S of Oral Implantolo A. Norman Cranin, pps, p. eng FAAID, FADSA, FICD, FAAHD, FADM, FACD, FBSE The Dr. Samuel Cranin Dental Center The Brookdale University Hospital anel Medical Center Brooklyn, New York Chairman, Department of Dental and Oral Surgery and the Dental Imphint Group ‘The Brookdale University Hospital and Medical Center Clinical Professor, Oral and Masillofacial Surgery and Lmplantology New York University College of Dentistry Clinical Professor, Oral and Maxillofacial Surgery, Prosthodontics and! Biomaterials University of Medicine and Dentistry of New Jersey Adjunct Clinical Professor of Oral and Maxillofacial Surgery University of Pennsylania School of Dental Medicine Associate Clinical Professor of Dentistry ‘The Mount Sinai School of Medicine City University of New York Consultant, Oral and Maxillofacial Surgeon Brooklyn Developmental Center Consultants Michael Klein, DDS Clinical Associate Professor Department of Implant Dentistry New York University New York, New York Clinical Assistant Professor Department of Prosthodontics, University of Medicine and Dentistry of New Jersey New Jersey Denial School Newark, New Jersey Private Practice Cedarhurst, New York Second Edition witb 1300 ilesravons NA Mosby Alan Simons, DDS Private Practice Farmington Hills, Michigan Formerly, Associate Professor Department of Diagnestics and Surgical Sciences University of Detroit Merey chool of Dentistry Detroit, Michigan St.Lods Bata Boston Carkbee cago Mieneapols New York Phiatebia.Porand Londen Min Syénor Tek. Teronos ae wares Metta ee Test Poeas Eve ys eet pres cet) Cea pee eerie PPS eT eee re ks ee SRSRNOIR ET FORS's oe erties PITTS dirt vie eet eae Perry Te RC ea iter Puree ee Be tI Perr eer cerret hen the editors at Mosby invited me to provide: Wi= with a second edition to this Atlas, not only ‘was I pleased and flattered to be an author for the outstanding medical publisher in the world, I also believed that Thad been granted a sinecure. ‘The assignment would probably be completed in a short time, correctinga paragraph here, inserting a photograph there, and updating the chapteron abutments. (Ob, those abutments!) [rd been teaching and operating regularly and did not real- ize the radical changes towhich our specialty has been exposed asked my fellows to update the root form implant charts, toreview the latest information on menibranes (GTRMs), and tocall forall the details on the newest abutments, and frankly, I thought that with « few hours at the computer, the revision would be completed As my more sophisticated readers know, this discipline of ours, from inuging to implant designs and textures, from abut- iments to methods of overdenture fisation, has grown expo- nentially over the past decade. ACKNOWLEDGMENTS Cet eee! EL TaPER Pe sa ea SNOT LT Ran 2 Ree As the realization of the great quantity of new material came clear enthusiasm turned to panic. The book grew in and content, and a review demonstrated that our references hhad quintupled in nuamber and expanded enormously in con- tent. Surgical and grafting techniques had been found to be limited only by the capabilities and imagination of the sur- cons. Restorative dentists were producing lifelike results that defied nature With each new idea, each catalog and each publication, my avarice became greater for leaving no stone uted in mak ing this an eneyclopedie effort. Asa personal learning expeti- cence for my colleagues and me, there could have no greater exercise than updating and supplementing 10-year-old infor- ‘mation in an area of practice so vital and dynamic. itis my consummate desire that the information found in the pages ofthis Atlas will contribute to the comprehension, capabilites, and skis ofits readers and tothe improvement of the health, well-being, and quality of life of their patients. singular effort, Tneed to acknowledge the efforts ofa great number of friends and colleagues. I want to ten der gratitude to my senior fellow. John Ley. for assembling the chapter on abutments and for spending hours collecting, se- lecting, and labeling hundreds of new photograph; to Michael Katzap, iy junior fellow, who totally revised the reading lists, updated the many charts, virtually reconstituted Chapters 10 andl 11 (the new proprietaries) and spent hones with me on the improvernent of ilustrations; and to Edmund Derirdjan, ry new fellow, who wrote and rewrote many of the legends and spent hours reading proof. A IMhough producing this second edition was essentially Monica Grant typed this manuscript from the first page to the last, with sill, paticnee, and humor, and never so much as frowned whén yet another revision was put before hee My secretary and good friend, Ethel Brack-Leibowitz, anc herdaughter, Rachel, spent hours typing the seemingly encless lists of weferencesand reading, materials selected for inclusion in this Atlas and offered me the continuing encouragement sin portant in the dark days when the tack seemed almost ‘insurmountable, Michael Klein outlined three of the prosthetic chapters and was kind enough to have contributed some illustrations, ‘which improved their content, Alan Simmons organized several &of the introductory chapters, read proof, and assisted in the compilation of the materials in Chapters 10, 11, and 28. Mare Kaufman, a member of the Brookdale Dental Implant Group, rendered advice in regard to the prosthetic chapters and contributed a novel technique to Chapter 24 Aram Sirakian sent the spark erosion photographs; Robert Suimners supplied the information and illustrations on sub- antral osteotomies; Manuel Chanavaz-contributed the fist half ‘of Chapter 3 on health eare sereening; and Carol Cave-Davi ‘Chief Medical Librarian of the Brookdale University Hospital sand Medical Genter, served as an endless source of reprints and references. Joel Herring suffered resiliently with my many corrections and produced some lovely new artwork for Chapters 10 and 11. ‘The cooperation of the representatives of numerous im- plant companies made the cataloging of products simpler and allowed us to codify them into readily comprehensible charts and tables. Among them were Carl Misch of BioHorizons; Jim Tannaccone of Steri-Oss; Brian Banton of Paragon; Jack Wimmer of Park Dental Research; Mare McAllister of Innova Stereolithography; Rick Hayse of 34; Jay Huggins of Innova Implants; and the representatives of SulzerCalcitek, Stranmann, Lifecore, NobelBioeare, Bicon, Kyocera, Pacific Bone Bank, and the Cal Ceram Dental Laboratory. This second edition would not have core to fruition vere itnot for the confidence expressed in me by the senior ecitors ‘of my publisher, Mosby, Inc. of St. Louis. Particularly impor- tant are Linda Dunean, formerly in charge of dental publica: tions; Penny Rudolph, the current dental editor, and Angela Reiner, who listened to my every complaint ‘The Brookdale University Hospital and Medical Center, iny professional home for over three decades, believed in for- ‘mal dental implant training since 1970, when my prog fellowship were established, and continues to support it to this day. Aneffort of this magnitude could not have been completed without the support and understanding of « wonderful and pa tient wife, Marilyn Cranin made many pots of late night coffee and offered support and advice for which Iam very grateful, Dr. Bob James of Loma Linda University served as my dlear fiend and counsel until his untimely death, Many ofthe techniques described in this book were generated by his t= novative skills and fertile imagination Finally: my inspiration and dedication to dentistry were ini tiated by my dad, Dr. Sam Cranin, whose spirit, still tangible and vibrant, remains constantly with me, A. Norman Cranin Brooklyn, New York1 Introduction to the Atfas of Oral tmplantology, \ 2 Implant Types and Their Uses, « Implant Types, « Fadostal imports. & oat form implants, 4 ete Mince (thin dge) and other mini plots, 4 Bode moins $ aus lace adres ame, 6 Irasoseo! mpans, 6 Subpensea! mola, 7 Other implants, 7 Endodontic stabilzes 7 Iramxosol insets 8 Bore augmentation mateak, nding guicedtsue regeneration, 8 3 Evaluation and Selection of the Implant Patient, (0 Patient Screening and Medical Evaluation for Implant and Proprosthetic Surgery, 1 Introduction to Patient Screening and Medical Evaluation, 19 Absolute cntindcaiens, 1 feltvecontcntcaons, 3 Indications end Cortraindications for Teetment, 17 Laboratory Tests—in Office, 17 Heater examinator, 17 8cod sugar examination, Aettng tne, 7 Beeding ne, 8 ‘Absolute Systemic Contreindications, 16 Relative Systemic Contraindications, 12 ndocnopathies. 18 Localand onl problems 26 4 How to Choose the Proper Implant, 27 Diagnostic Methods, 27 Beriaton 27 Study ass, 23 atilgy, 30 CTscang. 32 _mehocs of pli aban, 33 Edertuleus ach, 36 Parily edentulous xc 37 papas of tetempae, 38 ernie tecsque, #1 ates 1 erretaon, #2 Wate 53 Photography, 54 Surgical Anatomy, #5 Staging, 57 Prosthetic Options that Influence Implant Selections, 5° Superstructures, 59 Cverdenures, 59 Fe ges 6 Fived-detachable bridges, 61 Sing rams, 82 Mesostructure Bars, 65 Continoows bars, 63 ‘Noncontinuous bars, 64 Methods of bar ration, 64 ‘Types of Superstructure Attachments, 65 Tiansepithelial Abutments, 66xii Contents aE 6 Preparations for Implant Surgery, 5° Armamentatium and the Operatory, 63 Amamentarum., 68 Tre operon, 69 Surgical deliery systems, 89 Fete elvery sens, 70 Como, 7 Ekeric mows, 79 Towbeshootna. 7 Handpces, 72 Power ranges of hardpeces, 13 ‘usc, 73 ‘ior roger powered systems, 74 Important ect of electing 0 delivery sytem, 74 Surgical Principles of Value to the Implantologist, 75 Preoperative regen, 15 Methods cf nessa, 75 Sutures ad suing, Sane ate 7% Sitre needles, 78 Metis of desu, 77 Intereped sutures 71 Horental matress sues. 18 Verto! mttess ute, 73 Continuous borlcksoties, 73 Peindoto sing sures, 81 Ligeting Splint, Stent, or Prosthesis, 02 CGraumesscus iain, 62 Grummeneituarligaton procedure, 82 Greuraygomatic lian procedse, 82 Transaheolar gain proce, 85 tigate rerrono 85 Preprosthetic Surgery, & Tat removal 86 Pletal 86 Mondblr tn, 87 Tuterostyreducion, 8 Alco, 88 Conectn ohgh orhypertophe muscle atechnents, #8 Epes fssuratum and cer hypesposs, 83 7 Soft Tissue Management and Grafting, »% ‘Armamentarium, 94 Caveats, 94 Incisions, 95 Fap Desig, Elevation, and Retraction, 36 Soft Tissue Grafting, estibuloplasty, and Pedicle Grafting, 98 Free grating ces and coectve ise, 0S cso gating, 0s Modern ‘Alege mucosa geting 105 Conreae wsue gating, 106 Hard Tissue Surgery and Bone Grattin; Amamentarium, 109 Caveats, 110 General Guidelines, 10 Bore manageren, 1 ‘asc rating procedures, V2 Peradontal defect cretion, V2 The eof uided tes regeneration membrane: resabcbe and manera, 6 Bdge maintenance, 123 Tecnu, 13 Caveats, 125 fdge augment, 124 Technues. 125 open op, 21 Maslofocalrecensrecton, 10 Pariuete 13 Hlockfo, 131 oreletcich ge 181 erimphort suppor repot,_185 Bone Grating for Root Form Implant Hest sites of nadequate Dimension, 136 Caveats, 157 Tedriqus hr obtiing evogorows bere, 137 Aoteoroe crest 187 Rb, wo Tuberesty, WO Aster border the manda ramus. 140 Late borer of te rebut onus, 2 Mondbulr physi: manvolretreval. 2 Monde saps reghine enero. 43 Gralting to Improve Ridge Dimension forthe ‘Accommedation of implants, 4? ‘Aneror andar wth cetcenes, 7 Avcoplesty, 7 Nowra boc grating, 7 “Antenormandbuler neg defences, 47 Monocots, 11 Inferior bode ugmentaton, 19 Posterior mand with defends, 193 ‘Avclplesty, 88 Monorail grating. 