Planning for Implant Treatment

What are some factors influencing wound healing?

1. Blood thinner medication

2. Ongoing chemotherapy

3. Ongoing corticosteroid medication

4. Ongoing/ recent bisphosphonate treatment (IV)

5. Uncontrolled Diabetes

6. Smoking (5 cig/day)

Why is ongoing blood thinner use important in implant patient selection?

Stopping blood thinners puts the patient at high risk of stroke or cardiac arrest

How is blood thinner medication typically managed before surgery?

It may be stopped 24 hours to 1 week prior, depending on medical guidance

What must always be done when a patient is on blood thinners?

Contact the patient’s physician

How do chemotherapy drugs affect cells?

They alter cell activity in both normal and malignant cells

How does chemotherapy affect wound healing?

It can impair healing by preventing cell division and protein synthesis

What is the effect of chemotherapy and radiation on healing?

They slow wound healing

Why is healing compromised in cancer patients?

Cancer treatments impact normal processes like:

• Cellular replication

• Inflammatory reactions

• Tissue repair

How does acute corticosteroid use affect wound healing?

If high-dose steroids are used for less than 10 days, there is no effect on wound healing

What is considered chronic corticosteroid use?

Doses >10 mg/kg for more than 1 week

What happens to patients on chronic corticosteroids before surgery?

They have:

• 2× increased risk of wound infection

• 2–3× higher risk of wound dehiscence

How long of steroid use increases surgical risk?

About 30 days prior to wounding or surgery

What is osteoporosis?

A systemic disorder with a generalized decrease in bone mineral density

Where is osseointegration more likely to fail in osteoporotic patients?

The maxilla (higher risk than the mandible due to lower bone density)

Does osteoporosis clearly impair bone healing?

No—there is no strong evidence that it has detrimental effects on bone healing

What loading protocol should be avoided in osteoporosis?

Immediate loading (3 mo of loading covered to heal)

What is recommended for implant healing in osteoporotic patients?

Extended healing time before loading

What is the concern with patients on bisphosphonates?

Elevated risk of osteonecrosis

What are some considerations with patients who are on psychoparacological medication?

1. Difficult to manage

2. Problems with communication

3. Frequently need sedation

4. Challenging to work on

5. Elevated risk of conflicts due to unrealistic expectations

6. High risk patients

What are some considerations for patients who are undergoing/previous exposure to radiation?

It leads to increased wound-healing complications

How does radiation affect saliva production?

It reduces saliva - It increases the risk of peri-implant infection

What happens to irradiated tissue over time?

It becomes hypoxic (low oxygen) and fibroblasts become dysfunctional

When is wound healing most affected after head/neck radiation?

When surgery is performed 6 months or more after radiation therapy

How does radiation therapy affect bone remodeling?

It damages osteoclasts and decreases proliferation of bone marrow, collagen, and blood vessels

What is the effect of radiation on bone vasculature?

Vascular injury leads to decreased microcirculation

What changes occur in irradiated bone marrow?

It becomes hypocellular, hypovascular, and shows fibrosis and fatty degeneration

Why do dental implants fail more often in irradiated bone?

The tissue becomes hypocellular, hypovascular, and hypoxic, impairing osseointegration

What information must you collect during treatment planning visit?

1. Patients chief complaints

2. Current radiographs- Peri-apical/ panoramic

3. Thorough clinical examination

4. Jaw opening range- must be sufficient for surgery

5. Evaluation of existing prostheses if any

6. Documentation of treatment needs

7. Impression diagnostic casts- mount on articulator

What is the criteria for ideal successful implant placement?

Good oral health!

1. No ongoing periodontal disease/fungal infections

2. Need for restorative treatment- composite restorations and crowns

3. No ongoing periapical infections

4. Extractions/removal of non-restorable teeth/residual roots /cysts/infections

5. Evaluation of occlusion

6. Super-erupted teeth; occlusal adjustment/crown therapy

7. Sufficient bone volume/height in the area

What dental conditions must be controlled before implant therapy?

Ongoing periodontal disease/fungal infections

What must a patient complete before starting implant treatment?

