Implants Placed too Lingually: Prognosis?

Since implant #36 was spinning at low torque, obviously it is not going to work....so remove it, place a fibrin or collagen plug at the base of the osteotomy, and place your bone grafting material.....Since #37 was torgued in at 50 Ncm...it has a good chance of survival...….restore when it is ready with a temporary corwn, that you can watch for 6 months....if it is asympthomatic, then put a permanent restoration....at this point, you can drill a new osteotomy for #36.

They will be ok. Just give them time to integrate.

This is the time when you need to start developing the right habits doing your surgeries so they become routine. If you make your flap adequate enough to view enough of the alveolar ridge, you would not have done this. Was the surgery flapless? Did you use a guide? Thanks for posting.

Any time you think you have a lingual perforation run your pink down there to palpate. Carlos is right. You are still learning so always flap. After you get more experienced...still flap

The lack of initial stability is in no way predictive of failure do just wait. Even in the event any of the implants need to be removed there is no need to graft as previously mentioned.

So important to learn from this...so kudo to you for posting. First off, NEVER place an implant without a CT scan. I'm sorry if anyone disagrees, but there is no such thing as an easy case. I have placed over 11,000 in my 25 years and all cases have their unique qualities. In this case, a scan would have shown you the lingual undercut that is present. And this next point won't help you with Buccal/lingual position, but ALWAYS after your pilot prep, TAKE A GUIDE PIN FILM! If you have to re-direct, you can. And someone else made this point and I totally agree, palpate the internal aspect of the prep. If you don't feel bony walls all around, abort and especially on the lingual... abort case! Neil Zachs Periodontist, Scottsdale AZ

At 36 you felt a drop as it may be a lacuna of medular bone. 36 has bone all around. It will be fixed in few months. Maybe. :) A had a 46 implant spinning, 50 %bone, 50% graft, and it got fixed in 6 months.

The lingual plate will most probably resorb with no bone left on that side of the implant resulting in soft tissue on that aspect. I would suggest explanting, place bone graft, let the area heal for 3 months and place the implant with a guide. Many years ago I posted on Dentaltown (a mistake) that conebeam will be a standard of care and I got chewed up by many who claimed to be able to implants with their eyes closed. A conebeam and surgical guide is needed to place an implant more predictably and less stress. Sometimes I place implants without a guide but with much more stress. Full flap reflection is important to visualize the anatomy. And yes as mentioned by another comment it’s a good idea to take a verification radiograph at the time of initial osteotomy. This is when you can change the direction. With a well planned surgical guide you may get away without this radiograph. However, it’s not a bad idea to take this radiograph. Thanks for posting. It is always a learning experience to hear what others suggest. Each one of have made mistakes as I have and no one is perfect.

These implants may work if the cortical bone is still intact. Wait and see. Dude, get yourself an X-Guide machine. Only $30,000.......worth every penny. Through the goal post implant placement every time.

1. Initial Stability School believes no initial stability guarantees failure. 2. J Clin Exp Dent. 2018 Jan; 10(1): e14–e19. Published online 2018 Jan 1. doi: 10.4317/jced.54441 PMCID: PMC5899809 PMID: 29670710 Effect of the lack of primary stability in the survival of dental implants Carlos Cobo-Vázquez,1 David Reininger,1 Pedro Molinero-Mourelle,corresponding author2 José González-Serrano,3 Blanca Guisado-Moya,4 and Juan López-Quiles Evidence says no difference in fixture survival regardless of initial stability. 3. Sharing My first spinner (management tele-supervised by mentor) - 3.5 x 11.5mm lower incisor area. Stable at 6 month. My first wobbler - 6.0 x 8.5mm lower second molar. Cover screw loose and exposed 10 weeks post-placement, I could screw in a healing abutment and unscrew it without fixture coming out with it. For me, the issue with no initial stability is not whether it will integrate, but when.

After placing over 5000 implants I can say with certainty that I have had more failures with initially stable implants than with spinners and I have placed a lot of spinners. I actually prefer one to go in a 10-20Ncm as I feel comfortable that there is no pressure necrosis and no lateral movement for which success is nearly guaranteed.

One does not need to remove a spinner unless there is vertical movement. It has been demonstrated that spinners more often than not will have an equally good if not better survival than those torqued very high. I’m happier that an implant that torques at 20 than 50ncm. I would have concern regarding the implants placed so lingual for a number of reasons: 1) less than 1.8mm of bone. 2) high torque of purely cortical bone leads to an increase of pressure necrosis (with less than 1.8mm in this case I’d be concerned regarding exposure of threads). 3. With such lingual placement, your restoration will have a buccal-lingual cantilever increasing strain on the implant, components ie abutment and screw as well as crystal bone. Why do you need such high torque if you aren’t immediately loading?

I'll hang with the watch and see croud on the spinner issue. i usually bury these implants and with L-PRF I am finding (like Dr Nelson Pinto) that NO STABILITY can be overcome with enough growth factors to stimulate integration. Another bigger issue is the lack of crestal bone thickness on the lingual. You'll get recession there unless the soft tissue is thick enough to resist it. Consider a CTG there. Good luck and hats off for getting help when things go South.....these things happen to us all.

Also the paper quoted stated that poor primary stability WAS NOT statistically tied to implant loss.