‫" عالمة صدقنا أن منضي يف هذا الطريق حتى آخره ‪ ,‬حتى الشهادة "‬

‫‪ -‬الشيخ صاحل العاروري‬

 ‫قال تعاىل ‪ ":‬وَ َأنْ لَيْسَ لِإلِنسَانِ إِلَّا مَا سَعَى ۝ وَأَنَّ سَعْيَهُ سَوْفَ يُرَى "‬

‫• 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

• See the implant here for example :

- White rectangular represent biological width of implant
- It is successful implant and stable , no resorption will occur
- Notice the resoption is until the first thread of implant only
 • Q : what is the biological width ?
- It is combine dimension of junctional epithelium and connective tissue
attachment
- The average biological width in natural tooth is 2.04 mm , in implant the depth
is more
- The biological width regarding implant , I have junctional epithelium , but
regarding the connective tissue attachment is controversial :
There some study tell that I don’t have CT attachment
‫ ليش ؟؟ النه اما من‬, crestal bone ‫ على طول بوصل ال‬, ‫واجي افوت زيادة شوي‬probe ‫يعني لو اجيب ال‬
‫ ليش‬, we have weak CT attachment ‫ او االشي االصح من هيك‬,, CT attachment ‫األصل ما عندي‬
: ‫ضعيفة ؟؟النه‬
‫بتكون اقل‬fiber tissue ‫ كمية ال‬-1
attachment ‫ وال عاملة‬angular ‫ما بتكون جاي بشكل‬,circular ‫بتكون‬direction ) ‫ وكمان تختلف ب‬-2
)to abutment or crown
, less blood vessels ‫ عندي‬-3
less fibroblasts -4
• Biological width of implant is junctional epithelium and very weak CT attachment ,
but thicker than natural teeth
• It is very easy to reach bone during probing around implant because I have very
weak CT attachment , while in natural teeth we have sharper's fiber that attach to
the tooth and make resistance to penetration
 ‫ بس اخذتها‬, ‫• نوت كانت الدكتورة حاطيتها تحت الساليد‬
‫سكرين‬

• From where we drive the numbers ( 1.5 mm and 3 mm )??

‫ وحكينا‬, circumferential bone resorption ‫بسبب‬biological width formation ‫كلنا اتفقنا انه حيصير عنا‬
:vertical and horizontal dimensions ‫ال‬biological width ‫انه‬
1- Vertical dimension:
- variable according 1.the type of implant , 2.type of junction between implant
and abutment ( more secure connection , less resorption ) , 3.shape of neck of
implant , 4.more soft tissue thickness above the implant lead to less bone loss
( because already we have supra -crestal biological width )
- from 0.5 to 3 mm
 - physiological until 1st thread of implant , if resorption happen beneath the 1st
thread → pathological resorption " peri-implantitis "
2- Horizontal dimension : also has been found horizontal bone resorption occur , this
horizontal bone loss range from 1- 1.4 mm of each implant

‫ وحيصير‬, ‫• هس نيجي نفترض عنا زرعتين‬

‫جنب كل‬bone resorption 1.4 mm
,, 2.8 mm ‫ محسب المسافة بتطلع‬, ‫زرعة‬
‫ مم بين الزرعتين‬3 ‫اذن عشان هيك بدنا‬
:peak of bone ‫عشان احافظ على هذا ال‬
A = 1.4 mm
B = 1.4 mm
D ( horizontal loss ) = A+B = 2.8 mm ≈3 mm

