft tissue enhancement
around the implant prosthesis. These factors are broadly
(
Address for correspondence:
Dr. Manu Rathee, Department of Prosthodontics, Post Graduate
Institute of Dental Sciences, Pandit Bhagwat Dayal Sharma University
of Health Sciences, Rohtak - 124 001, Haryana, India.
E-mail: ratheemanu@gmail.com
categorized as the anterior (single/multiple) and posterior
quadrants (single/multiple) [Figure 1]. The dentist must evaluate
the elements during clinical examination as shown in Figure 2.
General assessment of the patient’s profile
The initial decisions involve meticulous case history
involving medical and psychological examination for implant
therapy. A medical evaluation is made from a questionnaire,
a patient interview, and any medical consultations
necessitated by the history. Medical conditions that make
surgery complicated or adversely affect healing must
be taken into consideration. If any significant medical
contraindication exists and cannot be resolved promptly,
implants are not indicated and alternative approaches must
be sought.[3,4] If the patient is medically and psychologically
well-adjusted and understands the aesthetics or functional
benefits of an implant approach, the consequences of the
edentulous or partially dentulous condition should be
considered next.[2,3]
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DOI: 10.4103/2231-0754.172929
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Basics of clinical diagnosis in implant dentistry
Manu Rathee, Mohaneesh Bhoria
Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak,
Haryana, India
ABSTRACT
Implant-based prosthetic rehabilitation requires an understanding of associated anatomical structures. The
ultimate predictability of an implant site is determined by the existing anatomy as related to dentition and
the associated hard and soft tissues. Meticulous clinical assessment helps in determining the suitability
of the potential site for implant placement. The purpose of this article is to present the clinical assessment
for dental implants’ placement to modulate peri-implant tissue characteristics in individual clinical need.
Key words: Dental implant, diagnosis, gingival biotype, residual ridge
Cite this article as: Rathee M, Bhoria M. Basics of clinical diagnosis in implant
dentistry. J Int Clin Dent Res Organ 2015;7:13-8.
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Rathee and Bhoria: Diagnosis in implantology
S14 Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
Specific assessment of patient profile
Meticulous assessment of the future dental implant site is
a must for optimizing healthy aesthetic gingival appearance
and establishing a functionally successful implant-supported
restoration.
Aesthetic assessment (lip lines, tooth position, and
other features)
Implant placement requiring replacement of an anterior tooth
In almost all the cases, the primary concern is an aesthetic tooth
replacement; it is important to establish clinical concepts with
well-defined parameters for successful aesthetics outcome with
long-term stability of the peri-implant tissues. The aesthetic
evaluation involves lip activity and lip length. In an average
smile, 75-100% of the maxillary incisors and the interproximal
gingiva are displayed. In a high smile line, additional gingival
tissues are exposed. Less than 75% of the incisors are exposed
in a low smile line. Other aids, such as previous photographs,
may help in determining the natural position of the patient’s lip
when smiling. Considerable challenges occur in a high smile line
as the implant prosthesis and gingival tissues are completely
Figure 1: potential prognostic clinical assessment for dental implant placement
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displayed. In these types of clinical situations, maximal efforts
toward maintaining peri-implant tissue support throughout the
planning, provisional, surgical, and prosthesis phases will be
required. The low smile line is a less critical scenario where the
implant prosthesis interfaces are less visible behind the upper
lip. The tooth position needs to be evaluated clinically in three
planes, that is, apicocoronal, faciolingual, and mesiodistal. The
clinical tooth position assessment will considerably influence
the presenting gingival architecture, papilla height, and contact
area location.[4,5]
Existing three-dimensional clinical evaluation
The three-dimensional clinical evaluation is dependent on
many elements listed as follows:
1. Available space
2. Soft tissue ridge support
3. Periodontal status
4. Occlusal considerations
Assessment of the available space
In the posterior region, clinical assessment should ensure
that the implant prosthesis unit restores functions as close
to the natural dentition as possible to allow appropriate
reestablishment of the occlusion and embrasure forms.
