8years later

EAO CERTIFICATION PROGRAMME 2016
C A S E Number: 1
Dr Emmanouil Symeonidis
Hamad Medical Corporation Al Wakra hospital
Dental department periodontics clinic # 3
82228 Al Wakra
QATAR
Mobile phone: +30 6932223074 /+97433299012
Email address: manosemm@gmail.com
CERTIFICATION PROGRAMME 2016 case #1

General introduction
M.K. female 32 y.o.a. Architect.
Medical History : Clear , No Known Drug
Allergies
CC: “I don’t like my Anterior Tooth”
Medical History : Clear
smoking up to 7 cigarettes per day
Dental History : Previously RCT surgery
….. “with some kind of grafting” in a
hospital in Athens Greece

Standardised Documentation for Implant Treatment 9E AO
Pre-operative assessment: periodontal status
Bleeding on
probing
Bleeding on
probing
Plaque
Toothnumber
Pocket
depth
Plaque
Pocket
depth
Toothnumber
labial
lingual
labial
lingual
labial
lingual
labial
lingual
labial
lingual
labial
lingual
Date: 10/04/2010
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- - - - -- - - - - - - - - - - - - - + + + + - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - -- + + + + + + + + + - - - - - - - - - - - - - - - -
3 3 3 3 3 3 3 2 3 3 3 3 2 1 2 3 3 3 3 3 4 5 6 7 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 5 6 6 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 4 4 3 3 3 3 3 3 3 3 4 2 2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
- - - - - - - - - - - - + + + + + + + + + + + + + + + + + + - - - - - - - - - - - -
- - - - - - - - - - - - + + + + + + + + + + + + + + + + + + + - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - + + + + + + + + + + + + - - - - - - - - - - - -
- - - - - - - - - - - - - - - + + - + + + + + + + + + + + + + - - - - - - - -

CBCT Axial view at the level of the CEJs distance of cuts 2 mm (#31-40 )real dimensions

CBCT Panoramic views Planes 2 & 4 including the area of interest #21

CBCT Sagittal view of 21
Periapical pathos is
Possible fenestration
Buccal plate not visible

• Thick Flat Periodontium
• Altered passive eruption Coslet classification 1A normal distance CEJ bone crest wider keratinized mucosa
• Inflamed papilla and gingival margin
• Bleeding on Probing
• Class V composite restoration extending below the gingival margin

Treatment plan
Initial assessment
Initial Impressions
Indexing of the anterior teeth/ bite registration
Radiographic examination
Scaling
Oral Hygiene Instructions
Lab processed/ Self carved provisional: removable or fixed provisional crown supported on neighboring teeth
Extraction
Depending on the presence abscense of the buccal plate (Dscan vs clinical )
Implant placement
NO ? YES ?
Install the implant immediately ? Wait ?
Primary stability ?
TIME Ridge Augmentation ?
Comfort Would the implant support the ridge by itself ?
Need for bone graft material ?
Provisional ? Screw Retained ? Cemented?
Soft tissue Management ?
Second Stage uncovering the implant ?
Restorative Treatment ? Metal Free?

Albrektsson T, Brånemark P-I, Hansson H-A, Lindström J. Osseointegrated
titanium implants: requirements for ensuring a long-lasting direct bone-to-
implant anchorage in man. Acta Orthop Scand 1981; 52:155–170.
1) status of the bone (or, better, the implant site)
2) loading conditions
3) surgical technique
4) implant design (or macrostructure)
5) implant finish (surface)
6) implant material

