Wild implant placement

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Wild implant placement - Courtesy ROOTS

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From: Terry Pannkuk
To: ROOTS
Sent: Wednesday, August 11, 2010 10:33 AM
Subject: [roots] Challenging Implant Placement-CBCT definitely required!

Here’s 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 wasn’t 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 I’m sure the referral
would have bitched about the angulation/lingual position and the crappy esthetic emergence.

Here’s the planning CBCT.  (I attached some captures from the CBCT I took after placement today).
If primary stability or ideal placement hadn’t 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

Protaper flaring 6 yr old Empress Cvek pulpotomy Middle mesial Endo misdiagnosis MTA retrofill Resin core BW importance Bicuspid tooth Necrotic #8 treatment Finding MB2 / MB3 Deep in a canal Broken file retrieval Molar cases Pushed over apex MB2 and palatal canal Long lower third Veneer cases CT Implant surgury	Weird Anatomy Apical trifurcation Canal and Ultrasonics Cotton stuffed chamber Pulp floor sandblasting Silver point removal Difficult acute curve Marked swelling 5 canaled premolar Sealer overextension Complex anatomy Secondary caries Zygomatic arch Confluent mesials LL 1st molar (#19) Shaping vs Cleaning First bicuspid In Vivo mesial view Inaccesible canals	Premolar 45 Ortho and implant Radioluscency Lateral incisor Obturation Churning irrigant Cold lateral Tipped to lingual Acute pulpitis images Middle distal canal Silver point Crown preparation Epiphany healing Weird anatomy Dual Xenon Looking for MB2 Upper molar resorption Acute apical abcess Finding MB2	Gingival inflammation Irreversible pulpitis AG BU ortho band TF Files using TF files Broken bur Warm technique Restorative prognosis Tooth # 20 and #30 Apical third 3 canal premolar Severe curvature Interesting anatomy Chamber floor Zirconia crown Dycal matrix Cracked tooth Tooth structure loss Multiplanar curves