153 Poster mori hight dete, 4 Morera Hock grating, 184 Mandir newoplsty and rerteavageren, 154 Antex mila ath deen, 157 Monocertva Bock rating, 187 ‘parson by oneal stn, 197 setae (Ses-03 and ates), 158 Atos aly heh deicerces, 160 Hock rating, 180 sao levetion, 150 Poster marilryw deficerces, ‘6 fidgespting, 0 Monecrted Bock rating, 160 Posteri mailer beg eines 2 ‘sus or eleaon, closed recinques, 152 Sinus for clevaon open techniques 185 Poster malar define and mince, 70 10810 Root Form Implant Surgery: Generic, 175 ‘Armamentarium, 175 Caveats, 16 Surgical Templates, 116 Single oth replace cr edeuous pans etwen natal eth 76 Fiend saddle edertous arc, 16 Comply edertous ses, 71 Surgical Techniques, 177 "ade preapping ingot, 18 heeded seltcpping ipl, 182 Nentreoded pest mpl, 162 tnmedateploceret oft frm plat irto xtracon sts orforer ilo sis. 184 Suigelecinqu, 83 Uncovering submerge imple 87 Root Form Implant Surgery: Proprietary I, 192 Caveats, 192 Nobel Biocare and 3i Systems, 195 ‘Sulzer-Caleitek implant System, 129 Spline Cylinders (Groove and Slot Abutment Connection System), 125, Integral System (Nonhexed), 95 Omniloc System (Externally hexed), 195 Paragon Implant Systems, 196 Blower 196 Sccewent, D6 Toperlock sewer 196 Meroe 196 Ster-Oss, 197 Ster:O5treade implants 197 Sie Osreploce sien, 198 Ster:Os indica pressftimplonts 198 425,525 Hen 38 58 He 5 Het 198 Sai ON imports, 199 Psst nes, 200 Implant Innovations incorporated, 202 Straumann i, 202 Holo cide, holon seen ipl, 202 Halon cylinder, hollow se, 202 Sci screw, 202 TS soew, 202 Root Form Implant Surgery: Proprietary Il, 2: BioHorizons Maestio System, 206 icon, 206 Park Dental Startanius, Starvent, 207 Oratronics Spiral, 205 Omni-R, 209| Kyocera Bioceram, 210 Innova Endopore Implant, 210 Friatec and Frat 2, 211 Sargon, 212 Astra Tech Dental Implant, 212 Osteomed Hextrac Focture, 21 12 Blade and Plate-Form Implant Surgery, 21° Aemamentatium, 215 Caveats, 215 Surgical Techniques, 21 Camertina fade implant: single se 218 Ancien ard reflector, 205 Osetony, 217 Jimplant placement, 219 ose, 220 Arable lads mplens 21 Submeigbetlade nd plae‘orn imports 21 Coated blade ard pt form plans, 222 Custorm-cast implants, 225 Marly pester bide and pltefr npn 225 Antetior blade and plate‘orn implants, 225 inmedatplcerent of blade mat io xan tes, 226 Blode npc, 228 13 Ramus Frame and Ramus Blade implant Surgery, 250 ‘Armamentatiue, 250 Caveats, 230 RA-2 Ramus Freme (Pacific Implant Company), 250 Suge, 230 A-1 Ramus Frame (Pacific Implant Company), 254 Suge, 234 Ramus Blade, 255 Suwoen, 235 14 Mandibular Subperiosteal Implant Surgery, 2: ‘Armamentarium, 238 Caveats, 238 Completely Edentulous Designs, 88 Procedure 259 ison. 233 election, 239 _npression making, 240 Sagi ow relarship-cetic recording, 291 ere, 24 imple ces, 24 Impenttsrton, 22 Edentulous Tripodal Design: Brookdale Bar, 244 Procedure, 284 incor, 244 Relletion 244 Caveats, 245 Impression 245 Design of costing 246 inser, 246 Partially Edentulous Designs, 245 ‘Superiosteal implant Prosthodontics, 267 ‘Computer Assisted Design-Computer Assisted Manufacture (CAD-CAM) Technique, 248 ‘Armamentarium, 249 Caveats, 243 Preparing forthe son, 249 fe ofthe dogs, 250 Stereothorcphy se forming technology), 250Ce 8 16 " Fabrceton ofthe cnt, 251 Inplontfabrcation 251 Tube ond stylus technique fer establishing ceric relaenships, 251 Suegry for incon ofthe aplont 284 ‘Maxillary Pterygohamular Subperiosteal Implant Surgery, 256 Armamentarium, 256 Caveats, 256 Completely Edentulous Designs, 257 Procedure, 257 inesion, 257 Fefeion, 251 Impression meking. 258 Surgical jewrelaonsip: ent recording. 258 ore, 259 Inplnt design. 260 Inplatinserion, 261 Partially Edentuious Universal Designs, 263 Partially Edentuious Unilateral Maxilary Pterygohamular Designs, 265, Intramucosal Insert Surgery and Prosthodontics, 257 ‘Armementarium, 257 Caveats, 257 Intramucosal insert Supported Complete Maxillary Dentures, 263 Intramcosal Insert Supported Unilateral Partial Dentures, 274 Relining Full Upper Dentures that Have Lost Retention after Having Had Intramucosal Inserts, 275 Endodontic Stabilizer Implant Surgery, 2/5 ‘Armamentatium, 276 Caveats, 276 Matte-Finished Tapered implants (Howmesica, Park), 277 Stabilizers for Nonconforming Teeth, 28) Threaded Implants, 230 CCoramie Coated Implants, 202 Transosteal Implant Surgery, Including the Mandibular Staple Bone Plate and Alternatives, 2:3 ‘Armamentarium, 284 Caveats, 284 Single-UnitTransosteal implant, 265 Mandibular Staple Bone Plate, 290 rocede, 250 ‘Armamentarium, 290 ‘Caveats, 290 Smooth Staple Implant System (Interphase/Interpore), 295 ‘TMI @Bosker Transmandibular Reconstruction System), 294 19 Crete Mince and Other Miniimplant Surgery and Prosthodontics, 2¢ ‘Armamentarium, 236 Caveats, 296 rete Mince Implants, 296 Surg! ond presthodenic techniques, 297 Movtransitoral implants 500 ‘Miisubperiostea button inglons wah intracra\ bar welding, 302 Implant Prosthodontics: Introduction to Chapters 20, 21, 22, 25, 24, 25, 26, and 27, 501 ‘Armamentarium, 305 Caveats, 305 Preliminary Prosthodontics: Fabricating a ‘Template, 306 Fully Edentulous, 506 Provisional Prostheses, °1? Totally Edentulous Interim Prosth fist stoge, 32. Second stage, 313 Partially Edentulous Interim Prostheses, 314 Single tocth implant retrains, 514 Fis sage, 318 Seeord sage, 84 Pertaly ecertus, mut implant restrain, 514 first sage, 31 Fited prevsana prostheses, 34 CComposte retaned fed provsonal Rerrovableprovisona prostheses 316 Second tege. 317 ‘ued provisional prostheses, 317 Progressive loading, 317 Rerrovable pronsona prostheses 318 ge, 319 22 Root Form Implant Prosthodontics: Abutments, 510 Cement versus Screw Retention af Abutment-borne Prostheses, 522 Cement retention, 322 ‘Advantages. 322 Disadvantages, 525 Screw retenion, 328 ‘Attachment of Abutments to their Implants, 525 Abutment forfatsuifced implons, 323 Abutment forimplants wth atrotatona features, 324 ‘Antsotaonal eetures of varous implant systems, 524 Abutments that engage the artirotatona companent 325 Gistom abutments, 527 Abutment that bypas the cnircainat component 327 ‘Abutment for imparts wth he Morse-aper interface, 327Sutpericstet ingle, 414 Lessofaresthsi. 18 Inability 0 make on accurate impression, 414 ‘nab emeve an impression ato Seat tay ete ofl upper (oteygohamar desig) aro lower (ltr rar design) sutpenstea implant. 444 ‘Ava petra, 418 Inaccurate adaptatcn off or une subperesteal implants, 815 Incr adaptation of tripe subpenoseo! motets, 415 ‘ny tthe oat! or mentalnenes 6 ShortTerm Complications (First 6 Postoperative Months), 6 Endosteal molots, 816 Pastoeraive ifction, 816 Dyesttesia, «17 Deniscer wourds 418 Defiscere plans 419 Radobiencies 419 ‘Aaa cmpleations 18 Inplant moby, 422 Posrgcal scr contracture, 422 Subperosec plans, 424 Shut oposire 24 Pasoretatve nfeton, $25 Scar contour, plerygamordinar phe, or anterior mandibular vesibuie, 25 Long-Term Complications, 425, Endotealinplarts, 425 ‘lig fling faked irplants 425 ‘Acti, 452 Prttete monagement afimplart os, 432 Fratred rot tr plats. 435 plats o improper angtton: the doubleborecique, 433 ‘Boker pestiticinses, 438 Screw probes, 436 Fatiaton of implant bore tenporay prostheses, 436 Featured mesesttse bars 835 Poi! losening of cemented brs or prostheses, 438 Inacerete feo casings. 438 Featured blede abutments 438 Subperiosteal Implant, +49 Bone resorption 440, srt censcence, 40 Fecurentgercenal gronularnas, 440 Brolen abutments. 442 ‘iter more sinc soto, 42 Postubperoseasublngua oor elevation, 2 Jmplantation in the iradiated Jaw, 485 29 Maintenance and Hygiene, 46 Portes, 486 Poctet wath, 481 Mecsurements, 447 Pato sis, 87 Recal vist, 487 Home cre, 447 ‘Appendices A Pest Medical and Dental History, 438 B Laboratory Values, «si CAD-CAM Computed Tomography, 460 D Stereolithographic Reproduction of Anatomic Structures Using CSean, 62 E Treatment of Metals, $e F implant Surgery Consent Form, 16s G Postoperative Guidelines for the Surgeon, 456 H Postoperative instructions forthe Patient, 47 1 Recommended Diet Following implant Surgery, 16? J Implant Patient Follow-Up Form, 468 Equipment Menafactuers, 459 LL Distributors of Musculoskeletal Tissue, 47? ‘M Antibiotic Prophylactic Regimens, 474Ses Perchetie eee eripite reeeeereeet rot ees ps pete eaeere te tia Sere cee Create SEO ees pee Sep on et Peeve PaeRe e welcome the reader to the second edition of Ailes of Oral Inplantology. This book is a struetional manual on how to choose patients, eval uate host sites, select implant types (however, no preferences ue given for specific proprietary produets), place implants step by sep, observe patients, diagnose incipient problerns, institute remedial techniques (“troubleshooting”), perform a wide variety of restorative modalities, and maintain and follow patients dur- ingthe postoperative period “This atlas is arranged in a unique manner. It is suggested that it be read in its entirety before any future workups are performed or patient care is rendered. There are chapters, or portions of chapters, in which the reader may have no interest However, in order to harvest the optimal benefits from the book, an understanding of its design and the material de- scribed should be acquired in their entirety Chapters 2,3, 4,5, and parts of the Appendices explain the values and applications of implants in general, how to choose the appropriate design for each condition presented, which patients should be treated with implants and why, the tests that should be performed to assess the eligibility of patients, ‘what the anatomic characteristics of potential host sites may be, how the hasie implant designs differ, and, in these differ- ‘ences, how they may serve dector and patient best. Read these chapters frst before proceeding to any later chapters,on spe- cific techniques. Chapter Gexplains the armamentarinm an implant surgeon is expected to have before undertaking any procedure, In ace dition, the beginning of each implant technique chapter gives a list of special or additional instruments peculiar to the spe- cific modality being described. As added information, mo chapters start with “caveats” for each described technique. be forewarned isto be forearmed, Chapter 6 suggests & classic operatory design as well, and although itis not mandatory that specific room be dedicated to implant surgery: i is necessary to have al the requisite instruments and supplies available that will permit the implantologist to perform the surgery or change ‘teatinent plan during the procedure, For example, a blade might be indicated instead of a planned root form because the i eet bree a3 2 Seo er erate é SSE ridge is too narrow, or a larger diameter implant may be re- «quired ifthe osteotomy becomes too wide. Chapters 9, 10, and 11 concern root form surgery and offer this information be- case not all companies have implants of larger diameters that can serve this purpose. In fact, the decision to do a subperios. teal implant should be a viable one if endosteal are not suit: able, The supplics and facilities for such a procedure must be immediately available as well. tis hoped that the reader will become a “complete” implantologist, that is, one who acquites the capabilities to manage any situation in which implants of any design may be used or substituted for the type that had been selected at the time of treatment planning. Incidentally, itis suggested that a practitioner ought not attempt to insert implants ifthe necessary experience obtained from having taken hands-on courses is lacking or ifthe equi site surgical sells gained from previous training and clinical involvement are absent. In addition, the information given in these chapters is not etched in stone, There are often specific problems, deviations from the expected, and the eceurtence of ‘unpredictable events that must be anticipated as one proceeds with planning and operative efforts, Chapter 5 is important because it offers advice on the prostheti¢ options available, The method of reconstruction should be selected before the implants have been placed. A decision as to the choice of an overdenture, a single tooth re- placement, a fixed-detachable prosthesis, or a cemented bridge should be made with the assistance of the patient. Patient pref renee, local conditions, costs, and the doctor's skills and philosophies all play a role in governing these selections. fier a prosthetie technique has been chosen, the reader will find in Chapters 2, 5, 9, 10, and 11 the specifie implant types that lend themselves to the prosthetie options that best suit the patients needs. In Chapter 4, relatively noninvasive techniques that serve as guides to “sound” the bone, that is, measure its height and its ‘width, are offered so that the kind of implant that i simplest to use and offers the best chances for success will be chosen, The principles of surgery and anesthesia are of paramount impor- tance. Chapters 6, 7, and 8 offer instruction in incision mak-[ERINNEINNNIENINCHAFTERTTININTRODUCHON To THe ANAS OF Osa. IMPLANTOIOGY gaa i ing techniques of dissection and reflection; methods of retrac- tion; use of coolants; handling of drills, burs, andl handpieces: ‘management of osteotomies, soft and hard tissue manipula tions, bone grafting: oral plastic surgery; and the types of and sways to use available sutures, These fundamentals may seem rudimentary, but itis suggested that they be read because they. apply toal implant techniques. In addition, Chapter 6 and all other basic or introductory chapters (such as Chapter 9 on the generic root form implant) have been written and illustrated toinake the use of this atlas simple and efficient, They contain basic principles that apply to all techniques and methods and allow the reader to preceed as being guided by a personal tutor ‘on how to ineise, reflect, cut hone, and suture because these topics are logically arranged chapter after chapter, Once the appropriate implant design has been chosen, the reader should proceed as follows: Ifitis to be a root form implant, review Chapter 9. Here one may find, regardless of which root form design has been chosen (threaded, sel-tapping or non-selF-tapping, press-fit, one-piece, or two-stage submergible), instructions on haw to perform the initial stops of placement, such as bur and drill sizes, number-by-murnber, up tothe requisite diameter, By fol Jowing these instructions, the surgeon can supply himself with agenericdill set (i, Brasseler) that is not only economical in cost and time, but may also be used forall ofthe steps