Are there Risks into choosing the immediate implant as intervention of choice ?
In patients with an intact buccal bone wall and thick gingival biotype, treated by means of flapless surgery
and an immediate implant crown, the frequency of advanced midfacial recession was low (<10%)
A systematic review on the frequency of advanced recession following single immediate implant treatment J.Cosyn,N.Hooghe, H.Bruyn J Clin Periodontol. Vol. 39(6)2012 pp.582–589
Would the single tooth implant in the anterior Maxilla be a predictable result in the course of time ?
immediate single implant treatment in the anterior maxilla after a 3-year observation period.
thick gingival biotype, ideal gingival level/contour and intact socket walls at the time of tooth extraction.
• minimal mucoperiosteal flap elevation,
• immediate implant placement
• insertion of a grafting material between the implant and the socket wall
• connection of a screw-retained provisional restoration.
• Not immediately loaded
• cemented crown 6 months thereafter.
• implant survival 96%
• hard and soft tissue conditions mid facial recession 8%
• PES < 8 & WES <6 : 21% (failures) 58% acceptable 21% perfect
C:valuable and predictable treatment option for right case selection with almost full papillary re-growth and a
low risk for advanced midfacial recession.
Immediate single-tooth implants in the anterior maxilla: 3-year results of a case series on hard and soft tissue response and aestheticsJan Cosyn,A. Eghbali, H. Bruyn,
K. Collys, R. Cleymaet, T. Rouck Jclin. Periodontol.. 38(8), 2011 pp746–753

Placing and loading a single implant in a fresh extraction socket in the Anterior Maxilla, is it a
total or calculated risk?
Immediate restoration/loading of immediately placed single implants: is it an effective bimodal approach?
MA. Atieh,AT. Payne, WJ. Duncan, MP. Cullinan COIR 20(7), 2009 pp.645–659
A systematic comparison meta analysis of survival and radiographic marginal bone level
changes
immediate implant protocols in the aesthetic region; immediate single implant
restoration/loading in extraction sockets (the bimodal approach) VS. same in healed sites.
C: bimodal approach adds a certain risk
may offer an advantage with respect to the favorable changes in marginal bone levels.

Wilson & Weber (1993) Immediate Same day as extraction
Recent 30–60 days after extraction
Delayed Following hard tissue maturation
Mature Months to years after extraction
Mayfield (1999) Immediate Same day as extraction
Delayed 42–70 days after extraction
Late 6 months after extraction
Immediate restoration/loading of immediately placed single implants: is it an effective bimodal approach?
MA. Atieh,AT. Payne, WJ. Duncan, MP. Cullinan COIR 20(7), 2009 pp.645–659
Hämmerle et al. (2004) Type I In fresh extraction sockets
Type II After soft tissue coverage ( 4- 8 weeks)
Type III Radiographic bone fill (12-16 weeks)
Type IV Healed socket (>16 weeks)
Esposito et al. (2006) Immediate In fresh extraction sockets
Immediate-delayed < 8 weeks post extraction
Delayed > 8 weeks post extraction
Immediate implants following tooth extraction. A systematic review
J.Ortega-Martínez, T.Pérez-Pascual, S. Mareque-Bueno , F.Hernández-Alfaro, E. Ferrés-Padró
Med Oral Patol Oral Cir Bucal. 2012 Mar 1;17 (2):e251-61
Implant placement protocols

• Immediate restoration or immediate non-functional (non-occlusal) loading
Within 48 h of implant placement but not in centric or eccentric occlusal contact with the opposing dentition during
healing
• Immediate loading or immediate functional loading
Into occlusal loading within 48 h of implant placement
• Progressive loading
In light occlusal contact initially and then gradually adjusted into full occlusal contact
• Early loading
Between at least 48 h and not later than 3 months after implant placement
• Conventional loading
• In a second procedure after a healing period of 3–6 months
• Delayed loading
• After a conventional healing period of 6 months
Cochran, D.L., Morton, D. & Weber, H.P. (2004) Consensus statements and recommended clinical procedures
regarding loading protocols for endosseous dental implants. International Journal of Oral & Maxillofacial
Implants 19 (Suppl.): 109–113.
Implant loading Protocols