Clinical evaluation of the mesiodistal space involves adequate
prosthetic space assessment so as to reestablish adequate tooth
contours. If prosthetic space is inadequate, enameloplasty
of the adjacent teeth or orthodontic repositioning must be
given consideration. The mesiodistal space required depends
on the type and number of teeth being replaced. Clinically-
based decisions need to be made with regard to the implant
size. The following guidelines may be used when selecting
implant size and evaluating the mesiodistal space for implant
placement: The implant should be at least 3 mm away from the
adjacent teeth, the implant should be at least 3 mm away from
an adjacent implant, and the diameter of the implant should
be selected based on the tooth to be replaced. Based on the
above guidelines, for two 4-mm diameter dental implants,
a space of 17 mm is required. This amount of space would
suffice to replace two premolars. If two premolars and a molar
are required, an additional space is necessary. This situation
can be resolved by the placement of two dental implants and
fabrication of a fixed partial denture (FPD) or placement of
Figure 2: clinical diagnostic aspect in implant dentistry
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three dental implants. If three implants are planned, a total
space of 24 mm is required [Figure 3]. Clinical evaluation of
the buccolingual space, at least 6 mm of bone buccolingually,
is required for the placement of a 4-mm diameter implant
and 7 mm for a wider diameter of 5-mm implant. Posterior
mandibular dental implant should be planned so that the exit
angle of the screw access points toward the inner incline of
the palatal cusp. Posterior maxillary implants should be placed
so that the exit angle of the screw access points toward the
inner incline of the buccal cusp. Clinical evaluation of the
occlusogingival space can be evaluated under crown height
space availability. Sufficient crown height space must exist for
harmonious aesthetic and functional replacement with the
adjacent teeth. On clinical examination, the space between
the residual ridge and the opposing occlusal plane should be
evaluated. For instance, if replacing the premolar and molar
teeth, a space of 10 mm must exist between the residual ridge
and the opposing occlusion. A 7-mm space would be considered
the minimum space required. In situations where the opposing
teeth overerupt and compromise the prosthetic space,
enameloplasty or minimal restorative therapy, orthodontic
intrusion, elective endodontics, crown lengthening, and full
coverage of the crown may be required to create space.[6,7]
Evaluation of the soft tissue ridge support
The health or quality of the soft tissue influences harmonious
aesthetic outcomes in dental implant rehabilitation. The
supracrestal soft tissue constituting the papillae positioning
influences the harmony between the new prosthesis, the
remaining teeth, and the surrounding soft tissues. Classically,
soft tissue topography is determined by parameters
such as contact point position, crown dimensions, tooth
implant distances, and implant diameter. The assessment
of keratinizing mucosa that surrounds the adjacent teeth
is thought to be a positive factor in maintaining the health
of the soft tissue around the dental implant. Enough
space between the implants is needed to allow interdental
papilla reconstruction or at least soft tissue preservation.
When the space between the dental implants is too close,
insufficient blood supply may result in papilla collapse and
when the dental implants are placed far apart, unsupported
inter-implant papilla may collapse. The contour of the ridge,
along with the height and width, can be visually inspected and
carefully palpated. The presence of concavities, particularly
on the facial aspect, is detected with ease. However, accurate
assessment of the underlying bone dimension is clinically
difficult when the overlying tissue is fibrous, especially on
the palate where the tissue palpated may be of thick variant
and can result in pseudo-impression of the healthy bone
profile.[5,6]
Ridge mapping
Techniques such as ridge mapping may clinically help in
assessing the bone profile. The area of concern is assessed
under local anesthesia and the thickness of the soft tissue is
measured by puncturing through to the bone, using either a
graduated periodontal probe or specially designed callipers.
The same information is then transferred to a diagnostic cast
that is sectioned through the ridge. This method provides a
better indication of the bone profile than simple palpation but
error is inevitable. Whenever evaluation of the bone width
and contour is critical, radiographic assessment is advised.[2]
Ridge angulation
The relationship of ridge angulations and the opposing
dentition is important to assess. The available distance
should be measured to ensure adequate room for the
prosthetic components. Proclined and retroclined ridge
forms tend toward angled implant placement that could
affect the aesthetics and loading protocol. Large horizontal
discrepancies between the jaws, for example, the pseudo class
III jaw relationship following extensive maxillary resorption
is not suitable for treatment with fixed bridges. The clinical
Figure 3: clinical assessment of available space for implant placement
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examination of the ridge also allows assessment of the soft
tissue thickness that is important for the attainment of
good aesthetics. Keratinized tissue that is attached to the
edentulous ridge provides a better peri-implant soft tissue
than nonkeratinized mobile mucosa. The length of the
edentulous ridge can be measured to give an indication of
the possible number of implants that could be accommodated
in the edentulous span. However, this also requires reference
to radiographs to allow a correlation with the available
bone volume and the diagnostic setup for the proposed
tooth location. In partially edentulous ridges bound by
teeth, the available space is affected by angulations of the
adjacent tooth roots, which may be palpated or assessed
radiographically.[7]
If the height or width of the recipient ridge areas is
inadequate or the trajectory is unsatisfactory, an implant
may not be feasible. Bony undercuts also present problems
as do the positions of anatomic features, such as the mental
foramen. If the ridge is inadequate for any reason, an implant
is inappropriate and alternatives should be considered.[6,7]
Assessment of periodontal status
A complete periodontal examination is considered to be an
appropriate screening tool. The best way to clinically assess
the implant site is preextraction evaluation of the failing
tooth[8-10] [Figure 4]. An understanding of the associated
anatomical structure is essential. The ultimate predictability
of the implant site may be determined by the patient’s
presenting anatomy more than the clinician’s ability to
manage the state-of-the-art procedures. The factors that need
to be considered include relative tooth position and location,
form and type of the periodontium, natural teeth periodontal
condition, and available ridge defect classification (Seibert’s
classification).
