No Drill Implant Placement

As planned, A PA is taken prior to surgery (Fig.1).  The root of the tooth #4 is somewhat deviated mesially.  A 4.5x14 mm bone-level implant is planned to be placed distally (Fig.2).  When the tooth is extracted (Fig.3 illustration), a 4.5x17 mm tap is inserted with stability (Fig.4 white box).  Clinically the apical portion of the tap appears to be deviated buccally.  An osteotomy is created in the apicodistopalatal socket (Fig.4 red line) until 3 mm.  When the same tap is re-inserted (Fig.5 T with stability), it does not apparently go to the osteotomy (dashed red lines). 

In order to maintain the stability, a 4.5x17 mm implant is placed without any further modification.  It is in a less ideal trajectory (Fig.6 I).  But the insertion torque is >60 Ncm.  A 3.5x3 mm abutment is placed (A); an immediate provisional is fabricated and temporarily cemented (^).

To place the implant distally, a systemic approach should be adopted as follows.  An osteotomy should be initiated in the distal wall of the socket more coronally (Fig.7) than Fig.4.  Once the drill penetrates the lamina dura, it should be straightened along the axis of the tooth (Fig.8).  As the osteotomy increases, it may be deviated mesially slightly (Fig.9).

In one word, no drill implant placement is possible when the root is slender.  If the axis of the implant needs to corrected, the osteotomy should be initially overcorrected with drills.

The patient returns for final restoration 6 months postop.  The apical socket radiolucency remains without ill effect (Fig.10 *).  No bone graft was attempted to be placed in the apical socket, since the graft may interfere with implant insertion.

The gingiva buccal to the implant crown looks healthy, although concave apically (Fig.11 *) 1 month post cementation, 9 months postop.  It remains the same 2 years 9 months post cementation (Fig.12).  The crown dislodges with loose abutment 4.5 years post cementation.  The unipost, which seems to have not been cemented, is recemented with RelyX Ultimate bonding with excess cement escaping between the abutment and implant.  The 3.5 mm unipost appears to be small (4.0 mm may be better).  Pick up impression is taken while the crown is temporarily cemented, since the mesial marginal ridge is fractured.

Return to Upper Bicuspid Immediate Implant, 8, 9,12,31 Xin Wei, DDS, PhD, MS 1st edition 06/03/2015, last revision 08/24/2020