: ‫ 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

• The distance between 2 implants is 3 mm ,,,and 1.5 mm between tooth and

implant , but from where we measure ??
➔ We measure from the neck of implant ( from CEJ of tooth ) , but dr add note to
measurement method : ‫كثيررر مهمة‬
‫حوالين‬1.5 mm ‫ يعني بالصورة بدي‬, CEJ or neck ‫ بكل الكتب موجود انه بقيس المسافة من‬-
bone lose occur from CEJ ‫) عشان ال‬mesially and distally ( ‫الزرعة من الجهتين‬
‫ ما فيه‬,coronally ‫ ولكن لما نطلع فوق‬,root ‫ "ما بكفي يكون عندي مسافة بين الزرعة وال‬: ‫ولكن‬
‫تكون اقل من‬high of contour of tooth ‫<يعني المسافة بين الزرعة وال‬--"!!crown ‫مكان ل‬
prosthodontic ‫ ما بزبط هذا الحكي من ناحية ال‬, 0.5 mm
‫ هس الزرعة بقدر اركب عليها ؟؟هون‬, ‫ هس نطلع فيها‬,1.5 mm ‫ الزرعة بالصورة بتطلع حوالي‬-
‫ وال‬good emerging of crown ‫ هس يا بدخل ع طول الخط األبيض (ما حيكون عندي‬, ‫المشكلة‬
Hight of ‫ و‬implant ‫بين ال‬1.5 mm ‫<لذلك انا بدي كمان‬-- )aesthetically ‫حيكون مقبول‬
contour of the tooth
‫ حيعمل‬,1.5 mm )hight of contour ‫ طبعا عشان طلبنا يكون المسافة فوق (بين الزرعة و ال‬-
‫ ليش ؟؟ النه لو ال‬, ‫ هون فش مشكلة‬, 1.5 mm ‫)اكثر من‬CEJ ‫المسافة تحت ( بين الزرعة و‬
hight of contour ‫لكن لو‬, ‫ <تمام‬-- ‫تحت وفوق‬1.5 mm ‫زابط بانه يكون‬emerging of crown
‫من فوق‬1.5 mm ‫ ال وقتها الزم اوخذ‬, ‫كبير‬
‫ مش بس حيعملي‬,1.5 mm ‫اقل من‬hight of contour ‫ كمان اذا ما عملت انه المسافة بين الزرعة و‬-
‫ النه انا بس حشرت التلبيسة‬, black triangle ‫ ال كمان رح يعمل مشكلة‬,emerging ‫مشاكل ب‬
 ‫ يصعب على المريض تنظيف‬food impaction ‫حشر وحيعمل فراغ مع السن الي حنبه ويصير‬
infection (peri-implantitis ) ‫ ورح يتبعه‬, ‫اسنانه‬
‫ اذا كانت المسافة مع‬, ‫فوق وتحت‬1.5 mm ,respect the distance ‫فاحنا شو نعمل ؟؟‬:‫• الخالصة‬
‫ او‬2 ‫بروح بزيد المسافة ( وعادي بزيد المسافة تحت تكون‬1.5 mm ‫ اقل من‬hight of contour
‫عشان مسافة التلبيسة‬1.5 mm ‫ بس ضروري يكون فوق‬. ) ‫ونص مم‬2

• 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

• Here we lose attachment with adjacent because we don’t recpect the

space → soft tissue and bone lose
• The implant is labially positioning
 • Now we will talk tooth by tooth , start with 1st premolar ( either upper or lower )
• 1st premolar is easiest tooth replacement by implant , why ??
1- we don’t have anatomic landmark in this area ( usually "not always" , the 1st
premolar be anterior to sinus and mental foramen , but remember anterior
loop which need CBT to verify )
2- Bone trajectory is vertical :
‫ السبب النه كل ما رحت‬,tilting ‫ وما في داعي ال‬, ‫يعني بفوت اعمل حفرة للزرعة عموديا وبشكل مباشر‬
‫ بنزل‬,4 & 5 ‫ بس في حاالت ال‬, ‫ فحضطر اعمل تمييل للزرعة‬concavity of mandible ‫حتزيد ال‬backward
‫ بس غالبا هيك بتكون‬,verification on CBCT and palpation ‫ طبعا اكيد الزم أكون عاملة‬,, ‫عمودي‬Drill ‫بال‬
‫ بس مع هيك الزم نتأكد‬,undercut ‫ نادرا ما يكون في‬, ‫الطريقة‬

‫الي قصدها فيها الدكتورة بتزيد كل ما رجعنا ورا‬concavity ‫• هاي ال‬

mandible ‫بال‬

• 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

• Now talk about premolar implant selecting diameter :

