4/24/2018

ADVANCED IMPLANT
SURGERY: FROM TREATMENT
PLAN TO TEMPORIZATION
Alexandre Khairallah DDS. HSSD. PGD.DEADMFR.MBAIRD
Post Graduate Diploma in Oral Biology
High Specialized Studies Diploma in Oral Surgery
Post Graduate Diploma in Oral & Maxillo-Facial Imaging
Diplomat of the European Academy of Dento-Maxillo-Facial Radiologist
Member of the Implant Council -BAIRD- British Academy of Implant &
Restorative Dentistry
Partner/Opinion Leader Kavo Dental GmBH - Radiology division
Partner/Opinion Leader Carestream health - dental division
Training Director CBCT program Carestream health – Middle East
International speaker/ Consultant Neoss implant - England
Hamet North Chef de Service Oral & Maxillo-Facial Imaging Dpt / Dental School – LU
Lebanon Founder & manager of CLIR "Centre de Lecture et d’Interprétation
June 2014
Radiologique “
http://clir-3d.blogspot.com Courtesy of Olivier Sorel

Immediate Immediate
Implantation Implantation

Private collection
Property of CLIR

Immediate Immediate Delayed

Implantation Implantation failure

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Delayed Delayed Delayed

failure failure failure

Delayed
failure

Private collection Private collection

Property of CLIR Property of CLIR

Immediate
Radiological assessment of
implantation steps
pre-extraction site
*Tissue biotype. *Gingival biotype
*Bone type
*Tooth morphology
*Atraumatic extraction
*Presence of a buccal plate
*Implant design and position
*Primary stability
*Gap filling
Private collection
*Temporization Private collection
Property of CLIR Property of CLIR

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Radiological assessment of Radiological assessment of Treatment

pre-extraction site pre-extraction site
*Gingival biotype *Gingival biotype
plan
-In immediate implant restorations, patients
with gingival thickness <1.5 mm (‘‘thin-
*Radiographic exams
scalloped’’ mucosa) often had more tissue
recession.
-Dentascan
-As opposite to patients with Gingival
-CBCT
thickness ≥2 mm (‘‘thick-flat’’ mucosa) who
tend to maintain the implant papillae height.
Private collection
Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 2008;19: 73-80. Property of CLIR

Radiological assessment of
pre-extraction site
*Gingival thickness

Private collection
Property of CLIR

Private collection
Property of CLIR

Private collection Private collection

Januário.A, Barriviera M, Duarte,d. Soft Tissue Cone-Beam Computed Tomography: A Novel Method for the Measurement of
Property of CLIR Property of CLIR
Gingival Tissue.Esthet Restor Dent 20: 366–374, 2008

Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site
*Gingival thickness
*Crestal bone height
Private collection
Property of CLIR
-The site of Imm. Imp. should be carefully
examined for crestal and especially labial bony
defects.
-The bony height of the alveolus should at least
be equal to 7-10 mm.
-If labial bone defect is severe, the site is not
suitable for Imm. Imp.
Private collection
Property ofPrivate
CLIR collection Private collection
Property of CLIR Property of CLIR
Douglass GL, Merin RL. The immediate dental implant. J California Dent Assoc 2002;30:362-5.

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6.91±1.17 mm
13.03±0.85 mm

Alex
Froum SJ, Wagenberg B. A retrospective study of 1925 consecutively placed immediate implants from 1988 to Froum SJ, Wagenberg B. A retrospective study of 1925 consecutively placed immediate implants from 1988 to Froum SJ, Wagenberg B. A retrospective study of 1925 consecutively placed immediate implants from 1988 to
2004. Int J Oral Maxillofac Implants 2006;21: 71-80. 2004. Int J Oral Maxillofac Implants 2006;21: 71-80. 2004. Int J Oral Maxillofac Implants 2006;21: 71-80.