TYPE 1: Implant placement immediately following tooth extraction and as part of the
same surgical procedure
Advantages
• Reduced number of surgical procedures
• Reduced overall treatment time
• Optimal availability of existing bone
Disadvantages
• Site morphology may complicate optimal placement and anchorage
• Thin tissue biotype may compromise optimal outcome
• Potential lack of keratinized mucosa for flap adaptation
• Adjunctive surgical procedures may be required
• Procedure is technique-sensitive
Consensus Statements and Recommended Clinical Procedures Regarding the Placement of Implants in Extraction Sockets
Christoph H. F. Hämmerle, Stephen T. Chen, Thomas G. Wilson Jr
IJOMI Vol 19 Supplement 2004
Certification Programme Exam case #1

TYPE 2 : Complete soft tissue coverage of the socket (typically 4 to 8 weeks)
Advantages
• Increased soft tissue area and volume facilitates soft tissue flap
management
• Resolution of local pathology can be assessed
Disadvantages
• Site morphology may complicate optimal placement and anchorage
• Treatment time is increased
• Socket walls exhibit varying amounts of resorption
• Procedure is technique sensitive

TYPE 3 : Substantial clinical and/or radiographic bone fill of the socket (Typically 12 to 16 weeks)
Advantages
• Substantial bone fill of the socket facilitates implant placement
• Mature soft tissues facilitate flap management
Disadvantages

TYPE 4 : Healed Site (typically 12 to 16 weeks)
Advantages
• Clinically healed ridge
• Mature soft tissues facilitate flap management
Disadvantages
• Large variations are present in available bone

Full thickness flap was raised
Composite Resin violating biological with altering the bone crest contour
Altered Passive Eruption Coslet type 1A (normal distance of CEJ to bone crest/ wider keratinized mucosa)

Type 1 classification CHF Hammerle 2004:
• Extraction of #21
• Immediate placement of dental implant

Type 1 classification CHF Hammerle 2004:
• Extraction
• Immediate placement
• Buccal bone present thickness of 1 mm aprox.

A prospective, controlled clinical trial evaluating the clinical radiological and aesthetic outcome after 5 years of immediately placed
implants in sockets exhibiting periapical pathology.
R.E. Jung,B. Zaugg,A.O. H. Philipp,TC. Truninger,DW. Siegenthaler, CHF Hammerle COIR 24: (8)2013 Pp :839–846
• Presence of buccal plate with 1 mm of
thickness approximately
• Atraumatic extraction with the help of Nobel
Biocare periotome was achieved
• No Rotational movements
• Effort and Care was made to respect the
socket’s dimensions
• Remnants of the RCT are obvious at the
palatal wall of the socket

Correct Implant Position
MD dimension
comfort zone away from danger zones which are located close to adjacent root surfaces 1-1.5mm
OF dimension
Implant shoulder is positioned about 1 mm palatal to the point of emergence of adjacent teeth
Too facially will place the implant in danger of recession Too palatally will need the crown to have ridge
lap design
AC dimension
1 mm apically than the adjacent CEJ
Too deep will created a deep sulcus difficult maintenance * cemented crowns !!
Too coronally shoulder exposure and mechanics revelation with shoulder exposure
Buser D, Martin W, Belser UC.Optimizing Esthetics for Implant Restorations in the Anterior Maxilla:
Anatomic and Surgical Considerations.
International Journal of Oral & Maxillofacial Implants . 2004 Supp., Vol. 19 Issue 7, p43-61

• primary stability
• the presence of a buccal plate
• filling of the gap between the buccal plate and the implant or jumping distance
• tissue biotype,
• implant design.
A NEW PROTOCOL FOR IMMEDIATE IMPLANTS. THE RULE OF THE 5 TRIANGLES: A CASE REPORT (PAGES 4 & 5)
J. Jiménez García, D.Sanguino Dec. 2014
http://www.eao.org/new-protocol-immediate-implants-rule-5-triangles-case-report-pages-4-5-0#sthash.llMbGKrP.dpuf
• atraumatic extraction prevents pronounced bone loss.
• the void should always be grafted with biomaterial.
• compensate soft tissue remodeling, by overbuilding
• Biomaterial
• soft tissue graft.
• Provisional crowns in immediately placed implants can help
maintain soft tissue contours.
• Implant design is recommended to be self-tapered, so it can
favor reaching primary stability