4 ‫ طب مين بحدد‬,3.5 mm ‫هي‬premolar ‫ والحد األدنى الي ممكن اتقبله في‬, ‫ مم‬4 ‫ غالبا بكفيني‬-
‫؟‬or 3,5 mm
→The main dimension I measure is mesiodistal :
- If mesiodistal =7 mm → 4 mm
- If mesiodistal =6.5 mm→ 3.5 mm
 ‫‪ -‬هس بالنسبة ل ‪,buccolingual‬اذا الزرعة ‪ 4‬مم ‪ ,‬بدي ‪minimal 1.5 buccally and 1.5 mm‬‬
‫‪ , lingually‬احنا بدنا ‪ 7‬مم ‪ ,buccolinguall‬اذا ما عنا ‪ 7‬مم ‪u should manage by bone ,‬‬
‫‪ ,,,, grafting etc..‬مش مسموح احط زرعة اقل من ‪ 3‬ونص مم في ‪premolar‬‬
‫لكن احط زرعة ‪ 3‬مم في ‪lateral‬مقبول ‪ ,,,‬مش مسموح احط زرعة اقل من ‪3.5 mm diameter‬‬
‫في ‪ , posterior segment‬النه الزرعة ممكن تكسر‬

‫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

• The minimum accpeted molar diameter is 4 mm,,,,,3.5 mm ‫بتتمشى بحاالت ما‬

‫تكون‬splinted
• If the space = 13 mm:
1- 13- 6 = 7 mm → we can put 2 implants of 3.5 mm with splinting
There is trend " we don’t prefer 3.5 mm posteriorly due to increase biting
forces , so 4 is better than 3.5 mm , 5 mm is not needed because it is so
wide "
2- We can put one implant 5 mm → because we have 4 mm cantilever
mesial and distal →but we need to make sure that forces is centrally by
articulating paper
3- Better option is make enameloplasty or ortho uprightening or place
diagoal to gain 1mm → the space become 14 mm → we can put 2
implants 4 mm
 • This table is guideline , not must
• Conclusion :
- We should avoid cantilever 5 mm when we choose implant
- The minimal accepted implant in molar is 3.5 mm , better is 4 mm as minimal
diameter
- It is not preferable to use very wide implant ‫النه بتيجي على حساب العظم‬
- If we put implant 5 mm and we have buccolingual 7 mm → 7-5= 2 mm , the
bone remaining is very few
‫ يعني كل ما كان كمية العظم اكثر من‬, ‫بكون احسن‬bone ;titanium ratio ‫احنا كل ما زدرنا‬
‫تسبب يصير‬compromization of blood supply ‫ النه الزرعة بتعمل‬, ‫الزرعة بكون افضل‬
‫ مم ما‬5 ‫ فاكثر من‬,, ‫ بدي احافظ على الزرعة اكثر بدي إياها تكون محاطة بعظم اكثر‬, bone loss
‫في داعي نستخدم‬
‫ مش موضوعنا‬,rescue implant ‫ اسمهم‬, ‫ بس قليل جدا‬, ‫ مم‬7‫ و‬6 ‫في زرعات‬
- We can put 4 , 4.5 mm in molar area , but without cantilever more than 5 mm
 Part 3

• There is no space maintainer option, because it is esthetic zone

• Resin boned is more successful in anterior zone because the debonding
rate in anterior is less
 • Nowadays , our criteria for success is not only osteointergration , we need beside
osteointegration , good esthetic results
• This pic we have : this implant is esthetic failure
- White esthetic ; incorrect shade
- Pink esthetic : marginal level is higher than adjacent , metal showing , redness ,
abnormal texture , abnormal convexity ( no stripples ) , papillary level meisaly
lower than distally , convextity of root
‫ وبطلع بتقييم للجمالي‬,evaulation ‫بناء على‬esthetic ‫احنا بنعطي عالمة لل‬
• Single missing implant in esthetic zone consider advance case
‫ وال يزرع‬,mental foramen ‫ زرعات تحت بين‬4 ‫يعني مريض اجا بدو يزرع‬,, ‫مع انها زرعة وحدة‬
‫عندي كثيير معاير اصعب‬upper ‫ النه ال‬,lower 4 implants ‫ مين اسهل ؟؟ ال‬,central ‫وحدة بال‬
 • We consider replace single tooth in anterior maxilla is advance case,while single
tooth in anterior mandible is simple case

• Q: what is the diagnostic factors we use to evaluate the case ??

