Incomplete Seating of Implant

A week preop Arestin was injected to the buccal pocket of the tooth #19.  When the patient returns for immediate implant, the 2 buccal fistulae disappears, but a lot of granulation tissue is curetted from the buccal portion of the mesial and distal sockets after extraction.  The septum has a round top (Fig.1 *).  A 2 mm pilot drill should be difficult to make an entrance. While Clindamycin gauze is inserted to the sockets, a surgical hand-piece and a fissure bur are used to make a slot in the septum (Fig.2 white area) so that the pilot drill makes a steady penetration (Fig.3 black circle).  The initial depth is 8 mm (Fig.4), far from the superior border of the Inferior Alveolar Canal (red line).  Following sequential osteotomy at 50 RPM, a 5 mm tap is inserted to test stability (Fig.5), which is high.  A 5x12 mm implant  has difficulty being seated (Fig.6 (arrow: the lower border of the osteotomy)).  The bone is dense (bruxism).  The patient is nervous and reports pain.  After Inferior Alveolar Nerve block, the implant is seated deeper (Fig.7), but cannot be seated further, because the implant driver automatically disengages from the implant.  Clinically, the implant is more or less at the septal crest level.  Bone graft is placed in the socket and around the coronal portion of the implant (Fig.7 *).  An abutment (7.8x4(2) mm) is placed for an immediate provisional.  When the patient returns for final restoration 3 months postop, the provisional has lost for a few days.  Grafted bone appears to have consolidated; a few of distal microthreads are not covered by the bone (Fig.8).  It appears that a shorter implant is more appropriate (5x10 mm).  The implant could be placed deeper.  The abutment does not need to be trimmed.  The mesial abutment margin is subgingival with loss of the provisional.  For impression, the existing abutment is changed to a smaller one (5.8x4(2) mm).

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Xin Wei, DDS, PhD, MS 1st edition 08/17/2015, last revision 11/17/2015