A Near Miss in Dental Implant Placement

Most of my patients will find me from social media, and I have a personal consultation with them and take all the appropriate records, including CBCT Scans. 

This case was different, it was an internal referral, and all I had was a basic PA bitewing. 

This bridge has failed, and it was sectioned distal to the UL3. 

The plan was to place a dental implant in the UL4 region, and the referring dentist I work with (a LOT), thought this was a simple case. 

It does look simple. 

I nearly didn’t take a CBCT scan! (and I scan EVERYONE before dental implants).

Anyway, I am glad that I did, this is what it looked like: 

These are the same image, with the dental implant virtually placed on one. 

The width of this dental implant is 3.8mm.

So what are the options?

We could consent the patient for a bone graft, and do that either with or without the implant, or reschedule the whole thing, so she can think about this. 

What about the cost? There is going to be additional costs, and we are telling the patient at the eleventh hour about this! This isn’t good practice! 

Also, this patient is anxious about this treatment, the last thing I want to do is to make her feel uncomfortable about the whole thing. Remember this is the first time I am seeing her. 

This is what we did. 

Take the time to explain what we have seen. This is the most important part of the whole appointment. 

The surgery is the fun bit, explaining everything is long and boring. But there is a general structure: 

1. be positive in tone: “its a REALLY GOOD thing that we took the CBCT, we found something out…” 

2. Show, rather than tell: On the CBCT Screen, show the area we are thinking to put the implant in, measure it, place a virtual implant, the patient can see the problem for themselves! 

3. Offer solutions, basically the options above. 

4. Be human, personally, I feel really uncomfortable increasing the cost at this stage, it feels like trapping the patient. So I always give the option to think about it and come back another day, or we can do the bone graft, and we will only charge the cost of the materials… Even though the bone graft is the most time consuming part of it all! 

She chose to have the implant and the bone graft. 

This is how I did it… Without getting the hammer out. 

This picture shows a split thickness flap (3 sided), where I made a vertical incision to bone, where the implant is poking out! 

I did the osteotomy, and we placed the implant. This was tricky, but we got a torque of 35ncm. 

Next, I measured the membrane and sutured it into position, using the periosteum to suture to. 

The advantage is that we don’t need to tac the membrane. It needs stabilisation, otherwise the whole procedure is pointless and the graft will dissipate or fail. 

I could have tacked in, but I didn’t want to make the patient any more traumatised, and this is a decent solution. 

In this photo, the periosteum is highlighted, so you can see it more clearly. 

You can see the sutures from the membrane to the periosteum, and I have put in one suture to close the gingivae, but there is a healing cap on the dental implant. This means that its not going to close easily. 

I put my initial suture in the wrong place. 

there is a greater distance from the distal of the graft to the distal of the 3 sided flap. So I would like to have that area with a slight opening (2re intention healing), if it needs to be. 

So I took that suture out, and apposed the mesial aspect of the flap first. 

I made sure that there was good soft tissue adaption around the implant healing cap as well, then closed the distal. 

You can see the slightly open wound to the distal of the site. 

Now, remember, this was a split thickness flap, and there is blood supply from the periosteum and the flap. This should make this area heal more quickly than if we had a full thickness flap, which may have left us with some exposed bone. 

(If we did this, a blood clot would first develop and we hope this does not dislodge, so the soft tissue can grow) 

I think that by having this split thickness flap, the flap itself is more mobile, and full closure is less important – as long as its not open over the graft. 

Let me know what you think about this. 

Also, if you want to dramatically increase your case acceptance and understanding on how to carry out complex cases, you can sign up to my mentoring program, and for a monthly fee you get access to all of my online courses, premium newsletter (with a lot more business and sales stuff in it), and we can talk through complex cases that you may have coming. 

You can find out more about this from the links below. 

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