‫؟؟هل هاي الحالة بقدر يعملها‬high risk or low risk ‫انها‬esthetic ‫يعني كيف أقيم هاي الحالة من ناحية‬
‫؟ كيف أقيم صعوبة او سهولة الحالة ؟؟ايش هي ال‬specialist ‫طبيب اسنان عادي وال الزم احولها ل‬
‫؟؟‬esthetic zone ‫الي الزم افحصها بكل حالة تعويض في‬factors
→we need to evaluate :
1- Patient expectations : this is the 1st factor need to evaluate
‫ حتكون الحالة اصعب‬, ‫كل ما كانت توقعات المريضة اعلى‬

2- Smoking habit : if I plan to do implant for smoker patient (esp. above 10

cigarettes/day)→this will lead to more infection if I want to do bone or soft tissue
grafting and this also increase the risk of peri-implantitis on long run
- Smoker patient increase the esthetic risk due to predictability of making bone
graft and soft tissue graft will be less
 3- Lip line :
- High lip line : show more than 2 mm of gingival margin when the patient smile (
more showing mean more difficulty , here we plan to achieve good white and
PINK esthetic )
zenith ‫ كمان ب‬,high of the margin ‫ رح نهتم ب‬, ‫ وتماثل بين الزرعة واالسنان الطبيعية‬, ‫رح نهتم بلون اللثة‬
‫وغيره‬,,,,,,,comparable to contralateral side ‫يكون متماثلين و‬papillae on each side ‫ وكمان‬,point
→so each item of pink esthetic (gingiva)should be taken in consideration , and
this case "high smile line ‫ "الي بالساليد‬need multiple procedures to achieve good
esthetic results

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 )

• We can do soft tissue grafting on day of 1.implant placement 2. uncoverage stage ,

3.between implant placement and second stage surgery
- We need to know :
9Augment soft tissue in thin biotype
 Soft tissue augmentation by placing connective tissue graft is predictable
procedure for healthy patient if done properly ( while less predictable for
patient with heavy smoking habit , diabetic patient )

• 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

Failure case due

to no space for
restoration
 5-interocclusal relationship : ‫نكمل عن معايير الي بتساعدنا في تقييم صعوبة الحالة‬
- In second pic we notice there is no interocclusal space , the dr put implant and
don’t take in consider the lack of interocclusal space
‫ طب شو الصح‬, ‫ اذا ما كنت انا اعملت المريض عن هاي المشكلة‬, ‫هاي ممكن تنتهي بمشاكل كثير كبيرة مع المريض‬
:‫بهاي الحالة ؟؟‬
→Leveling of the lower occlusal plane before or at the same time of implant placement
‫ يعني مثال اعمل‬,orthodontic ttt ‫ يعني بدي أكون مفهمة المريض انه حيكون بحاجة ل‬-
‫ طبعا احنا بنكون مستشيرين اخصائي تقويم هل في إمكانية انه نعمل‬,, intrusion of lower teeth
intrusion and leveling of lower occlusal plane
‫ طبعا اكيد فيه‬,crown lengthening and cut of crown ‫ ممكن نعمل‬,,‫ هس اذا بنفعش االورثو‬-
restorable and ‫ هل السن حيظل‬, crown root ratio ‫الزم نفكر ب‬draw backs
maintained
, ‫ وكان خيار التقويم مش متاح‬, ‫ كثير عالية‬intrusion ‫ اذا كانت كمية ال‬, ‫ هس في بعض الحاالت‬-
‫ وحيدخل‬, restore the upper ‫ عشان تعمل‬, lower teeth ‫فممكن لألسف نضطر نخلع ال‬
lower ‫المريض برضو بقصة زراعة لل‬
• Even we plan to make fixed bridge , we must study " do we have sufficient intra
occlusal space or not ?"→ if not sufficient , I should gain sufficient then go for
opposing side and make the restoration
• We should study the availability of the space prior to make any restoration even RPD
 6-vertical bone height : it is important factor I should examine at time of implant
placement is the distance between interproximal crestal bone level to the inferior border
of the contact area
, evaluation case ‫ يوم الي بدي اعمل فيه‬, )‫• لنفترض بدي ازرع بهاد المكان (اعبتروا انه ما فيه زرعة‬
interproximal bone ‫ الزم اقيس المسافة عموديا بين‬,esthetic risk ‫لحتى أقيم انها سهلة او ال من ناحية‬
of the adjacent tooth (adjacent to my implant site ) to inferior border of contact area
papilla formation at the ‫ هاي المسافة ( سهم األخضر ) رح تحددلي احتمالية انه حيصير عندي‬-
implant crown
 • For example this case :
‫ او اعرف كم يحكون طول ال‬,??papilla fill ‫كيف اعرف بالمستقبل لما احط زرعة حيكون عندي‬
‫ من‬interproximal bone ‫ ؟؟شو بعمل ؟؟بقيس المسافة ال‬papillae on each side of my implant
: ‫ وبطلع‬central
- If above until 5 mm , I could say that my papilla will grow up 5 mm almost
always
, ‫ وحتى على الجهة الثانية‬grow up 5 mm ‫ على هاي الجهة‬papilla ‫ متأكدة انه ال‬%99 ‫يعني بكون تقريبا‬
‫ بكون عارفة انه هاي‬,implant crown ‫ بس مجرد ما حطيت‬, ‫بعد الخلع‬shrinkage ‫حتى لو كان صاير‬
, ‫معمولة بطريقة صح بين الزرعة والسن‬contact area ‫ شهور وكانت ال‬6 ‫ ل‬3 ‫مع الوقت من‬papilla
papilla grown 5 mm from interproximal bone to coronally ‫بكون عارفة انه ال‬
implant adjacent to 2 natural teeth ‫طبعا هاد الحكي لما يكون عندي‬,,,,,,,,,,,,,
‫ بس لو كانت‬,papilla fill ‫ هون االحتمالية بتكون كثير اقل انه يصير‬,7 mm ‫ اذا كانت المسافة مثال‬-
papilla will fil this space ‫ واقل بكون ضامنة انه‬5 ‫ يعني‬, 4 ‫ او‬5

