**2. Patient-related factors**

These are defined as factors mainly pertinent to the patient him/herself that include and not limited to the medical background, anxiety, allergy, smoke history, anatomical variations, implant site local challenges, local bone type, local topography, and the personal preference. The patient preferences can be limitless, which include a demand in implant type, surgical intervention, grafting technicality, prosthetic end result, and the mostly challenging the time frame demand. The reason that time frame is very challenging, as it is mainly affected by the body's healing power, which some time can never add much except of waiting few more weeks [3]. However, research shows promising results by modifying the implant surface itself, as will be discussed in the forthcoming chapters. On the patient's level, the use of stem cells, growth factors, and systemic drugs to improve osseointegration is being experimented to improve the healing power [3,4].

#### **2.1. Surgical site alveolar deficiency**

Hence, the dynamic advancement in the field is taking place on different levels that are important for any implantologist to comprehend, at the clinical, micro, and nano levels. The implant surface characteristics, the implant soft tissue interface, alveolar bone reconstruction, the involvement of micro-organisms, the indications of antibiotics in implant surgery, osseointegration, cellular attachments, and the advancement of implant designs are all areas of important research topics nowadays that are going to be explored in the book hoping to

It is well known that training in the dental implant field usually starts with the basics of planning, starting from case interview, examination, investigational images, analyzing the data, considering case requirement, finalizing the rehabilitation plan, dental extraction, alveolar reconstruction, implant surgical installment, prosthetic rehabilitation options, patient cooperation, and establishing a recall schedule. It is unfortunate that a lot of training programs are focusing mainly on the technicalities including implant placement and prosthetic restora‐ tion while forgetting the importance of the scientific background in applying the clinical practice. And it causes a dilemma via producing graduates who are not able to connect the basic science, research, clinical application, and the future potential to improve the field. Therefore, it is not uncommon that during residents teaching, rounds, and board exams, candidates might show technicality excellence without knowing the justification, and hence, reaching into a block when facing a challenge in a case, a complication, or an examination

The technical advancement in dental and medical care is continuously improving and producing ideas; however, still a lot of doubts that one day technology might replace a human surgeon to operate on another human solely. The reason behind that doubt is the simple existence of human race that will always show variable clinical conditions that can never be the same and might differ on three major categories, patient's, operator's, and material's

These are defined as factors mainly pertinent to the patient him/herself that include and not limited to the medical background, anxiety, allergy, smoke history, anatomical variations, implant site local challenges, local bone type, local topography, and the personal preference. The patient preferences can be limitless, which include a demand in implant type, surgical intervention, grafting technicality, prosthetic end result, and the mostly challenging the time frame demand. The reason that time frame is very challenging, as it is mainly affected by the body's healing power, which some time can never add much except of waiting few more weeks [3]. However, research shows promising results by modifying the implant surface itself, as will be discussed in the forthcoming chapters. On the patient's level, the use of stem cells, growth factors, and systemic drugs to improve osseointegration is being experimented to improve the

present more options for future care.

4 Dental Implantology and Biomaterial

question.

pertinent factors.

healing power [3,4].

**2. Patient-related factors**

Surgical site evaluation to identify vertical or horizontal deficiency has been an area of continuous challenge to implantologist [5]. The techniques of management are beyond the scope of this chapter, but the importance of mastering more techniques to manage such challenges is an area that should be considered while training. Not to mention that not all cases would accept manipulating their jaws in a way to reconstruct it back to its original. And hence, the necessity to formulate boundaries in the practice according to what can be done for a patient or what has to be compromised (**Figures 1**–**5**).

**Figure 1.** Intraoral clinical images showing bone deficiency at the vertical and horizontal levels leading to minimal gin‐ gival recession pertinent to the lower canine teeth.

**Figure 2.** A periapical radiograph showing remaining roots of a previously attempted dental extraction performed in another practice few months ago. The patient was upset and demanding dental implant treatment on site without de‐ lay. Therefore, after thorough discussion on the operative procedure, risks, benefits, alternatives and modification plan, careful manipulation of the surgical site was exercised to remove the buried roots aiming to preserve the sur‐ rounding bone structure otherwise placing an implant immediately can be aborted and switching the procedure to al‐ veolar bone grafting only will take place. However, the extraction was performed successfully with preservation of the buccal plate and confirming the socket dimension area with the periapical radiograph on the right side.

**Figure 3.** The surgical site was carefully prepared and the implant osteotomy was performed aiming at bone conserva‐ tion and immediate implant placement that was accomplished successfully with good primary stability achieved at the apical portion at the sinus cortical boundary.

**Figure 4.** A radiograph of a 50-year-old patient showing limited vertical bone height to place dental implant. The pa‐ tient was offered a sinus lift procedure and was not a choice of preference to the patient. The option of short implant insertion was discussed including risks, benefits and alternatives, and it was more appealing to the patient. The figure on the right shows the pin guide indicating the length and parallelism.

