E.A.O. guidelines for the use of diagnostic imaging in implant dentistry 2011. A consensus workshop organized by the European Association for Osseointegration at the Medical University of Warsaw

Dentomaxillofacial imaging with panoramic views and cone beam CT

Panoramic and intraoral radiographs are the basic imaging modalities used in dentistry. Often they are the only imaging techniques required for delineation of dental anatomy or pathology. Panoramic radiography produces a single image of the maxilla, mandible, teeth, temporomandibular joints and maxillary sinuses. During the exposure the x-ray source and detector rotate synchronously around the patient producing a curved surface tomography. It can be supplemented with intraoral radiographs. However, these techniques give only a two-dimensional view of complicated three-dimensional (3D) structures. As in the other fields of imaging also dentomaxillofacial imaging has moved towards 3D imaging. Since the late 1990s cone beam computed tomography (CBCT) devices have been designed specifically for dentomaxillofacial imaging, allowing accurate 3D imaging of hard tissues with a lower radiation dose, lower cost and easier availability for dentists when compared with multislice CT. Panoramic and intraoral radiographies are still the basic imaging methods in dentistry. CBCT should be used in more demanding cases. In this review the anatomy with the panoramic view will be presented as well as the benefits of the CBCT technique in comparison to the panoramic technique with some examples. Also the basics as well as common errors and pitfalls of these techniques will be discussed. Teaching Points • Panoramic and intraoral radiographs are the basic imaging methods in dentomaxillofacial radiology.• CBCT imaging allows accurate 3D imaging of hard tissues.• CBCT offers lower costs and a smaller size and radiation dose compared with MSCT.• The disadvantages of CBCT imaging are poor soft tissue contrast and artefacts.• The Sedentexct project has developed evidence-based guidelines on the use of CBCT in dentistry.

Guidelines for clinical use of CBCT: a review

OBJECTIVES

To identify guidelines on the clinical use of CBCT in dental and maxillofacial radiology, in particular selection criteria, to consider how they were produced, to appraise their quality objectively and to compare their recommendations.

METHODS

A literature search using MEDLINE (Ovid(®)) was undertaken prospectively from 1 January 2000 to identify published material classifiable as "guidelines" pertaining to the use of CBCT in dentistry. This was supplemented by searches on websites, an internet search engine, hand searching of theses and by information from personal contacts. Quality assessment of publications was performed using the AGREE II instrument. Publications were examined for areas of agreement and disagreement.

RESULTS

26 publications were identified, 11 of which were specifically written to give guidelines on the clinical use of CBCT and contained sections on selection criteria. The remainder were a heterogeneous mixture of publications that included guidelines relating to CBCT. Two had used a formal evidence-based approach for guideline development and two used consensus methods. The quality of publications was frequently low as assessed using AGREE II, with many lacking evidence of adequate methodology. There was broad agreement between publications on clinical use, apart from treatment planning, in implant dentistry.

CONCLUSIONS

Reporting of guideline development is often poorly presented. Guideline development panels should aim to perform and report their work using the AGREE II instrument as a template to raise standards and avoid the risk of suspicions of bias.

The impact of CBCT imaging when placing dental implants in the anterior edentulous mandible: a before-after study

OBJECTIVES

To evaluate the impact of CBCT imaging when placing dental implants in the anterior edentulous mandible, using a "before-after" study design.

METHODS

Eight dental practitioners, who regularly place dental implants in independent dental practice in the North West of England, were presented with realistic simulations of four edentulous cases. The practitioners were asked to assess case difficulty, select implants and then drill osteotomies in preparation for dental implants in the lower canine regions to support a complete overdenture. In the "before" part of the study, a panoramic and a trans-symphyseal view were available. In the "after" part of the study, a CBCT image was added. Perception of case difficulty, implant selection and the incidence of perforations or "near miss perforations" of the lingual cortical plate were recorded. Two cases were regarded as "regular" and two as "challenging".

RESULTS

In challenging cases, the availability of CBCT led practitioners to select narrower implants and to assess cases as more difficult. In the challenging cases only, there were fewer perforations of the lingual cortical plate after the availability of CBCT, but this difference was not statistically significant. There were no perforations in the regular cases either before or after the availability of CBCT.

CONCLUSIONS

Perception of case difficulty and implant selection are of importance only if they change the outcome for the patient. This study provided weak evidence that CBCT is helpful in avoiding perforations in challenging cases. The availability of CBCT had no impact in regular cases.

