risk factors for implant pre and post.pptx

risk factors on implant

1. Good Morning 8 -07-2024

2. Assessment Guided By :-Dr. Ravi Kiran N. R I SK Implant in Dentistry Presented By :-Dr. Inder PG iii year

3. CONTENT 01 02 03 04 05 06 01. Introduction 06. References 03 Risk Factors 04. Principle of Risk Management 02 Clinician as a Risk 05. Conclusion 01-07-2024 Department of Periodontology and Implantology, DDCH 3

4. What was once the domain of specialist practice is now a common treatment modality in many, if not most, general practices. It has long been recognized that clinical situations present with different levels of difficulty and with different degrees of risk for esthetic, restorative, and surgical complications . Despite the advances in knowledge and improved techniques, implant dentistry is not free from risks of complications or suboptimal outcomes . Implant dentistry is a crucial component of contemporary dental practice, offering a compelling evidence-based solution for restoring the smiles of patients who are missing some or all of their teeth. Ongoing advancements in both clinical techniques and technology have bolstered clinicians' confidence in this type of treatment and have made it more widely adopted in everyday practice.

5. Implant dentistry is a crucial component of contemporary dental practice, offering a compelling evidence-based solution for restoring the smiles of patients who are missing some or all of their teeth. Ongoing advancements in both clinical techniques and technology have bolstered clinicians' confidence in this type of treatment and have made it more widely adopted in everyday practice. What was once the domain of specialist practice is now a common treatment modality in many, if not most, general practices. It has long been recognized that clinical situations present with different levels of difficulty and with different degrees of risk for esthetic, restorative, and surgical complications . Despite the advances in knowledge and improved techniques, implant dentistry is not free from risks of complications or suboptimal outcomes .

6. Implant dentistry is a crucial component of contemporary dental practice, offering a compelling evidence-based solution for restoring the smiles of patients who are missing some or all of their teeth. Ongoing advancements in both clinical techniques and technology have bolstered clinicians' confidence in this type of treatment and have made it more widely adopted in everyday practice. What was once the domain of specialist practice is now a common treatment modality in many, if not most, general practices. It has long been recognized that clinical situations present with different levels of difficulty and with different degrees of risk for esthetic, restorative, and surgical complications . Despite the advances in knowledge and improved techniques, implant dentistry is not free from risks of complications or suboptimal outcomes .

7. The successful osseointegration of an implant is no longer the primary focus of treatment. Rather, the range of potential problems with implants and their related prostheses has come into sharper focus. It is in this environment that the SAC classification has evolved to assist practitioners in recognizing risk factors and providing appropriate levels of care.

8. The successful osseointegration of an implant is no longer the primary focus of treatment. Rather, the range of potential problems with implants and their related prostheses has come into sharper focus. It is in this environment that the SAC classification has evolved to assist practitioners in recognizing risk factors and providing appropriate levels of care. Renouard and Rangert (1999 ) published a classification system that addressed the risk factors involved with the surgical and restorative phases of implant rehabilitation – Absolute and Relative Risk Factors Sailer and Pajarola introduced the term SAC in 1999 to classify risk factors for dentists performing oral surgery. They used the classification S = Simple, A = Advanced, and C = Complex.

9. In 1999, the Swiss Society of Oral Implantology (SSOI) introduced the SAC classification during a congress on dentistry quality guidelines. The International Team for Implantology (ITI) adopted the SAC classification in 2003. In 2006, the ITI Education Core Group made a slight modification to the original classification and changed Simple to Straightforward In March 2007, the ITI held a conference in Palma de Mallorca, Spain to improve the SAC classification from subjective to more structured and objective. The results were published in an adjunct to the ITI Treatment Guide series in 2009 (Dawson & Chen, 2009).

10. In 2009, the ITI developed an SAC Assessment Tool for clinicians to determine the normative classification and identify modifying factors for their patients.

11. In 2018 and 2019, a review group met in Zurich and Berlin to update the SAC classification scheme and develop an improved SAC Assessment Tool, which clinicians prefer for assessing patients' treatment needs.

