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Single Tooth Replacement Part 2& 3 Summary Note
Single Tooth Replacement Part 2& 3 Summary Note
• احنا بلشنا الحاضرة الماضية عن ,single tooth replacementووصلنا لعند خيار ال single
, implantهس حنكمل نحكي عن single tooth implant
• Q: what are the advantages of single tooth implant ??
- When we have sound adjacent tooth , rather than prepare it , we can put single
tooth implant and preserve the sound tooth
- Psychological : mean patient don’t want to prepare teeth to replace just one
tooth
- More hygienic : because patient have single crown not splint يعني مش مرتبطwith
other crown
الباقي بالجدول
• Q:what are the disadvantages of single tooth implant ??
- Surgical invasiveness ( but nowadays with guided implant surgery , the surgery
become easier )
- More time ( time for osteointegration , especially when the primary stability is
low so need more time )
- Cost مش متأكدة هاي األخيرة الي حكتها او ال
• Q : if we have 2 cases ( well-made 3 units fixed bridge VS single tooth implant ), do
we have differences in success rate ?? /////or in other words : is there clinical
study told me that single implant is better than 3 units fixed bridge ??
ANS : NO , we don’t have , BUT " "بالتأكيد يعني والمنطقif we have sound teeth , I would
prefer place implant rather than fixed bridge
الها برضوimplant النه ال, well- made برضو حينجح "بشرط" يكونbridge لكن لو عملنا
long term بالذات علىcomplications
• If we have 2adjacent teeth, teeth are heavily restored and endo treated need
crowning → here I can do 3 units bridge or single implant with separate crowns
all options are available , اتس اوكييي
spacing requirements رح نحكي من نواحي, single tooth implant • نبدأ هس بموضوع
طول ما انت طبيب اسنان انت, وهللا شكله كلمة ريكويرمنتز مش بس حنسمعها بالجامعة, ) ندخل مني
) محكوم بريكويرمنتز لطول الحياة
: • هناك قاعدة معروفة
We need space for :Implant to tooth 1.5 mm , implant to implant 3 mm
But the question is : from where we take or measure these numbers ??( من وين
)نقيس يعني ؟and why these numbers ??
➔ Do we measure from CEJ ?or from hight of contour ??
• 1mm of bone should be present on facial and lingual aspect of implant
• First of all : why 1.5 between implant and tooth ,, and 3mm between implant and
implant ?? from where these number came ?? answer is saucer
oral لexposure of implant لما تتعرض او يصير,implant هس أي,saucer • عشان نفهم ال
biological width around this implant will form ال, cavity
- This biological width dictate some bone resorption will occur , and we consider
this bone resorption as physiological , we don’t consider this resorption as
pathological , until it is not exceed certain amount
او اسمbiological width الزم تكون, oral cavity يعني أي زرعة بالدنيا مجرد ما تنكشف لل
resorption هاي ال,bone resorption بتكون نتيجة, peri-implant soft tissue cuff ثاني
physiological normal resorption اذا ما تغطى حد معين بعتبره
➔ This phenomena called " implant saucerization " which mean circumferential
bone loss around the implant
- This bone loss have vertical and horizontal dimensions
- Why this phenomena occur ??one the most accepted theory behind this bone
resorption is biological width formation
: حيصير عنا احتمالين, peak of bone حيذوب ال, مم3 • في حال كانت المسافة بين الزرعتين اقل من
1- Recession of papilla and follow the bone
2- If thick soft tissue biotype → deep pocket
واي, deep pocketing وصار عنا, بس العظم ذاب وصار نحت, مكانهاsoft tissue يعني ال
بس حسب ما فهمت, بكون _______________ ( ما سمعت,pocket more than 4 mm
) peri mucositis or peri implantitis انه بزيد احتمالية
• Clinical example of 2 implants :
- 2 centrals are too close to each other
- The papilla between 2 centrals and recced and loss , because the distance
between 2 implants is less than 3 mm → bone loss→papilla follow the bone
and recede
• Sometimes , the tooth have big convexity or have mesial tilting , it is preferable
during final impression before make final crown , do enameloplasty → to make
contact between tooth and abutment wide , not point to prevent food impaction
• The implants in both x ray images consider failure implant , why ?? because we
can't load prosthesis over implant , even there is good osteointegration
بس بقدرش اركب عليها
ortho او األفضل طبعاtrimming كمان عملنا شوي, الزرعة كان الزم تنحط انه تكون مايلة اكثر لتستقبل التركيبة
up rightening