Preoperative implant planning considering alveolar bone grafting needs and complication prediction using panoramic versus CBCT images

Purpose

This study was performed to determine the efficacy of observers' prediction for the need of bone grafting and presence of perioperative complications on the basis of cone-beam computed tomography (CBCT) and panoramic radiographic (PAN) planning as compared to the surgical outcome.

Materials and Methods

One hundred and eight partially edentulous patients with a need for implant rehabilitation were referred for preoperative imaging. Imaging consisted of PAN and CBCT images. Four observers carried out implant planning using PAN image datasets, and at least one month later, using CBCT image datasets. Based on their own planning, the observers assessed the need for bone graft augmentation as well as complication prediction. The implant length and diameter, the need for bone graft augmentation, and the occurrence of anatomical complications during planning and implant placement were statistically compared.

Results

In the 108 patients, 365 implants were installed. Receiver operating characteristic analyses of both PAN and CBCT preoperative planning showed that CBCT performed better than PAN-based planning with respect to the need for bone graft augmentation and perioperative complications. The sensitivity and the specificity of CBCT for implant complications were 96.5% and 90.5%, respectively, and for bone graft augmentation, they were 95.2% and 96.3%, respectively. Significant differences were found between PAN-based planning and the surgery of posterior implant lengths.

Conclusion

Our findings indicated that CBCT-based preoperative implant planning enabled treatment planning with a higher degree of prediction and agreement as compared to the surgical standard. In PAN-based surgery, the prediction of implant length was poor.

Patient selection and treatment planning for implant restorations

Dental implants are an indispensible tool for the restoration of missing teeth. Their use has elevated the practice of dentistry by improving both our technical ability to rehabilitate patients and general quality of life. To routinely achieve the associated high expectations, diligent attention to details must be observed and addressed from the outset. Of central concern is the attainment of osseointegration and the location of implants to ideally support the intended restoration. The pivotal point in treatment planning for dental implants occurs when the location of bone is viewed radiographically in the context of the planned prosthesis. This most often requires diagnostic waxing or tooth arrangement using mounted diagnostic casts.

Tomographic evaluation on bone morphology in posterior mandibular region for safe placement of dental implant

The aim of this study was to examine the morphology of submandibular fossae at edentulous posterior regions of dried mandibles and to determine a safe range for proper lingual angulation during the placement of a dental implant in the posterior mandibular region, with a computerized tomographic scan study. Spiral computed tomographic images of 77 dry adult human mandibles were evaluated to determine the deepest area in the submandibular fossa. Then, the proper lingual angulations for the placement of a dental implant at these regions were measured. Pearson's correlation coefficient was calculated to show the relation between the depths of submandibular fossa and lingual implant angulations. "Paired t test" was used for differences between the lingual implant angulations and the depths of submandibular fossa on each side of the mandibles. Depths of the submandibular fossa and lingual implant angulations were varied between 1.1 and 4.6 mm: 62°-84° on right side of the mandibles, and 1.1-4.5 mm, 65°-83° on left side of the mandibles. There were statistically medium negative correlations between the degree of lingual implant angulations and the depth of submandibular fossa on each side of the mandible (r = -0.44, p < 0.001, and r = -0.38, p = 0.001). There was a statistically significant difference between the right and left sides of the mandibles in terms of the depth of submandibular fossa (p = 0.01). Within the limits of this study, the depth of submandibular fossa was measured as ≥ 2 mm in around 71.5 % of examined regions, and lingual implant angulations were between 62° and 84°. These results may be considered by clinicians who are planning the dental implant placement in posterior mandible to avoid potential risk of lingual cortical plate perforation.

A technique for the presurgical simulation of the position of computer-assisted, template-based, planned implants: a clinical report

Computer-assisted oral implant surgery offers several advantages over the traditional approach. However, several unexpected procedure-linked adverse events during guided implant placement indicate that the clinical demands on the surgeon are no less than those observed during conventional placement. The aim of this report was to present a novel technique for the presurgical simulation of the position of computer-assisted, template-based, planned implants immediately before surgery. The presented technique could increase the clinician's confidence and the safety of the surgical procedures, which allows changes to the original plan if needed. The potential benefits of the present method should be confirmed by randomized clinical studies.