12. The SAC classification assesses the difficulty and risk of implant-related treatments, guiding clinicians in patient selection and treatment planning. It offers an evidence-based framework for assessing treatment complexity and can help clinicians determine if they have the necessary skills or need to refer the patient to a more experienced clinician. It also serves as a checklist for more experienced clinicians to ensure all relevant risks are considered in patient assessment and treatment planning.

13. isk factors refers to any preexisting condition, treatment option, or material choice that may have an adverse effect on the outcome of treatment. These factors have the potential to influence the final SAC classification of a clinical situation. Is the Clinician a Risk Factor? Dental implant treatments are popular, but the risks for clinicians are often overlooked. According to Derks et al. (2016) , there's a significant correlation between dentist experience and implant complications from peri-implantitis. R

14. Factors impacting the clinician as a risk factor Experience Training Self assessment Shared learning Short learning courses Structured education and training The Conscious Competence Learning Model Curtiss & Warren, 1973 01-07-2024 Department of Periodontology and Implantology, DDCH 14

15. Stress as a risk factor Renouard and colleagues highlight stress as a significant issue in healthcare settings, affecting performance and decision-making. Stress factors such as time pressures, staff problems, and interpersonal frictions can lead to automatic, unhelpful responses. These findings are applicable to daily issues like lack of sleep, financial problems, and health or family issues (West et al, 2006). 01-07-2024 Department of Periodontology and Implantology, DDCH 15

16. Clinician risk factor in relation to other sources of risks In implant dentistry, risks can be attributed to the patient, treatment approach, biomaterials, and the clinician. Chen and Schärer (1993) initially described the relationship between the clinician, materials, and patient factors. Buser and Chen (2008) further illustrated potential interactions between these factors. The clinician has a significant influence in selecting the patient, treatment approach, and biomaterials. Any flaws in their knowledge or skills can put the patient at greater risk, making the clinician a potential significant risk factor.

17. Clinician risk factor in relation to other sources of risks In implant dentistry, risks can be attributed to the patient, treatment approach, biomaterials, and the clinician. Chen and Schärer (1993) initially described the relationship between the clinician, materials, and patient factors. Buser and Chen (2008) further illustrated potential interactions between these factors. The clinician has a significant influence in selecting the patient, treatment approach, and biomaterials. Any flaws in their knowledge or skills can put the patient at greater risk, making the clinician a potential significant risk factor.

18. The SAC Assessment Tool now enables users to classify their specific case based on reported risk factors in four broad areas. General Esthetic Edentulous Surgical Prosthetic

19. General Risk

20. General Risks Identification of general risk factors is almost always done in the anamnesis and clinical examination. These factors relate to potential problems arising out of the patient’s medical and dental history and their presenting condition. These general factors fall into three main clusters: Patient medical factors Patient-related attitudinal/behavioral factors Site-related factors

21. Patient Medical Factors Medical Fitness Medications Radiation Growth Status

22. The ASA Physical Status classification system (Doyle et al, 2019) Medical Fitness A patient’s current health status has the potential to influence their fitness to undergo treatment, and also how well they will heal after implant surgery. The ASA Physical Status Classification.

23. Medications Pharmaceutically active substances, including prescription medications, over-the-counter medicines, herbal remedies, dietary supplements, and recreational substances, may directly impact implant healing and peri-implant tissue health or indirectly affect the patient's behavior.

24. Medications Pharmaceutically active substances, including prescription medications, over-the-counter medicines, herbal remedies, dietary supplements, and recreational substances, may directly impact implant healing and peri-implant tissue health or indirectly affect the patient's behavior.

25. Medications Pharmaceutically active substances, including prescription medications, over-the-counter medicines, herbal remedies, dietary supplements, and recreational substances, may directly impact implant healing and peri-implant tissue health or indirectly affect the patient's behavior.

26. Medications Pharmaceutically active substances, including prescription medications, over-the-counter medicines, herbal remedies, dietary supplements, and recreational substances, may directly impact implant healing and peri-implant tissue health or indirectly affect the patient's behavior.

27. Medications Pharmaceutically active substances, including prescription medications, over-the-counter medicines, herbal remedies, dietary supplements, and recreational substances, may directly impact implant healing and peri-implant tissue health or indirectly affect the patient's behavior.