Primary Stability–first tringle
• sufficient bone apical to the extracted tooth’s alveolus.
• approximate 2-4 mm of bone apical to the alveolus is necessary to obtain primary
stability This can be enhanced by the type of implant used, which is of a tapered
design.
A NEW PROTOCOL FOR IMMEDIATE IMPLANTS. THE RULE OF
THE 5 TRIANGLES: A CASE REPORT (PAGES 4 & 5)
http://www.eao.org/new-protocol-immediate-implants-rule-5-
triangles-case-report-pages-4-5-0#sthash.llMbGKrP.dpuf

Schwartz D, Chaushu. The ways and wherefores of immediate placement of implants into fresh extraction sites:
a literature review. J Periodontol 1997;68:915-923
1) high rate of survival, ranging between 93.9% to 100%;
2) implants must be placed 3 to 5 mm beyond the apex in order to gain a maximal degree of stability;
3) implants should be placed as close as possible to the alveolar crest level (0 to 3 mm);
4) there is no consensus regarding the need for gap filling and the best grafting material;
5) membranes do not imply better results-on the contrary, membrane exposure may carry complications
6) the absolute need for primary closure remains to be established

Buccal bone-second triangle
• 2mm buccal plate is crucial to avoid soft tissue recession, and
• an inter-implant distance of 3mm should always be present in order to allow papilla formation
• implant adjacent-tooth distance of 1.5 mm maintained to
• preserve bone tissue
• fiber attachment
• the presence interproximal papillae.
Grunder U, Gracis S, Capelli M. Influence of the 3D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent. 2005 Apr; 25(2):113-9
implant position will dictate the emergence profile of the final restoration
Kois JC. Predictable single-tooth peri-implant esthetics. five diagnostic keys. Compend Contin Educ Dent. 2004 Nov;25(11):895-6, 898, 900

Fill the gap-third triangle
horizontal resorption of bone dimension that amounts up to 56%
void created between the buccal wall and the implant.
Araújo et al.
• They state that filling the gap with deproteinized bone mineral has beneficial outcomes:
• hard tissue healing process is modified
• additional hard tissue is present at the re entrance of the socket after a period of bone healing
• soft tissue recession is prevented
• improvement of the marginal BIC
• xenogenic material in the void between the buccal wall and the implant surface, compensates for the
hard tissue lost after a tooth is extracted.

Tissue Biotype- fifth triangle
Thick-flat vs Thin scalloped periodontium
Interproximal osseous position and thus, the overall soft tissue architecture
process of remodeling following implant placement
Kois JC. Predictable single-tooth peri-implant esthetics. five diagnostic keys. Compend Contin Educ Dent. 2004 Nov;25(11):895-6, 898, 900
compensate this remodeling.
1. Grunder
Subepithelial Connective Tissue Graft Control: 1.063mm vs. No Change in Test Group
no soft tissue dimension changes in the test group. Flapless no compromise of blood supply
2. Capelli et al.,
graft internally
place biomaterial between the soft tissue and the buccal plate to maintain the ridge contour., and thus, “overbuilding”
the buccal aspect
De Rouck et al.
single immediate implants with instant provisionalization, can help optimize esthetics.
this can limit the amount of midfacial soft tissue loss
implant position will dictate the emergence profile of the final restoration
A NEW PROTOCOL FOR IMMEDIATE IMPLANTS. THE RULE OF THE 5 TRIANGLES: A CASE REPORT (PAGES 4 & 5)
http://www.eao.org/new-protocol-immediate-implants-rule-5-triangles-case-report-pages-4-5-0#sthash.llMbGKrP.dpuf

Implant Design-fifth triangle
• influence the biomechanics of the environment where an immediate implant is
placed
• self-tapping implants for achiening primary stability as their design compress the
alveolar bone as the implant is inserted.

