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Endo tips    Better Endo    Endo abstracts    Endo discussions

  Implant after extraction of first molar

The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. Photos courtesy Terry Pannkuk - ROOTS
From: Terry Pannkuk
Sent: Tuesday, February 03, 2009 10:43 PM
Subject: [roots] Yesterday's Implant

This implant was placed 6 months after I extracted the first molar.
The 2nd molar had been extracted 8 years ago.

The patient did not want to go for 2 implants which would have been 
a bit more ideal utilizing the excellent bone in the 2nd molar area 
(edentulous for 8 years). This was not a spinner but very light 
torque....maybe 15 at best.  When I hand tightened the cover screw 
it did not turn and I could put all the force I could muster and it 
wouldn't budge.  I feel that it's ok, but still no healing cap and
I buried it.  Using the tissue punch after the initial twist drill 
gave me good visibility when developing the osteotomy site which was 
very helpful to visualize the bone.  Tapped the sinus about 3.5 mm 
into it last using a 4.5 off-angle osteotome, no foo foo and then 
placed a 5.0 x 11.5 NBC Replace select. I'm very happy with the 
placement and angulation.  The reslutant crown occlusion will
hopefully capture just a bit of the mandibular second molar to keep 
it from supererupting over time. It hasn't so far since I extracted 
the max. 1st. M. There was a weird little snafu with the 5.0 NBC 
implant drivers both short and long. They wouldnt' fit into the 
osseoset handpiece because of some shank irregularity.
When I looked at them under the scope there was no corrosion and 
there was no problem with any of the other drills.  I finally had 
to break out a new driver from the pack but all I had was a long and 
this woman was very petite with limited opening.  I'm going to read 
my Nobe Biocare Rep the riot act.   It was a clumsy
treatment but it went well. Once I got the implant started I put 
the weird driver in the torque wrench and tightened it the rest of 
the way by hand which is how I normally do it.

All in all, I'm happy with this case.  It took quite a bit of finesse 
to position the implant in the ideal position, with the minimal torque, 
it didn't slide off path at all.

I make surgical guides for all cases but sometimes I don't use them much.
In this case I needed it only for the intial precision drill penetration.
Once ideal alignment and depth was validated, the guide is discarded 
and the larger drills are used. The guide tends to be a problem in cases 
of limited jaw opening and tight posterior access like this one. The sinus 
tapping likely pushes some nice, loose, chipped autogenous bone up against 
the Schnederian membrane as it tents it up.  I don't push the envelope 
much further than 3mm of tapping into the sinus to avoid potential ripping. 
If I feel that I need more than that I flap and perform an open sinus lift 
- Terry

Terry, would you consider tapered implant - to achieve better primary stability/insertion torque? - Dmitri Terry, what is your surgical guide technique? Are you still doing suck downs on a wax up and cutting an access hole in the suckdown for the osteotomy drill? - Dan Shalkey No, straight are better. I try to avoid tapered implants when possible. Better surface area and stability with straight - Terry

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