except the final one needed to seat every type of rot form implant. In addition, the names, addresses, and telephone numbers of the manufacturers whose products are described in this atlas are listed in the Appendixes, ‘After completing Chapter 9, the reader may proceed 10 Chapters 10nd 1 and choose a specific implant among those described, In these chapters, there are step-by-step reviews of the surgery for virtually every implant system, from the first to the final proprietary maneuver, by name or mumber, in- lading counter-sinks, bone taps, try-ins, andthe seating of the {mplant. Logically, the healing screws, caps, or inserts that are available are described next, Closure is covered in Chapter 6, along with suture types, materials, and techniques. Of primary importance to the reader is the new section that follows in Chapters 20 to 27: “Prosthodontics.” This is the next logical step in completing implant-borne reconstruction, and the chapters have been organized so that each of the numerous alternatives are available to the restorative dentist, from sin- ge tooth implants to the complexities of abutment selection and fixed-detachable, full arch rehabilitation. Ifa blade implant, a ramus frame, a subperiosteal, or even anintramucosal inser is selected, there are specifi chapters to guide the reader through each of the relevant procedures. Not to be forgotten are endodontic implants, ridge main- tenance, and augmentation procedures using autogenous bone and bone substitute grafting materials (hydroxyapatite, trical- cium phosphate [TCP], demineralized freeze-dried bone [DFDB], irradiated bone, and others): membranes, both ab- sorbable and nonabsorbable; and for the oral and maxillofa- dial surgeon, jaw augiventation, skeletal reconstruction with biomaterials, and transosteal implant procedures that are de~ scribed in detail in Chapters § and 18, If during implant surgery, the practitioner runs into a problem, or if, during the postoperative period, difficulties or unexpected sequelae arise, help is available in Chapter 28. The Appendixes offer product ane manufacturers’ infor- mation; methods of metal passivation, defatting, and steriliza- tion: suggestions For postoperative managernent; and one rea- sonable example of aa implant surgery consent form. A glossary ofimplant terminology and newly expanded suggested reading lists are also included within this atlas It is hoped that this book will meet many of the needs of the practitioner in clinieal implant activities Suggested Readings Alle. A 15 year study of oscointegrated implants the treatment of the edentulous jaw Lat J Ora Sure 6:3 Bahat O: Treatment planning and placement of implants in the poste- ‘or maui: report of 732 consecutive Nobelpharma implants, otf (Oral Maciljae plnes 8151, LOR. Bain CA, Moy PR: The association between the fare of dental plants ‘und cigarette smoking, Int J Oral Maxlofoc Implants 8609, 1962, alin BE: Tmplant dentistry: historical overview with eurrent perspec- tie, J Dent Ed 52:683-685, 1988. Branemark PI: Osseointeyzation and its experimental background {J Prosthet Dent 399-410, 1988. Deve C: Tellstrom A, Nelstrom H: Magnetic resonance agg n pa~ ‘vents with dental implant: a chnical report, In| Oral Maxillofac Inplants 12:354-358, 197. hurr: Locating the mandibular canal in panoramic racagraphs, Tht J Oral Mexillofe Iinplands 1213-117, 197. Femande2 RJ, Azarbal M, Ismail YH: 4 cephalometric tomographic technique to visualize the buceolingual and vertical dimensions of the mandible, J Prosthet Dent 58:445-470, 1987 Giller! GH, Minaker KL: Prineiples of surgical nk assessment ofthe elderly patient, J Oral Mazilofac Surg 48:972:979, 19. Higginbotiom F Wilkon'T Three-8-mm vertical bone height >5.25-mm bone width (buccal to lingual) >65-mm bone breadth (mesial to distal) per implant, includ ing the interproximal spaces mesially and distally Créte Mince (Thin Ridge) and Other Mini Implants Crete Mince i tals (Fig, Prosthetic options: These Créte Mince, thin-ridge implants add retention to long-term fixed bridge prostheses by pinning them through their pontcs to the underlying bone, or they may be used to support transitional prostheses (Fig, 2-4, B,C). ants are threaded, self-tapping, titanium spi Fig. 2-1 Endosteal rcot form implants, 325- to 4-mm diameters, press-fit, both hycroxjapatite coated,When placed into confined areas between teeth or implants, they add long-term additional buttressing to superstructures. Blade Implants Blade implants are available as submergible, two-stage and single-stage, one-piece devices (Fig, 2 Prefabricated Custom-cast Alterable (by cutting, hending, and shaping at chairside Prosthetic options: Single or multiple abutments. The sug gested use for blade implants is for fixed bridge prostheses in ‘ombination with natural tooth abutments, although they may be used in multiples for full arch edentulous reconstructions, I there is adequate height but inadequate width of available bone for root forms and osteoplasty is not an option, these are the second choice in implant selection. The design of the blade that is chosen should follow that of the anchor philoso- Fig. 2-2 Commercally pure (CP) titanium, selttapping implants are of the Brdnemark syle an gph tied acai threaded implant, HA coated, 2 coordinated HA-coated pr Fig. 2-3. Ste of bone. Adjacent same diameter. quires pre-tapping fit design of the Ivar Toes 5 phy in which the shoulder does not meet the cerdx at right angles but rather dipsin a semicircular configuration atthe site of the neck, Suitable arch: Maxillary or mancibular, completely or par tially edentulous. Required bone -8.nm vertical bone height ~3-mnm bone width (buccal to lingual 10-mm bone breadth (mesial to distal except for single tooth designs, whieh require less) Fig. 2-4 A, Ciéte Mince (Ml Chérchéve) titanium threaded implant thin ridges. B and €, Dentatus implants of small dimensions ca placed in strategic sites forthe suppor of interim prostheses during the Periods of osseointegration ofthe conventional implants at sites No. 246 Giiapre® 2 IveLavr Tyres AND THEIR Uses Ramus Blade and Ramus Frame ‘The ramus implant is a one-piece blade made for use in the posterior mandible when insufficient bone exists in the body of this jaw (Fig, 2-6). The ramus frame is a three-blade, one- piece device designed for relatively atrophied mandibles for which the subperiosteal implant, because of cost or operator preference, is not desirable, Prosthetic option: overdentures Suitable arch: mandibular, completely edentulous Required bone: >6-mnm vertical bone height (symphysis, rami) >3-mm bone width (buccal to lingual) ‘Transosteal Implants ‘Transosteal implants are one-piece, transmandibular complex implants or are available as individual abutments. A submen- tal skin incision is required under operating room conditions when this modality has been selected. One advantage of using the transosteal implant is predictable longevity. Several de- signs are available: Single component (Fig, Multiple component, staple designs (several varieties) (Fig. 2-8) Prosthetic options: The us application for these im- plants is to support an overdenture, Fixed bridges are rarely made as alternatives. Suitable arch: Mandible, anterior region, completely or partially edentulous (single component may be used in the presence of adjacent teeth). Required bone >6-mm vertical bone height sm bone width (labial to lingual) Fig. 2-5 Titanium, submergible blade implant with its abutments at tached (Park/Startanius). The anchor configuration is embodied in the shoulder design. Fig. 2-7 Chrome alloy, threaded transosteal implants (Cranin/Vitalium) Fig. 2-6 Ramus blade, a plate form implant designed for the mandi- Ula ramus in instances when insufficient bone exists in the body of the mandible Fig. 2-B Titanium, two-component staple implant (. Small/Zimmen)Subperiosteal Implants Complete, Universal, and Unilateral Use subperiosteal implants, which generally are quite reliable, when sufficient bone is unavailable for the use of endosteal \arieties. However, when extreme mandibular atrophy exists, mandibular augmentation (see Chapter 8) further improves 2-9) implants are always custom made. They may be fabricated either by makin Chapter 14) or by using stereolithographic technology. Th may be used in any part of either jaw, and will serve as abut- ‘ments for a variety of prosthetic configurations, although the overdenture is the most widely used to complement the com- plete subperiosteal implant (Figs, 2-10 and 2-11). the prognosis (F Subperioste 1 direct bone impression (see Prosthetic options: overdentures, fixed bridges Suitable arch: maxillary or mandibular, completely or par tially edentulous Required bone: >5 mm or mandibular augmentation is Extremely thin (peneil-like) mandibles and maxillae may permit subperiosteal implants to settle through them. There- fore, seek a moderate amount of vertical bone height (at least 5mm), or make plans to augment the inferior mandibular bor- der or elevate the antral floor on a preventive basis Other Implants Endodontic Stabilizers Endodontic stabilizers are highly successful, tooth root- lengthening implants. One reason for their success is that they nucosal penetration because they are placed th the apices of natu have no site of pe into bone thro This implant offers a one-stage treatment for the stabiliza- tion of teeth that suffer from inadequate crown-root ratios. ‘Their percentage of success when periodontal problems have that of c nventional endodontic deen treated approach therapy. - 2-9 Titanium mortise mesh form, filed with autogenous bone harvested from the anterior ilac crest, materially alters the shape ofthe atrophied mandible Ian TPES it Prosthetie options: Crown and fixed bridge abutments Suitable arch: maxillary or mandibular; any tooth may be treated Required bone: n of lesion-free bone in direct proxim ity o the apex—within the long axis ofthe recipient root canal Fig.2-10 A, Additional cortical bearing areas are used bythe maxilay pterygohamular subperiosteal implant B, The mandibular subperiosteal Implant has undergone mary design changes, Fig. 2-11 Unilateral mandibular subperiosteal implant employs the same design principles asthe complete device.a (ChveteR 2. WuPLanT Types AND Twin Uses Fig. 2-12 Smooth-surfaced, mattesinished Co-Chro-Mo alloy er odontic implant (Howmedica/Vitalum) Fig. 2-13. Intrarnucosal inserts (stainless stee!) processed into a den ture (lernyn/Densert, Intramucosal Inserts Intramucosal inserts are buttonlike, nonimplanted retention devices that can be used to stabilize full and partial maxi and mandibular removable denture prostheses (Fig. 2 Because ofthe simple and relatively noninvasive nature of the procedure placement, they are of particular value for patients who are poor medical risks. Prosthetic options: removable dentures, full or partial Suitable arch: maxillary, completely or partially edentulous: mandibular, partial only Required bone: none; required mucosa, 2.2 mm thick (bone beneath thinner mucosa may he deepened in nonantral areas) Bone Augmentation Materials, Including Guided Tissue Regeneration Membranes Use bone augmentation materials for ridge maintenance after dental extractions, or ridge augmentation, for periodontal and periimplant repair and support, and for maxillofacial surgical onlay and inlay purposes when bone replacement is required Fig. 2-14 Classical donor site for autogenous bone is the parasym physeal area. Repair of the area is done with demineralized freeze-dried Bone (DFDB) mined with HA and covered with a resorbable Vien mesh membrane. (Fig. 2-14). None but autogenous bone and possibly bone morphogenic protein (BMP) is osteogenic, Demineralized freeze-dried bone (DFDB) is said to be asteoinduetive, Ceramic Resorbable, tricalcium phosphate (TCP) Nonresorbuble: hydroxyapatite Porous particulate and block forms Nonporous particulate and block forms Blocks are available as particles held together in resorbable collagen media, strung like beads with polyglycolic acid suture for supported in a matrix of caleium sulfate (plaster of Paris- Hapset) Powneric Hard tissue replacement (H'TR) particulate and porous Dlock forms Browocic Antogenous bone Irradiated bone DFDB Bovine (i.c., BioOss) Membranes: Resorbable and nonresorbable Suggested Readings Abourgia MB, James DF: Temperature rise during driling through one, fut j Oral Maxillofac Implants 12:942-353, 1997, Albrektseon T et al: Osseointegrated oral implants: a Swedlish multicen- ter study of 8,139 consecutively inserted Nobelpharma implants, J Periodont 58:287-296, 1988, Babbush CA: Dental implants: prine 191, WB Saunders. Bubbush CA: ITT endosteal hollow eylinder implant systems, Dent Cin North Am 30:133-149, 1986. Balkin BE: Implant dentistry: historical everview with current perspec tive, J Den! Educ 52:683-685, 1985, es and practice, PhiladelphiaPatient Screening and Medical Evaluation for Implant and Preprosthetic Surgery Manuel Chanavaz ‘mplant and preprosthetic surgeries