In vitro assessment of artifacts induced by titanium, titanium-zirconium and zirconium dioxide implants in cone-beam computed tomography

AIM

The aim of this study was to test whether or not the intensity of artifacts around implants in cone-beam computed tomography (CBCT) differs between titanium, titanium-zirconium and zirconium dioxide implants.

MATERIALS AND METHODS

Twenty models of a human mandible, each containing one implant in the single-tooth gap position 45, were cast in dental stone. Five test models were produced for each of the following implant types: titanium 4.1 mm diameter (Ti4.1 ), titanium 3.3 mm diameter (Ti3.3 ), titanium-zirconium 3.3 mm diameter (TiZr3.3 ) and zirconium dioxide 3.5-4.5 mm diameter (ZrO3.5-4.5 ) implants. For control purposes, three models without implants were produced. Each model was scanned using a CBCT device. Gray values (GV) were recorded at eight circumferential positions around the implants at 0.5 mm, 1 mm and 2 mm from the implant surface (GVT est ). GV were assessed in the corresponding volumes of interest (VOI) in the control models without implants (GVC ontrol ). Differences of gray values (ΔGV) between GVT est and GVC ontrol were calculated as percentages. One-way ANOVA and post hoc tests were applied to detect differences between implant types.

RESULTS

Mean ΔGV for ZrO3.5-4.5 presented the highest absolute values, generally followed by TiZr3.3 , Ti4.1 and Ti3.3 implants. The differences of ΔGV between ZrO3.5-4.5 and the remaining groups were statistically significant in the majority of the VOI (P ≤ 0.0167). ΔGV for TiZr3.3 , Ti4.1 and Ti3.3 implants did not differ significantly in the most VOI. For all implant types, ΔGV showed positive values buccally, mesio-buccally, lingually and disto-lingually, whereas negative values were detected mesially and distally.

CONCLUSIONS

Zirconium dioxide implants generate significantly more artifacts as compared to titanium and titanium-zirconium implants. The intensity of artifacts around zirconium dioxide implants exhibited in average the threefold in comparison with titanium implants.

Does cone-beam CT alter treatment plans? Comparison of preoperative implant planning using panoramic versus cone-beam CT images

PURPOSE

The present study was performed to compare the planning of implant placement based on panoramic radiography (PAN) and cone-beam computed tomography (CBCT) images, and to study the impact of the image dataset on the treatment planning.

MATERIALS AND METHODS

One hundred five partially edentulous patients (77 males, 28 females, mean age: 46 years, range: 26-67 years) seeking oral implant rehabilitation were referred for presurgical imaging. Imaging consisted of PAN and CBCT imaging. Four observers planned implant treatment based on the two-dimensional (2D) image datasets and at least one month later on the three-dimensional (3D) image dataset. Apart from presurgical diagnostic and dimensional measurement tasks, the observers needed to indicate the surgical confidence levels and assess the image quality in relation to the presurgical needs.

RESULTS

All observers confirmed that both imaging modalities (PAN and CBCT) gave similar values when planning implant diameter. Also, the results showed no differences between both imaging modalities for the length of implants with an anterior location. However, significant differences were found in the length of implants with a posterior location. For implant dimensions, longer lengths of the implants were planned with PAN, as confirmed by two observers. CBCT provided images with improved scores for subjective image quality and surgical confidence levels.

CONCLUSION

Within the limitations of this study, there was a trend toward PAN-based preoperative planning of implant placement leading towards the use of longer implants within the posterior jaw bone.

The influence of sinus membrane thickness upon membrane perforation during transcrestal sinus lift procedure

OBJECTIVES

Schneiderian membrane perforation is one of the main complications during sinus augmentation. The reasons may be associated with surgical technique, septum, inadequate ridge height, and membrane thickness. However, reports that used cone-beam computed tomography (CBCT) to quantify the thickness of sinus membrane were limited. The aims of this retrospective study were: to study the correlation between membrane thickness and perforation rate during transcrestal sinus lift and to propose a classification system of sinus membrane thickness based upon CBCT data.

MATERIAL AND METHODS

One hundred and twenty-two subjects who received dental implant restorations over posterior maxilla with a total of 185 transcrestal sinus lift procedures between years 2010 to 2013 were selected consequently. Each patient selected had to have taken CBCT in the initial examination and immediately after surgery. The membrane thickness, perforation rate, residual bone height, and elevated bone height were recorded and processed for statistical analysis.