• Clinical measurements is always measure clinically , we don’t depend only on x
ray
2d x ray خوفا من أخطاء بصورة االشعة بالذات ال
• There is 2 specific points regarding 1st premolar implant :(esp maxillary 4):
1- 30% of canine is tilting distally → usually , because of this distally tilting of
canine , we also tilt 4 to be parallel with maxillary canine
؟؟بنعملهاmesiodistally بس شو مشان ال,Buccolingual لما حكت الدكتورة بتحط الزرعة عموديا فهي قصدها
9 او10 في عندي خيار ثاني احط زرعة اقصر مثال,, root of canine فرح نطبparallel اذا مكانتش,tilting
ونص
short and standard length of بل هي الحد الفاصل بين,short implant ال تعتبر9 mm • ال
implant
2- If pt extract 1st premolar for 1or 2 yr , you will notice bone concavity (bone
resorption pattern in maxilla is palatally →)يعني بفوت لجواthis concavity will
cause esthetic problems , what is the solutions ?:
a) It is highly recommended to manage this concavity by bone grafting and soft
tissue grafting to have good esthetic and good contouring for your finally
crown
حطيت, رحنا عملنا زرعة وكله تمام, نالحظ الصورة هون-
النه لما العظم ذاب,more palatally الزرعة بس كانت
:final results هون هاي,, palatally بروحmaxilla بال
It is good from OH , function , biology point of view ,,,,,but it is
not accepted esthetically → called recessed emergence profile
→ the solution if bone graft buccally لحتى ارجع اطلع العظم برا
وبعدين ركبت التركيبة صح
b) Second option اذا بدناش نزرع ونصلح شو راحis crown with ridge laping
و بس شوgood esthetic حتعطيني, اكثرbuccally يكونcrown يعني برز ال
مشاكلها ؟؟
للزرعة الي هيlabially التلبيسة رايحة كثير,biomechanics من ناحية.1
حتعمل,palatally والزرعة كثير,labially بس تيجي القوة, palatally
cantilever of axial load
2. The most important complication is food impaction ( from biology point of view )
beneath crown
3. Prevent probing labially
4. Have poor prognosis ( bad OH , cause peri- implanitits )
5. Very important note in prosthodontic : The gingival side of any prosthesis , never be
concave , should be either flat or convex
يعني,concave هس ب هون مبين,concave ما يكونgingival side of pontic or crown يعني ال
المريض لو جاب كل طرق التنظيف ما حيقدرsaddle pontic is contra-indication هس ال,saddle
bad odor وحيصير يشكي من, ينظف تحتيه
• Conclusion :The solution of this concavity is soft and bone grafting then implant or
the patient accept the appearance of implant
- If pt refuse bone graft and appearance → ridge laping but on pt responsibility ,
and every 3 months pt come for crown removal and cleaning beneath it
• The second premolar is also easy , but remember the sinus in upper and mental in
lower → so we either do sinus lifting in maxilla or use shorter implant in case no
enough bone hight
وأخيرا نحكي عن ,1st molarال mesiodistal dimensionبشكل عام يتراوح من 8ل 14مم : •
-اذا كان ال ,mesiodistal width = 14 mmهل فيني احط زرعة 4مم ؟؟ هس نطرح 4مم ,بظل
عندي 10مم 5 ,مم على الجهتين ,mesially and distallyرح تعملي cantilever effect
• This table to make the planing easier مش ضروري نلتزم فيه مية بالمية:
- MD = 7 mm → implant of 4 mm
- MD = 12 mm → if we use 4 mm , we will have 3.5 mm cantilever effect ,
this 3.5 mm acceptable ( but we prefer to make all foces centrally when
we examine with articulating paper )
- MD space = 14 mm and more → this space is for 2 implant ( because
we use 2 implant we subtract 6 mm (6 come from 1.5 between tooth and
implant + 3 between implant )
for example sapce = 15 mm → 15 – 6 = 9 mm → we can put 2 implants
of 4.5 mm in diameter
space =14 mm → put 2 implants of 4 mm in diameter
space = 16 mm→
مم4 مم ؟؟احسن احط5 هل من المنطق احط زرعة
4- Gingival biotype :
- We have 2 main gingival biotype : (note : there is no clear cut between thick
and thin بس ممكن نحكي شوي عن ارقام وطرق لتمييز, )يعني حد واضح نفرق بينهم
1. Thick biotype : thickness more than 1 mm , wider keratinized gingiva , tooth غالباis
short square teeth , short papillae between teeth
- We know zone between free gingival margin and mucogingival junction is
keratinized attached gingiva
2. Thin biotype :thickness is 1 mm or less, narrower keratinized gingiva , غالباlong taper
triangular teeth , long thin friable papillae
• Once the tooth has been extracted , papilla is easily to be shrink and lost
• There is thick , medium , thin biotype →
thin and thick بس الدكتورة بدها تركز على
• Q:How to measure the width of keratinized attached gingiva ?
