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With understanding tissue punch and engagement of drill as much as possible into guide sleeve before pressing pedal, guided surgery is accomplished with confidence (Fig.1,2). With undersized drilling, there is no thread exposure palatally, when a flap is raised. Vanilla graft is placed, since it has been prepared before incision. No membrane is used. It appears that the palatal bone expands while the implant is being placed. There is mild crestal bone loess 4.5 months postop (Fig.5).When the patient returns for periodic exam and prophy 6 months post cementation, the crown is found to be loose, which is more likely associated with heavy mastication (long roots) and poor crown/implant ratio. Since the distal contact is light, the case returns to lab. PA taken following reseating the repaired abutment/crown shows crestal bone loss, which may be associated with the narrow ridge and/or the loose abutment (Fig.6). The gingival cuff is less healthy. The screw becomes loose again 4 months later. When it is retightened, the distal proximal contact turns open (Fig.7 ^).
Xin Wei, DDS, PhD, MS 1st edition 08/07/2019, last revision 08/10/2019