Radiological assessment of
Radiological assessment of
pre-extraction site
pre-extraction site
*Crestal bone height *Crestal bone height
Periodontal probe

Implants placed after

tooth extraction because Surgical stent
of periodontal disease
9.64±1.2 mm
12.7±1.15 mm were 2-3 times more likely Alveolar crest
to experience failure.
Private collection
Property of CLIR

Alex
Froum SJ, Wagenberg B. A retrospective study of 1925 consecutively placed immediate implants from 1988 to Froum SJ, Wagenberg B. A retrospective study of 1925 consecutively placed immediate implants from 1988 to Caplanis N, Lozada J L , Kan J YK Extraction Defect: Assessment, Classification and Management International
2004. Int J Oral Maxillofac Implants 2006;21: 71-80. 2004. Int J Oral Maxillofac Implants 2006;21: 71-80. Journal of Clinical Implant Dentistry, January-April 2009;1(1):1-11

Extraction General Socket Biotype Hard Distance to Extraction General Socket Biotype Hard Treatment Extraction General Socket Biotype Hard Treatment
Defect assessment wall tissue reference Defect assessment wall tissue recommendation Defect assessment wall tissue recommendation
type affected loss type affected loss type affected loss

EDS1 Undamaged 0 thick 0 0-3 mm EDS1 Undamaged 0 thick 0 Immediate EDS1 Undamaged 0 thick 0 Immediate
implantation implantation

EDS2 Undamaged 0-1 Thin 0-2 3-5 mm EDS2 Undamaged 0-1 Thin 0-2 Site EDS2 Undamaged 0-1 Thin 0-2 Site
to slightly or to slightly or preservation or to slightly or preservation or
damaged thick damaged thick immediate damaged thick immediate
implantation implantation
EDS3 Moderate 1-2 Thin 3-5 6-8 mm EDS3 Moderate 1-2 Thin 3-5 Site EDS3 Moderate 1-2 Thin 3-5 Site
damage or damage or preservation damage or preservation
thick thick then thick then
implantation implantation

EDS4 Severe 2-3 Thin ≥6 ≥9 mm EDS4 Severe 2-3 Thin ≥6 Site EDS4 Severe 2-3 Thin ≥6 Site
damage or damage or preservation then damage or preservation then
thick thick augmentation thick augmentation
then implantation then implantation
Caplanis N, Lozada J L , Kan J YK Extraction Defect: Assessment, Classification and Management International Caplanis N, Lozada J L , Kan J YK Extraction Defect: Assessment, Classification and Management International Caplanis N, Lozada J L , Kan J YK Extraction Defect: Assessment, Classification and Management International
Journal of Clinical Implant Dentistry, January-April 2009;1(1):1-11 Journal of Clinical Implant Dentistry, January-April 2009;1(1):1-11 Journal of Clinical Implant Dentistry, January-April 2009;1(1):1-11

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Radiological assessment of pre- Radiological assessment of pre- Radiological assessment of pre-

extraction site extraction site extraction site
*Crestal bone height *Crestal bone height *Crestal bone height

Fu J H, Yeh C.Y, Chan H.L,Tatarakis N, et al. Tissue Biotype and Its Relation to the Underlying Bone Morphology; J Fu J H, Yeh C.Y, Chan H.L,Tatarakis N, et al. Tissue Biotype and Its Relation to the Underlying Bone Morphology; J Fu J H, Yeh C.Y, Chan H.L,Tatarakis N, et al. Tissue Biotype and Its Relation to the Underlying Bone Morphology; J
Periodontol . Volume 81 • Number 4,April 2010 Periodontol . Volume 81 • Number 4,April 2010 Periodontol . Volume 81 • Number 4,April 2010

Radiological assessment of pre- Radiological assessment of pre- Radiological assessment of pre-

extraction site extraction site extraction site
*Crestal bone height *Crestal bone height

-Radiographic measurements of bone

height correspond to clinical B
measurements.

-CBCT could be used to determine hard

tissue height.
Private collection
EDS-1
Fu J H, Yeh C.Y, Chan H.L,Tatarakis N, et al. Tissue Biotype and Its Relation to the Underlying Bone Morphology; J Property of CLIR Private collection
Periodontol . Volume 81 • Number 4,April 2010 Property of CLIR

Radiological assessment of pre- Radiological assessment of pre- Radiological assessment of pre-

extraction site extraction site extraction site

2mm 3-5mm
>5mm
B B B

EDS-2 EDS-3 EDS-4

Private collection Private collection Private collection
Property of CLIR Property of CLIR Property of CLIR

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Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site
*Crestal bone thickness *Crestal bone thickness
-In dentate patients, labial alveolar bone remains
stable even if it is less than 1mm width due to the
periodontal ligament which provides the blood
supply.
-In implanted patient, only the cancellous bone will
supply blood to peri-implants regions, a labial
alveolar width of more than 1.2mm is required to
induce trabeculae beneath the cortical bone.
Private collection
Property of CLIR Yasukasu M, Tadakazu O. Dental cone beam computer tomography analysis of postoperative labial bone thickness in