It is between gingival margin and mucogingival junction
• Q : how to verify the gingiva is thick or thin biotype ?
1- We can use the digital caliber to measure the thickness of gingiva
2- We can use CBCT , if we make separation between lip , check and gingiva
during taking x ray by cotton roll or lip retractor , to prevent these soft tissue
appear as one segment → so I can measure the thickness of gingiva labially and
palatally ( but we focus on labial part )
3- Simple easy technique : Place periodontal probe in the sulcus → a)if I see the
probe from underneath gingiva , I consider
the gingiva is thin biotype b) while if I cant
see , the gingiva will be thick biotype
• Q: what is the effects of gingival thickness on the complexity of the case in esthetic
zone ?
- If the gingiva is thick biotype , we consider it less esthetic risk , for many
reasons :
1. Mask easily the underneath abutment or implant apical part →so shadow
of metal or grayish color of abutment will not appear
2. On the long run , low possibility of recession will occur due to thick , in
contract to thin biotype which is more suspectable for peri-implant soft
tissue recession
3. Papillae already are short, no need to reconstruction of papilla or make
adjacent tooth longer to increase contact area to gain papilla after loss as
in thin biotype
- Soft tissue recession will cause more bone loss → affect final results of esthetic
and biology of my implant -crown
- Th only drawback of thick biotype is more prone to scaring , if we do surgery (
for example : surgical releasing incision )→ increase of post surgical scaring
→a.Surgical vertical releasing incision do distal to the canine , no vertical
releasing incision in anterior zone
b.if we do in anterior zone , it is preferable to use small suture and remove it in
very short time ( not more than 5-7 days) to decrease risk of post surgical
scaring
c.It is also preferable to not extend vertical release incision beyond
mucogingival junction
esthetic zone فيthick biotype • مع هيك بنفضل ال
• Thin biotype is more difficult , more challenging , less predictable case , need more
procedures ( more costy , more time , need more skills of dentist )
• In case of thin biotype in esthetic zone , rule " always I should try to make case from
thin to thick or medium biotype "
- All case in esthetic zone with thin biotype , and I plan to do immediate or delay
implant placement أي كانت الطريقة, I need to transfer the biotype from thin to
thick making soft tissue grafting
- Soft tissue grafting or gingival grafting is predictable procedure, يعني سهلة تنعمل
- Transfer from thin to thick biotype is highly recommended in the esthetic zone
• If we don’t do soft tissue grafting or augmentation , the case more prone for
recession and not mask the color of metal components
• It is highly recommended to use zirconia abutment and zirconia crown
- It is very important abutment be
zirconia
• We can also place implant slightly more palatal and slightly more deeper in comfort
zone for same purpose (to mask the colour of metal components )
• Use zirconia abutment , the color is white so no grayish color of titanium abutment
• If we do soft tissue grafting , the using of zirconia does not matter
- More than 2 mm thickness of gingiva on labial zone , it is not matter if I use
zirconia or titanium abutment, both are accepted
- If the gingival thickness is 2 mm or less → it is highly recommended to use
zirconia abutment to prevent graying color showing under neath the gingiva
→So the criteria that determine the predictability of papilla fill between implant and natural
tooth is the level of interproximal bone on the adjacent teeth not implant
Site 2 Site 1
Implant
crown
• In this case we have upper left central implant crown , papilla here is about to fill
• If we evaluate the pink esthetic score , one of item is papilla level :
➔ Papilla level on site 1 in comparison with contralateral site ( site 2 ) is deficient ,