RESULTS

The mean thickness of the Schneiderian membrane was 1.78 ± 1.99 mm. There was a significant correlation between membrane thickness and perforation rate (P < 0.05), and the perforation rate was higher in thicker (≥3 mm) and thinner membrane (≤0.5 mm). Among the thickness group, Class B (between ≥1 and <2 mm) had the lowest perforation rate. No significant difference was between the perforation and the membrane morphology. A negative relationship between residual bone height and membrane thickness was found. Trend showed that in the thicker and the thinner residual bone height, the higher the perforation rate would be.

CONCLUSIONS

There was a significant correlation between membrane thickness and perforation rate. The perforation rate was lowest when the thickness was 1.5-2 mm.

Radiographic stents: integrating treatment planning and implant placement

The pivotal point in treatment planning for dental implants occurs when the location of bone is viewed radiographically in the context of the planned prosthesis. Radiographic planning for dental implant therapy should be used only after a review of the patient's systemic health, imaging history, oral health, and local oral conditions. The radiological diagnostic and planning procedure for dental implants can only be fully achieved with the use of a well-designed and -constructed radiographic guide. This article reviews several methods for construction of radiographic guides and how they may be utilized for improving implant surgery planning and performance.

Analysis of bite marks in foodstuffs by computer tomography (cone beam CT)--3D reconstruction

The use of three-dimensional (3D) analysis of forensic evidence is highlighted in comparison with traditional methods. This three-dimensional analysis is based on the registration of the surface from a bitten object. The authors propose to use Cone Beam Computed Tomography (CBCT), which is used in dental practice, in order to study the surface and interior of bitten objects and dental casts of suspects. In this study, CBCT is applied to the analysis of bite marks in foodstuffs, which may be found in a forensic case scenario. 6 different types of foodstuffs were used: chocolate, cheese, apple, chewing gum, pizza and tart (flaky pastry and custard). The food was bitten into and dental casts of the possible suspects were made. The dental casts and bitten objects were registered using an x-ray source and the CBCT equipment iCAT® (Pennsylvania, EUA). The software InVivo5® (Anatomage Inc, EUA) was used to visualize and analyze the tomographic slices and 3D reconstructions of the objects. For each material an estimate of its density was assessed by two methods: HU values and specific gravity. All the used materials were successfully reconstructed as good quality 3D images. The relative densities of the materials in study were compared. Amongst the foodstuffs, the chocolate had the highest density (median value 100.5 HU and 1,36 g/cm(3)), while the pizza showed to have the lowest (median value -775 HU and 0,39 g/cm(3)), on both scales. Through tomographic slices and three-dimensional reconstructions it was possible to perform the metric analysis of the bite marks in all the foodstuffs, except for the pizza. These measurements could also be obtained from the dental casts. The depth of the bite mark was also successfully determined in all the foodstuffs except for the pizza. Cone Beam Computed Tomography has the potential to become an important tool for forensic sciences, namely for the registration and analysis of bite marks in foodstuffs that may be found in a crime scene.

Outcomes of implants placed with three different flapless surgical procedures: a systematic review

The aim of this systematic review was to evaluate the outcomes of flapless surgery for implants placed using either free-hand or guided (with or without 3D navigation) surgical methods. Literature searches were conducted to collect information on survival rate, marginal bone loss, and complications of implants placed with such surgeries. Twenty-three clinical studies with a minimum of 1 year follow-up time were finally selected and reviewed. Free-hand flapless surgery demonstrated survival rates between 98.3% and 100% and mean marginal bone loss between 0.09 and 1.40 mm at 1-4 years after implant insertion. Flapless guided surgery without 3D navigation showed survival rates between 91% and 100% and mean marginal bone loss of 0.89 mm after an observation period of 2-10 years. The survival rates and mean marginal bone loss for implants placed with 3D guided flapless surgery were 89-100% and 0.55-2.6mm, respectively, at 1-5 years after implant insertion. In 17 studies, surgical and technical complications such as bone perforation, fracture of the surgical guide, and fracture of the provisional prosthesis were reported. However, none of the identified methods has demonstrated advantages over the others. Further studies are needed to confirm the predictability and effectiveness of 3D navigation techniques.