**Figure 5.** A periapical radiograph showing the short implant in situ and the crown placed in favorable status. The re‐ storation and functional result were satisfying to the patient and achieved the "case requirement" demands.

#### **2.2. Local blood supply deficiency**

The era of osseointegration is based on the viable existence of an implant and bone interface. The former is anatomically defined via a viable osseous region containing adequate blood perforates to facilitate the implant-bone relation. Sometimes, missing to identify cortical areas of poor blood perforates, especially in older patients, can be the reason behind the success or failure. The following cases show examples of local compromise (**Figures 6**–**9**).

**Figure 6.** A 75-year-old female patient who was known to be diabetic that is controlled and followed by an endocrinol‐ ogist. The clinical image shows alveolar bone local limited blood supply at the crestal level when compared to the buc‐ cal plate perforates. It has to be carefully considered when planning osteotomies for implant placement.

Introductory Chapter : Dental Implantology, The Challenging Scenarios between Training, Resources, and Patients' Demands http://dx.doi.org/10.5772/63834 7

**Figure 7.** A 19-year-old male patient went through road traffic accident leading to avulsion of the anterior central inci‐ sors, dentoalveolar fracture, and a minimally displaced left lateral incisor. The primary care was undergone at the emergency department as localized dentoalveolar reduction and lateral incisor reduction with wire splinting. The pa‐ tients presented to the clinic 3 days after the accident are concerned about the rehabilitation of the anterior maxilla. This scenario might lead to significant post-trauma alveolar bone loss and gingival deformity if not planned carefully for dental implant-based rehabilitation.

**Figure 4.** A radiograph of a 50-year-old patient showing limited vertical bone height to place dental implant. The pa‐ tient was offered a sinus lift procedure and was not a choice of preference to the patient. The option of short implant insertion was discussed including risks, benefits and alternatives, and it was more appealing to the patient. The figure

**Figure 5.** A periapical radiograph showing the short implant in situ and the crown placed in favorable status. The re‐

The era of osseointegration is based on the viable existence of an implant and bone interface. The former is anatomically defined via a viable osseous region containing adequate blood perforates to facilitate the implant-bone relation. Sometimes, missing to identify cortical areas of poor blood perforates, especially in older patients, can be the reason behind the success or

**Figure 6.** A 75-year-old female patient who was known to be diabetic that is controlled and followed by an endocrinol‐ ogist. The clinical image shows alveolar bone local limited blood supply at the crestal level when compared to the buc‐

cal plate perforates. It has to be carefully considered when planning osteotomies for implant placement.

storation and functional result were satisfying to the patient and achieved the "case requirement" demands.

failure. The following cases show examples of local compromise (**Figures 6**–**9**).

on the right shows the pin guide indicating the length and parallelism.

**2.2. Local blood supply deficiency**

6 Dental Implantology and Biomaterial

**Figure 8.** Periapical radiographs showing the central incisors intact socket status, and the implants were placed 10 weeks after the accident to minimize the bone resorption trauma effect especially at the buccal plate aspect. The dental implants were placed carefully aiming at keeping sufficient hard and soft tissue for future cosmetic rehabilitation in addition to buccal plate augmentation. The radiograph on the right shows the preservation of the vertical height of the interimplant site to help supporting the interdental papilla later on.

**Figure 9.** The radiograph shows a favorable crown coping and favorable interimplant bone level as being counted for the future support to interdental papilla, avoiding black triangles in the anterior maxilla, a dangerous cosmetic region.

## **3. Operator-related factors**

The operator's factors include the expertise, training background, operator's capabilities, personal interest to introduce new techniques, knowledge of data interpretation, the presence of a supporting team, and the talent to adjust with the challenging case requirement. As much as it is fair to all patients, as much being part of the code of ethics at any area of practice around the world, the capabilities of practice must be clearly disclosed. An example of the surgical specialties is oral and maxillofacial surgery (OMS or OMFS) that is a practice of intensive training in the oral, facial, head, and neck regions that would share continuous interventional skills at the maxillomandibular complex. It can include major interventions or millimeter cosmetic part of care. OMFS intensive training around the area usually produces practitioners of crucial sense when it comes to estimating details of blind maneuvers, osteotomy direction, depth gauging, tactile dexterity to length and width, tactile sense to osteotomy structure of nature, and confidence in managing perisinus structures and jaw components [5]. As more specialties are sharing the implant part of health care practice, it is important to consider such reality in managing cases of special challenges, systemically as well as locally. Especially those implant survival studies show variable success outcomes depending on the specialty of practice [6–8]. Nonetheless, the interspecialty consultation to manage a case is what matters to clients seeking dental implants. The multispecialty consultations and teamwork practice will always provide the best care possible.

#### **3.1. Narrow dental implant**

In locations of limited mesiodistal width, the ability to place an implant can be jeopardized by a lot of factors, such as the flap design, root angulation, coronal tilting, alveolar bone dimen‐ sion, and operator's clinical skills to place an implant usually via one or two drilling sequences only, which can leave no room for corrections neither over preparation of osteotomy sites (**Figures 10**–**12**).