Patient who did an orthodontic treatment maxillary anterior implants: Comparing immediate and delayed implant placement. Int J Periodontics Restorative Dent
2011;31, 3
Private collection
Property of CLIR

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

Radiological assessment of Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site pre-extraction site
*Crestal bone thickness *Crestal bone thickness *Crestal bone thickness

Private collection Private collection

Private collection Property of CLIR
Property of CLIR
Property of CLIR

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Radiological assessment of Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site pre-extraction site
*Bone type *Bone type *Bone type

... ...
..... ....
................. ....................
. .......
Private collection Private collection Private collection
Property of CLIR Property of CLIR Property of CLIR
Type I Type II Type III

Lekholm U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA, Alberktsson T, eds. Tissue Lekholm U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA, Alberktsson T, eds. Tissue Lekholm U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA, Alberktsson T, eds. Tissue
integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence, 1985: 199-209 integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence, 1985: 199-209 integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence, 1985: 199-209

Radiological assessment of Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site pre-extraction site
*Bone type *Bone density *Bone density
`

Private collection
Property of CLIR
Type IV

Lekholm U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA, Alberktsson T, eds. Tissue Private collection
integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence, 1985: 199-209 Property of CLIR

Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site
*Bone density *Bone density
-Increased HU, as calculated by Density Hounsfield Units D5
D4
D2
D3 D3
D2
dentascan, can predict increased primary
implant stability. D1 1250
D2 850-1250
-CT using HU is therefore a suitable
assessment tool for bone densities prior to
D3
D4
350-850
150-350
D3
D2 D2
D3
D1
dental implantation. D5 <150 Private collection
Property of CLIR
Fuh LJ, Huang HL, Chen CS, Fu KL, Shen YW, Tu MG, Shen WC, Hsu JT. Variations in bone density at dental implant
sites in different regions of the jawbone. J Oral Rehabil 2010; 37: 346-351. Misch CE: Density of bone: Effect on treatment plans, surgical approach, healing, and progressive Misch CE: Density of bone: Effect on treatment plans, surgical approach, healing, and progressive
loading, Int J Oral Implant 6:23-31, 1990. loading, Int J Oral Implant 6:23-31, 1990.
Misch CE: Density of bone: Effect on treatment plans, surgical approach, healing, and progressive
loading, Int J Oral Implant 6:23-31, 1990.

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Radiological assessment of
Radiological assessment of Radiological assessment of
pre-extraction site
the tooth before extraction the tooth before extraction
*Inter-radicular bone
*Tooth morphology *Tooth morphology

-The inter radicular bone is very cancellous, of

poor quality and is considered not stable
Private collection
Property of CLIR

because of its tendency to resorb over time.

Wagenberg BD, Ginsburg TR. Immediate implant placement on removal of the natural tooth: Wagenberg BD, Ginsburg TR. Immediate implant placement on removal of the natural tooth: Wagenberg B, Froum SJ. A retrospective study of 1925 consecutively placed immediate implants from 1988 to
retrospective analysis of 1,081 implants. Compendium of Continuing Educ Dent 2001;22:399-404.. retrospective analysis of 1,081 implants. Compendium of Continuing Educ Dent 2001;22:399-404.. 2004. Int J Oral Maxillofac Implants 2006;21: 71-80.

Radiological assessment of Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site pre-extraction site
*Inter-radicular bone *Inter-radicular bone *Inter-radicular bone

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

Radiological assessment of
pre-extraction site

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

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Atraumatic extraction Threw the tooth drilling Implant design

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

Implant design Saucerisation Papillae formation

1mm 1mm

2mm 2mm ≤ 5mm

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

a = 4 mm a’ = 4 mm a = 4 mm

b’ = 1 mm b’ = 1 mm b = 1 mm b = 1 mm
Platform switching
b = 1 mm b = 1 mm
c’ = 0.5 mm c’ = 0.5 mm c = 0.5 mm c = 0.5 mm
c = 0.5 mm c = 0.5 mm

c’ b’ a’ b’ c’ c b a b c
c b a b c

D’ D
L D L
D’=4+1+1+0.5+0.5=7mm D = 4+1+1+0.5+o.5=7mm
L
D== 4+1+1+0.5+0.5=7
2+1+0.5=3.5 mm mm
Private collection
Property of CLIR L=D+D’=7+7=14mm Private collection
Property of CLIR