A full periodontal evaluation and treatment

What should be done with hopeless or compromised teeth?

They should be extracted and replaced with good-quality provisional restorations or prostheses

When should post-treatment results be evaluated?

At a 6-week evaluation

Why is patient compliance important?

Successful implant outcomes depend on hygiene and follow-up care

How are mild to moderate fungal infections treated?

• Nystatin

• Meticulous oral and denture hygiene (for removable prostheses)

How are severe fungal infections treated?

• Fluconazole or another antifungal

• Given orally or IV if not responsive to fluconazole

What is required if a periapical lesion is detected?

The patient must undergo endodontic treatment.

How should active caries be managed before implants?

• Remove caries

• Place restorations and crowns as needed

Why must these conditions be treated first?

To eliminate infection and create a healthy oral environment for implant success

What are components of a site specific clinical evaluation?

1. Mesial-Distal space

2. Buccal-lingual alveolar ridge width

3. Condition/anatomy of teeth adjacent to the site

4. Health of mucosa

5. Site specific occlusion-super eruption/ vertical clearance

6. A dental implant requires about 1- 2mm of bone around the entire implant body

How much horizontal space is needed?

1. Minimum space between tooth and implant: 1.5 mm

2. Avoid damaging PDL, preserve proper blood supply

3. Minimum space between implant and implant: 3 mm

4. Adequate space to allow for soft tissue “cuff”/papilla formation

5. Buccal/lingual bone layer at least 1 mm thick

Tooth dimensions and recommended implant diameter

What are some considerations regarding the width of ridge?

1. Careful extractions

2. Socket preservation- bone augmentation

3. Buccal bone plate plays a major role

4. Always do Cone Beam CT/ surgical exploration if indicated

What position should the implant be placed?

Ideally in the same position where the missing tooth was

What are the consequences of having an incorrect buccal/lingual implant position?

1. Cosmetic problems

2. Hygiene problems

3. Oral comfort problems

4. Increased risk of failing implant

What are the consequences of having inadequate mesial/distal space?

After extraction, when does major remodeling of the bone happen?

8 weeks

After extraction, when does major resorption of the bone happen?

6 mo- 2 years

Where in the mouth would you see more severe bone resorption?

Buccal bone plate where the bone is thinner

What does resorption affect?

Both vertical and horizontal bone height

After extraction in the molar/bicuspid area, what can you see 12 months later?

Reduction of the alveolar ridge width up to 50%

When should bone graft be recommended after extraction?

If the site is planned for an implant

What is the exception for grafting following extraction?

Immediately EXCEPT if there is an ongoing infection (wait 4-6 weeks before re-entering and grafting)

What type of extraction is recommended in esthetic zones?

Gentle extraction (peritome) to preserve buccal bone

What are the steps for ridge preservation?

1. Rinse and clean socket properly

2. Pack the graft material leveled with the surrounding bone

3. Place non-resorbable membrane (Cytoplast) or collagen plug/membrane to protect the graft

4. Never touch the graft materials or membrane with gloves or non- sterile instrument!!

5. Two week follow-up visit

6. Remove sutures and membrane

7. Complete soft tissue covering the socket

8. 6-9 month healing before surgical implant placement.

What are the steps for ridge preservation follow-up?

1. Take PA 3 mo after EXT to evaluate bone healing / degree of mineralization

2. Graft materials look “grainy” on PA

3. Dark areas indicate failing graft

Osteoinductive

Process why which osteogenesis is induced

Osteoconductive

Ability of bone-forming cells in grafting area to move across a scaffold and slowly replace it with new bone overtime

What are some osteoinductive graft materials?

1. Autografts (autogenous graft)

2. Demineralized Allograft Bone Matrix

3. Bone morphogenetic proteins (BMPs)

What are some osteoconductive graft materials?

1. Hydroxyapatite

2. Xenograft (bone from cow)

3. Coralline-derived hydroxyapatite

4. Tricalcium phosphate

5. Calcium sulphates

6. Glass ceramics (tissue graft from a donor of same species but not genetically identical)

What do you have to check for in interocclusal clearance?

Opposing teeth for supereruption, occlusal adjustment may be necessary