and this will affect esthetic especially in patient with high smile line
• Papilla need 3-6 months to grow ,but how could I tell or determine if my papilla will
filled this space or not ??ماشي بدها وقت بس كيف اتأكد انها قاعدة بتملي المسافة ؟؟
- We use perio probe and measure from this level دائرة زرقاto interproximal bone
on adjacent tooth :
If distance = 3mm → بس استنى يا مريض وانا متأكد, مم2 بابيال معها مجال تنزل كمان
)انه حتنزل%99(
If distance = 5 mm → possibility of grow of papilla 2 mm is much less ( 50-60 %
sure ) so predictability of papilla fill is less
1
5mm
8-faciopalatal width should be evaulate
• The pic (1) show case need implant to replace central incisor , let is evaulate esthetic risk :
1- Gingival marginal level is very excellent in comparable with adjacent teeth
2- Bone sounding is 2 mm apical to this point →perfect buucal bone height إشارة خضرا انه األمور تمام لهس
3- In CBCT , buccolingual width is 5 mm :
عادة ما,3.5 to 3.8 mm احنا في مكان سنترال عادة بدنا زرعة تكون تتراوح من,esthetic zone مم في5 هس-
3.8 وما في داعي برضو احط زرعة اكثر من, 3.3 mm او3 مثلcentral incisor فيnarrow بنحط زرعة
mm
- 3.8mm is perfect implant size to replace central incisor , but 3.8 mm in esthetic zone
6.8 mm =3.8 + 3 < فهيك بدنا-- buccal and lingual عظم يكون1.5 mm ونحط كمان
more buccal bone بدي,) هاد بشكل عام1.5 mm (الesthetic zone ونحط كمان اشي زيادة خاص ب
مم2 يعني يفضل يكون اكثر من,thickness
➔ Summary : 3.8 mm(size of implant )+2 buccally in esthetic zone +1.5 ligually = more than 7
mm is needed
1.5 mm و,buccaly مم2 بدي يكون اكثر من,3.8 mm وبدي احط زرعة, مم5 • تخيلوا تكون السهم األسود يساوي
horizontal bone augmentation at time of < اذن الحالة حتحتاج-- مم سمك العظم7 يعني بدي اكثر من,,lingually
buccal bone وبدها زراعة عظم لنزيد سماكة,more risky وهيك صارت العملية,implant placement
• Other important factor to evaluate is mesiodistal gap :
- We measure it at CEJ level, also at the height of contour
- In the case show in pic , even the space between root and
implant is sufficient , the space for prosthesis is
insufficient → failure implant
• كل ما كان االسنان المجاورة للزرعة ,intactو ,,not crownedبكون االشي احسن من ناحية predictability of implant
,,placementلما يكون في crown or bridgeبزيد من صعوبة الحالة
• برضو الزم نقيس ,,mediodistal widthأحيانا بكون عرض missing toothاكبر من ,,contralateral toothهذا االشي
بنفحصه بأول الجلسات قبل ال اعمل ,implant placementبانه بنعمل ,wax up of caseحتى لو كان virtually or
,digitall or manually wax upحتى اشوف ال future of implant crown
• نالحظ السن بالصورة ,عرض السن كثير كبير ,فاالولى بهاي الحالة ن حكي للمريض"تمام حنعمل زرعة هون ,بس عشان
المنظر يكون احلى ومتناسب ,بدنا نعمل veneerعلى السن الي جنبه ,وبنحصل على تماثل بين سنترالز"هذا الحكي يقرر من
الجلسات األوائل ,مش لما أوصل لمرحلة التركيب اقرره
Q: how to anticipate this problem ?? by making diagnostic wax up prior to any implant procedure
• This table is summary of esthetic risk evaluation
• In smoking , we calculate pack/ years , how many years have been the patient smoker ??if it > 5 ,
increase difficulty of ttt ( bone and soft tissue grafting , implant success rate )
• Triangular tooth often with long thin friable papilla → after implant crown , it need veneer of
adjacent to make lengthening of contact area
• Width of the span : the easiest case to work with is single gap according to esthetic success
much better compare ,Esthetic results حتكون الكيس من ناحية,single tooth in esthetic zone كل ما كانت
with two or more missing adjacent teeth
• Bone anatomy : bone within 2-3 mm from gingival margin → case is straightforward , while more
than 3 mm from gingival margin to buccal bone crest → case need bone augmentation and more
difficult
• Lets evaluate this pic :
1- Missing 2 teeth
2- High lip line
3- Thin biotype ( from shape of tooth and long papilla)
مع هيك الزم افحص كلينيكاليي
4- High expectations of patient
➔ Have the maximum esthetic risk
• Now we will talk about section 2 of this lec , موضوع كثير مهم,is planning positioning
- Where to place my implant ??