aim to restore normal anatomic contours, function, comfort, esthetics and oral health, As such they are not lifesaving procedures, The prime concern must therefore be not to undermine the pa- tient overall health and safety. Take every step to select the ‘appropriate treatment plan and maximize the longevity of the implanted system, inchiding the overlying prostheses ‘One important category into which a number of possible ‘complications may fll isthe inadequate systemic screening of patients before implant and bio sertion. Without ‘wishing to enter into the whole human pathology, itis no longer appropriate to limit the general contraindications of impl tology to the traditionally considered malfunctions of the pan- reas, liver, or hematopotetic system and to ignore the devas- tating long-term effects of smoking or inadequate dietary habits. There are, in fact, a number of systemic problems that may occur to create major risk factors. On the other hand, ‘modern standards of care should not systematically exclude the use of implant surgery on patients with relative or marginal health conditions without exploring the possibilities of impro ing and stabilizing those conditions. As newer techniques of general anesthesia and intravenous sedation are more fre~ quently used on an ambulatory basis allowing implant surgeons to take their patients into various degrees of conscious or deep sedation, the patient sereening should also take into consider- ation factors related to this form of management An arbitrary guideline for patient seleetion may be based on the classification of the American Society of Anesthesiology: This guideline restricts (with very few exceptions) intraosseous implants and implant-related graft si © patients who fall into ASAI or ASA2 categories of the classification In the domain of subperiosteal implants for treatment of advanced atrophy of the mandible, the body response seems to be much less dramatic than to endosseous devices. The corti- cal histoarchitecture and metabolism are, by far, less affected bby organ disorders than the deeper endosscous structures, This chapter presents a number of absolute contraindica- tions and analyzes a series of relatice contraindications for which the doctor’ judgment remains the decisive factor, In this latter case, it proposes treatment patterns that could opti ‘mize certain marginal heath conditions or stabilize unbalanced biological functions before or at the time of surgery. As life ex- peetancy in the industrial countries is continually increasing, greater number of elderly patients are equipped with implant- supported prosthetics, The effort must therefore be focused on keeping a regular and watchful eye on their general health and screening for possible geriatric conditions responsible for long-term implant failure ‘An optimal knowledge of internal medicine must be a pre- requisite for the future academic implant education. Introduction to Patient Screening and Medical Evaluation* ‘Technically speaking, contemporary implant surgery is a rela- tively innocuous procedure. Itis also conceivable to recognize that a stable, well-integrated implant is as “clean” as a healthy tooth, However, whereas the management of complications in patients with minor systemic disorders is usually straightfor ‘ward and successful, this may not be the case with patients “Reprinted fom the Journal of Oral Inplantoloey 24290-2297, 1998.2 Vateular prosthesis: The onset of bacteremia in patients fitted with valvular prostheses constitutes a major threat to the longevity of the cardiae valve, The oral cavity has tra: ditionally been recognized as the principal gateway to such infections. Itis therefore important not to plan any implant surgery until the patients stable condition is reached, ust- ally between 15 to 18 months after cardiac surgery: Ac- cording to the type of valve used, the patients may be on permanent, potent anticoagulants (for mechanical valves) and mild plasma volume elevators (for porcine valves). Any planned procedure must take into consideration the oc currence of the surgical stress, anticoagulant imbalance, and infection risk, which may in extreme cases lead to acute malignant endocarditis and loss ofthe axtifcial valve. Severe renal disorder: The severe renal disorder is prob- ably the most important single contraindication to any form of implant or bone graft surgery. This ean occur from number of possible causes, of which the most common are recurrent kidney infections (nephritis), malignant or voluminous benign tumors (or multiple cystic kidneys) uncontrolled diabetes and/or complications arising from Kidney stones, Most recently in Europe and other indus- trial countries, the reappearance of tuberculosis of the Gil Diet 1100 mg 1000 mg E Secretion 200 mg ‘CHAPTER 3 EVALUATION AND SELECTION OF THE IMPLANT PATIENT = Aon URE) kidneys has further expanded the list of potential compli- cations. In all events, damage to the nephrons may eause bone destruction by urinary calcium loss and interruption in the production of the active metabolite of vitamin D. In fact, the lack of reabsorption of Ca** together with the malfunction of parathyroid hormone (PTH) in the sec ondary loop of Henle could lead rapidly to metabolic os- teopenia and retention of p infection risks satic endotoxins with major Figure 3-1 illustrates the daily ealeiurm metabolism ‘The kidneys initially filter some 10g of calcium per day into the primary urine Treatment-resistant diabetes: vere diabetes, which does not respond to proper treat ment. The complications are related to the serum hyper is refers to confirmed, se- osmolarity (sugar, urea, ions, ete.), metabolite disorders (Cl, Na*, Mg**, ete.) dehydration, and micro/macro an glopathia. The latter may in turn predispose the patient to tissue degeneration and compromised healing with in- creased risk of infection, Generalized secondary osteoporasis: This is an anatomic and structural syndrome with significant loss of bone mass and volume leading to rarefaction of cancellous bone and aH ~ 8 \ Porat | \ 1 \ Deposition 400 mg ou ae SP Pa \ Absorption 300 m OY es | <7 Bone Vv 1,000,000 mg 0 Feces Glomerular " Liver fiteote 125 picC Kidney Urine 107mg Fig. 3-1 The complex mechanisms governing calcium metabolism. ECF extracellular uidthinning of the cortical plates. Bone becomes devoid of osteoid, and presents osteoclasia and medullary fibrosis, It results in nonintegration of endosseous implants. One practical und useful sereening tool to evaluate the extent of osteoporosis is bone densitometry (Dual Photon Ab- sortiometry). Use it regularly on all patients who have clin- ical signs of bone fragility Chronie or severe alcoholism: This is a major condition leading frequently to liver disorder, cirrhosis and medullary aplasia with a cascade of possible complications such as platelet diseases, distress infarction, and risk of insidious hemorrhage. Patients suffering from se- vere alcoholism often present retarded healing aggravated by malnutrition, psychologic disorder, inadequate hy: giene, and major infection risk. The most common tests, for hepatie disorders by the implant surgeon focus on measuring the following: * ¥-Glutamyl-transpeptidase: (y-GT) (<25 mU/ml), ele vations in alcoholie cirrhoses to 50, hepatitis to 100, jaundice to 200 to 300, and panereatic cancer to 1000. + Transaminases: serum glutamo-oxalic transaminase (SGOT) (5 to 35 1U) and serum glutamopyruvie transaminase (SGPT) (5 to 25 1U), which are increased in hepatic eytobysis, infectious and toxic hepatitis and prolonged salicylic treatment, In myocardial infarction, SGOT alone is increased. * Bilirubin: (total <10 IU or 6 mg +2), which is increased in cases of hemolysis, cholestasis, and jaundice. * Allaline phosphatases: with a pH 9.2 (13 to 39 1U or 0.22 to 0.65 m mols), which are increased in parathyroidism, Paget’ disease, hepatic disorders, and bone metastases. + KAPITT kephalin-activated partial thromboplastin time test or prothrombin-activated kephalin test, which is a coagulation indicator. Vitamin K participates in eo- agulation with factors I, V, VIL, IX, and X. Treatment-resistant asteomalacia: Rickets is a rare disease in the industrial countries, seldom found in adults. This tmineralization deficit (hypophosphocalcic bone with os- teoidosis), which leads to demineralized osteopathy (soft bone), responds favorably, in more than 95% of the cases, to vitamin D therapy in conjunction with the intake of a calcium supplement. However, when the treatment fails, osteomalacia may lead to nonintegration of an implant and increased infection risk Radiotherapy in progress: Disruption of defense mecha- nisms, a compromised endosseous vascular system and inhibition of osteoinduction are the main insults to the body while radiotherapy is in progress. However the periosteum is the principal “organ” of which physiologic activities are virtually entirely disrupted. This may lead, depending on the proximity of the irradiated zone, to soft and hard tissue necrosis, major infection risk, and disrup- tion of osteoconduction Severe hormone deficiency: This refers to patients with more than two different families of hormone disorders, ‘The endocrine systems most affected that may be sercened are thy and gonads 10. Drug addiction: Most drug addicts suffer from the loss of sense of priorities, low resistance to disease, predisposi- tion to infection, malnutrition, psychologic disorder, lack of hygiene, and difficulty with follow-up. LL. Heavy smoking habits (more than 20 cigarettes per day) This factor was added to the list of absolnte eontraindica- tions in 1996 because of the occurrence of a number of | long-term implant complications in heavy smokers who had no other systemic disorder, The main problems, other than early stage poor healing, arose from relatively accel- erated bone loss (possibly due to altered vascularity) and disorders related to poor oral hygiene. and parathyroid, pancreas, adrenal, pituitary, Relative Contraindications ‘These contraindications are related directly to the nature and severity ofthe systemic disorders and whether they can be sat- isfactorily corrected before surgery: They require a meticulous screening of the patients medical records. In realty, patient selection in relation to relative contraindications is much more subtle, where among other criteria, the doctor's judgment rermains the critical factor. For a dental practitioner who is not medically oriented, it may mean referral to other special- ists. Ifthe disorder is adequately corrected, carry out the treat- ment plan; otherwise, postpone the procedure until optimal conditions prevail. Tuble 3-2 shows the impact of implant and bone graft surgery on patients with relative contraindications. ‘The number of + relates successively to the degree of the gravity of the complications, patients’ responses to treatment, and predictability of the implanted system. One + isthe least complicated or least favorable, and four + +++ is the most complicated or most predictable. Zero corresponds to total un- predictability. A question mark (2) represents variable and un- certain responses. 1. AIDS and other seropositive diseases: A. seropositive (HIV-positive) patient may be considered normal, since current statistic life expectaney after primary infection is about 15 t0 20 years. On the other hand, the implant lication for a confirmed AIDS patient is evaluated in ac- cordance with the Atlanta CDC classification, The stage of development of the disease, life expectancy, and patient’ wishes are very important considerations. A careful as- sessment of possible systemic complications arising from the disease may entirely contraindicate any form of surgery or may dictate a pragmatic treatment plan with more realistic objectives based on function, comfort, and relief 2. Prolonged use of corticosteroids: This scenario is often as- sociated with retarded healing, disorders of phosphocaleie metabolism (osteoporosis), and medullary aplasia. A num- ber of authors have also reported bone fragility, renal and adrenal deficiency, metabolic disorders, including blood glucose metabolism, and water retention, Furthermore, the prolonged use of corticosteroids may inhibit bone for- mation, It is therefore important to determine why suchRises For ne’s Heat conomon CGINGRAL MEAL” OUAGNOSIS OR TREATMENT __APLANT SURGE TREATMENT 1. AIDS (1) and other seropositive diseases (2) +++ (I) 0 ++ 0 ++) ++ 4 +t 2, Prolonged use of corticosteroids +H + ++ 68 3, Disorders of P-Ca metabolism ee + +4 +tt 4, Hematopoietic disorder +H me + tee 5. Buccopharyngeal tumors +e o ++ +++ 6. Chemotherapy in progress +t 0 +4 ++ 7. Mild renal disorder + ° ++ tet 8, Hepatopancreatc disorder tHe ° ++ +++ 9. Mutiple endocrine disorder tet ° + +t 10, Psychologic disorder, psychosis + + +4? He 11. Unhealthy ie-style + + tee +++ 12, Smoking habits vy + +7 +t 13. Lack of understanding and motivation ° + + + 14, Unvealistc treatment plan ° ? 