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Platform switching Platform switching Radiological assessment of

pre-extraction site
*Implants can be as close as 1mm *Implant position
to teeth, and still maintain the
interproximal bone peak
*Implants can be placed as close as
1.5 - 3mm to each other, and still,
obtain a greater coronal bone-to-
implant contact, thus preserving
the interproximal bone
Courtesy of H.
Zipprich

Radiological assessment of
pre-extraction site
*Implant position
2 mm
4-6mm

3-5mm

Private collection Female 56 year old

Property of CLIR Private collection
Male 18 year old Private collection
Property of CLIR
Property of CLIR

Male 64 year old Private collection

Private collection
Property of CLIR
Property of CLIR

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Radiological assessment of Anterior implant planning

pre-extraction site Bucco-palatal implant direction
L B
*Implant position

Private collection Private collection

Property of CLIR Property of CLIR Private collection
Property of CLIR

Anterior implant planning Anterior implant planning Anterior implant planning

Bucco-palatal implant direction Bucco-palatal implant direction Bucco-palatal implant direction

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

Anterior implant planning

Radiological assessment of
Bucco-palatal implant direction
pre-extraction site
*Bone morphology

Private collection Private collection Private collection

Property of CLIR Property of CLIR
Female 38 year old Property of CLIR

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Radiological assessment of Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site pre-extraction site
*Bone morphology *Bone morphology *Bone morphology

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

Radiological assessment of Radiological assessment of Radiological assessment of

pre-extraction site pre-extraction site pre-extraction site
*Bone morphology *Bone morphology *Bone morphology

Private collection
Property of CLIR Private collection Private collection
Property of CLIR Property of CLIR

Radiological assessment of
pre-extraction site
*Bone morphology

Extraction of the two deciduous molars with immediate implantation

Private collection Private collection Private collection

Male 44 year old Property of CLIR Property of CLIR Property of CLIR

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Radiological input in immediate

implant planning
*Anatomical landmarks
-Naso palatine foramen

Type A Type B Type C

Bornstein MM, Balsiger R, Sendi P, Von Arx T. Morphology of the nasopalatine canal and dental implant surgery: a Male 36 year old Private collection Male 36 year old Private collection
radiographic analysis of 100 consecutive patients using limited cone-beam computed tomography. Clin. Oral Impl. Res. Property of CLIR Property of CLIR
22, 2011; 295–301.

Radiological input in immediate

implant planning
*Anatomical landmarks
-Maxillary sinus
9.98±1.15 mm

1.80±0.57 mm
Private collection
Female 43 year old Private collection
Drikes S. , Delcampe P. Computed tomography study of the lower alveolar intra-mandibular nerve path. Revue de Stomatologie Property of CLIR
Property of CLIR
et de Chirurgie Maxillo-FacialeVolume 109, numéro 6:352-360

Female 65 year old Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

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Radiological input in immediate

implant planning
*Anatomical landmarks
-Cortical lingual plate

Private collection Private collection

Property of CLIR Private collection Property of CLIR
Property of CLIR

Submandibular Gland Radiological input in immediate

Tooth NO of Risk assessment for
implant planning type
analyzed lingual plate perforation
teeth in Imm. Imp
*Anatomical landmarks
-Cortical lingual plate PM2 14 1/14 7%

M1 12 2/22 9%

M2 22 4/13 31%
L L L

Private collection Froum S, Casanova L, Byrne S, Cho SC. Risk Assessment Prior to Extraction for Immediate Implant Placement in the
Property of CLIR Posterior Mandible - A Computerized Tomographic Scan Study. J Periodontol. 2010 Sep

Tooth NO of Risk assessment for

analyzed
type teeth
lingual plate perforation
in Imm. Imp

PM2 14 1/14 7%

M1 12 2/22 9%

M2 22 4/13 31%

Froum S, Casanova L, Byrne S, Cho SC. Risk Assessment Prior to Extraction for Immediate Implant Placement in the Female 53 year old Private collection
Private collection
Posterior Mandible - A Computerized Tomographic Scan Study. J Periodontol. 2010 Sep Property of CLIR Female 63 year old Property of CLIR

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Radiological input in immediate Radiological input in immediate

implant planning implant planning
*Anatomical landmarks *Anatomical landmarks
-Inferior alveolar nerve -Inferior alveolar nerve

Alex
2.92±0.75 mm 8.29±0.88 mm

28%
37% Drikes S. , Delcampe P. Computed tomography study of the lower alveolar intra-mandibular nerve path. Revue de Stomatologie
Private collection Private collection et de Chirurgie Maxillo-FacialeVolume 109, numéro 6:352-360
Property of CLIR Property of CLIR