• facilitation of progenitor cells influx
• improvement local formation of angiogenesis
• formation of new bone
Hämmerle CH1, Schmid J, Lang NP, Olah AJ.
Temporal dynamics of healing in rabbit cranial defects using guided bone regeneration.
J.Oral Maxillofac Surg. 1995 Feb;53(2):167-74.
Cortical / Intramarrow Penetrations D1mm :
Mellonig JT, Bowers GM, Bright RW, Lawrence JJ.
Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects.
J Periodontol 1976;47: 125-131
Sepe WW, Bowers GM, Lawrence JJ, Friedlaender GE, Koch RW.
Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects — Part II.
J Periodontol 1978;49:9-14.
Froum SJ, Coran M, Thaller B, Kushner L, Scopp IW,Stahl SS.
Periodontal healing following open debridement flap procedures. I. Clinical assessment of soft
tissue and osseous repair. J Periodontol 1982;53:8-14.
.Yukna RA, Harrison BG, Caudill RF, Evans GH, Mayer ET, Miller S.
Evaluation of Durapatite ceramic as an alloplastic implant in periodontal osseous defects. II.
Twelve month reentry results. J Periodontol 1985;56: 540-547.
Rompen EH, Biewer R, Vanheusden A, Zahedi S, Nusgens B.
The influence of cortical perforations and of space filling with peripheral blood on the kinetics of
guided bone generation. A comparative histometric study in the rat. Clin Oral Implants Res. 1999
Apr;10(2):85-94.
Zybutz MD, Laurell L, Rapoport DA, Persson GR.
Treatment of intrabony defects with resorbable materials, non-resorbable materials and flap
debridement. J Clin Periodontol 2000;27:169-178.
Crea A1, Deli G, Littarru C, Lajolo C, Orgeas GV, Tatakis DN.
Intrabony defects, open-flap debridement & decortication: a randomized clinical trial.
J Periodontol. 2014 Jan;85(1):34-42.

• 5mm BAT X 13.0 (Southern Implants SLA ) external
Hex implant
• 4 mm of implant anchorage into native bone
Lazarra RJ. Immediate implant placement into extraction sockets:surgical and
restorative advantages IJPRD 1989;9:333-343
Lioubavina–Hack N, Lang NP, Karring T., Significance of primary stability for
osseointegration of dental implants. COIR 2006; 17:244-250
Froum SJ. Immediate placement of implants into extraction sockets :Rationale,
outcomes, technique Alpha Omegan 2005; 2005 98 :20-35
Optimizing Esthetics for Implant Restorations in the Anterior Maxilla:
Anatomic and Surgical Considerations DM Buser; UC. Belser. IJOMI 2004 Suppl,
19(7), p43-61
IMPLANT PLACEMENT POSITION
MD: within the comfort zone 1.5 mm
OF: placement :palatal
AC: surpassed the root apex > primary stability.

Double layer of resorbable membrane
Primary stability was achieved and no countertorque device
was used to removed it
Immediate Loading of the implant will be tried
Implant mount was used to register the implant position

was fabricated by block
negative carving with
acrylic resin and
covered with composite
resin interproximal
areas were over
contoured and
flattened so that tissue
would fall without
tension and fill the area
Single-Tooth Anterior Implant: A Word of Caution, Part II AS. WEISGOLD, J-P ARNOUX, J. LU JERD Vol 9(6), Nov 1997 pp.285–294
Single-Tooth Anterior Implant: A Word of Caution, Part I AS. WEISGOLD, J-P ARNOUX, J. LU JERD Vol 9(5), Sept 1997 pp.225–233

Pin point interrupted non resorbable 4-0 sutures were used
Primary closure periosteal separation released any possible tension on the covering flap
Screw Retained Provisional crown (no cement)

1 week
Special care was given to the interproximal emergence to
allow tissue to heal without pressure

Immediate post operative Panoramic Xray
4mm abutment was used switching the 5 mm implant head platform

1 month
• Oral Hygiene is fair
• Soft tissue management of right central incisor Slight manipulation of the
provisional crown
• Gingival Margin of #11 was corrected with gingivectomy and bone
reconturing with hand instrument . Kois JC. The restorative-periodontal interface: biological parameters.
Periodontol 2000. 1996;11:29-38.

