Forgot cover screw and concerned about implant position: opinions?

I am new to the field of implantology. This is my 11th dental implant placed and I really try not to have important errors in my first cases, but last week this happened. I forgot to place the cover screw on this 3.75×13 mm SEVEN implant. I was too worried verifying the implant position and angulation and then I moved to suturing without remembering about the cover screw. I am now also in doubt about the implant position, after I saw the post-op x-ray, despite the fact that I was pleased with the angulation at the moment of placement.
It is important to note that the patient refused an orthodontic approach for the mesially tilted second molar. The surgery and placement went very well with good primary stability (about 35 N) and I did not need to graft the site. Any opinions on this case?
Thank you !

23 thoughts on: Forgot cover screw and concerned about implant position: opinions?

  1. WJ Starck DDS says:

    Implant position is fine. Missing cover screw no big deal. You will just have a nice fibrous plug in there when you uncover to restore.

  2. Dr. David Morales says:

    The implant position looks okay. You can still place a cover screw, just let patient know you want to place a tissue contouring healing screw. Good luck

  3. VIKRAM says:

    I won’t loose my sleep over cover screw but next time have your assistant look from her side as well to verify the position. In this case distal could challenge you in prosthetic phase .Have the Lab go for wide contact to avoid food trap.
    Good luck for all the coming ones!

  4. Robert Friedstat DDS says:

    Although I do not place implants, I have restored them for 41 years. I lecture on implant complications for the restorative dentist.Using a tissue punch for the size of the implant should work. Cleaning out the implant without damaging the internal portion can be a challenge. I would still be very careful with titanium scalers and would recommend the glycine spray by Hu Friedy ,30% phosphoric for 30 seconds,followed by disinfecting with Cloysis mouth wash. The Cloysis will not damage the soft tissue attachments around the implant.

  5. Najeeb Hussain says:

    I think its an excellent placement. Its very prosthetically driven and I think you will have a great result. If its still fresh, you can always make an H- Incision and place a cover screw on the implant. Other wise no big deal 🙂
    In future, if you ever struggle, trim off the mesial edge of the Lower left second molar to accomodate a nice mesiodistal width of the prospective implant crown ( with patient’s consent of course. I think the implant certinaly is in an optimal position from a prosthetic point of view. Great work !!

  6. Matt Helm DDS says:

    Implant position is fine! For the sake of argument, the only way you could have “improved” it is by placing it about 1-1.5mm more distally and angling it slightly mesially, by “eyeing” an angle slightly shallower than that of the molar, by using the molar as a visual guide. But that’s uselessly nitpicking for the sake of nitpicking. It would’ve resulted in perhaps a “prettier” x-ray, but that’s all. The advantage to your placement is that you will most likely be able to use a straight abutment.
    Use a tissue punch ASAP and install a healing abutment to avoid further build-up of fibrotic tissue inside the implant.
    You are also dealing with a failed RCT on the UL 5, a required RCT on the UL 6 (possible endo-perio lesion) and a required RCT on the LL 7, due to large distal penetrating caries.
    BUT, since the UL 5 and 6 don’t look too great from a prognosis standpoint, I would consider extractions and implants in those sites. Good luck!

  7. Alex Galo says:

    Why would you place a cover screw (rather than a healing abutment) if you have good stability? Have the patient back and place a healing abutment.

    • WJ Starck DDS says:

      No, no, no – a hundred times no!

      There is nothing wrong with that implant.

      The enemy of better is best, and you have no guarantee that your placement will be substantially different/better the second go around.

    • Matt Helm DDS says:

      Johnny David, ever hear that “if it isn’t broken, don’t fix it”? Sadly you’re dead wrong on both counts. This implant is fine, and we’ve seen truly bad cases on here, that might deserve that “crow” remark. This one ISN’T one of them, not by a long shot! Oh, and about that “crow” remark, right back at ya! Good buddy, that remark is pretty insulting to a colleague with legitimate concerns despite his good work, and it was certainly UNCALLED FOR! Shame! Sorry, but justice itself called for this reply!

  8. Dr. TK says:

    The other doctors have given you good advice on this case.

    Some things for you to consider on future cases: I screw retain crowns unless there is a profound reason not to. On a case like this, I would absolutely use a screw retained crown. I am moving away from UCLA/PFM crowns. More often I use a stock abutment and request the lab make a zirconia crown with a screw access hole. I cement them extraorally so that I can clean up the cement. When I deliver the crown, rather than throw away the model, I box it up and ask the patient to keep it in their sock drawer. If the porcelain ever chips we can send the case back to the lab with the original model.