2 ++ treatment is being administered and to evaluate the pax tients response to it. Ifcorticosteroids are used exclusively for their antiinflammatory properties, reversal of th traindication may be as simple as changing the medica- tion to one of the many newer nonsteroidal antiinflam- matory drugs. Disorders of phosphocaleic metabolism: An imbalanced diet (excessive protein, inadequate Ca*, and/or vitamin D) may frequently lead to such disorders. However, minor hormone deficiencies, especially during menopause, in conjunction with systemie disorders and an unhealthy life- style may combine to bring about a phosphocalcic (P:Ca) imbalance. One typical example is a disorder of the ga trointestinal tract such as repeated colitis, chronic diarrhea, or Crohns disease, which may be corrected or contained by carefully planned long-term treatment. In patients for whom such problems are not managed effee- tively, daly caleium and phosphorus absorption may be completely disrupted, leading to metabolic bone disease (phosphocalcic imbalance) and poor quality of mineral- ized bone. = The possible complications aris- ing from hematopoietic disorders in the short- and medium-terms are not as dramatic as those encountered in other forms of frank bone pathology and osteoporosis. However, satisfactory funetioning of the hematopoietic system remains an essential factor for the long-term sue- cess of implant and reconstructive surgery. In a suspected bone marrow disorder, in addition to exploring the matu- ration eyele of the megakaryoeytes, which are precursors of platelets, itis important to screen the transformation of the premonocyte lineage to macrophages, osteoclasts, and circulating monocytes. The same attention must be paid to the lymphocyte cycle. 5. Buccopharyngeal tumors: Analyze these tumors in regard to their malignancy or nonmalignancy, their proximity to the proposed implant site, and the oncologic treatment being carried out, Obviously if radiotherapy has been used very close to the planned surgical site, the contraindica- ion becomes absolute. However, discourage routine 1 Jection grafts or implants after resective surgery: If there is no obvious reason to suspect short- and medium-term metastases or extension of the tumor ina patient with oth- enwise satisfactory systemic screening, he or she may be offered improved oral health rather than the observation of an indefinite period of waiting until a possible recur rence of the tumor is excluded. 6. Chemotherapy in progress: The administration of ant ‘cancer drugs has rarely been a subject of study by implant and bone graft surgeons, who have frequently followed a restrictive general guideline with some ambiguity. In fact many of the drugs used in contemporary anticancer regi- ‘mens have a very limited or unknown direct destructive role relative to implantology. For instance, methotrexate, mon chemotherapeutic agent, is extensively used (in, smaller dosage) in contemporary rheumatology: However, it may produce severe thrombopenia and a disturbed os teogenic eycle when used in massive doses in oncology: The otherapy is essentially related to the damage eased to the vital organs, which may also he involved in calcium metabolism. Furthermore, when ‘chemotherapy is used for bone metastases, patient sereen- ing should preferably take into aecount the extension of the metastasis rather than the actual drugs used to con- tain it, One additional factor to analyze before implant surgery is the patie istered drugs. In any event, a close collaboration between the implant surgeon and the oneologist is mandatory contraindication of elImooucion To PaneNT SCREENING AND MeDicaL EvaLuarion 00S! avmicavcer om Commerc. INCIPAL COMPUIATONS, onncant nue racy sean [NSORDENS, Om AFFECTED ORGANS 1. Antimetabolc *Antifoic Methotrexate ‘Thrombopenia, osteogenesis 2. Alylating sNitrogen-emustards (ll) Hosfamide Blood, bone (osteogenesis) sNitrogen-rea (IV) Streptozocin Renal, hepatic, blood “Mitomycine Ametycin Renal, hepatic blood 5. Spindle poisons ‘vine alkaloids (i) Vincristine Renal, hepatic, blood 4, interpolating WA Nya N/A 5. Spliting *Bleomycin Bleomycin Pulmonary fibrosis 6. Cytolc *Picamycin Mithramycin Renal, hepatic, blood, (ay +Progestates Medronyprogesterone Ethynodiol 7. Steroids Norethisterone Renal, hepatic “Estrogens DES Breast uterine malignancies Fosfestrol 8, Interferons (Int) sini alfa-2a Intron Dehydration, thyroid, parathyroid sine alfa-2b Roferon-A 9. Interteukin-2 “Aldesteukin-2 Proleukin Cardio-nephro-hepato:myelotosic Modern chemotherapy uses a wide range of drugs be- longing to 10 to 12 pharmacologic families. The treat- ‘ment for each patient may include a complex combina tion of these drugs. Table 3-3 shows the principal cancer treatments that may present absolute contraindications toimplantology at the time of their administration or for up to a minimum of 6 months thereafter. Table 3-2 also shows a proportionately limited number of drugs that are incompatible with the simultaneous insertion of implant devices. The interpolating agents on the whole, seem to he devoid of adverse effects on implantology. The inter- ferons and interleukins prescribed in advanced stages of pathology, however, are particularly contraindicated Mild renal disorder: These common disorders (uremia and creatinemia) are frequently revealed by an initial blood test after the first physical examination, However, such disorders may be predictors of the onset of major re- nal disorders or other systemic conditions, which will then become absolute contraindications to implant and preprosthetie surgery (absolute contraindications). It is therefore wise to investigate all renal problems and ascer- tain that they are no more than mild disorders, responding to treatment and not compromising calcium metabolism Hepatopancreatic disorder: Gall stones and infections and viral hepatitis (except the severe B, C and E family) are among liver disorders that have very litle destructive ef- fect on the long-term success rate of implant surgery. Nevertheless, further hepatic tests, after a thorough phy ical examination, may reveal the onset of more serious liver or pancreatic conditions, which would be detrimen- tal to the outcome of implant treatment. Multiple endocrine disorder: This is a complex syndrome, ranging from metabolic loss of calcium (PTH) to sec ondary osteoporosis induced by hyperadrenocortism, or glucocorticosteroid disorders (Cushing’s syndrome, Addi- son's disease), mineralocorticosteroid syndrome (Conn's syndrome), or hyperandrogenism, any of which may lead to failure of the implanted material One arbitrary but practical method of sereening a sus- pected hormone deficiency for an implant candidate may be the preoperative evaluation of the hormones involved in bone remodeling, These hormones can be classified into two cate- gories according to their dependence levels on calcium home- stasis (Ca-H): I-Ca-H dependent, 2-non-Ca-H dependent. Ca-H-dependent hormones are essentially: parathon which stinmulates bone resorption (SBR), vitamin D or 1-25- Gihydroxycholecaleiferol (SBR) and caleitonin, which inhibits bone resorption (IBR). Parathormone (PTH) is a monoeatenary, hormonal polypeptide secreted by the parathyroid glands. It has four principal functions which are of interest to implant and bone graft surgeons: + Itis hypercaleemie (or less accurately referred to as osteo- porotic) by removing the calcium ions from bone and trans- ferving them to the circulating blood. * It increases the urinary elimination of phosphates by re- ducing their tubular reabsorption # It contributes to maintaining an optimal calcemia by inter- vening in physiologic kidneys’ tubular reabsorption of cal cium, + It plays an important role in the intestinal absorption of eal cium in synergy with vitamin D. Vitamin D3. (1-25-dihydroxycholecalciferol) is renal metabolite intimately linked with PTH activity. Principal func- tions inclnde active absorption of calcium in the proximal in- testine, in vitro inereases in the mumber and the activity of os teoclasts and the production of collagen, GLA bone proteins,and alkaline phosphatases, and direct action on PTH secre tion, which however, has not been shown, Galeitonin is a 32 amino-acid peptide synthesized by the C cells of the thyroid. Its principal functions are related {o inhibiting bone resorption (antiosteoclastic and. hypo- caleemic). Non-Ca-H-dependent hormones: thyroid hormones (SBR), estrogens (IBR and SBR), glucagon (IBR), insulin (stimulates bone formation [SBF]), growth hormones (SBR), and cortico- steroids inhibit bone formation (IBF) ‘Thyroid hormones: Thyroglobulin (Iodoprotein) > Todothyronines > Ioxlotyrosines, T,: Triodothyronin (70 to 190 ng/100 ml) ‘Te: Thyroxine or tetraiodothyronin (4 to 12 pg/100 ml) ‘TSH: Thyroid-stimulating hormone (adenohypophysis hor- mone) (0.5 to 3.5p. U/ml) Thyroid pathology and treatment: Table 3-4 shows the two possible origins of thyroid disorders and the standard treat tment regimens before implant surgery. 10. Psychologie disorders, psychoses: This is one of the most difficult contraindications to evaluate and implement. Tt depends essentially on the severity of the disorder and the patient's response to psychotherapeutie medication. A number of the psychoactive drugs severely alter the oral environment and eause dryness of the mouth, mucosal ir Station, or polyaphthosis. All of these conditions can po- tentially cause damage to peri-implant tissues. In all events, analyze these conditions in collaboration with th ‘hiatrist considering the patient's priorities ion, comfort, and esthetics. Make the patient aware of the decisions involved. Avoid implant surgery in psyehotic patients who are not under strict surveillance and therapy 11, Unhealthy life-style: Poor mutrition, chronic dieting, lack of exercise, inadequate hygiene, and excessive use of drugs, alcohol, and tobacco contribute to an unhealthy life-style. Imegular eating habits, repeatedly identical or unvaried menus, fast foods (imbalanced det), and inade ‘ate time allocated to consuming each meal are common problems in modem society. Chronic or “yo-yo” diet especially in the female population and in patients with ‘anorexia or bulimia, may eanse serious health and bone disorders, These contraindications are further aggravated by a lack of regular physical exercise. If the patient is amenable to correcting these habits, implant and pre~ prosthetic surgeries are viable forms of therapy; otherwise a markedly unhealthy life-style becomes an absolute con- traindication, 12, Smoking habits: Tobacco is one of the most severe limit tions becanse it damages the angiogenic mechanisms for forming and maintaining bon nplant and peri- odontal soft tissues. Depending on the daily consumption of cigarettes, the patient's awareness of the dangers of smoking and his or her willingness to drastically reduce or ‘completely stop the habit, this particular contraindication Table 3-4 Thyroid Pathology and Therapeutics “Tirmo10 Hormones moomes NRE oF oonDet Ammo. onus 2) infenor origin (lower) Thro sland disorder iothyronine x: Popythiouei Benzytnouract BASDENE “Thyroxine Hyperthyroidism 4, coesmazol Lthytoxin, ‘Hypothyroidism —(idazole) Netercazle Levothyrox ) Superior origin (oper) Adenoty- pophysis disorder TSH: Thyroid extracts ‘may be reconsidered. Ifnot, smoking remains an absolute contraindication for the long-term success of implant systems 13, Lack of understanding and motivation: Patients who do not have a clear understanding ofthe implant techniques in spite of repeated explanations or who remain entirely passive to any form of motivation may constitute a cate- gory for whom extensive implant treatment should be avoided. On the other hand, if they respond positively to motivation, comprehend the explanation of the proposed treatment, understand the necessity of a close collabora- tion with the implantologist, and recognize the importance cof regular follow-up sessions, they may become satislnc- tory candidates for implant surgery. Attempting to treat an norant, unmotivated patient is a disaster for all con- comed. 