Final Provisional . 5 to 4 platform switching
The running room has been adjusted with Jet Acrylic In order to support the soft
tissues and recreated an new anterior Zenith
Healing time will the chance for tissues to mature more and registration of the peri-
implant sulcus will follow in order to communicate with the Ceramist Mr. Nontas
Vlachopoloulos , Aesthetic Lab Athens Greece

Tissue Maturation

ABUTMENT/CROWN MATERIAL SELECTION
Metalic Abutments vs. Ceramic Abutments (approx. 5 years observation)
1. 97.4 % 99.1%
2. Supporting Ceramic crowns same survival rate (Cer. Abtm /Cer. Cr. better)
3. Technical Complications : Abutment screw loosening
4. Biological Complications : Similar
Is the performance of Ceramic Abutments similar to that of Metallic Abutments?
Sailer I, Philipp A., Zembic A., Pjetursson BE, Hammerle CHF, Zwallen M COIR 20 (Suppl. 4): 4-31

Abutment Material Selection

For Cementation temporary cement was used, after retraction cord was inserted in
order to prevent escape of excess cement into the per-implant tissues

Final Case inserted 2010 !
Zirconia Custom Abutment and Cementable Zirconia Crown

Furhauser R., Florescu D., Benesh T., Haas R., Mailah G., Watzek G. Evaluation of Soft Tissue
around single-tooth implant crowns: the pink esthetic score COIR 16, 2005: 639-644
1 2
3
4
5
6 7
PES: 2-1-0
M pap : 2 complete
D pap : 2 complete
LSM : 1 minor 1-2 mm
STC : 1 fairly natural
Alv Pr : 2 none
Softissue C: 2 no diff.
Softissue T: 2 no diff.
Sum: 12/14

April 2010 Nov 2010 May 2016

CERTIFICATION PROGRAMME
2016 case #1

2010

2016

2010 2016 2010

MAY 2016

May 2016 full smile

Treatment Plan Since 04-2010 on to 11- 2010 final recall05-2016
Impressions Radiographic examination Scaling (gingivitis) Oral Hygiene Instructions Surgical
Appt
CHX .2%, Local Anesthesia Sulcular Incisions
Vertical incision distal of 22 maintaining the papilla Full thickness flap was raised supra level
of Apex
#21 was surgically and atraumatically extracted
RCT remnants removed. Socked with saline, waited for bleeding and implant placed with
15rpm at 70 Nm Southern Implants BAT 5mm 11.5 mm, tapered by SLA external Hex .
Position, palatal portion of the socket engaging the palatal wall surpassing the level of root
apex . Relatively to adjacent CEJs of 11 and 22 , 2-3 mm deeper (Weisgold). Excellent primary
stability. Visual of the adjacent CEJs , along with visualization of defect diagnosed on CBCT.
Duralay indexing, fabrication Provisional
cortically penetrated with 1 mm surgical bur bone grafted and buccally (Araujo) with bovine
allograft (BioOss) and covered with Collagen resorbable Membrane
Vickyl sutures interrupted / pin point to maintain papilla position for one week. Healing
Abutment covered the implant.
lab processed screw retained provisional was fabricated and corrected slightly intraorally for
no functional occlusion. Implant was immediately loaded.
06/07-2010
Maturation additional 3 months . soft tissue manipulation correction of alered passive
eruption new lab processed provisional 10-2010
Final impression
Zirconium cement retained Crown Last recall May 2016

THANK YOU
EMMANOUIL SYMEONIDIS
Manos

8years later

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