→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

• I should evaluate the interproximal bone on the adjacent teeth

• On x ray : if distance ‫ سهم برتقالي‬is 7 mm (‫ مم‬5 ‫→)مبينة هي ع الصورة اكثر من‬less possibility
of papilla fill ( 50-60 % ‫)احتمال‬
papilla on distally ‫ لما قسنا المسافة ( الحظوا انه المسافة ل‬, ‫ بدو يحط زرعة‬,) ‫اجانا مريض بدو يخلع هذا السن (عليه اكس‬ •
‫ المهم‬, ) ‫صاير‬recession ‫ فيه‬,contralateral side ‫ مقارنة ب‬,natural tooth with crown ‫ على‬shrink ‫أصال‬
‫ هل‬, - papilla of contralateral side ‫ بكون على مستوى ال‬, ideal level ‫ مم—طبعا احنا بنقيس من‬5 ‫المسافة اكثر من‬
orthodontic extrusion ‫قبل الخلع؟؟اه فيه اسمها‬papilla grow ‫ معينة اخلي ال‬technique ‫في‬
apparatus sound ‫ يعني شوي‬useful ‫ لكنه‬, ‫فبروح لخلع‬ferrule effect ‫ يعني مثال ما في‬hopeless ‫ هس السن‬-
‫ فممكن استفيد من السن قبل‬,, perio problem of mobility or ankylosis or root resorption ‫ يعني ال فيه‬,
‫< تسمى ب‬----ortho extrusion to augment soft tissue and the bone ‫ال اخلعله انه اعمله‬
orthodontic neogenesis
 bone ‫ ال‬, ‫نزلت‬soft tissue ‫ وشوفوا كيف ال‬,extrusion of two teeth (central and lateral ) ‫فاحنا لنعمل‬ -
excess of soft tissue which is very useful in ‫ وهيك بصير عنا‬, and soft tissue grown coronally
implant placement
- More excess soft tissue and more excess bone → more predictable case
- Final result show symmetrical of papilla on both side

7-vertical height of buccal bone crest :

• Other factor to be evaluated is vertical height of buccal bone crest

• The pic show case of lateral incisor placement :
- Note the gingival margin is symmetrical with contralateral site so soft tissue is good and
comparable with contralateral site
- Other point I should know "where is the buccal point crest ?"→ I could evaluate by CBCT ,
also I can evaluate clinically by making bone sounding ( give
anesthesia , by perio probe measure from coronal level of
gingiva up to bone level )if the distance :
-2-3 mm→ case will be more predictable , because this is the
normal level between gingival margin and buccal bone crest
-5 mm → there is 2 mm deficiency of bone need bone
augmentation to place my implant in correct place ( increase
case difficulty )
• Note the recession amount here , esthetic risk is :
1- Soft tissue deficiency , the soft tissue is not comparable with contralateral site
2- Vertical Bone deficiency ( about 2 mm apical ) ‫من كمية الفقد للسوفت تيشو نتوقع يكون العظم هيك كمان‬
➔ Complicated case from esthetic point of view , should be refer to specialist need bone and
soft tissue augmentation to try to achieve esthetic result comparable to adjacent teeth