14, Unrealistic treatment plan: This contraindication can be lifted if an in-depth analysis both from the clinical and ccconomic standpoints is carried out. This analysis should consider whether there isa gross disproportion among the proposed treatment plan and the patient’ chief complaint, cultural predisposition, life-style, social environment, and finances. The assessment of the physical and psychological status of a patient must be realistic in relationship to te proposed treatment.” Inall events, implant surgery will have to be considered as are all medical disciplines for which efforts must be focused on meticulous patient selection and on keeping a regular and watchful eye over patients’ general health to treat possible trie conditions possibly responsible for long-term implant failure. The reader should now proceed to the next section, which presents additional specific information of great clini. cal value designed to complement the observations just made. “This ston appeared oriinally in the foun of Ol plato 24 223-35, 1508 rtLasonsrony TESTSAN OFFICE! Indications and Contraindications for Treatment Aram Sirakian Marcia Cahn-Geller fone is thorough in the evaluation of an implant patient, com- plications and the possibilities of failure are minimized. It is important to determine whether the patient can successfully tundergo implant therapy or whether existing medical or psy- chologic conditions contraindicate treatment. The guidelines already introduced in this chapter offer an excellent overview: Specifically, the mechanics of evaluation employ the health history as the most important step (see Appendix A). This lows assessment of the patient’s existing systemic conditions, Follow any positive responses with specific questions to elicit details of the past medical history: Take vital signs as part of the routine sercening process. Laboratory Tests-In Office ‘These establish a baseline for each candidate. Record pulse, blood pressure, respiration, and temperature. Verify and re- solve any significant variations from normal Along with the health history, record vital signs, proper ‘medical consultations, routine chemistries, blood counts, and Urinalysis before surgery. Tables of normal values are found in Appendix B. These offer suggestions of the presence of some of the listed diseases, Note any discrepancies and make proper referrals for evaluation and treatment In-office blood sugar hematoerit, bleeding and clotting time examinations are of value. Hematocrit Examination After preparation of a fingertip on the patient's nondomi- hand, pierce the skin with a disposable stylet, blot the alcohol dry, squeeze the fingertip to obtain a fresh drop of blood, and lay the open end ofa capillary tube alongside the drop. Draw the blood into the tube by capillary attraction, and after about 60% to 70% has been filled, remove it, swab the fingertip with alcohol, and use a dry sponge for tam: ponade, Plug each end of the tube with clay and place it into slot in the microhematocrit centrifuge. Place a second tube across from it for balance, close the top, and rotate th tubes for 3 minutes. On retrieval of the tube, examination reveals that the cells have been spun to the bottom and the percentage of serum to cells may be determined by inserting the tube into a reader. Blood Sugar Examination ‘To establish a reasonably accurate serum ghucose level, obtain a second drop of blood from the same finger stick, and fol- low the instructions on the label of the bottle of reagent strips. Select a strip, cover the chemically treated end with blood and, after 60 seconds, wash it under cool running water for 60 seconds. Compare the color ofthe strip at the blood site with a chart of standards that is printed on the bottle label, which reveals the result, Acetone levels should be given as well The practitioner should be sure to note at the time that these values are recorded if and when the patient had eaten, when insulin or other antihyperglycemic medication had been taken, and whether these are part of a regular regi men, This history plays an important role in assessing the levels of glucose and acetone. Clotting Time This test is performed easily with simple supplies. They in- clude a finger-stick stylet, and 10-cm long, fine, glass capillary tubes. After fingertip sterilization, pierce the skin, ay down the glass tube with one open end obliquely against the bleeding site. Capillary attraction will draw the blood into the tube. At 30-second intervals, break off a small length of tube and lay it aside. Do this until the blood strings out with a fibrinous nd divide thread. At that juncture, count the glass segments by two, The result presents clotting time in minutes (normal 4 to 6 minutes) (Figs. 3-2, 3-3) Fig. 3-2. A glass tube, when placed obliquely against the blood drop from a finger stick, fils by capilay attractionFig. 33 Every 30 seconds a segment of capllay tube is broken uni the blood threads out as a result of fibrin (arrow). Courting the glass segments and ding by to gves the doting time in minutes, Bleeding Time “This testis performed simultaneously with clotting ti quires a clean piece of white filter paper, Use the tip puncture for this simple evalnation. After each capillary tube segment s broken off (30-second intervals), touch the untreated Absolute Systemic Contraindications Some conditions should be considered as absolute contraindi- cations for implant treatment. These inclade: + Uncontrolled diabetes mellitus + Long-term immunosuppressant drug therapy +# Diseases of connective tissue (e.g, disseminated lupus exythematosus) ‘© Blood dyscrasias and coagulopathies (e.g, leukemia, he- mophilia) + Regional malignancy (e.g. oral, perioral) + Metastatic disease «# Previous radiation to the jaws that might lead to post= surgieal osteoradionectosis ‘= Alcohol or drug addlietion # Severe psychologic disorders Fig. 5-4. Ascertan bleeding time using the same finger stick. Touch the bleeding spot toa dean piece of bloting paper unt no blood sain appears, court the marks, and dnide by tW0 f0 give the bleeding time in minutes, fingertip (Le.,no gauze, no pressure, no alcohol) tothe filter pa- per. Alter cessation of blood transfer marks, count the red dots and divide by two. The result is bleeding time in minutes (nor 5 to8 minutes) (Fig, 3-4) In addition, there are many relative contraindications to treatment. If these are managed properly, however, a patient ‘may undergo implant surgery with very good chances for suc ‘cess. Consultations with a patient's physician may be required nt acceptability is clarified and the requisite de- apy are instituted Some of the more in so that pati tails of surveillance and support throughout and after the procedure portant relative systemic contraindications are found in tabu- Jar form in the following sections.RELATE SYSTEMIC, CONTRANDICATONS Relative Systemic Contraindications Endocrinopathies tthe clinical level, endocrinopathy can result from hormon deficiency, hormone excess, or resistance to hormone action, Hormone Deficiencies Diabetes mellitus, pituitary and adrenal_ insufficiency, hypothyroidism Hormone excess Overproduction by the usual site ofits production (endocrine gland) thyrotoxicosis, acromegaly, Cushing’ disease Hormone produced by a tissue (usually malignant) that ordi- narily is not an endocrine organ (e.g., ACTH production in oat-cll carcinoma). Overproduction of hormon lating prohormones. Iatrogenic causes (es, overadministration of glucocorticoids). peripheral tissues from circus HORMONE RESISTANCE Universal feature: presence of a normal or elevated level of the hormone in the circulation in a patient with evidence of deficient hormone action; frequently secondary to hereditary causes (e.g, pseudohypoparathyroidism), While evaluating the patient, certain symptoms either sub- jective or objective may become apparent. The following list presents them, If they are present, further in-depth investiga- tion és warranted. Most of the pathoses included in this chap- ter do not constitute absolute contraindications to implant surgery: luteinizing horsione ‘mean eoepuscular hemoglobin concentration ‘mean eorpuscular volume = pneumocystis carinii pneumonia prothrombin time plasma thromboplastin antecedent += plasina thromboplastin component parathormone ‘partial thromboplastin time red blood cell = total iron binding capacity = thyroid-stinuating hormone ite blood cell count Diasetes metuTus Type I: Insulin Dependent Clinical Findings Polyuria and thirst Weakness and fatigue Polyphagia and weight loss Recurrent blurred vision Valvovaginitis or pruritus Peripheral neuropathy Noeturnal enuresis Laboratory FindingsStulies High fasting 140 mba ‘ype Il: Non-insulin Dependent (Adult Onset) Clinical Findings Laboratory Findings/Stulies Polyuria Same as for type Weakness and fatigue Recurrent blurted vision Vulvowaginitis Peripheral neuropathy Often asymptomatic Prrumary INSUFFICIENCY Clinical Findings ‘Weakness and fatigabilty Fasting blood glucose may be ow Lack of resistance to stress, Marked insulin sensitivity cold, and fasting (measured by Axillary and pubic hair oss Mild anemia Sexual dysfunction Laboratory Pindings/Studies Dilutional hyponatremia Decreased growth hormone Low T, (thyroid hormone) ‘Thyroid-stimulating hormone Decreased ACTH Low plasina cortisol Decreased testosterone Decreased estradiolACUTE ADRENAL INSUFFICIENCY (WATERHOUSE FRIDERICHSEN SYNDROME) Clinical Findings Laboratory Findings/Studies Headache Bosinophiia Lascitude Decreased blood ghucase and Nansea and vomiting sod Abdominal pain Hypercaleemia Diaerhew Decreased blood and urinary cortisol Fever >40.6° C (105° F) Confusion or coma Dehydration Hypotension Cyanosis, petechise Abnormal skin pigmentation swith sparse wsillary hair Lymphadenopathy Increased plasma ACTH if primary adrenal disease (200 py) Positive blood cultures (usually (CHRONIC ADRENAL INSUFFICIENCY (ADDISON'S DISEASE) Clinical Findings Laboratory Findings/Studies Weakness and fatigablity Moderate neutropenia Anorexia (5000/mnl) Nausea and vomiting Lymphoestosis Diarrhea Fosinophilia enous and mental irtability Fainting especially alter Hemoconeentration Increased BUN missing meals Increased K* Diffuse Hronzing ofthe skin Decreased fasting blow glucose Pigmentation af micons Hypercileemia membrane and gingivae Pigmentation around lips Viltligo 7 to 15%) Hyperplasia of ymphoid tissue Scant to absent aviary and pubic hair Absense of sweating CVA tendemess Low ast cortisol accompanied by slmultancous inerease in ACTH. Hypornvroinism Clinical Findings Laboratory Findings/Studies ‘Weakness and fatigue Ty <35 mg Cold intolerance Free T, 7 ng/ml in active phase Inorganic phosphate >4,5 mg Gonatlotropins normal or los lucosuria and hyperglycemia Insulin resistance ‘T, normal or lw Excessive sweating Enlarged tongue, tipping of teeth to buccal or labial sides Temporal headaches Photophobia and reduction Cusnine’s SyNoRoMe (HIYPERADRENAL CORTICAL SYNDROME) Clinical Findings Moone Laboratory FindingsStudies Glucose tolerance low often with Buffalo hump. hicosuria Obesity with protuberant Insulin resistance abdomen aud thin extremities Absence of diurnal variation of Osteoporusis cortisol Oligomenorshea or amenorshea Weakness Headache Hypertension Mild acne Hirsutism Purple striae Bruises easly Increased WBC or low eosinophils Lymphocytes under 20% Increased RBC HypopararyRoibiso Clinical Findings Laboratory FindingeStudies Muscular fatigue and weakness Numbness and tingling Hypoplasia of teth (when condition develops bef tooth formation), chronic candidiasis Hypocaleemia Hyperphosphatemia Decreased PTH HyperpararivRoioism, Clinical Findings Laboratory Findings/Studies Bone pain Joint stifness Pathologic fractures Urinary trac stones Giant cell tumor or eyst ofthe jase Generalized osteoporosis Malocclusion Hyperealeemia Hypophosphatemia Hyperparathormone Hypercaleuria Radiographic, general radioucency ‘of affected bone, oval lobulated lesions in the jas, "ground glas’ appearance Granulomatous Diseases Tusercutosis Clinical Findings Laboratory Findings/Studies Fatigue Weight los Mycobacterium tuberculosis in sputum cet eeClinical Findings Laboratory Findings/Studien Fever Positive tuberculin skin test seats Classic CXR, Cough Hemoptysis SaRco1posis Clinical Findings Laboratory Findings/Studios Fever Elevated ESR Malaise Dyspnea Shin ash Parotid gland enlargement Hopatosplenomegaly Cardiovascular Disease ATHEROSCLEROSIS Clinical Findings Intermittent claudication Weakness in legs Distal pulses absent Atrophic skin changes Dependent rubor Laboratory Finding Studies Angiography Elevated cholesterol and [AnrERIOSCLEROSIS (ARTERIOSCLEROTIC CORONARY HEART DISEASE) Clinical Findings Laboratory FidingsSt Chest pain FCG HYPERTENSIVE VASCULAR DISEASE Clinical Findings Laboratory Findings/Studies Elevated BP >140/00 mmHg, Increased BUN Ieadaches Increased creatinine Lightheadedness Proteinuria ‘Tanitus Granular casts in aldosteronison Pilptation Tow serum K* Often asymptomatic Increased! Na* and HCO, presentation ECG, stain pattern of ST segment XR that shows aortic dilation oF caleifeation OrTHOSTANIC HYPOTENSION Clinical Findings Syncope Dizziness Lightheadedaess on standing Increased heart rate Lowered BP on standing Disease ofthe aorta (see also Endocarditis) Peripheral Vascular Diseases TEMPORAL ARTERITIS Clinical Findings Laboratory Findings/Studies Headache Increased ESK Often associated with myalgia Malaise Anorexia Weight loss Lass of vision, Tenderness of sealp ‘ToRoMBOANGIMIS OBLITERANS (BUERGER’S DISEASE) Clinical Findings Laboratory Findings/Studies Intense rubor of feet Na pathognomonic diagnostic studies Superticial migratory thrombophlebitis Absent Foot pulses Decreased wlnar or radial pulse ARTERIOVENOUS FISTULAE Clinical Findings Laboratory Findings/Studies Headaches CT scan, electroencephulogran, Hemorrhage arteriography to localize site of lesion Seizures Auscultative bruit (CONGESTIVE