Guided surgery for a lower 2nd molar case?

I am working as an associate in a new office, which doesn’t have any implant surgery kit yet. We would like to utilize our CBCT and lean on guided surgeries. However if a patient presents with a request for lower 2nd molar implant placement (pt has opposing #1,2,3 molars), would the taller guided surgery drills even be possible to use given insufficient opening space in the posterior? We are about to export the data to make a surgical guide fabricated, but are hesitant to proceed. Should we commit to purchasing a basic surgery kit (unguided) for now? How would you approach lack of working space if you want to utilize fully-guided techniques?

3 thoughts on “Guided surgery for a lower 2nd molar case?

  1. Dr. Michael Pollak says:

    Hi Doctor:
    Second molar implant placements can be difficult, due to limited access and opening ability, as you note. Anatomically, the Inferior Alveolar canal is closer to the crestal surface, requiring shorter implants. Additionally, there is often a lingual undercut which needs to be considered to avoid a lingual perforation, and if the implant is angled to stay within the body of the mandible, prosthetic considerations need to be considered to ensure restorability. Bite forces are greater in the posterior, so occlusion will need to be designed to minimize forces. The risks/benefits of placing in a second molar site need to evaluated. Some companies and labs can fabricate ‘open’ surgical stents with a ‘half’ metal sleeve, allowing access of the bur from the buccal aspect. It isn’t as secure, but will help in the alignment of the implants placement. Good luck with this case.

  2. Dr.Howard Marshall says:

    Here are my observations after a long career of perio surgry and 8000 implants.
    Must use a Catscan. Assuming you do not need to ridge split to widen the ridge first, I found most ridges narrow in that area because of loss of buccal plate. So generally the ridge is between 3 and 5 mm. This means either using a narrow implant, a ridge augmentation on the buccal after perforating the buccal plate to get bleeding points, or indeed doing a ridge split augmenentation. Learn to use the Densah bur as it could eliiminate this augmentation problem as it widens the bone surrounding the osteotomy and can expand the width of the ridge before implant placement. Next point. Most often, one cannot easily use a stent, as they are most commonly made for vertical placement The anatomy in this area, because of the lingual shelf anatomy and the closer proximity of the mandibular nerve to the crest, lends toward slightly angling the path of the implant drill, between 10 and 30 degrees depending on what the Catscan shows. The last consideration is the particular implant system you are going to use. Generally, I have always had more than just one implant system available. I have had no trouble placing the MIS system in lower second molar areas. Today there are many systems out there whose total drill length from the back of the implant handpiece to the tip of the bur will accomodate the measurement needed based on the patient available mouth opening in the
    second molar area. Measure that opening first and check your implant drill after placing it in the handpiece and see the total distance available to you before placing it in the mouth.
    You can also Google for “short implant drill kits” and see what is listed. I think Megagen may make such a set or has implants that are not too long from drill tip to back of handpiece. Lastly,
    always make sure to take trial xrays with implant depth trial inserts before going to full depth to see where the inferior aspect of the drilling has reached relative to the anterior alveolar nerve. Using the above considerations will allow you to place a much more precise implant with confidence. I hope the above has been of some help. Again I suggest you learn to use the Densah bur to make your implant surgery easier.


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