Clinical Evaluation and Assessment

Clinicians must use comprehensive evaluation and assessment to determine if a patient is eligible for dental implants. If dental implants are placed, it is the role of each clinician to reevaluate and assess the implant patient to prevent potential implant complications. Proper evaluation and treatment planning is essential for dental implant predictability and success.

As mentioned prior, one of the most critical factors in clinical assessment is the biologic connection between the implant and bone. Healthy bone is required for successful osseointegration and long-term dental implant success.^11-12 The alveolar bone is measured in diameter and length. The spatial relationship of the bone must be evaluated in a three-dimensional view through radiographic imaging.⁵ The quality of the bone should be evaluated. Healthy bone reflects a continuous, uniform cortical outline and a lacy, well-defined trabecular core.¹⁴Large marrow spaces, discontinuous cortex or thin, sparse trabeculation should be evaluated, as these negative variables will contribute to poor implant stabilization.^26-27,29 Poor bone quality may require further healing after bone augmentation to maximize implant-to-bone contact before occlusal loading. A recent *Journal of Clinical Periodontology* systematic review and meta-analysis conducted by Thoma et al found lateral bone augmentation, in conjunction with dental implant placement is a sound treatment modality. However, to produce a defect height reduction, a barrier membrane and grafting material should be combined.⁵⁵

Clinical assessment of the proposed implant site will be evaluated. Adjacent teeth to the site are also evaluated. The interdental space is measured to determine placement and restoration of the implant. Depending on the implant system, the minimal mesial-distal space will be determined. For example, a 4 mm diameter dental implant placed between two teeth would need approximately 7 mm of space. For a 6 mm implant, the minimal space would be approximately 9 mm. There must be sufficient interproximal space for tissue health and patient home care. The interocclusal space needed for each of the implant components e.g., abutment, screw, and crown would vary depending on the type of components used (Figure 4). For example, the minimum interocclusal space required for an external hex-type implant is 7 mm.²⁹ Anatomic location is important, as the failure to accurately assess the location of anatomic structures can lead to unnecessary complications.

Figure 4.

Figure 4.

Courtesy of Dr. Samuel L. Corey.

Based on the patient’s parafunctional status, the evaluation of current bruxing and clinching habits and the current occlusion and bone levels are assessed. If needed, bone augmentation treatment e.g., localized ridge augmentation and/or sinus lift will be completed. A recent systematic review and meta-analysis conducted by Zhou et al found bruxing was a contributing factor in dental implant complications leading to implant failures.⁵³ A soft tissue evaluation may reveal future augmentation of gingival and connective tissue grafts required for keratinized mucosa during post-treatment healing. Clinical assessment should also include the etiology and duration of past tooth loss and, if there is a history of a traumatic extraction in the proposed implant site, indicating possible alveolar bone complications.