Lingual path
Tooth NO of Risk assessment for Tooth NO of Risk assessment for
analyzed analyzed
type teeth
Inferior alveolar nerve type teeth
Inferior alveolar nerve
injury in Imm. Imp injury in Imm. Imp
PM2 40 26/40 65% PM2 40 26/40 65%

M1 47 25/47 53% M1 47 25/47 53%

B L
M2 48 35/48 73% M2 48 35/48 73%

Froum S, Casanova L, Byrne S, Cho SC. Risk Assessment Prior to Extraction for Immediate Implant Placement in the Froum S, Casanova L, Byrne S, Cho SC. Risk Assessment Prior to Extraction for Immediate Implant Placement in the Private collection
Posterior Mandible - A Computerized Tomographic Scan Study. J Periodontol. 2010 Sep Posterior Mandible - A Computerized Tomographic Scan Study. J Periodontol. 2010 Sep Property of CLIR

Buccal path Virtual endoscopy

0.87 ± 0.18
PM: 649.18 mm
± 241.42
0.86 ± 0.18
M: 584.44 mm
± 222.73
C. Bone ≈1200 HU

-The average thickness of the bone that

surrounds the IAC and its density
are not hard enough to resist the drill.
Private collection Başa O and Dilek O.C. Assessment of the risk of perforation of the mandibular canal by implant drill using density and thickness Private collection
Property of CLIR parameters. Gerodontology 2011; 28: 213-220 Property of CLIR https://youtu.be/Hg66tGV5sdI

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Virtual endoscopy
simple bone cyst
Root
Normal
Trabeculae

Empty
Cavity

Private collection Private collection

Property of CLIR Property of CLIR Female 59 year old Private collection
Property of CLIR

Radiological input in immediate

-Over 6 hours, the compression of
peripheral nerve can evoke nerve implant planning
fibers atrophy. *Anatomical landmarks
-After 3 months, changes occurring -Inferior alveolar canal
in low density bone
within the nervous system may
respond to surgical treatment.
-Beyond 6 months, the changes
deemed to be permanent.
Rood JP, Shehab BA. The radiological prediction of inferior alveolar nerve injury during third molar surgery. Br J Oral
Maxillofac Surg. 1990 Feb;28(1):20-5.

Private collection Private collection

Property of CLIR Property of CLIR

-The close proximity between the -Nerve tissue is thought to be more

IAN canal roof and the implant bed sensitive to thermal insult than
may cause: bone.

*Hemorrhage into the canal -Thermal stimulus can evoke peri-

*Deposition of debris which may implant bone necrosis and
cause compression and ischemia postoperative secondary IAN
of the nerve. damage.

Khawaja N, RentonT. Case studies on implant removal influencing the resolution of inferior alveolar nerve injury. Br Dent Tehemar SH. Factors affecting heat generation during implant site preparation: a review of biologic observations and
J. 2009 Apr 11;206(7):365-70. future considerations. Int J Oral Maxillofac Implants. 1999 Jan-Feb;14(1):127-36. Review.

Private collectio
Property of CLIR
Female 56 year old

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Bone over heating How to avoid bone over

*The host site’s capacity to regenerate heating
bone is critical for the process of *Using sharp Drills
osseointegration *A gradual increase in drill diameter
*Additionally, a study showed that the
*Adequate drill speed
heating of bone above 47oC level
significantly affects the bone’s ability to
*Erikson and Albrekson have shown
regenerate. that 2000 rpm is the optimal speed
*Heat-injured bone is replaced by less drilling
differentiated tissue, which is incapable *According to Mish cancellous bone
of the normal adaptive remodeling ability should be drilled at 800 rpm and
of bone dense bone at 1500 rpm Private collection
Property of CLIR

Mental foramen’s position

Radiological input in immediate Radiological input in immediate
implant planning implant planning
*Anatomical landmarks *Anatomical landmarks
-Mental foramen -Mental foramen

Alex

*In 92.6% of all cases, it is located in the apical

region of the premolars.

