TRANSCRIPT:

Okay, so now I'm going to show you how I treatment plan from panoramic X-rays. I like to use Panos to give me a big picture overview of what's going on for that patient. I find it's the most expedient way to really get a snapshot and come up with a ballpark idea, ballpark figures, and timeline for that patient and kind of present something preliminary to them. If the patient is receptive to it and they want to move forward, that's when I go ahead and do my thorough examination, take FMX and check every tooth because you don't want to spend all this time, getting a full-on exam and making this huge treatment plan for somebody that's not really interested in that plan anyway.

So, it's really important to be able to treatment plan pretty quickly for implant treatments from a pano. Let's go over some together, and I'll just make comments on outlining the IA, on outlining the floor of the sinus, and some things in between. For example, this patient right here, I think it's a really great-looking case to start out with. This patient is missing number 13 right up here. I would recommend using the measuring tools that come on your pano machine or that come with the computer hooked up to your pano machine. Use those measuring tools, and what we're going to do is just kind of measure from the crest of the ridge to the floor of the sinus.

If they have 10 millimeters of bone height in the posterior maxilla, I feel that's comfortable to place implants. If they have less than 10 millimeters, I would advise maybe starting on a different case. The case has just become a little bit more challenging because you run into the possibility of breaking the floor of the sinus or entering the sinus, and it might be a little bit stressful if you're not super comfortable with implant procedures.

In this case, you can see that the inferior alveolar nerve canal is so low, and it appears to exit somewhere around here. You need at least 7mm of mesial-distal room to place an implant. For a 4mm implant, you're going to need 1.5 in the mesial and 1.5 in the distal, so a total of 7mm of mesial-distal room to place an implant. Make sure you have enough space from crown to crown also, not just by the roots but also by the crowns. 

On this other side, you also have very limited alveolar bone, about 3mm or so, and it's kind of wiggly here. It's not much room for your implants back here. The CBCT is always the best and the safest route to go, but just using this pano as a reference, it looks like the nerve is somewhere around here. This patient is a tough restorative case, and if you place an implant right here, you're going to be breaking through the floor of the sinus in this area. You definitely need a sinus lift.

For this patient, there are two spaces right here. This one right here looks like it's kind of pushing the envelope in terms of that height, about 8mm. You can place an 8mm implant, but you have to tell your patient that you could be going into the sinus a little bit, and you have to be prepared to manage that.

As I've mentioned, I routinely go into the sinus when I place my implants and generally heal uneventfully. Right here, there's definitely enough vertical height and looks like enough mesial-distal space. Down here, you can also distinctly see the inferior alveolar nerve Canal. You can follow it around this way, and this is a patient in which you can see that there's more limited height above the inferior alveolar nerve canal. This looks like the mental foramen right here. And so you still look like you have at least 10mm of space here. Right here, you might be getting a little bit tight.

Over on the patient's left side, you have an active infection. So these will need to be removed before placing implants. And note that, you know, even though the mental foramen is here, it looks like you can actually see the vasculature that goes forward, that goes anterior right here. Remember that the IA nerve exits through the mental foramen, becoming the mental nerve. Some vasculature does go forward, and if this vasculature is ruptured, it could be a little dangerous. So you definitely have to be aware of the vasculature that lies anterior to the mental foramen as well. It's not just the IA canal that you're worried about. Any time there's vasculature here that you're here, you have to make sure to be aware of it and be mindful of drilling too deep in this area.

Is another patient. And I want to show you this example because this site looks really nice, replant placement, right? Looks like about 10mm or a little bit more of vertical space. There's definitely enough mesial-distal room between the roots and the crowns. Right here, I want to show you this because you can see that it looks like there is enough height. It looks like it's unclear where the crest of the ridge is. It's almost like you can still see the little Shadows from the tooth being extracted, and this Shadow in particular looks a little bit makes me a little bit nervous. Because it looks like almost like a communication between the oral cavity and the sinus. Whenever I see any bone that has a shadow like this, I always err on the side of caution.

And I'm not expecting any for there to be any bone right here. There might be some granulation tissue, but I'm not expecting there to be any bone, and so I would expect that the situation right here will be to open it up, graft it, close it, and place the implant five months later. Four or five months later, but just want to show you whenever there's any sort of shadow, you know, at least err on the side of caution and don't over-promise. Don't go in trying to place an implant, and then your implant falls out goes into the sinus.

Okay, so now let's look at this patient. So this patient also looks like it's a little tough to see the inferior alveolar nerve Canal. This looks like it's it right here. Remember how I was saying that whenever I see, I can only see one line like, for example, right here, I can only see one line. I always assume it's the inferior border. And I see it go over there and looks like it loops back right there. So maybe the mental foramen is right here and then the little anterior loops right here. And obviously up here, there's no room for a dental implant. That looks like 3 millimeters of height.

Here's another patient. I hope this is starting to become a little repetitive because the more you look at this and the more that you practice this, you're going to start to get really comfortable with doing this for your patients, plenty of height here. This looks a little limited. This looks like it could be like 8 millimeters of height, the rest of it looks okay. This height looks like it could get a little bit limited for you. Right here, looks like you're following the top edge of that IA canal right here is the foramen, so you should be able to get away with 10mm of implants up here.

Okay, so one thing that a pano is not the best for, it's not really good at is planning anterior teeth, planting implants for anterior teeth. In this particular situation, this is a great shot of the anterior segment. A lot of times there's a lot of distortion at the anterior portion. But anyway, in this situation, you can see pretty well actually the nasopalatine fossa. That's what you're looking for. In the interior maxilla, you want to make sure you have enough room distal to the nasopalatine fossa, and you want to make sure you have enough boney height.

So here we can see that for the number 8 spot you have this, this is the crest of the ridge right here and then go all the way right there to the floor of the nose. Alright, and so we want that to be at least 10mm and from here to here. So from the edge of this route to this to this radiopaque area. Right next to the nasopalatine fossa, you want that to be at least 7mm as well. And so this area right here looks a little bit wider, but you definitely want to respect the nasopalatine fossa and you need to place your implants in such a way that they're not impinging on the nerve space there. Even though that nerve does not innervate a lot of things. If you do impinge on the nerve, you can definitely cause some altered sensations, and it's better to avoid all that altogether.

That's it right there. I hope that was useful for you. Let's get onto looking at how to plan your cases with a cone beam.

Lesson Summary

The text discusses the importance of measuring bone height and spacing when planning implant treatments using panoramic X-rays. It emphasizes the need to maintain adequate distance from the nasopalatine fossa and the inferior alveolar nerve canal to avoid complications.

The limitations of panoramic X-rays in planning anterior teeth implants are mentioned, and cone beam technology is suggested for more accurate planning.

The author explains their process of treatment planning from panoramic X-rays. They find panoramic X-rays useful for getting an overview of a patient's dental condition and coming up with a preliminary treatment plan.

• Ensuring at least 10 millimeters of bone height in the posterior maxilla for implant treatments
• Using measuring tools to determine the space available for implants
• Considering the position of the inferior alveolar nerve canal and the mental foramen to avoid complications
• Suggesting sinus lift in cases with limited bone height

Caution is advised when interpreting unclear areas on the X-ray, and the author suggests erring on the side of caution when considering implant placement.

Panoramic X-rays may not be ideal for planning implant placement in the anterior teeth.