**Figure 10.** A clinical image showing a challenging narrow location of missing left lateral incisor. The patient is 70 years old and asking for implant-based rehabilitation. The plan was to place a narrow implant in the area with minor odon‐ toplasty to plan for cosmetically pleasant maxillary lateral incisor. This area constitutes part of the cosmetically chal‐ lenging region, the anterior maxilla.

Introductory Chapter : Dental Implantology, The Challenging Scenarios between Training, Resources, and Patients' Demands http://dx.doi.org/10.5772/63834 9

**Figure 11.** A flap was raised to carefully prepare the narrow implant site as a single osteotomy attempt is usually valid for such cases with limited opportunity to redirect. Hence, a flapless procedure is discouraged in such cases. The clini‐ cal picture on the right shows favorable position for future rehabilitation based on the case requirement.

**Figure 12.** An intraoperative pin direction X-ray indicating the limited space and favorable inclination for drilling in correlation with the intraoperative clinical setting. The aforementioned counts are necessary to adjust location and di‐ rection on the first attempt. The postoperative radiograph on the right shows the implant position in accordance with the plan in the three dimensions, apicocoronal and mesiodistal. The clinical correlation is of prime importance to ad‐ just all the dimensions including the buccolingual dimension as presented in Figure 11.

#### **3.2. The challenge of onlay bone grafting**

**3. Operator-related factors**

8 Dental Implantology and Biomaterial

will always provide the best care possible.

**3.1. Narrow dental implant**

lenging region, the anterior maxilla.

(**Figures 10**–**12**).

The operator's factors include the expertise, training background, operator's capabilities, personal interest to introduce new techniques, knowledge of data interpretation, the presence of a supporting team, and the talent to adjust with the challenging case requirement. As much as it is fair to all patients, as much being part of the code of ethics at any area of practice around the world, the capabilities of practice must be clearly disclosed. An example of the surgical specialties is oral and maxillofacial surgery (OMS or OMFS) that is a practice of intensive training in the oral, facial, head, and neck regions that would share continuous interventional skills at the maxillomandibular complex. It can include major interventions or millimeter cosmetic part of care. OMFS intensive training around the area usually produces practitioners of crucial sense when it comes to estimating details of blind maneuvers, osteotomy direction, depth gauging, tactile dexterity to length and width, tactile sense to osteotomy structure of nature, and confidence in managing perisinus structures and jaw components [5]. As more specialties are sharing the implant part of health care practice, it is important to consider such reality in managing cases of special challenges, systemically as well as locally. Especially those implant survival studies show variable success outcomes depending on the specialty of practice [6–8]. Nonetheless, the interspecialty consultation to manage a case is what matters to clients seeking dental implants. The multispecialty consultations and teamwork practice

In locations of limited mesiodistal width, the ability to place an implant can be jeopardized by a lot of factors, such as the flap design, root angulation, coronal tilting, alveolar bone dimen‐ sion, and operator's clinical skills to place an implant usually via one or two drilling sequences only, which can leave no room for corrections neither over preparation of osteotomy sites

**Figure 10.** A clinical image showing a challenging narrow location of missing left lateral incisor. The patient is 70 years old and asking for implant-based rehabilitation. The plan was to place a narrow implant in the area with minor odon‐ toplasty to plan for cosmetically pleasant maxillary lateral incisor. This area constitutes part of the cosmetically chal‐

The science of onlay bone grafting is evolving rapidly to match up the challenges that are facing the surgeons in the field or oral implantology and reconstruction. It is well known that inlay defect bone fill is much more predictable than onlay defects [9–11]. The technique of application and the materials used are variable, including allogenic, alloplastic, bone morphogenetic proteins, and xenograft graft materials. Not to mention the time factor of managing extraction sockets in either immediate or late phase to prepare implant placement [12–14]. The operators have to have the ability to properly select the best reconstructing technique in each case separately and to avoid limited techniques to do so. The cases will always be different as introduced in the following cases (**Figures 13**–**15**).

**Figure 13.** A 33-year-old male patient presented with missing left central incisor for more than 6 years secondary to trauma. The clinical examination and investigatory cone beam CT scan images were suggesting the possibility of hav‐ ing an alveolar bone space for implant placement with simultaneous grafting.

**Figure 14.** A clinical intraoperative image of the previous case showing the flap raised and indicating an extremely poor alveolar bone horizontal width that prohibits the implant placement and switch the procedure to a local grafting using particulate allogenic graft with calcium sulfate carrier to improve the consistency and bulk.

**Figure 15.** A clinical picture showing a putty-like bone graft that can be molded and sustain acceptable consistency and bulk for alveolar bone reconstruction. The picture on the right shows the location postgrafting that did not require any membranes to be placed due to the consistency of the material and the carrier barrier [11,12]. The option of either using bone mophogenic protein delivered via carriers or using a graft contained in an alloplastic membrane cover is amenable for onlay or inlay alveolar defects reconstruction [13,14].