Svane TJ, Wolford LM, Milam SB, Bass RK. Fascicular characteristics of the human inferior alveolar nerve.
Private collection Private collection J Oral Maxillofac Surg 1986;44:431-434.
Property of CLIR Property of CLIR

Mental foramen’s position

Variation of position Variation of position

Alex

*In only 7.4% of cases the foramen is situated

more distally or mesially to the premolars

Svane TJ, Wolford LM, Milam SB, Bass RK. Fascicular characteristics of the human inferior alveolar nerve. Private collection Private collection
J Oral Maxillofac Surg 1986;44:431-434. Property of CLIR Property of CLIR

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Variation in size Variation in level Variation in number

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

Private collection Private collection

Property of CLIR Property of CLIR

Gap management Gap management Gap management

Rosenbach D. Gap management around immediate implants; dentaltown.com « SEPTEMBER 2014 Fu J H, Yeh C.Y, Chan H.L,Tatarakis N, et al. Tissue Biotype and Its Relation to the Underlying Bone Morphology; J
Periodontol . Volume 81 • Number 4,April 2010

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Gap management Gap management Gap management

*Practically speaking, particulate bone graft cannot
easily fit into gaps less than 1mm in dimension, and so
these gaps need not to be grafted.
*Peri-implant gaps, greater than 1mm in dimension,
should be grafted to prevent ridge width deficiency and
promote greater bone-to-implant contact.
*If considerable undercuts exist under the coronal
extent of the facial plate of bone, graft material may
be introduced prior to implant placement, especially in
the anterior.
*Even if less than 2mm, peri-implant gaps ought to be
grafted because, the potential benefits of doing so
vastly outweigh the potential risks of not doing so.
Private collection Private collection
Rosenbach D. Gap management around immediate implants; dentaltown.com « SEPTEMBER 2014 Property of CLIR Property of CLIR

Temporization Temporization Filling the gap and temporisation

Private collection Private collection Private collection

Property of CLIR Property of CLIR Property of CLIR

Subepithelial Connective Greater palatine Artery

tissue harvesting

Private collection
Property of CLIR

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Greater palatine Artery Greater palatine Artery Subepithelial Connective

tissue harvesting

1%

13% 12.7-14.7mm

86%
16mm
Private collection Private collection
Property of CLIR Property of CLIR

Socket Shield technique Socket Shield technique Socket Shield technique

*Based on the literature since the *Created by Hurtzeler
1980’s *Mesio-distal tooth sectioning
*If the remaining part of a *The palatal portion of the root
tooth’s root is in perfect is extracted
condition, it can be gingivally *The vestibular portion is
submerged preserved as to prevent the
*It will preserve the bone bundle bone resorption.
structure
Hurtzeler M, Zuhr O. Socket Shield Technique. Approach of Principle Report Dog
Troiano M, Benincasa M, Sánchez P, Guirado JLC. Bundle bone preservation with Model. J Periodontol. 2010; 37:855-862.
Root-T-Belt: Case study. Annals of Oral & Maxillofacial Surgery 2014 Apr 12;2(1):7.
Private collection
Property of CLIR

Socket Shield technique Socket Shield technique

*Another technique is also
describe by Cherel and Etienne *Combination of the two
*Their sectioning is vestibulo- pre-described techniques
lingual
*The whole periphery of
*The proximal preserved
the tooth is preserved
remainder of the root will
protect the papilla.
Cherel F, Etienne D. Papilla preservation between two implants: a modified socket-
shield technique to maintain the scalloped anatomy? A case report. Quintessence Troiano M, Benincasa M, Sánchez P, Guirado JLC. Bundle bone preservation with
Int. 2014;45(1):23-30. Root-T-Belt: Case study. Annals of Oral & Maxillofacial Surgery 2014 Apr 12;2(1):7.

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Immediate Implantation Tenderness #22 after

Immediate Implantation

32 year old female 32 year old female

Private collection Private collection
Property of CLIR Property of CLIR

Immediate Implantation Immediate Implantation Pouch roll technique

32 years old female 28 year old female

Private collection Private collection Private collection
Property of CLIR Property of CLIR Property of CLIR

Pouch roll technique Immediate Implantation Immediate Implantation

12-6-2012

1-4-2012

1-4-2012

Private collection
10-1-2013
Property of CLIR

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Great people don’t

do different
things, they do
the same things 3D
differently IMAGING
Female 23 year old
Private collection
Property of CLIR

Alexandrekhairallah@hotmail.com Alexandrekhairallah@hotmail.com
Alexandrekhairallah@Gmail.com Alexandrekhairallah@Gmail.com
http://clir-3d.blogspot.com http://clir-3d.blogspot.com

Mobile: +961 3 264332 Mobile: +961 3 264332

Wind mill
Mykonos Greece
2013

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