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Before Surgery

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As with any dental procedure, it is important to ensure that your patient is a good candidate for the treatment you provide. This means taking a thorough medical history, social history, and investigation of the presenting complaint. If the patient has any pre-existing dental disease, this must be brought under control before dental implant treatment can commence.

Whilst dental implant treatment can be a fantastic restorative option for many patients, there are a few medical contraindications. As such, it is important to carefully consider whether a patient is a good candidate for dental implant treatment or not.

 

Patient assessment

Preoperative assessment for dental implant treatment involves a thorough evaluation of the patient through history taking, clinical examination, and special investigations (Barker, 2012).

 

Patient History

Key aspects to cover include:

  • Chief Complaint: Detailed information about the patient's main concern and its history.
  • Dental History: Previous treatments, parafunctional habits (e.g., bruxism and clenching).
  • Family History: Relevant genetic disorders and aggressive periodontal disease.
  • Patient Expectations: Understanding of the patient's expectations, motivation, and compliance.
  • Social History: Smoking and alcohol consumption.
  • Medical History: Includes bone diseases, diabetes, bleeding disorders, cardiovascular conditions, mucosal diseases, immune system disorders, history of cancer and relevant treatments, drug addiction, and psychiatric conditions (Donos and Calciolari, 2014).
  • Medications: History of chemotherapy, radiotherapy, use of bisphosphonates, and anti-metabolics.

 

Clinical examination

A comprehensive clinical examination is crucial for successful dental implant planning and placement. This involves both extraoral and intraoral assessments to evaluate the various factors that can affect implant outcomes.

Extraoral Examination

  • Mouth Opening: Assess the range of motion to ensure that the patient can open their mouth sufficiently for implant procedures.
  • Temporomandibular Joints (TMJ): Evaluate for any signs of dysfunction or discomfort in the TMJ, which could impact implant function and placement.
  • Lymph Nodes: Check for any swelling or abnormalities that could indicate underlying issues.
  • Facial Asymmetry: Note any asymmetries that might affect implant placement or aesthetics.
  • Smile Line and Lip Support: Assess how the smile line and lip support will influence the aesthetic outcome, particularly when planning implants in the aesthetic zone.

Intraoral Examination

  • Oral Soft Tissues: Examine the health of the mucosa and other soft tissues to ensure they are suitable for implant placement.
  • Edentulous Spaces: Measure the available mesiodistal and occlusogingival space, as well as assess bone height, width, volume, and quality.
  • Gingival Phenotype: Evaluate the gingival type and its level relative to the cementoenamel junction (CEJ) of adjacent teeth.
  • Periodontal Health: Assess periodontal status to ensure that the surrounding tissues are healthy and will support the implants.
  • Aesthetic Considerations: Examine the shape, position, and height-to-width ratio of clinical crowns in the anterior region to ensure the implants will align aesthetically with existing teeth.
  • Occlusion: Assess occlusion, including overjet, overbite, interocclusal space, anterior guidance, occlusal plane, and any malpositioned teeth or asymmetries.
  • Restorative and Endodontic Status: Review the condition of remaining teeth, including restorative work and endodontic treatments.

 

Aesthetic and Functional Considerations

  • Smile Line: Evaluate the smile line type:
    • Low Smile Line: The upper lip exposes less than 75% of the anterior teeth with no gingival display.
    • Medium Smile Line: The upper lip exposes 75-100% of the anterior teeth with interdental papillae display.
    • High Smile Line: The upper lip exposes all maxillary teeth and the gingival margins.
  • Shade Analysis: Perform shade analysis using polarised and bare flash views to match the implant restorations with the natural teeth.
  • Lip Coverage: Assess the coverage provided by the lips during normal function and smiling to ensure adequate support for anterior restorations.
  • Diagnostic Setups: Use diagnostic setups or provisional restorations to evaluate the appearance and function of planned restorations, and to create surgical stents or guides for precise implant placement.
  • Pink Aesthetics: Consider soft and hard tissue grafting to achieve optimal aesthetic outcomes.
  • Tissue Condition: Evaluate the condition of the keratinised tissue and the position of the frenulum.
  • Ridge Shape and Volume: Assess the shape and volume of the ridge to determine the suitability for implant placement.
  • Occlusal Analysis: Consider functional aspects, such as occlusion, especially in cases with missing molars, and assess for shortened dental arch.

 

Bone Quality Classification (Lekholm & Zarb)

  • Type 1: Homogeneous compact bone.
  • Type 2: Thick cortical bone surrounding a core of dense trabecular bone.
  • Type 3: Thin cortical bone surrounding a core of dense trabecular bone.
  • Type 4: Thin cortical bone surrounding a core of low-density trabecular bone.

A thorough clinical examination ensures that all factors affecting implant success are considered, leading to more predictable and effective outcomes.

 

Special investigations

When planning dental implants, additional and radiographic assessments are crucial to ensure successful outcomes. These assessments provide detailed information about the implant site and surrounding structures:

  • Sensibility Testing: Evaluate the sensory function of teeth adjacent to the planned implant site to ensure they are healthy and responsive.
  • Radiographic Examinations:
    • Oral Panoramic Radiograph: Provides a comprehensive view of the teeth, bone levels, and anatomical structures, helping to identify overall bone quality and quantity.
    • Periapical Radiographs: Offer detailed information about the teeth adjacent to edentulous areas, focusing on specific regions that are relevant for implant placement.
  • Cone Beam Computed Tomography (CBCT): Used when conventional radiography and clinical examination do not provide sufficient detail. CBCT is particularly useful in complex cases, such as:
    • Ridge defects requiring significant bone grafting.
    • Sinus augmentation procedures.
    • Distraction osteogenesis.
    • Placement of zygomatic implants.
    • Computer-guided implant surgery (Harris et al., 2012).

 

Radiologic Examination Considerations:

  • Adjacent Teeth: Assess the condition and alignment of teeth near the implant site.
  • Anatomical Structures: Identify critical structures such as the sinus, mandibular canal, and mental foramen.
  • Bone Quality and Quantity: Evaluate the density and volume of the bone to ensure it is suitable for implant placement.

These assessments help in accurately planning the implant procedure, ensuring that all anatomical and clinical factors are considered for successful implant integration and function.