    At an implant CE course, the presenting surgeon told us that (as a service to the restoring dentist) before suturing, he takes an open tray bone/implant level polyvinyl impression. He uses the carrier as the impression coping, and it takes just a few minutes. He sends the impression and parts to the restoring doctor’s lab and they make a temporary crown (billing the restoring dentist). The patient gets a nice temporary with ideal contours fabricated entirely outside of the mouth (a fabulous service indeed). I raised my hand and asked why we needed the temporary at all. “Why can’t the lab just use that impression to make the final crown?” No one in attendance could provide an answer.

    So that is how I would have approached this case. Implant placement, open tray impression, cover screw (or healing abutment), suture. Crown delivered 3-5 months at the patient’s hygiene appointment. Lidocaine infiltration, mid-crestal incision, conservative flaps, deliver screw retained crown, sutures and then close the screw access hole (Tephlon tape, opaque layer, composite).

    • Vinothkumar S says:

      You don’t give a permanent crown because you need to load the implant progressively with a soft acrylic type material and also the soft tissue on healing may recede sometimes…. Acrylic crowns can be relined or remade easily at chair side- one more reason not to go for a definitive crown/ceramics, which require relining or adjustment to be done at the lab….. Plus you allow/create an emergence profile with temporary crowns….. And once you are satisfied you can make an impression with customised impression coping to support the papilla you formed….

  9. Vinothkumar S says:

    I too have experienced the same problem with respect to Angulation…. The x-ray position always almost seems akward most times when you compare it clinically, in the mandibular posteriors due to the fact that mandible tends to go up towards the ramus…. Many times I have ended up going at awkward angles trying to get a good position in the xray…. However, when I started placing more and more implants I did learn to get the positions right everytime both clinically and radiographically…. So, no worries about the position… As far as the missing cover screw, it is not going to be a problem… Even if you find some bony in growth, that bone is going to be super spongy and it shouldn’t be a trouble removing it…. When you are trying to remove the growth inside, if it is going to be soft tissue use ablation with heat or laser, if it looks like bone try using an ultrasonic scaler tip that is sharp, instead of air rotors and diamond burs….. Hope that was helpful….

  10. Wes Haddix says:

    Others have stated the obvious: aside from the missing cover screw, this appears to be an excellent placement! I’d skip replacing the cover screw at this point. Proceed with a punch exposure or similar , irrigate the implant body with chlorhexidine and remove all traces of blood from the inner aspect of the implant body, and place of a permucosal extension/second stage cover screw no more than 1mm above tissue level. This will allow gingival contoring to begin whilst the implant healing continues. In similar cases I almost always placed a stage 2 extension at placement where I had good primary stability. As another surgeon mentioned, taking an open tray impression at placement is also a time saver, thus you might consider evolving in that direction. Otherwise, under the conditions you have outlined, you have executed an excellent example of the best replacement option for this case, missing cover screw notwithstanding, and a few years from now when you’re retrieving an errant bone tack from a sinus when the cortical bone infractured as you tacked down the collagen membrane, you’ll quietly smile as this missing screw is relegated to a minor and almost meaningless incident. Prayers and all the best to you and your patient!!

  11. Dr. Gerald Rudick says:

    You did a good job my boy !!!! In future, you could have a checklist for yourself, that your assistant will read to you before you place your sutures…….there is no blood supply in the concavity of the implant, bone will not grow there…and if there is some fibrous tissue, just use a spoon excavator and remove…… the upper bicuspid should be investigated as well as the upper third molar.

  12. Arrif Lalani says:

    following on from this thread if the healing abutment comes off a few week later for what ever reason. How long after placement is it safe to go back and replace it. If too early then will the integration be effected? or is it better to leave till fully integrated then deal with the soft tissue over growth?

    • Matt Helm DDS says:

      By now you should have gone back in, cleaned up whatever tissue build-up was inside the implant head, replaced the forgotten cover screw, and resutured. Or you could have placed a healing abutment instead. In either case leave it alone till implant integrates at 3-4 months. If the healing abutment comes off replace it immediately! Never leave an implant completely uncovered! Always keep it covered and osseintegration will not be affected.

  13. WJ Starck DDS says:

    Option 2. No need to get one’s panties in a twist over this.

    Bone will not grow into the internal aspect of the implant, so just uncover when you normally would and put a healing abutment on at that time, and impressions a few weeks after that. Not a big deal.

  14. Arrif Lalani says:

    May 22, 2018 at 10:10:47 WJ Starck DDS says:
    Option 2. No need to get one’s panties in a twist over this. thanks for comment.. ps I wear boxers!

  15. Rob Wolanski says:

    all excellent comments. Just a note abut the comments on decay, careful not to mistake decay from panographic artifacts . There are better more diagnostic x-rays for that.

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