• Here we do horizontal bone augmentation

• Case :other example of how we use orthodontic extrusion to make excess soft tissue
- Look at first image prior to ttt,1st step is to evaluate the esthetic risk "how much difficult the
case is?":
1.The level of gingival margin is less than adjacent (recession occurred), this is the 1st
difficulty ‫إشارة حمراء انه األمور عم بتصعب‬
2.The bone level by bone sounding , there is bone deficiency
- is there any way to use this hopeless tooth prior the extraction ??yes , if the tooth ( no perio
problem , no mobility , no ankylosis , no resorption )→ extrude slowly and drawing 1 mm of bone
and soft tissue each month → make case easier surgically due to excess bone and soft tissue →
case will be more predictable in comparison of soft tissue and bone grafting
Dis-adv : increase time

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

• Now talk about tooth by tooth in esthetic zone :

- In general , when we want to put implant in central incisor , it will be 1.5
0.5 - ‫ انا بحط الزرعة‬,encroachment of incisive canal ‫ لحتى نمنع‬, ‫غالبا ما بحط الزرعة بنص السن تماما‬
violation of 1.5 m distally to ‫ وبنفس الوقت ما بنكون عاملين‬,1mm distally to mid tooth position
adjacent tooth
‫ واذا باإلمكان نحط‬,bone graft ‫ ونحط‬,content ‫ لنشيل ال‬, nasopalatine neurectomy ‫أحيانا نضطر نعمل‬ -
with ‫ ممكن احط الزرعة الحصل على‬larger canal ‫ او أحيانا اذا كانت‬,, ‫الزرعة بنفس الوقت في المكان الصح‬
‫ ثم بحط‬, ‫ شهور‬4 ‫ ل‬3 ‫ بستنى‬, ‫بسكر‬bone graft ‫وبحط‬content ‫بانه بشيل ال‬good primary stability
‫الزرعة‬
slightly distal to midtooth position ‫واحيانا بكفي انه ازيح الزرعة‬ -
‫ القرر اشيل وال ازيح بكفي‬planning ‫ بنعمل‬,CBCT ‫ بكون موخذة‬, ‫طبع ا كل هاد الحكي بكون مقررته قبل العملية‬ -

• No consequences of removing nasopalatine nerve , because there is greater palatine nerve

posteriorly innervate premaxilla region

• 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

• Second important dimension is where to place implant faciopalatally ?

- The most common error in placing implant in esthetic zone is faciopalatal dimension
- The implant should be 2 mm palatal to point of emergence of adjacent teeth
‫ الزرعة الزم‬,cervical margin between 2 natural teeth ‫ لو رسمنا خط (خط األسود على الصورة ) على‬-
palatally ‫ مم‬2 ‫ حيكون‬,comfort zone ‫ او‬green zone ‫تكون ب‬
danger zone ‫هيك بكون دخلت ب‬facially ‫ مم‬2 ‫او‬palatally ‫ اكثر مم‬2 ‫اذا رحت‬
‫ مم‬2 ‫ وبس اجي احط الزرعة الزم يكون‬,adjacent teeth ‫وبلفه حوالين ال‬floss ‫ بانه بجيب‬, ‫طريقة لرسم هذا الخط‬
floss / ‫للخط‬palatal
• The most common error in implant placement is placing the implant more facially , for many
reasons :
1- Immediate implant placement , the implant is easily push facially
2- Palatal bone is more dense , so wit is easy to drill facially
‫ نسبة النجاح‬, ‫ (من ناحية الجراحة‬, ‫ عالجها حيكون كثيير مكلف للمريض‬, ‫ النه حتعملي كثيير مشاكل‬, ‫كثيير مهم هذا الحكي‬
massive bone loss facially ‫ الوقت ) النه مش مضمون بس اعيد الزرعة النه حيكون عندي‬,

,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

• What about too palatally positioning ?