28. Radiation Radiotherapy can significantly affect bone healing, leading to osteoradionecrosis, which impedes proper bone healing following surgery in irradiated bone. The radiation dosage in the area where implant placement is planned is a key consideration, with doses greater than 50 Gray likely making implant placement inadvisable. Factors like time after radiation therapy, smoking, and oral hygiene also impact the likelihood of developing osteoradionecrosis of the jaw.

29. Growth Status Implants, similar to ankylosed teeth, can slow bone development and should not be placed in growing individuals. Implant-supported prostheses may lose aesthetic appeal due to infraocclusion caused by continued bone growth. This can also occur in older patients due to slow facial growth.

30. Patient Attitudes/ Behaviors Smoking Habits Compliance Oral Hygiene Patient Expectation

31. Smoking Habit Tobacco smoking is related to increased risks of implant failure and peri-implant disease Heitz -Mayfield & Huynh-Ba, 2009 There is some evidence of a dose related effect, and that this is mediated by nicotine and other tobacco-derived chemicals that compromise wound healing, the immune response, and increase the risk of scarring. For detailed learning refer to

32. Compliance A patient's willingness and ability to follow instructions are crucial in any complex treatment where long-term success depends on maintenance and optimal treatment outcomes in the short term. Noncompliant patients are more likely to experience treatment problems and less likely to take the necessary steps to address these issues. Poor compliance can be seen as a relative contraindication for implant therapy until the patient becomes motivated to support their treatment.

33. Oral Hygiene Bacterial biofilm accumulation is linked to peri-implant mucositis and peri-implantitis. Regular removal of these deposits is crucial to prevent these complications. If patients can't maintain oral hygiene, implant therapy should be delayed or other prosthetic reconstruction considered. For detailed learning refer to

34. Patient Expectations Patients' unmet expectations can lead to complaints or legal action against practitioners, especially for expensive and invasive implant treatments. It's important to communicate realistic expectations and manage patient outcomes before treatment. Some patients may have high but reasonable expectations based on their social status or job, while others may have unrealistic expectations, which can be very challenging. For example, patients with body dysmorphic disorder may have extreme expectations. If these expectations cannot be managed, it's best not to proceed with implant rehabilitation.

35. Site-related Factors Periodontal status Access Previous surgeries in the planned implant site Nearby pathology

36. A history of treated periodontal disease has been associated with an increased risk of biologic complications. Active periodontal disease with pockets deeper than 5 mm also poses a risk. Before considering elective rehabilitative treatment like an implant-supported prosthesis, ensure all active oral diseases are under control. It is mandatory to address and manage any periodontal disease before implant placement if implant treatment is planned. Heitz -Mayfield & Huynh-Ba, 2009 For detailed learning refer to Periodontal status

37. Access Implant treatment requires ample space. If there isn't enough, treatment may need to be adjusted or additional treatment may be necessary for implant placement and restoration.

38. Previous surgeries in the planned implant site Prior surgeries in the implant site can complicate placement and healing. Scarring is linked to reduced blood flow, which may hinder healing. Multiple surgeries significantly increase the risk of problems.

39. Nearby pathology Elective treatments like implant therapy should only proceed after addressing any other health conditions. Pathologies that could affect implant healing must be managed before placing the implants. For example, infections in neighboring teeth should be treated before the implant procedure.

40. Esthetic Risk

41. Esthetic Risk Width of edentulous span Shape of crown Restorative status of adjacent teeth Gingival phenotype Volume of surrounding tissues

42. Esthetic Risk Esthetic concerns are important when the implant and surrounding tissue will be visible during normal activities or when the patient smiles. Implant therapy in the esthetic zone can be complex due to patient expectations and anatomical challenges. Failure to achieve ideal results could lead to additional surgical and restorative procedures. Buser et al, 2004; Levine et al, 2014

43. Width of the edentulous space When evaluating spaces for tooth restoration, careful attention to the materials and space requirements is crucial. Decreased space limits options and compromises esthetics. Multiple missing teeth increase esthetic risk due to unpredictable tissue support and maintenance challenges Mirtrani et al, 2005; Mankoo , 2008 The risk of esthetic complications is higher when there are missing teeth adjacent to each other, especially when planning for adjacent implants. For detailed learning