other criteria وحنركز هس على,mesiodistally وين نحطها, اخذنا جزء منه -
• We need 1.5 -2 mm from CEJ , but we should else take height of contour in consideration , less than
1.5 mm → I could not make good emergence profile of my crown → so we measure from CEJ and
height of contour
• If the adjacent tooth is bulgy → remove some bulging to widening the contact area between the tooth and
implant crown , especially in non esthetic zone
• The green area is comfort zone while red area is danger zone
فهيك احنا دخلنا بالمنطقة الحمراء وبنعرف شو تبعات هذا المكان, مم قريبين على السن المجاور1 كل ما كنا اقل من
• This is example of implant crown in ideal position mesiodistally , this maintain the papillae and bone
level , no resorption occur
• Less than 1 mm to adjacent lead to :
1- Bone loss on adjacent teeth → papilla loss →black triangle
2- Bone loss on adjacent without papilla loss → deep pocket , any pocket more than 4 mm is highly
amenable to peri-implantitis
• Encroaching the nasopalatine canal → trauma → nasopalatine cyst (appear as swelling lingually)
• Management : controversial :
1- Better to remove implant and do enucleation , but this lead to need massive bone augmentation
2- Other option is apicectomy and enucleation completely of cyst , there is risk of no complete removal of
cyst cells on implant threads → recurrence
,diagnostic wax up احنا عادة بنعمل, 2 mm palatal to emergence of future implant crown كمان الزم يكون •
simple guide to guided surgery (cad /cam guide ) وبتراوح الموضوع من
Simple
Cervical area of
guide
future implant
crown
Emergence profile
of implant
نالحظ,, diagnostic wax up of future implant crown ناتج منstent عبارة عن, simple guide هون مثال على •
cervical margin of future implant crown لpalatal مم2 يكونemergence of implant ال
Immediate
implant
placement Healed side
implant
• Here talk about immediate implant placement in esthetic zone , the distance between implant and
inner surface of buccal bone plate (junction gap )more than 1.5 mm نقطة كثير مهمة, mean never make
contact with buccal bone plate
غالبا بfacial plate of esthetic zone ال,post extraction remodeling النه الطبيعي بعد الخلع يصير اشي بنسميه
resorption وهذا العظم حيصيرله,just bundle bone (very thin bone ) من الحاالت بكون% 90
➔ If the implant make contact with facial plate at time of extraction /immediate implant
placement → this bone is surely be resorbed → and the implant will be out of bone
envelope يعني مش محوطة بعظم من كل الجهات
• Junctional gap is recommended to fill with bone graft ( not left empty )→ to decrease buccal bone
remodeling amount
• In healed site implant ( )يعني خلعت وصار شفاء بعدين زرعت, here we want buccal bone more than 2 mm
in esthetic zone , in this image the amount is insufficient and need bone grafting
• If the implant put in danger zone , the bone will recced
او,,* ممكن بعد سنتين من وضع الزرعة, بس صارت بهاد المكان مع الوقت ولما ذاب العظم, • الزرعة ما انحطت بهاد المكان
معcontact بس عملbuccal plate كان فيه, الدكتور حط الزرعة,immediate implant placement ممكن خالل
,socket collapse ال, bone remodeling or buccopalatal bone collapse العظم فذاب العظم مع الوقت النه صار
thin buccal plate , thin buccal ولكن معظم الناس عندهم,, في كثير عوامل بتتحكم فيه,variable الموضوع طبعا
شهور حيصير6 بعد اقل من,buccal plate فاذا كانت الزرعة عاملة كونتاكت مع ال, هذا العظم حيروح,bundle bone
,reccesion حيصير,soft tissue thin واذا كان ال,,contact with soft tissue فيه ذوبان وتصير الزرعة
عندي حتبين كما في الصورةimplant وال
• This ( buccal implant mal -placement ) is the most common error and one of the most complicated
and coslty error to be corrected
• The error here is implant placement facially malposition ,,, cbct show the implant out of the bone
)............ الدكتورة عاد ت الحكي الي فوق ( هي ما كانت بهل المكان
Cbct show
implant out
of bone
Here on
periapical
show
perfect
result
الزرعة, الزرعة طالعة برا العظم تماما,guide من دون,flapless surgery الد كتورة بتحكي هون انه ممكن الدكتور عمل •
,, bone grafting الحل هو إزالة الزرعة ونعيدها ونعمل,,,,crown loading حتعملي مشاكل كثير بعد
• We can't نحكمcase on 2d radiograph
Here is
healed
implant
Here is
immediate
implant