➔ Here correction is easier than facially malposition , we have to remove implant and put it in correct
position ( no buccal bone resorption occur)
➔ If implant is too palatally and I want to make implant crown →ridge laping crown ‫وحكينا عنها قبل‬
 • 3rd position is apicocoronal position : ( forth one is trajectory position )
‫قديش انزل بالزرعة ؟‬
- Rule : as shallow as possible ,and deep as necessary to achieve good emergence profile
‫ سهل انه‬,sulcus depth shallower ‫ بكون‬,biology ‫كل ما كان افضل من ناحية‬shallower ‫كل ما كانت الزرعة‬
unaccepted ‫بكون‬esthetic ‫من ناحية‬shallower ‫ لكن كل ما كان‬, sulcus clean ‫نبقي ال‬
‫ نقرب‬, ‫ مم‬4 ‫قطر الزرعة (( نحكي احنا‬3.8 mm ‫ حكينا من قبل بنستخدم‬::central incisor implant ‫ نحكي مثال‬-
average diameter of central incisor at cervical margin cej = 7 mm ‫و‬,,)) ‫يعني‬
 ‫ انا بدي اطلع من‬,apically ‫مم‬1 ‫ يعني بس‬,apical to gingival margin ‫ مم‬1 ‫<تخيلوا زرعة محطوطة بس‬--
‫ مم تعمل‬1 ‫ فانتو تخيلوا بس مسافة‬,, ‫ مم‬7 ‫ كراون السنترال الي هو حيكون‬dimension ‫ مم‬4 ‫الزرعة الي هي‬
‫كيف؟؟ كيف حيكون شكل الكراون ؟؟رح‬,, ‫ مم‬7 ‫ مم ل‬4 ‫ يعني بدي اطلع من‬,,,enlargement of implant crown
gradual emerging ‫ يعني ما بكون‬, abrupt emergence profile ‫ ويسمى ب‬,unaccepted ‫يكون‬

• Normal emerging profile ( esthetically and biologically ) is gradual enlargement

‫ يسمح بالتدرج للكراون‬very good emergence ‫ حيكون عندي‬,apical to margin ‫ مم‬3 ‫فاذا الزرعة محطوطة‬
• Good apicocoronal position is 3-4 mm apical to mid-buccal gingival margin to achieve good
emergence profile and not too deep implant
- More than 4 mm depth → deep sulcus and pocket → difficult maintain clean → more
suspectable for infection and peri-implantitis

Here is
healed
implant
Here is
immediate
implant

• In healed site , there is bone loss

‫ عشان‬, future cervical margin of the crown ‫ بكون محدد فيه‬,surgical guide ‫ بعمل‬, ‫ طبعا ال‬, ‫ الوصل للعظم‬, ‫هل اظل نازلة‬
,bone augmentation ‫ بعمل‬, ‫ واذا ما كان عندي عظم على المستوى الي حددته‬,, apical to this position ‫ مم‬4-3 ‫احط الزرعة‬
‫حتى أوصل للعظم‬Apically ‫بس ما بظل نازلة‬
‫وبوصل للعظم‬mid buccal gingical margin ‫ بحسب لتحت‬, ‫ بكون لسا مش صاير ذوبان‬, ‫في الزراعة الفورية‬ •
• Note here the implant is very shallow → dr make ridge laping to get good emergence profile
• Shallow implant → metal showing sometimes
• Deep implant → deep pocket (thick biotype ) or recession ( thin biotype )
 ‫ ونص مم مش مقبول ال من ناحية جمالية وال قوة الزرعة‬3 ‫ اقل من‬,,,) 3.8,,,3.5( ‫ ومشتقاتها‬4 ‫• يعني في سنترال‬
• Lateral incisor may use 3 or 3.3 mm implant is sufficient for emergence and biomechanics
• Canina is sufficient to use 3.8 mm , no need more than 4 mm ( it is accepted for esthetic and emergence and
strength )
‫ ننساش بدنا العظم اكثر‬,,buccolingual width very wide ‫حتى لو‬, wide implant ‫• ما في داعي نستخدم‬
• Final position is trajectory or angulation of the implant : it is highly recommended that implant in the esthetic
zone to have direction in cingulam area if possible , or may be slightly palatal to incisal edge
screw retained restoration ‫ تمكني اعمل‬,restoration ‫ عشان من ناحية ال‬, facially ‫بس ما بدي إياها تكون رايحة كثير‬
‫‪-‬‬ ‫‪-‬تم بحمد هللا‬