Less is More

The buccal plate of the socket of #4 is thin and short (Fig.1, 5B (coronal section of the socket) red area) with apical perforation (Fig.5B >).  Osteotomy at #4 starts with 1.6 mm drill in the palatal slope (Fig.2 circle; Fig.5C blue arrow), while that at #5 with Magic Split (Fig.2 black line).  In fact sinus perforation occurs with the 1.6 mm drill. Osteotomy increases by using Magic Drills sequentially (2.8 and 3.3 mm) at #4 and Magic expander (3.0 mm) and the same Magic Drills at #5 (Fig.3).  A 4x11 mm dummy IBS implant is placed with insertion torque of 45 Ncm at #4 with apparently intruding into the sinus (Fig.3).  When a 4.5x9 mm implant is placed, the insertion torque is actually reduced (<35 Ncm, Fig.4).  As osteotomy or implant diameter enlarges, it shifts buccally with less bone contact buccally (Fig.5D, as compared to Fig.5C)).  In brief, once a dummy implant has achieved a reasonably high stability, do not over seat it.  A small immediate implant may have more solid bone contact.

At the healed site (#5), insertion torque of a 4x11 mm implant is >50 Ncm (Fig.4).  Because of supraeruption of the tooth #28 (Fig.6 arrow), a healing abutment (4x2 mm) is placed at #5 (data not shown), while a pair abutment (4.5x4(2) mm) is placed at #4 (Fig.4,6).  In fact a splinted provisional is placed at #4 and 5 with a low occlusal table.  There is no apparent bone loss 1 years 5 months postop (Fig.7).  In fact the implants either perforate the palaatal or buccal (B) plate, as revealed by CBCT (1 year 6 months postop, immediately post cementation, Fig.8,9).  It appears necessary to have guided surgery and smaller implant in the narrow ridge.

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Xin Wei, DDS, PhD, MS 1st edition 02/22/2017, last revision 09/01/2018