**4. Material-related factors**

technique in each case separately and to avoid limited techniques to do so. The cases will

**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‐

**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

**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

using particulate allogenic graft with calcium sulfate carrier to improve the consistency and bulk.

amenable for onlay or inlay alveolar defects reconstruction [13,14].

always be different as introduced in the following cases (**Figures 13**–**15**).

10 Dental Implantology and Biomaterial

ing an alveolar bone space for implant placement with simultaneous grafting.

When it comes to the material's factors, it includes the implant surface type, length, diameter, internal design, external design, laboratory capabilities, managing challenges, images capa‐ bilities, surgical stents, radiographic imaging, cone beam CT scanning (CBCT), and finally, the proficiency to manage the time factor.

It is not uncommon these days to observe cases being treated while omitting the role of case planning in the laboratory and mocking future results. The former is much critical when planning a case going through comprehensive care including orthodontics management. The controversy of completing the dental alignment before implant insertion is advocated in order to avoid any misplacement of the dental implant [15]. Proponents claim the loss of alveolar bone by the time of completing the orthodontic care couple of years later that warrants more challenging reconstruction, grafting, implant insertion, and delaying the rehabilitation care, not to mention the cumulative cost. Proper planning and inter specialty consultations can provide better results and can always manage such cases either way (**Figures 16**–**18**).

**Figure 16.** The planning of implant insertion while performing orthodontic treatment is an issue of discussion. It has the advantage of utilizing the bone while in favorable width and height better than waiting for the prolonged time of orthodontic treatment that will lead to significant alveolar bone resorption and hence a future challenge of implant placement, root exposure, not to mention the further delay in oral rehabilitation [15]. This can only be applied in select‐ ed cases based on careful planning.

**Figure 17.** This case was planned for multiple dental implants in the upper right maxillary region using surgical stent that was reviewed in the lab by the prosthetic team. The stent was used in the presence of the right wisdom tooth help‐ ing in precise stability of the stent in localizing the future implant sites, AKA, tooth-supported surgical guide, that is considered more precise compared to the other two types of surgical guides, the mucosa-supported and the bone-sup‐ ported surgical guides. However, the wisdom tooth will be extracted once the objective is achieved intraoperatively [16].

**Figure 18.** The implant locations were precisely identified using pin guides with clinical relevance to carefully place the implants in this limited site from buccopalatal dimension. The right maxillary wisdom tooth (third molar) was ex‐ tracted at that point. The buccal plate deficiency reconstruction was considered at earlier stage in addition to the ex‐ pected inlay defect post third molar removal [17].

#### **4.1. Dental wax-up and surgical stent fabrication**

The dental wax-up is a necessary tool used to plan dental implant treatment. It is not only used for estimating the exact location and size of an implant, it is used as well to plan orthodontic movement and future grafting sites [16,17]. The application of the conventional laboratory surgical stent or CBCT-based stent might lead to the same result. The comprehension of the best utilization and avoiding possible errors are the factors that matter. Hence, interspecialty consultation at the primary visits would save time and interventions from the surgical point of view. As more time elapsed, the more bone loss, and the more challenging alveolar reconstruction and implant care.

#### **4.2. Cone beam scan application in dental implant therapy**

Part of the advancement in dental implantology care is represented by the use of cone beam CT scan (CBCT). Although not all cases might require CBCT image-based planning, the significance does exist among specific cases where the three-dimensional orientation is the key to success [16,18]. Hence, it requires knowledge and skills for analyzing the images and supporting the clinical correlation (**Figures 19**–**21**).

**Figure 19.** A 42-year-old female patient presented with a missing left second premolar that is challenged horizontally by crown tilting and pneumatized maxillary sinus. The radiographic image shows the shadow of maxillary sinus pneumatization leaving limited alveolar height, radiographically. Therefore, CBCT scan was carried out and showed an overimposed sinus floor distopalatally with an extraction socket space barely limited for an implant placement without sinus lifting. The case review, risks, benefits, and alternatives were discussed and consented to proceed.

Introductory Chapter : Dental Implantology, The Challenging Scenarios between Training, Resources, and Patients' Demands http://dx.doi.org/10.5772/63834 13

**Figure 20.** The surgical site was exposed and the previous socket space was identified and carefully followed to place the implant in situ. The evaluation of the osteotomy site confirmed intact edges without sinus violation, and hence, the implant was inserted. The postoperative periapical radiograph can be deceiving to the position of the implant as it shows a superimposition on the sinus floor and close proximity to neighboring teeth which was double confirmed clin‐ ically and using a postoperative CBCT scan (see Figure 21).

**Figure 18.** The implant locations were precisely identified using pin guides with clinical relevance to carefully place the implants in this limited site from buccopalatal dimension. The right maxillary wisdom tooth (third molar) was ex‐ tracted at that point. The buccal plate deficiency reconstruction was considered at earlier stage in addition to the ex‐

The dental wax-up is a necessary tool used to plan dental implant treatment. It is not only used for estimating the exact location and size of an implant, it is used as well to plan orthodontic movement and future grafting sites [16,17]. The application of the conventional laboratory surgical stent or CBCT-based stent might lead to the same result. The comprehension of the best utilization and avoiding possible errors are the factors that matter. Hence, interspecialty consultation at the primary visits would save time and interventions from the surgical point of view. As more time elapsed, the more bone loss, and the more challenging alveolar

Part of the advancement in dental implantology care is represented by the use of cone beam CT scan (CBCT). Although not all cases might require CBCT image-based planning, the significance does exist among specific cases where the three-dimensional orientation is the key to success [16,18]. Hence, it requires knowledge and skills for analyzing the images and

**Figure 19.** A 42-year-old female patient presented with a missing left second premolar that is challenged horizontally by crown tilting and pneumatized maxillary sinus. The radiographic image shows the shadow of maxillary sinus pneumatization leaving limited alveolar height, radiographically. Therefore, CBCT scan was carried out and showed an overimposed sinus floor distopalatally with an extraction socket space barely limited for an implant placement without sinus lifting. The case review, risks, benefits, and alternatives were discussed and consented to proceed.

pected inlay defect post third molar removal [17].

12 Dental Implantology and Biomaterial

reconstruction and implant care.

**4.1. Dental wax-up and surgical stent fabrication**

**4.2. Cone beam scan application in dental implant therapy**

supporting the clinical correlation (**Figures 19**–**21**).

**Figure 21.** A postoperative CBCT scan shows the previous case of proper implant location that is not violating the si‐ nus or dental structures as confirmed by parasagittal and axial views.

It can be noticed that all the former categories, such as the patient's, operator's, and material's, are linked to all the implant cases, in this chapter, forthcoming chapters, and possibly all over the world. Improving the service, survival, time factor, esthetics, and final results are the factors that result in success. And that is the involvement of current research to improve the implant therapy. Hence, cases are not going to be the same, and the difficulty levels will always dictate the methodology of intervention.
