Making a Lower Molar Dental Implant Easier… But its still hard!

If you are beginning your journey into dental implant placement, one of the best things that you can do is to select easy cases, or make cases easier. 

So, for example, instead of doing an immediate placement for a lower molar, you could remove the tooth, let it heal, and if your patient still wants it in a few months, you can place the dental implant. 

That is exactly what we did here. 

The LL6 needs replacing, and the LL7 is already an implant that we placed a few years ago. 

But, what is that red bit on the gum? 

I pressed it, and sure enough, a little pus came out! 

We were about to place a dental implant, and the last thing I want is pus. 

In addition to this, the CBCT scan, didn’t look like I wanted it to either! 

Why has this not healed fully? Its been 4 months since we removed the tooth! 

Taking the sinus on the gum and the radiographic appearance into account, could this be a cyst?

The important thing to do here, is let your patient know in a non alarming way – after all, we don’t know all the facts. 

So I essentially said,

‘I am not sure if the socket has fully healed – it was a big tooth that was removed, and it had a big infection, so sometimes they take longer to heal. If its not healed, then we may not be able to place the implant.’

The patient was cool with that. 

From the patients point of view, he needs to know there is a possibility that the implant may not go in – we don’t need to talk about cysts or anything like that, because that is all they will be thinking about during the surgery, and we want our patients calm! 

So I poked into the sinus, and it didn’t go very far – which is a good sign, suggesting that the sinus doesn’t communicate, with the radiolucent area. 

I made my incision to the lingual of the sinus, aiming to remove the sinus from only one side of the flap. IMG_0399

Once the site was open, it was clear what the problem was, there was a small fragment of either tooth or necrotic bone on the surface, so I removed this, and felt a lot better, and also checked for deep communication to the radiolucent area… there was none. 

I then cut out the sinus area from the buccal flap, and started my osteotomy. 

If this was a cyst, then my drill would probably drop into it, and the fluid in the cyst would come out. But there is a possibility that this is just naïve bone. 

As I drilled, the bone was softer after I passed the cortical plate, but there was something there. 

My concern was now primary stability.

The planned implant was 5mm wide, and I want to place this 4mm from the top of the gum level, this is why I have marked this measurement on the CBCT Scan. 

The problem with this is that its completely past the corticated bone, and I want some sort of primary stability! 

This is what I did: 

  1. I went to full depth with the 4mm wide drill, and this one, I used in reverse, so that it would compact the bone. (obviously, I used all the drills before this in the normal protocol!!)
  2. I felt the inside of the osteotomy with a probe, if this was a cyst, it would balloon out, but the osteotomy had a hard defined edge, the shape of the drill – so good news there! 

Finally, I prepared the cortical part of the bone to 5mm, and placed the implant. 

The torque was about 30ncm, and I was confident to place the healing cap on the implant and suture up. 

I think the moral of this case is that we can see things that may alarm us, but sometimes its best to move slowly and tackle one problem at a time, investigating your hypothesis as you go! 

The reason that I place the implant 4mm below the gum is that there is a train of thought to say that this a reliable distance to minimise the amount of bone loss around the implant. This is supposed to be a bone level implant, but bone level is the worst place to put an implant – I always get bone loss to the first thread if I place at bone level. 

We need a good soft tissue adherence around the dental implant, and this can protect the implant from significant bone loss, so the attachment for the soft tissue here is the platform shift on the implant. 

If you are looking to improve your dental implant skills (or at least get going!), I offer dental implant mentoring, where you can come and see me do the surgery, we can discuss the cases and you will get a deep insight into the world of dental implant placement. 

Contact me if you would like to find out more

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