44. Shapes of tooth crowns An implant restoration 11 with contours mismatched to those of the adjacent tooth. Triangular tooth shape associated with high-scalloped tissue architecture. The clinical outcomes in esthetic dentistry are greatly influenced by the symmetry of restorations, their shape, contours, and textures . Gallucci et al, 2007 Mismatched implant restorations can negatively impact the esthetic outcome, but the presence of square teeth and a thick gingival phenotype can help reduce associated risks. Stellini et al, 2013 Teeth with square-triangular and triangular shapes pose a higher risk due to the surrounding tissue anatomy. Aesthetic concerns are heightened when a triangular tooth shape is linked to specific periodontal issues and the disappearance of interproximal papillae . Takei, 1980; Gobbato et al, 2013

45. Restorative status of adjacent teeth Consider the condition of surrounding teeth and planned surgical area as it can affect the esthetic outcome. The presence of restorations on adjacent teeth or subgingival margins can pose esthetic risks, leading to complications such as exposed restorative margins or altered gum architecture after implant placement. Richter & Ueno, 1973; Lindhe et al, 1987; Felton et al, 1991; Sanavi et al, 1998 Exposure of crown margins of teeth 11 and 22 subsequent to extraction of tooth 21.

46. Gingival phenotype Phenotypes describe an individual's physical characteristics, and they are influenced by their genotype. The characteristics of the gingival phenotype (thick or thin) at an implant site can affect the treatment approach and the ability to achieve an acceptable esthetic outcome. "A thick gingival phenotype presents a low esthetic risk when replacing single missing teeth in the front. Patients typically have thick, resistant gingival tissue. "Chen & Buser , 2014; Chen et al, 2009; Kan et al, 2003; Kois , 2001 ” The thin gingival phenotype is characterized by a highly scalloped gingival architecture, often associated with attractive single-tooth implant outcomes. Successful maintenance of the soft tissue architecture depends on the support of facial bone and periodontal support from adjacent teeth. The thin and friable nature of the soft tissues is conducive to the formation and maintenance of natural and predictable interproximal papillae, but there's an increased esthetic risk of mucosal recession in situations where immediate implants are used. Cardaropoli et al, 2004; Kan et al, 2003; Kois, 2001; Weisgold, 1977 Chen & Buser, 2014; Chen et al, 2009

47. Volume of surrounding tissues The ERA factors relate to the volume of mucosal tissues and supporting bone in the implant site, influencing implant placement and restoration for aesthetic symmetry and harmony. Issues like bone resorption and mucosal recession can increase aesthetic risk and treatment difficulty.

48. Edentulous Esthetic Risk Assessment

49. Edentulous Esthetic Risk Assessment (EERA) LTR CLASSIFICATION Facial support Labial support Upper lip length Buccal corridor Smile line Maxillomandibular relationship

50. In fully edentulous cases, implant-supported prostheses may not adequately support or blend with facial structures, teeth, smile line, and alveolar ridge. The EERA is part of the SAC classification and can help identify risk factors affecting esthetic outcomes. Systematic use of the EERA checklist during diagnosis and planning can reduce esthetic, technical, and biologic complications. "The findings are probably because of the anatomy of the lower two-thirds of the lower one-third of the face, including the lip and its surrounding muscles, as well as the impact of the prosthesis on facial support, the smile line, and phonetics (minimal disruption of speech seal)."

51. The classification is based on the defect present between the ridge and the lip horizontally and the prosthetic tooth and ridge vertically. The bone availability for implant placement does not influence the type of indication. Pollini et al, 2017 Utilization of the LTR classification assists clinicians in identifying esthetic risk based on a combination of lip dynamics as well as structural risk based upon prosthetic space availability.

52. When using the EERA, it's important to consider all treatment options to make informed choices. This involves using both analog (wax try-in) and digital tooth arrangement to evaluate potential outcomes.

53. Facial support Determining optimal facial support is crucial in planning. It relies on existing bone and teeth, denture base extensions, and denture teeth position. Anatomical factors like the alveolar ridge and subnasal structures influence support, impacting patients' esthetic perception. Zitzmann & Marinello , 1999

54. Labial support When evaluating patients with missing teeth, the shape of the gum ridge and contour of the upper front teeth have a significant impact on lip and tissue support. Factors such as muscle structure of the upper lip, dry part of the lips, and tooth length/position also play a role. Patients with thin upper lips are at higher esthetic risk as any issues with gum shape, implant position, or prosthetic design will be more noticeable and challenging to address. Duplicated denture with labial flange removed.