Understanding the biological principles for achieving healthy
soft tissue surrounding a dental implant is essential for
health, function, and aesthetics. Formation of a biological
connection between the hard and soft living tissues start
during tooth development and that has to be created during
the healing process after placement of the implant. The
aesthetics of dental implant prosthesis depend on the health
and stability of the peri-implant mucosa. Understanding
of soft tissue healing and maintenance around the dental
implants are of paramount importance for implant success.
Hence, an assessment of suitable implant site(s) based on
soft tissue profile is a must during treatment planning and
therapy.[4] Gingival biotype has been described as one of
the key elements for a successful treatment outcome in
implant dentistry. It has been suggested that the presence
of papilla between the immediate single tooth implants and
the adjacent teeth is correlated with a thick-flat biotype.
Moreover, more gingival recessions at the immediate single
tooth implant restorations have been noted with a thin
scalloped biotype. A thick gingival biotype is a desirable
characteristic that positively affects the aesthetic outcome
of an implant restoration because a thick tissue biotype is
more resistant to mechanical and surgical insults. Based on
the current literature, thick gingival biotype is geared up
against thin gingival biotype variety as the thicker biotype
available with a thick labial plate potentiate regeneration
around the implant by holding the bone graft and soft
tissue graft in position, enhancing primary wound closure,
enhancing revascularity, and protecting the site. Moreover,
resistant to mucosal recession or mechanical irritation,
better peri-implant soft tissue depth can be achieved that is
better at concealing the titanium/metal margin and is more
accommodating toward a different implant position and the
resultant abutment angulation. Although in cases with thin
biotype variety, the selection of abutment provides more
concerns due to its inability to be a barricade to conceal
the titanium/metal margin and it being highly prone to
mucosal recession on irritation/insult. Hence, for thin tissue
phenotype variety, minimally invasive or flapless surgery is
more appealing because it minimizes or compromises the
blood supply of the underlying bone and decreases the risk
of recession after implant placement.[4,5]
Occlusal considerations
Masticatory forces achieved by implant-supported
restorations are considered to be equivalent to
natural dentition. When clinically assessing a case for
implant-supported restorations, a general assessment of the
load to be placed on the dental implants should be made.
If the patient is a bruxer, the clinician may plan additional
implants to allow for more favorable load distribution.
Unlike natural teeth, osseointegrated dental implants are
without an intervening periodontal ligament and the mean
axial displacement is noted to be approximately 3-5 µ when
compared to 25-100 µ range of motion of teeth in the socket.
The range of motion of osseointegrated implants has been
Factors Questionable/hopeless
Periodontal Residual periodontal pocket depth ≥6 mm and
bleeding on probing present, probing attachment loss
of approximately 50%, furcation involvement degree II
or III, root proximity/insufficient residual attachment
Endodontics No clinical signs and persisting radiolucency/
symptomatic situation and radiolucency, no
further treatment feasible
Prosthetics Reduced retention/resistance form (<3-mm wall
height and/or >25° convergence angle)/insufficient
residual tooth substance (<1.5-mm circular ferrule),
no crown lengthening or extrusion feasible
Occlusal factors History of repeated tooth restoration/fractures
Figure 4: Clinical assessment of the failing tooth
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Rathee and Bhoria: Diagnosis in implantology
S18 Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
reported to show deflection in a linear and elastic pattern
and movement of the implant under the load is dependent
on the elastic deformation of the bone. There are studies
supporting the finding that implants are more susceptible to
occlusal overloading than natural teeth, that is, displacement
of a tooth begins with an initial phase of periodontal
compliance that is nonlinear and complex followed by a
secondary movement phase occurring with the engagement
of the alveolar bone. The occlusion should be evaluated and
organized so that there is anterior guidance and disclusion
of the posterior teeth. There should be no contact of the
posterior teeth with the nonworking sides. If the canine is
compromised, group function is acceptable.[11]
CONCLUSION
The clinical assessment of a candidate for implant therapy
follows several conventional criteria from the evaluation
of temporomadibular joint to prognosis of the failing
tooth to the available residual alveolar ridge. This initial
evaluation possibly determines the final decision for implant
case selection/placement. However, the final treatment
strategy is largely dependent on the anatomical limitations,
expectations/desires, and financial requirements.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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