Conventional radiography and cross-sectional imaging when planning dental implants in the anterior edentulous mandible to support an overdenture: a systematic review

The objectives for this systematic review were to determine if the pre-operative availability of cross-sectional imaging, such as cone beam CT, has a diagnostic impact, therapeutic impact or impact on patients' outcome when placing two dental implants in the anterior mandible to support an overdenture. The Cochrane Oral Health Group's Trials Register (CENTRAL), MEDLINE® and Embase were searched up to, and including, February 2013. Studies were considered eligible for inclusion if they compared the impact of conventional and cross-sectional imaging when placing dental implants in sites including the anterior mandible. An adapted quality assessment tool was used for the assessment of the risk of bias in included studies. Pooled quantitative analysis was not possible and, therefore, synthesis was qualitative. Of 2374 potentially eligible papers, 5 studies were included. Little can be determined from a synthesis of these studies because of their small number, clinical diversity and high risks of bias. Notwithstanding, it may be tentatively inferred that cross-sectional imaging has a therapeutic impact in the more challenging cases. In terms of impact, this review has found no evidence to support any specific imaging modality when planning dental implant placement in any region of the mouth. Therefore, those who argue that cross-sectional imaging should be used for the assessment of all dental implant sites are unsupported by evidence.

Basic training requirements for the use of dental CBCT by dentists: a position paper prepared by the European Academy of DentoMaxilloFacial Radiology

Cone beam CT (CBCT) is a relatively new imaging modality, which is now widely available to dentists for examining hard tissues in the dental and maxillofacial regions. CBCT gives a three-dimensional depiction of anatomy and pathology, which is similar to medical CT and uses doses generally higher than those used in conventional dental imaging. The European Academy of DentoMaxilloFacial Radiology recognizes that dentists receive training in two-dimensional dental imaging as undergraduates, but most of them have received little or no training in the application and interpretation of cross-sectional three-dimensional imaging. This document identifies the roles of dentists involved in the use of CBCT, examines the training requirements for the justification, acquisition and interpretation of CBCT imaging and makes recommendations for further training of dentists in Europe who intend to be involved in any aspect of CBCT imaging. Two levels of training are recognized. Level 1 is intended to train dentists who prescribe CBCT imaging, such that they may request appropriately and understand the resultant reported images. Level 2 is intended to train to a more advanced level and covers the understanding and skills needed to justify, carry out and interpret a CBCT examination. These recommendations are not intended to create specialists in CBCT imaging but to offer guidance on the training of all dentists to enable the safe use of CBCT in the dentoalveolar region.

Localization of impacted maxillary canines and root resorption of neighbouring teeth: a study assessing the diagnostic value of panoramic radiographs in two groups of observers

OBJECTIVES

To assess the diagnostic value of panoramic views (2D) of patients with impacted maxillary canines by a group of trained orthodontists and oral surgeons, and to quantify the subjective need and reasons for further three-dimensional (3D) imaging.

MATERIALS AND METHODS

The study comprises 60 patients with panoramic radiographs (2D) and cone beam computed tomography (CBCT) scans (3D), and a total of 72 impacted canines. Data from a standardized questionnaire were compared within (intragroup) and between (intergroup) a group of orthodontists and oral surgeons to assess possible correlations and differences. Furthermore, the questionnaire data were compared with the findings from the CBCT scans to estimate the correlation within and between the two specialties. Finally, the need and reasons for further 3D imaging was analysed for both groups.

RESULTS

When comparing questionnaire data with the analysis of the respective CBCT scans, orthodontists showed probability (Pr) values ranging from 0.443 to 0.943. Oral surgeons exhibited Pr values from 0.191 to 0.946. Statistically significant differences were found for the labiopalatal location of the impacted maxillary canine (P = 0.04), indicating a higher correlation in the orthodontist group. The most frequent reason mentioned for the further need of 3D analysis was the labiopalatal location of the impacted canines. Oral surgeons were more in favour of performing further 3D imaging (P = 0.04).

CONCLUSIONS

Orthodontists were more likely to diagnose the exact labiopalatal position of impacted maxillary canines when using panoramic views only. Generally, oral surgeons more often indicated the need for further 3D imaging.