55. Labial support When evaluating patients with missing teeth, the shape of the gum ridge and contour of the upper front teeth have a significant impact on lip and tissue support. Factors such as muscle structure of the upper lip, dry part of the lips, and tooth length/position also play a role. Patients with thin upper lips are at higher esthetic risk as any issues with gum shape, implant position, or prosthetic design will be more noticeable and challenging to address. Duplicated denture with labial flange removed. Try-in of “flangeless” duplicated denture. Labial support evaluation with and without labial flange on prosthesis.

56. Labial support When evaluating patients with missing teeth, the shape of the gum ridge and contour of the upper front teeth have a significant impact on lip and tissue support. Factors such as muscle structure of the upper lip, dry part of the lips, and tooth length/position also play a role. Patients with thin upper lips are at higher esthetic risk as any issues with gum shape, implant position, or prosthetic design will be more noticeable and challenging to address. Duplicated denture with labial flange removed. Try-in of “flangeless” duplicated denture. Labial support evaluation with and without labial flange on prosthesis.

57. Fully edentulous patients with a thin or short lip, restored with a flangeless prosthetic solution, may show a transverse upper labial crease while smiling. This crease can be influenced by certain extraoral clinical factors. Beer and Manestar found that 38% of women over 40 had an upper labial crease at rest, and 70% had one when smiling. It's important to assess for this crease in the diagnostic phase and discuss potential cosmetic treatment with the patient.

58. Upper lip length Measurement for upper lip length. The upper lip's position and length play a crucial role in the aesthetics of a person's smile. It affects the display of teeth, especially for those with no upper teeth. A shorter upper lip may increase the visibility of dental prosthetics, while a longer upper lip may cover them.

59. Buccal corridor Smile attractiveness is influenced by various factors including tooth alignment, tooth exposure, and the size of the buccal corridor. A study found that smiles with smaller buccal corridors were rated as more attractive than those with larger ones Martin et al, 2007 Evaluation of narrow buccal corridor in a maxillary and mandibular hybrid patient. In edentulous patients, the buccal corridor and the position and size of the alveolar ridge affect aesthetics. A narrow upper arch may result in a prosthesis extending off the ridge, leading to food entrapment and maintenance challenges. Evaluation of excessive horizontal positioning of teeth in the implant-supported prosthesis to minimize the buccal corridor

60. Smile line Tjan et al. (1984) classified dentate patients' smiles as high, medium, or low based on upper lip position. The smile line is assessed during a forced smile with and without the prosthesis. In edentulous maxillary scenarios, patients showing the residual maxillary ridge when smiling face higher esthetic complication risks, requiring careful consideration of planned prosthesis and preimplant surgical intervention. Patients with a high smile line and advanced alveolar ridge resorption often prefer implant-supported overdentures because of the added support from the labial flange. There's a higher esthetic risk for patients with a high smile line and short lip length due to the potential display of the transition line. An example of a high smile line and short lip length exposing the transition line, resulting in esthetic compromise. Clinical example of visualization of the residual alveolar ridge with dental implants at full smile in a patient planned for a fixed solution.

61. Maxillomandibular relationship The extraction of teeth can lead to bone resorption in the alveolar ridges, which may continue over years. This resorption can affect the relationship between the upper and lower jaw. During treatment planning, it's essential to evaluate this relationship and the position of the teeth in relation to the ridges for proper occlusion and support. Solutions to these problems may include: Not placing implants Orthognathic surgery prior to implant placement Bone grafting procedures An alternative prosthetic treatment plan that avoids the anticipated complications ( eg , using a removable solution rather than a fixed prosthesis) In situations with inadequate intermaxillary space, reduction of the ridge height toallow for greater prosthetic volume

62. Principles of Risk Management In general, this cycle aims to: Identify potential problems Measure the incidence of these adverse outcomes and the impact that they have Educate users about these potential problems Develop strategies to mitigate the incidence or effect of these problems Review the effectiveness of these mitigation strategies This is a continuous process where outcomes are monitored, and refinements are made to mitigation strategies to incrementally improve process outcomes.