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After use of 2.2 mm IS drill, DIO parallel pins are inserted, but they are unstable at #2 and 3, partially due to shallow osteotomy. PA is not taken with parallel pins. When dummy implants are placed, the axis at #3 is noted to be off; but instead of moving the apical end of the osteotomy distal (Fig.1 red line), the coronal end is moved mesial.
Since the tooth #2 has shifted mesially with mobility III, osteotomy is initiated in slightly palatal aspect of the single socket. Access to #3 site is obtained by using a 4 mm tissue punch. The gingiva is ~ 7 mm thick. The trajectory of osteotomy is difficult to control when the gingiva is thick. The sinus floor is perforated at #3, which is repaired with a piece of PRF membrane and Vanilla graft (*) before implant placement.
Xin Wei, DDS, PhD, MS 1st edition 04/24/2018, last revision 09/30/2018