HEART FAILURE Clinical Findings Laboratory Findinge/Studies Dyspnea Diagnostic tests Onthopnes Chest xeray Dry, hacking cough Electrocardlogram Paroxysmal nocturnal dyspnea Echocardiogram Chest pain Radionucleotide angiography “gated Noxturia blood poo! sean’ Tnereased heart size ‘Cardiae catheterization and Sinus tachycardia ‘myocardial biopsy Ventricular gallop, Stress testing Tales Systolic versus diastole dysfunction Neck vein distention Peripheral pitting edema EnDocaRbimis/VALVULAR DISEASE (REQUIRES ANTIBIOTIC PROPHYLAXIS) Mirrat STENOSIS, (Clinical Findings Laboratory Findings/Studies Onthopnea ECHO, shows thickened valve that Dyspnea ‘opens and closes sowly Paroxysmal nocturnal dyspnea Pulmonary edema hemoptysis Middiastolie murmur (MITRAL REGURGITATION (INSUFFICIENCY) Clinical Findings Laboratory Findinge/Stuelies Pangystolie murmur Enlargement of left atrium on CXR Orthopnea ECHO Cardiae catheterization to assess let ventrienlar function and pulmonary artery pressure Exertional dyspnea Paroxysmal nocturnal dyspnea ight heart failure (MITRAL VALVE PROLAPSE Clinical Findings Laboratory Findings/Studies Mostly asymptomatic ECHO presentation Chest pain Fatigue Palpitation Late systolic murmur Midaystoli clickREAR RERO ST ‘Agric INSUFFICIENCY cli cal Findings Laboratory Findings/Studies ECHO shows diastole flattening of anterior mitral valve leaflet or Soft diastolic murmur Evertonal dyspnca Chest pain Heat failure septum prodoced by negungitant jet TricuseiD STENOSIS Clinical Findings Right heart failure Hepatomegaly Ascites 's diagnostic Depend Cyanosis Jaundice Diastolic rumble Liver pulsation Laboratory Findings/Studies ECHO demonstrates the lesion ‘TRICUSPIO INSUFFICIENCY Clinical Findings Harsh gstolie murmur along, Jefe sternal border egurgtant stole V waves Presence of an inspiratory $3 Laboratory Findings/Studies ECHO Hypersensitivity Reactions ‘ATOPIC DISEASES (HAY FEVER, ATOPIC DERMATITIS, ALLERGIC ASTHMA, ALLERGIC ECZEMA, ANAPHYLACTIC REACTION) Clinical Findings Laboratory Findings/Studies Eczema itching rash on face, ‘nk, extremities methacholine, eosinophilia History of asthma Pesitve skin test to multiple anti- ‘Atopic spontaneous allergy gens, increased IgE binding to Staphylococens aureus Delayed blanch reaction to ANapivianis Clinical Findings Apprehension Paresthesia Generalized Edema Choking Cyanosis Wheezing Incontinence Shock Fever Dilation of pupils Less of consciousness Laboratory Findings/Studies Convulsions Urnicania Glinical Findings Laboratory Findings/Studies Wheals Hives ching Skin testing Swelling Fosinophila ANGIONEUROTIC EDEN Clinical Findings Laboratory Findings/Studies Edema commonly ofthe lips ‘or another part ofthe face Drug Hypersensitivity ical Findings Rash Fever Wheeving Cough Eosinophilia Cyanosis Increased ESR. ‘Abdominal pain Loss of eonseiousness Convulsions DeRmaromucosinives Pemphigus vutcaris c ical Findings Laboratory Findings/Studios Relapsing erops of bullae Superficial detachment of skin alter pressure (Nikolsky’s sign) ‘Tender on lesions “Teanck test shows acantholysis ‘on biopsy Increased ESR, anemia Ensinophilia| Leukoetosis BULLOUS EROSIVE LICHEN PLANUS Clinical Findings Laboratory Findings/Stuies Pruritic papules Histopathology Koebner's phenomenon Erosive pupules Prediletion for flexor surfaces and trunk and in the oral ewity Metasouc/oTHER DISEASES OF BONE Hisnocrtosis X (LaNGERHAN'S Ce GRANULOMATOSIS) Hano-ScHOLLER-CHRiSTIAN DISEASE (utmFOcAL EOSINOPHILIC GRANULOMA) Clinical Findings Laboratory FindingsStudies nele or multiple areas of Anemia ‘punched: out bon Leukopenia Bone destricton in skull ‘Thrombocytopenia Unilateral or bilateral cxophthalmos Diabetes insipidus in young adults Tissue tenderness and swellin facial sy Otitis meta Nodular lesions of skin Sore mouth, gingivitis Loose teeth Failure of healing following textmctions Loss of alveolar bone Histologic confirmation EOSINOPHILIC GRANULOMA Clinical Findings Local pain and swelling, skull ane! mandible common sites Laboratory FindingsStudies Radiographic, irregular radio Tcencies of jaws and other bones Paneytopenia, histologic eonfir: ration ‘General malaise aad feverOrcanomecaty LerrereR-Siwe DISEASE (CHILDREN AND TEENAGERS) Clinical Findings Skin ash involving teunk, sealp, and extremities Lanw-grade, spiking fever with ‘malaise and invtability (in ints) Splenomegaly, hepatomegaly {ymphadenopathy Oral ulcerative lesions Ginga hypertrophy Diffnse destruction of hone in jaw Preinature eruption of teeth ‘etopically placed Laboratory Findings/Studies Progressive anemia Leukopenia Thrombocytopenia Pacer Disease (OSTEMTS DEFORMANS) (Cincel Findings Laboratory FindingyStudies Bone pain Radiographic, initial deosiication Headaches fallowed by osteoblastic phase Sletal deformity ving "cotton woo!” appearance Deformities of Increased serum alkane and tibia phosphatase Progressive enlangement of Increased urinary hydeenyprokine shal spacing of teeth, Normal eaeium and phosphorus pathologie fractures Powyostomic Fibrous DysPtasia (AtaRiGi’s DISEASE) Clinical Findings Laboratory Findings/Studies Painless swelling of bone Bones lesions and ests “Trauma fractures (Café aw lat spots on skin ‘wsualy directly over ‘bone lesions Precocious puberty Hspogonadismy Hypertiyroidisn Enlarged jaw Calcium and phosphorus normal Alkaline phosphatase and urinary Iyelroxyproline inereased Bauiograph reveals rarfuction and expansion of bones with multi- Tacolar gstic appearance Blood Dyscrasias and Hematologic Disorders MEGALOBLASTIC ANEMIA linia Findings Laboratory Findingy/Studies yreased MCV (lange red els) Megaloblasts Anorexia Fatigue Diarrhea Paresthesis in peripheral Deerese vbration and postion senses Glossiis Deficiency state of folate and vitamin By ALLERGIC PURPURA (HENOCH-SCHONLEIN DISEASE) (Clinical Findings Laboratory Findings(Studlies Purpurie rsh on extensor Inereased anemia sures of arms, legs, Inereased ESR buttocks Increased alpha-globulin and Colic abdominal pain Aibsinogen Polyarthralgia Normal muscle enzyme levels Clinical Findings Laboratory Findings/Studies ‘erays shows mareing of joint spaces COsteoplyte formation Bone eysts Increased density of subchondral Polyarthritis Hematuria [HEREDITARY HEMORRHAGIC TELANGIECTASIA (Oster-Weser-Renou Syyoroute) Clinical Findings Laboratory Findings/Studies pitas Murmur of arteriovenous malformation over lung fields Multiple telangiectasia (vealily seen on skin and {in month) (may’also he internal) Anemia IDIOPATHIC THROMBOCYTOPENIC PURPURA (Clinical Findings Laboratory Findings/Studies Purpura Decreased platelet count Mncosal, gingval, and skin Inereased normal morphology bleeding bleeding time Epistans Some lange platelets Menorthagia Mild anemia Petechine Positive tourniquet (Rumple-Leeds test (>8 petechiae in a 25-em cir- cle below inated BP eal systolic after T minute) ‘SECONDARY TO HYPERSPLENISM (Clinical Findings Purpura Enlarged spleen Laboratory Findings/Studies Decreased platelet count Hereditary Coagulation Disorders Hemopnitias (Factor VII DeFicieNcy) (Clinical Findings Laboratory Findings Studies Bleedinginto joins, muscles Anemia el gintointestinal act Normal PT Fever Increased PTT Anemia ons Factor VI Massive gingival hemorrhage Normal Factor VII antigenic Only makes afecs set Normal von Willebnind fietor VON WILLEBRAND'S Disease (pSEUDOHEMOPHILIA) Clinical Findings Laboratory Finding Sts Epistass Prolonged bleeding time Bruises easily Low Factor VIII cougulation actisity Menorthagia Defective in vito platelet azure Gingival bleeding ‘Troublesome bleeding after ‘mild laceration oF dental extraction Bither sex may be affected tion in response to rstovetin Platelet number andl morphology normal Low Factor VILL antigen activityFactor DEFICIENCIES. Factor IX, Ciristatas Factor (PTC pericient) Clinical Findings Laboratory Findings/Studios Bleoding Low Factor IX Increased PTT Factor X, STUART FACTOR Clinical Findings Laboratory Findingy/Studies Bleeding Abuorial PT and PTT aww Factor X Factor XIl (PTA vericient) Clinical Findings Laboratory FindingsStudies Bleeling Increased PIT Low Factor XIL Acquited Coagulation Disorders DEFICIENCY OF THE ViTAMIN K-DEPENDENT COAGULATION FACTORS Clinical Findings Laboratory F Bleeding Increased PT, corrected by giving sitamin K (Hykinone) Normal binogen, prothrombin time, and platelet Count idings/Studlien Dissemnateo intRAvASCULAR coAGULOPATHY (DIC) Clinical Findings Laboratory Findings Studies Bleeding (especially from Deerease in plasma fibrinogen rutile sites) Frequently postraumatic) Purpura Bechymoses Digital ischemia and gangrene Increased fibrin degradation roxlucts Increased PT Increased PTT ‘Thrombocytopenia Depleted antithrombin IM levels Decreased hematocrit (GRANULOCYTOPENIA Clinical Findings Laboratory Findings/Studlios Opportunistic infections Decreased WBCs CYCLICAL NEUTROPENIA Clinical Findings Laboratory Findings/Studies Fever ical Actuations of WBCs, Malaise platelets, and RBCs Mouth ulcers (Have patient keep diay of oral lesions and attempt to match Comvcal adenopathy tem with laboratory findings.) LyupHocrToPeNta Clinical Findings Recurrent viral infections Laboratory Findings/Studies Decreased lymphocytes Leukemias [ACUTE MYELOID LEUKEMIA Clinical Findings Laboratory Findings Studies High fever Anemia Bleeding Thrombocytopenia Severe prostration Nentropen Infection Increased LDH Gingval hypertrophy Bone ancl jine pain Enlargement of iver, spleen and Iymph nodes Hypenuricemia Hypokalemia Auer red inclusions CCronic Myeto10 LEUKEMIA Clinical Findings Laboratory Findings/Studies Palpable splenomegaly Presence of Philadelphia Anemia chromosome Weight loss Platelets normal or elevated Hypercellular bone marress with Fever Tettshifted myclopoiesis Severe bleeding Decreased leukocyte alkaline Infection during blast evsis phosphatase ‘Acute LYMPHOCYTIC LEUKEMIA Clinical Findings Laboratory Findings’ Fatigue Paneytopenia Bleeding Positive surface markers of primitive Infection. Iyimphoid cells Positive terminal deoxynucleotide transferase in 956, postive rosette formation with sheep erythrocytes dentifestion of cell markers by ‘monoclonal antibodies in cell Enlargement of liver, spleen, andl Iymph nodes Conic LympHOCYTIC LEUKEMIA Clinical Findings Laboratory Findings/Stdien Fatigue Lamphortons Lymphadenapathy WBC 20,000 nlargement of ier Bane marrow inflation wth sal and spleen Ipuplonycs Hypogammaglobulinemia lymphomas Hoockin’s Disease Clinical Findings Laboratory Findinge/Studies Increased ESR ‘Thrombacytosis Painless, enlarged mass neck, ala, oF groin Fever Lenkoestoni Night sweats Deereased ion and irn-binding Fatigue capacity Weight loss Increased leukocyte alkaline Generalized pruritus phosphatase Non-Hoockin’s DIseAse (\yMPHOSARCOMA, RETICULUM eu SARCOMA) Clinical Findings Laboratory Findingytudies Painless adenopathy in lymph Peripheral blood usually normal nodes or extranodal sites” ‘Bone marrow with paratrabecular Night sweats Iymphotd aggregates Weight loss CXR, mediastinal massFactor DEFICIENCIES. Factor IX, Ciristatas Factor (PTC pericient) Clinical Findings Laboratory Findings/Studios Bleoding Low Factor IX Increased PTT Factor X, STUART FACTOR Clinical Findings Laboratory Findingy/Studies Bleeding Abuorial PT and PTT aww Factor X Factor XIl (PTA vericient) Clinical Findings Laboratory FindingsStudies Bleeling Increased PIT Low Factor XIL Acquited Coagulation Disorders DEFICIENCY OF THE ViTAMIN K-DEPENDENT COAGULATION FACTORS Clinical Findings Laboratory F Bleeding Increased PT, corrected by giving sitamin K (Hykinone) Normal binogen, prothrombin time, and platelet Count idings/Studlien Dissemnateo intRAvASCULAR coAGULOPATHY (DIC) Clinical Findings Laboratory Findings Studies Bleeding (especially from Deerease in plasma fibrinogen rutile sites) Frequently postraumatic) Purpura Bechymoses Digital ischemia and gangrene Increased fibrin degradation roxlucts Increased PT Increased PTT ‘Thrombocytopenia Depleted antithrombin IM levels Decreased hematocrit (GRANULOCYTOPENIA Clinical Findings Laboratory Findings/Studlios Opportunistic infections Decreased WBCs CYCLICAL NEUTROPENIA Clinical Findings Laboratory Findings/Studies Fever ical Actuations of WBCs, Malaise platelets, and RBCs Mouth ulcers (Have patient keep diay of oral lesions and attempt to match Comvcal adenopathy tem with laboratory findings.) LyupHocrToPeNta Clinical Findings Recurrent viral infections Laboratory Findings/Studies Decreased lymphocytes Leukemias [ACUTE MYELOID LEUKEMIA Clinical Findings Laboratory Findings Studies High fever Anemia Bleeding Thrombocytopenia Severe prostration Nentropen Infection Increased LDH Gingval hypertrophy Bone ancl jine pain Enlargement of iver, spleen and Iymph nodes Hypenuricemia Hypokalemia Auer red inclusions CCronic Myeto10 LEUKEMIA Clinical Findings Laboratory Findings/Studies Palpable splenomegaly Presence of Philadelphia Anemia chromosome Weight loss Platelets normal or elevated Hypercellular bone marress with Fever Tettshifted myclopoiesis Severe bleeding Decreased leukocyte alkaline Infection