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From: Terry Pannkuk
Sent: Wednesday, August 11, 2010 10:33 AM
Subject: [roots] Challenging Implant Placement-CBCT definitely required!
Hereís a wild implant placement I slipped through a narrow bone buttress extending into the sinus today.
The CT was critical in planning the osteotomy into the dome of healed MB socket bone. There wasnít much
margin for error. I extracted the molar in February. The sinus was pneumatized and there was severe
perio bone loss. The buccal plate was intact and I saw no reason to graft which would unnecessarily
lead to a loss of even more native bone critically needed for integration. The healed MB socket was
crucially important. When the patient came back in July the buccal plate and ridge looked excellent
except the CBCT showed a very challenging situation for implant placement with the healed MB socket
being the best site for the osteotomy with a decent dome of bone. If I had chosen the healed palatal
socket it seemed like it would be trying to land a 747 on an aircraft carrier and Iím sure the referral
would have bitched about the angulation/lingual position and the crappy esthetic emergence.
Hereís the planning CBCT. (I attached some captures from the CBCT I took after placement today).
If primary stability or ideal placement hadnít been possible, my back up option was to flap, perform a
Caldwell-Luk, lift the sinus place graft contained in a tacked membrane, close and repeat the attempt
in 6-8 months. The patient was prepared for that possibility. You always have to have a back-up plan!
I had one chance of placing it today; if the osteotomy had been slightly off and the dome
containment/stability lost, game over and the graft plan would have begun. If my post-placement
CBCT showed something different than what I expected and the implant had been out of position,
I would have unscrewed it and gone to the graft plan as well. The difference between endo and
implantology is that you can screw up an implant attempt and start over later. As an endodontist
and not used to getting Mulligans, it frees up your shot, and makes these things easier,
knowing you can re-tee.- Terry