Close to Neighboring Curved Root 3 10 12 18 30

Immediately postop PA (Fig.1) and panoramic X-ray (Fig.2) show that the implant at #14 is close to the root of the tooth #13.  Clinic exam and CBCT (Fig.3,4) demonstrate a reasonable separation.  The trajectory of #14 osteotomy may be altered while using 2.8 mm round drill for 7-9 mm for sinus lift (free hand).  There is no bone loss 8 months postop (Fig.5).

#15 looks good as planned and #14 seems quite close to the neighboring tooth and quite off from the planed position.
I am just wondering...Have to try to engage the fixture to the metal sleeve perfectly for implant placement after performing the sinus elevation?
After performing the sinus elevation, you placed the surgical guide back and placed implant right?

I followed the steps faithfully.  As CT indicates, the implants are pretty parallel to each other.  The suspected step is sinus lift using reamer (free hand).  Initially I placed the drill pretty parallel to the crown #13.  Later more or less oblique.  When the guide returned, I had no option other than to follow the guide.  If the implant really touches the root, can I redirect free hand?  

Yes that may be one of the reasons for difference from the planning.
As surgical guide has been made with precise digital software, there's not much possibility of going off from the original planning.
But to answer your question, if you don't think the implant is placing as it was planned, you can always go with freehand redirecting the position

Jennifer: Thanks for the reply.  In fact, I did something deviated from you instruction as I restudied the model and the guide.  When the implant at #14 was being placed between the 2nd and 3rd lines of the manual implant driver, the neighboring teeth prevented the wrench from turning.  I wish using a latch type implant driver to finish placement.  I did not because of warning of using manual one.  Instead the guide was removed; free hand for the last 1-2 mm.  The guide returned for depth confirmation.  When the patient returns for follow up 1 week postop, can I remove the implant free hand and place with the guide and the latch type implant driver 15 RPM?  Thanks again.


I double checked the sequence and based on what you meant by in between 2nd and 3rd line, I think you got confused with the line. It was supposed to be stopped at the exact 3rd line. Not in between 2nd and 3rd line. 
Please refer to the image below.



When you check the drilling sequence sheet you'll also notice that it was originally send as the right one.
So the reason why you had to go 1-2mm deeper than the surgical guide was that the fixture driver wasn't stopped at the intended line.
I should've been gone down deeper like as the right side picture.

And as I read your email, I am little confused. So please let me clarify whether I've understood you right so that I could answer your question.

I am trying to understand that, the torque ratchet connected with wrench was hitting the neighboring teeth so that it made you hard to rotate the ratchet? You were not keep rotating it right? Neighboring tooth were blocking you from moving forward and backward motion?


Lastly, is this what you meant by latch type?

If so, yes you can use this with really low RPM after fully engaging the contra angle type fixture driver to the metal sleeve.
Manually implant placement was suggested because we wanted to make sure that the operator was placing implant with really low rpm following the wall of the metal sleeve.

I have a question, which torque did you get for placing #14?

And for removing the implant, I am not sure which torque you have got for #14 when you were placing implant therefore I have no idea whether it will be possible to easily remove the implant with free hand, but if the bone is really soft, it won't work with the same implant size when replacing implant. So I suggest you to replace with a bigger diameter which is 5.0 for the replacement. 

If there's any other inquiries you have, please let me know.

Hi, Jennifer: Thanks for detailed explanation, which will be copied to my web.  I did not have any problem reading the lines this time, but how to get to the 3rd line with torque wrench.  Torque value is >35 Ncm.  I am glad to learn latch type implant driver could be used.  The lowest RPM for my machine is 15, but I could press the pedal the lightest.  The patient will return this Saturday.  If there is no symptom, I may not do anything.   With your help, I am closing to perfecto.  The corner of the mouth was also interfering with torque ratchet turning so that the implant driver did not go down.  Anyway, latch type driver may be a solution.

 

Return to Upper Molar Immediate Implant, Armaments, 3 10 12 18 30

Xin Wei, DDS, PhD, MS 1st edition 04/06/2018, last revision 12/15/2018