during blast evsis phosphatase ‘Acute LYMPHOCYTIC LEUKEMIA Clinical Findings Laboratory Findings’ Fatigue Paneytopenia Bleeding Positive surface markers of primitive Infection. Iyimphoid cells Positive terminal deoxynucleotide transferase in 956, postive rosette formation with sheep erythrocytes dentifestion of cell markers by ‘monoclonal antibodies in cell Enlargement of liver, spleen, andl Iymph nodes Conic LympHOCYTIC LEUKEMIA Clinical Findings Laboratory Findings/Stdien Fatigue Lamphortons Lymphadenapathy WBC 20,000 nlargement of ier Bane marrow inflation wth sal and spleen Ipuplonycs Hypogammaglobulinemia lymphomas Hoockin’s Disease Clinical Findings Laboratory Findinge/Studies Increased ESR ‘Thrombacytosis Painless, enlarged mass neck, ala, oF groin Fever Lenkoestoni Night sweats Deereased ion and irn-binding Fatigue capacity Weight loss Increased leukocyte alkaline Generalized pruritus phosphatase Non-Hoockin’s DIseAse (\yMPHOSARCOMA, RETICULUM eu SARCOMA) Clinical Findings Laboratory Findingytudies Painless adenopathy in lymph Peripheral blood usually normal nodes or extranodal sites” ‘Bone marrow with paratrabecular Night sweats Iymphotd aggregates Weight loss CXR, mediastinal massoe Re Se Burr's tupHioma Clinical Findings Laboratory Findings/Studlies Extralymphatic tor in Presence of Epstein-Barr vinas ones of jaws Abdominal viscera Ovaries, meninges, breasts PLASMA CELL DYSCRASIA AND MULTIPLE MYELOMA Clinical Findings Laboratory Findings/Studies Frequent or recurrent Increased ERS infections, especially Anemi pneumonias Rouleau formation on blood smear Chronic renal dysfunction Increased uri acid Painfl fractures and bony Hyperealeemia lesions Bence-Jones protein in urine Back pain inding of paraprotein on SPE. (monoclonal spike in beta or gamma-globulin region) Radiograph: Ite lesions or generalized osteoporosis CCOWAGEN (CONNECTIVE TISSUE) DISEASES Rreuwato1o agri (SEVERE) Clinical Findings Laboratory Findings/Studies Fatigue Rheumatoid factor Joint stiffness Inereased ESR yall Anemia Symmetrical joint swelling, Radiographic soft tissue swelling, proximal interphalangeal and! osteuporosis, erosion of peripheral ‘metacarpophalangeal joints bare space of hone surface not of fingers as well as wrist, covered by cartilage, joint space knees, ankles, and toes narrowing Subcutaneous nodules over ony prominences| ‘SvOGREN's SywDROME Clinical Findings Laboratory Findings/Studies Keratoconjumetitis Mild anemia Xerostomia Hypergammaglobulinemia Xerophithalmia Special antbody from Chronic arthritis salivary duct Parotid enlargement Positive RF in 70% Severe dental caries Dysphagia Pancreatitis Schirmer’ test to measure valiame Pleuritis ‘of tears and saliva secreted Vaseulitis Sysrewic Lupus EryTHEMArOsUS. Clinical Findings Laboratory Findings/Studlies Arthritis Positive lupus erythematosus cells Myalzia ANA positive Butterfly rash (nose) Increased BSR Nephriis Anemia Fever Leukopenia ‘Thrombocytopenia Decreased serum complement Mildly abnor LIFTS Weight loss Raynand’s phenomenon Splinter hemorrhage Nailfold infarees| SCLERODERMA (PROGRESSIVE SYSTEMIC SCLEROSIS) Clinical Findings Laboratory Pindings/Studies Diffise thickening of skin Anemia Subcutaneous edema Increased ESR Telangiectasia ANA positive Polyarthralgia RF and lupus enthematosns eels Raynandls phenomenon Anticentromere Dysphagia Scleroderma antibody Hypomatility of gastro- (SCL-70) postive in 35% intestinal tract of patients Pigmentation, depigmentation Limited oral opening Powmvosms Clinical Findings Laboratory Pindings/Studies Bilatoral prosimal muscle Increased CPK weakness On electromyography, polyphasic Papules over knuckles potentials Periorbital edema Fibrillation and high frequeney Ruynandls phenomenon action potentials Dermaromyosms ical Findings Laboratory F Increased CPK inge Studies Polymyositis symptoms: shin rash Vascuums Powarreiris Novosum Clinical Findings Laboratory Findings/Studies Fever Leukoeytosis Challs Anemia Tuchyeardia Proteinuria Arthralgia and myewitis with Gylinduria muscle reticularis Hematuria Hypertension FSH Abdominal pain RE Mononeuritis multiples ANA Serum complement normal or Immunodeficiency Diseases Acquineo Iatmunonericiency Srnorome (AIDS) Clinical Findings Laboratory Pindings/Studies Fever Decreased in'T4 Weight loss Increased in TS Lymphadenopathy Leukopenia Diaerhea Frequent infections Oral candidiasis ‘SEVERE COMBINED IMMUNODEFICIENCY DISEASE Clinical Findings Laboratory Findingy/Stuies Increased susceptibility to Immunoglobulin G-<1%, Infections at 8to 6 months lymphocytes <2000/mn! Diarrhea from Salmonella Decreased delayed hypersensitivity (or Escherichia coli reaction Pneumonia with PCP and Pseudomonas ‘Candidiasis in orl cavityLocal and Regional Problems Besides these systemie conditions, certain local problems also ‘exist that will need to be evaluated before undertaking implant treatment. These include the following Root tips sts Infections Neoplasms Fibro-osseous disease Once it has been ascertained that the patient does not pre- sent a medical or psychologic risk or that the risks ean be ad- cequately controlled, a specific oral reconstruetive approach, ray be initiated. Dr: Manuel Chanavas is professor and chairman of the de- partment of Oral and Maxillofacial Implants at the Lille University School of Medicine in Lille, France. Dr. Aram Sirakian was a Fellow in Biomaterials and Dental Implants at the Brookdale Hospital Medical Center and is now in the private practice of dental implantology in Boston, ‘Massachusetts. Ms, Marcia Cahn-Geller isa Certified Physicians Assistant and a student of metabolie diseases. Suggested Readings Bain ©A, Moy PK: The association between the failure of dental implants and cigarette smoking, Int J Oral Maxillofac Inyplant §:609, 1993, Boot AM etal: Bone mineral density and bone metabolism of prepa- bprtal children with asthma after long-term treatment with inhaled corticosteroids, Pediatr Pulmonol 24(6):379-384, 1997. Rot ta Fridlund D- Acute diarrhea, Lar Rev du Praticien 113-120, Jan 10, Braunwald et al: Harrison's principles of intemal medi York, 1987, McGrail, Chomienne C, Da Sika N: Hematopotetic growth factors, receptors in tracelllar signals, Pathologie Science 15-28, 199. Gite Rt ak Bane turnover in past menopsansal osteoporosis: effect of calcitonin treatment, J Clin Incest $2:1268-1274, 1988, Cline JL et al Effet of inereasing dietary vitamin Aon bone density in adult dogs, And Sei. 75(11): 380-2985, 1997, Consensus Development Conference: Diagnosis, prophylaxis aad treat ‘ment of esteoporess, Am J Med 94-646-650, 1995, (Coquard R: Late elfects of ionizing radiations on the hone marrovs, Can- ‘cer Radiother 1(6): 792-800, 1997, CGranin AN: Endosteal implant in patient with corticosteroid depen= dence, J Oral Implantol 7414-417, 1901 (Cranin AN: Physical evaluation of the surgical implant patient, Oral Im- planto, Springfield, HL, 1970, Charles C. Thomas “ed LI, New Crowley S et ak Collagen metabolism and growth in prepubertal chil dren with asthma treated with inhaled steroids, J Pediat 132 (3 Pr 1409-413, 1905, Desombere I, Willems A, Lerous-Rools G: Response to hepatitis B vac~ cine: multiple HLA genes are involved, Tissue Antigens 51(6) 5 605, 199, Dombret H: Intensive chemotherapy in myelodysplastic syndro Pathol Biol (Pars) 458)-627-635, 1997 Foa Pet al: Long-term therapentic efficacy and toxicity of recombinant werferon-alpha 2a in polyeythaemia vera, Eur J Haematol 65):273-277, 1908, Gagnon Leet al: Infuence of inhaled corticosteroids ane! dietary intake on bone density and metabolism in patients with moderate to severe asthma. J Am Diet Assoc 97(12) 1401-1406, 1997 Harris ST et al: Four-year study of intermittent eylicetiodronate treat- followed by one year of open therapy: Am J Med 95 Hellstrom-Lindberg E et al Treatment of anemia in myelodysplastic syn- Adromes with granulocyte colony-stimulating factor plus erthropoi- etn: results From a randomized phase Ht study and longterm fallow: up of 71 patients, Blood 1:99(1): 68-75, 198, Juul JV, Hopkins T. Farhan M: Severe leukocytosis with neutmplia (leukemoid reaction) in aleaholie steatebepatts, Am J Gastroenterol 95(6)-1013, 1998, Keouse DS et ak CD34: structure, biology; and clinical ait, Bld 87 1-13, 1996. Leroy J etal: Hmostase et thrombese, La Simarre 1-179, 1988, Marollean JP: Lhématopodise, Patholowte Science JL 1-13, 1996. Matson MA, Cohen EP: Acquired eystie kidney disease: occurrence, ‘prevalence, and renal cancers, Mridicine (Baltimore) 69(4) 217-236, 1900, Meunier PJ: Les osteoporcuses, La Rev du Pratiien 105% 1905, Mini Book 3: Endocrinologie-nétabolisme-nutrition, pp 9-76, 1991 Nguyen QH etal: Interleukin IL)-15 enhances antibody-dependent cel Tulareytotoseity and natural aller activity in neonatal ells, Cell m= ‘manol 185(2):83-92, 198. Pasanen M et al: Hepatitis A impairs the Fonction of human hepatie CYP2A6 in vivo, Toxtenlogy 543):177-184, 1907, Poullés JM: Apport de Tostéadensitometrie la definition et an diag- nostic des ostéoporoses, La Reewe du Praticien 1096-1101, 1995. Richardson ML: Bone marrow abnormalities revealed by MR inaging, AJR, Am J Roentgenol I71(1)-261-263, 10S, Saitz R: Patients with aleohol problems, N Engl J Med 19-3892) 130-131, 1997 Sancher-Penee Jet ak: Lichen planus and hepatitis C virus infection: a lineal and vrologe std, Acta Dern Venereol TS(4):308-306, 1908, Spikkelman A, de Wolt JT, Velleng E: The application of hematopoietic sgrouth factor in dng induced agranulocytosis. a review of 70 eases, Leukemia 8:2081, Vallespi Tet ak: Diagnosis, classification, and eytogeneties of myelodys- plastic syndromes, Haematologica 83(3):258-275, 1008, WHO Study Group: Assessment of fracture risk and its application to sercening for postmenopausal osteoporosis. In Who Techical Report Series 843, Geneva World Health Organization, pp 1-129, 19, Woodcock A: Effects of inhaled corticosteroids on bone density and n tabolism, J Allergy Clin Immunol 101:4(2)SS456-S459, 1998. 1135, MayPeas Bae Bee Diagnostic Methods Examination ince a decision has been made to perform implant therapy and the patient has been found to be phy cally and medically acceptable, complete a thor diagnostic evaluation and treatment plan to choose the proper approach. A visual examination should be the first step. View the edentulous areas and conceptualize the height, width, and. length of the proposed operative sites. Also, note the amount of attached and/or keratinized gingivae. In addition, note the level ofthe lip line and exposed gingivae along with a le attachments, If natural teeth remain, they should be free of decay, and the periodontal tissues should be healthy: Neither fections nor localized areas of pathologic change « permitted. ‘The next step in the diagnostic sequence is manual palpa- tion, With thumb and index finger, palpate the edentulous Fdges (Fig. 4-1), Assess the firmness and thickness of the soft tissues. A determination of the uniformity of thickness over the entire height and length of the underlying bone is impor- tant. Coneavities and convexitics may exist that might not be evident on visual or digital examination. To clarify and define the presence and extent of such irregularities, prepare to sound the bone (or delineate the shape by closed exan tion), Use a 30-gange needle to deposit a small amount of lo- cal anesthetic along the labial and lingual aspects of the eden- tulous areas that are being considered as potential implant sites. Then, use a sharpened periodontal probe to make soft tissue thickness measurements, These and all other calibra- tions should be recorded on a diagnostic chart. Next, use a sterilized Boley gauge with sharpened beaks to puneture the soft tissues by squeezing the calipers directly through tisstie san be to bone (Figs. 4-2, 4-3). The beaks should oppose one another so that an accurate reading will result. This presents a mea- surement of bone width at varying ridge sites, By doing this repeatedly from superior to inferior and from medial to distal at 5-mm intervals, the clinician develops a topographic map of the soft and hard tissue dimensions of the areas into which implant placement is intended. Record these measurements oon the chart. When these measurements are used, an accurate three-dimensional representation of the operative site can be sketched (Fig, 4-4) 4-1 Digital papaton ofthe planned host ste reveals under, regulates and defects of the bone. Zones of atached gingivae may be ascertained as wel 228 (GiveER 4 HowTo CHOOSE THE PROPER IMPLANT Fig. 4-2 A standardized Boley gauge can be sharpened and sterized ses of sounding. Such a device aso is available commercially hetization, the sharpened Boley gauge tips pene- Fig. 4-3 After an so that accurate direct bone dimensions may be trate the soft tissu {9 ry y Yes IS KEKE 3:D view of ridge, long axis Fig. 4-4 The Boley gauge measurements of bone ere tal chart. From th e as dimensional guides in ansfered t0 a d bers, cross-sectional and thiee-dimensional views can be plotted to ser millimeters during surgery.