Cone-beam computed tomography: time for an evidence-based approach

Cone-beam computed tomography (CBCT) is an imaging technology that has revolutionised dental imaging in the last decade. Although of particular value to specialists performing implant treatment, it is increasingly being adopted by general dental practitioners. As the radiation dose is higher than that of conventional radiography, it is important to consider its diagnostic efficacy for the common tasks performed in general dental practice, such as caries diagnosis, endodontics and the detection of periapical pathosis. Any new imaging technique needs to have proven advantages over existing techniques before it is adopted, yet the evidence remains quite limited. Furthermore, image quality and radiation doses vary enormously between different manufacturers' equipment, so that extrapolating results of one piece of research from one CBCT machine to another is fraught with pitfalls. Radiation doses with CBCT are typically an order of magnitude higher than conventional radiography. There is scope, however, for reducing these doses by judicious adjustment of exposure factors and limiting the field of view to the smallest dimensions consistent with the clinical situation. There is still a long way to go before we understand the value of CBCT in dentistry. High quality research evidence is needed, particularly with regard to assessing whether using BCT improves patient outcomes.

A questionnaire study to investigate custom and practice of imaging methods for the anterior region of the mandible prior to dental implant placement

OBJECTIVES

To investigate the custom and practice of private dental implant practitioners in the north-west of England when planning imaging methods prior to implant placement in the symphyseal region of the edentulous mandible. To gain an understanding of decision-making when prescribing imaging methods.

METHODS

A web-based questionnaire presented two realistic clinical scenarios. Both were of edentulous patients for whom implant-retained lower complete dentures were planned. A mixed mode survey methodology was employed.

RESULTS

169 dentists were surveyed with an 80% response rate. The results showed no agreement on prescription of imaging methods. Those in the 0-10 years qualified group were significantly associated with the prescription of three-dimensional (3D) imaging. Implant practitioners who place more than 100 implants per year were significantly associated with the non-use of imaging guides and prescription of the same view for both cases. The sample as a whole, however, changed their prescription according to the case difficulty. Those who have a cone beam CT machine available were more likely to use 3D imaging regardless of the difficulty of the case.

CONCLUSIONS

Existing guidelines are open to interpretation and could be construed to support a range of imaging choices. Training in dental implantology may leave dentists to make their own judgements about selection criteria. The idiosyncratic nature of independent dental practice may be an important factor in the chaotic pattern of prescriptions. There is a need for widely disseminated, evidence-based selection criteria for imaging prior to dental implantology which are clear and specific.

Cone-beam computed tomographic analysis of sinus membrane thickness, ostium patency, and residual ridge heights in the posterior maxilla: implications for sinus floor elevation

OBJECTIVE

To determine, using cone-beam computed tomography (CBCT), the residual ridge height (RRH), sinus floor membrane thickness (MT), and ostium patency (OP) in patients being evaluated for implant placement in the posterior maxilla.

MATERIALS AND METHODS

CBCT scans of 128 patients (199 sinuses) with ≥1 missing teeth in the posterior maxilla were examined. RRH and MT corresponding to each edentulous site were measured. MT >2 mm was considered pathological and categorized by degree of thickening (2-5, 5-10 mm, and >10 mm). Mucosal appearance was classified as "normal", "flat thickening", or "polypoid thickening", and OP was classified as "patent" or "obstructed". Descriptive and bivariate statistical analyses were performed.

RESULTS

MT >2 mm was observed in 60.6% patients and 53.6% sinuses. Flat and polypoid mucosal thickening had a prevalence of 38.1% and 15.5%, respectively. RRH ≤4 mm was observed in 46.9% and 48.9% of edentulous first and second molar sites, respectively. Ostium obstruction was observed in 13.1% sinuses and was associated with MT of 2-5 mm (6.7%), 5-10 mm (24%), and >10 mm (35.3%, P < 0.001). Polypoid mucosal lesions were more frequently associated with ostium obstruction than flat thickenings (26.7% vs. 17.6%, P < 0.001).

CONCLUSION

Thickened sinus membranes (>2 mm) and reduced residual ridge heights (≤4 mm) were highly prevalent in this sample of patients with missing posterior maxillary teeth. Membrane thickening >5 mm, especially of a polypoid type, is associated with an increased risk for ostium obstruction. In the presence of these findings, an ENT referral may be beneficial prior to implant-related sinus floor elevation.

Teamwork in implant dentistry: the provision of a maxillary implant retained overdenture

This case demonstrates a pragmatic, yet systematic, team approach to resolving a challenging clinical situation. It is essential to understand and accept the challenges presented and limitations of the treatment options available in the provision of an MIO. The dental surgeon and clinical dental technician collaborated using their combined skills set. Working as a team gives each clinician a greater appreciation of the difficulties faced clinically and technically. We believe that an enhanced standard of care is delivered to patients by using this team approach.