**5. Challenges of implant training vs. iatrogenic issues**

Just like anything in life, improper training will lead to disasters. The current observation of awkward complications is presented due to the jeopardized weekend diplomas, nonaccredited training programs, downgrading the training duration, and mixing the specialties of care. The phenomena of picturing dental implantology as a practice of placing a pin in the bone and then sticking a crown on top is putting this field in a lot of danger, not to mention the marketing twists in using medical terminologies such as flapless, sutureless, graftless, painless, harmless, and so on. The former will send false massages to the community, the students, and general practitioners. It is imperative to communicate evidence-based clinical application when it comes to health care science. The importance of basic science, the comprehension of variable methods of practice, and the advent of current technology will add up to the training products and will never facilitate shortcuts.

The last section of this chapter will be showing few examples of cases that could have been carried out in a better way. I had the chance to view these cases as consultations showing up as early as a month postimplant placement and up to two years postinsertion. All practitioners in the field would have cases that are not proud of, facing difficult cases, or probably incorrect choice at one time or another. The purpose of sharing some of these cases is for educating the target readers, to prophylactically avoid some of these pitfalls, and to introduce the current era of implant care discussed in the next chapters.

Managing challenges are areas of special concerns in the field of dental implants. It can be found secondary to any shortcomings of what were mentioned earlier, such as patient's, operator's, and material's. A deficiency in one aspect might lead to transferring a challenge into an actual complication [19]. Novel practitioners might be surprised with the power of handedness tendency even if all aspects of care were taken, still the vision of placing that implant in three dimensions can be deceiving and requires a plateau of proper training to gain accuracy (**Figures 22** and **23**).

**Figure 22.** A radiograph showing dental implant with unfavorable positioning, tilting, and improper apicocoronal seating. It will lead to a challenging restoration with diverged emergence profile angle, AKA, "a tomato on a stick."

**Figure 23.** A periapical radiograph showing an implant not seated deep enough apicocoronally, leading to extremely diverged emergence profile, AKA, "a tomato on a stick." The 42-year-old patient presented as an emergency visit com‐ plaining of tenderness at the implant of mandibular left molar site attempted in a different practice about a year ago. The patient stated that the pain is repeatedly eliciting providing the fact of changing the crown few times. The di‐ verged emergence profile formed a "housing" curve to collect food debris leading to subgingival abscess infection as seen on the right clinical picture. The patient underwent an emergency intervention of conservative incision and drain‐ age of the purulent discharge, copious irrigation, antibiotic prescription, and analgesics until deciding for a definitive care.

In other situations, underestimating the necessity of proper planning to calculate the implant space available for future prosthetic rehabilitation can lead to bizarre outcomes (**Figures 24** and **25**). Hence, even if the care is going to take place through the conventional laboratory waxup and surgical stent fabrication or through the soft-wear simulation programs, the result will be the same, and the surgeon is still in charge when deciding to place those implants in place or not [16]. The practitioner should comprehend that any data gathered will only be an additive item aiming to assist in placing the implant onsite, whereas the surgeon is the only person in charge at the intraoperative stage to place those implants, review the data again, modify the plan, or abort the procedure [18,19] (**Figure 26**).

methods of practice, and the advent of current technology will add up to the training products

The last section of this chapter will be showing few examples of cases that could have been carried out in a better way. I had the chance to view these cases as consultations showing up as early as a month postimplant placement and up to two years postinsertion. All practitioners in the field would have cases that are not proud of, facing difficult cases, or probably incorrect choice at one time or another. The purpose of sharing some of these cases is for educating the target readers, to prophylactically avoid some of these pitfalls, and to introduce the current

Managing challenges are areas of special concerns in the field of dental implants. It can be found secondary to any shortcomings of what were mentioned earlier, such as patient's, operator's, and material's. A deficiency in one aspect might lead to transferring a challenge into an actual complication [19]. Novel practitioners might be surprised with the power of handedness tendency even if all aspects of care were taken, still the vision of placing that implant in three dimensions can be deceiving and requires a plateau of proper training to gain

**Figure 22.** A radiograph showing dental implant with unfavorable positioning, tilting, and improper apicocoronal seating. It will lead to a challenging restoration with diverged emergence profile angle, AKA, "a tomato on a stick."

**Figure 23.** A periapical radiograph showing an implant not seated deep enough apicocoronally, leading to extremely diverged emergence profile, AKA, "a tomato on a stick." The 42-year-old patient presented as an emergency visit com‐ plaining of tenderness at the implant of mandibular left molar site attempted in a different practice about a year ago. The patient stated that the pain is repeatedly eliciting providing the fact of changing the crown few times. The di‐ verged emergence profile formed a "housing" curve to collect food debris leading to subgingival abscess infection as seen on the right clinical picture. The patient underwent an emergency intervention of conservative incision and drain‐ age of the purulent discharge, copious irrigation, antibiotic prescription, and analgesics until deciding for a definitive

In other situations, underestimating the necessity of proper planning to calculate the implant space available for future prosthetic rehabilitation can lead to bizarre outcomes (**Figures 24**

and will never facilitate shortcuts.

14 Dental Implantology and Biomaterial

accuracy (**Figures 22** and **23**).

care.

era of implant care discussed in the next chapters.

**Figure 24.** A panoramic radiograph showing three implants placed at the right mandible region. The implants are placed at improper locations pertinent to each other, surrounding structure, future rehabilitation, and opposing occlu‐ sion. Not using proper surgical stent to guide the future rehabilitation plan might lead to such devastating results.

**Figure 25.** A panoramic radiograph showing three implants placed at the right mandible posterior region. The three implants were placed at a location where a single posterior implant might suffice. Poor planning, careless intervention, or untrained practitioner will lead to such horrifying outcomes and unnecessary expenses. The improper relation and the close proximity to the neighboring right premolar will jeopardize the implant itself. As the premolar sounds to be poorly treated, and hence it will be a source of infection or extraction. Either will be placing the extremely close im‐ plant in jeopardy. The most distal implant is placed at a negative functional zone; hence, it has no role in the rehabilita‐ tion plan not to mention the unnecessary surgery and cost. Therefore, the general rehabilitation plan of the maxillomandibular complex does require careful revision especially considering the existence of poor prognostic teeth in both arches [18,19].

**Figure 26.** A periapical radiograph showing three implants next to each other with improper relation pertinent to fu‐ ture rehabilitation and as a relation to the neighboring tooth structure. The result showed leaving the implant in the middle in a sleeping status with questionable outcomes, indicating an unnecessary surgical intervention and cost [19].
