Management of max/posterior molar: any advice?

Last Updated: Jun 22, 2015

4 months ago, I extracted and completed socket preservation on #14 (max first molar). The site hadn’t healed very well with the graft, and the septum made for ideal placement very difficult. I had planned for a 5x6mm One Stage implant (by blue sky bio — straumman clone). Upon initial osteotomy the sinus was only about 5mm down, crestal lift with mineralized cortical allograft completed, the implant didn’t go in tight and resulted in a “spinner” when trying to place cover screw over and inability to completely cover implant platform. Wondering how to manage from here. Will the slight opening of the cover screw be a problem with soft tissue infiltration upon healing? Any advice is much appreciated.

![]14-implant](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2015/06/14-implant.jpg)

19 Comments on Management of max/posterior molar: any advice?

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p.fairbairn

06/22/2015

Hi my advice sadly is to remove the Implant let it heal for a few months then redo using a lateral window.... Too many variables and unknowns going on here , sure may get lucky and the body heals but I would not be happy with this case as placed a bit too deep even taking current fashion into account . All the best Peter

CRS

06/22/2015

You know this type of implant is transmucucosal right? It is not supposed to be buried, it is one stage. Anyway I think it should be removed as Peter stated above. Don't feel bad it is doing the right thing in the long run. If it were to integrate, it will be very difficult to restore. Careful not to push it into the sinus when removing.

dr gerald rudick

06/23/2015

I agree with my collegues above...the implant should be removed. When attempting to remove, my advice would be to open a full thickness flap to get an idea of what stage of development the osseous ridge is at......if at the crest it is spongy, place an instrument such as an explorer, through the lateral cortical bone horizontally to engage the implant.....use a second instrument as well.....you will be "holding the implant " and keeping it from slipping into the sinus. If you are able to loosen the cover screw, do so, and lassoo a piece of dental floss around it.......now attempt to remove the implant.......it cannot go too far..........Good luck Gerry Rudick Montreal

Ben manzoor

06/23/2015

CRS love ur comments . Finally u hv learned to be diplomatic. I can imagine what be going through ur head while looking at the post. No disrespect to author. My only advice is use open tray impression post to remove the implant to avoid transportation into sinus

CRS

06/24/2015

Thanks Ben anything is possible, you made my day! I guess I'm a work in progress, and I do get a lot of great tips from this blog.

Laz S

06/23/2015

I apologize for bluntness but This implant is too short for posterior maxilla. I like at least 12-13 MM. Bone quality is questionable. I would approach the removal from a lateral window approach. Then you can push it back down. There is a high probability if you try this from the crestal approach it will end up frustrating you, taking a long time and ending up in the sinus. If you are not comfortable with a lateral approach do a cool referral to someone who can.

Raul Mena

06/23/2015

I agree with most of the above comments of removing the implant. I am in total disagreement that the implant is too short. I use to favor long implants, now I am a true believer of short implants, There is no need for longer implants than 6mm. I am sure many will not agree with me, that is ok every one is entitled to their own opinion. You can see the results of Bicon implants in their web page. We have obtained similar results with Quantum Implants.

CRS

06/24/2015

I think if the implant is engaged in really good bone the length is not as critical but I am totally guessing here. I don't use the Bicon but the threads are pretty deep so perhaps a combination of thread design, length and osseointegration.

Tuss

06/24/2015

Raul makes a good point, research coming out now that an implant length may not be as critical to sucess as previously though with most loads being experienced in the first 4mm crestally. The only issue will be if failure occurs and the patient goes to another dentist and they make a massive song and dance about "implant being too short"

Dr Bob

06/24/2015

This implant needs to be removed. I agree with Dr. Mena. You can check out Bicon on the internet. There was plenty of bone here for a short implant. No I do not work for Bicon or Quantum Implants.

dr nitin sharma

06/25/2015

All is well if it ends well. Dear doctor, kindly raise a full thickness flap to explore the implant. The retrieval may further push it deep, so consider a buccal adnacement flap design. By no luck the implant has osseintegrated, u may also find the cortical plate loss. best of luck

Farhad Amini DDS

06/27/2015

Hi, You know looking at this case, I think the implant will fail, most likely due to the reason that is was a spinner, and basically that is what you want. The reason for that is because the position of the implant apico-coronally is not favorable. Now, it is important to distinguish between an infected site vs. an unintegrated site. I would first inform the patient that this implant will not integrate sot hat patient is expecting the result. I would leave the implant in there for four months and remove it (Anti-torque) in four months. Either graft the site and try again or place another implant in a better prosthetic position. Best of luck !! Farhad.

CRS

06/28/2015

I just thought of something, re read the post, the case would have been technically easier with a real Straumann bone level, Nobel active or Zimmer. I would advise not using a knock off implant to save a few dollars. Also bury it when it is a compromised placement no transmucosal on this case. I took a look on the tread pattern on the X-ray. Maxillary bone tends to be soft and it may have gotten chewed up here, spinners are okay in good bone which is totally protected from any movement while integrating. It is an experienced judgement call on whether to have an implant exposed during healing. Remove it graft the site and go back in four-six months. When replacing, rely on more pushing vs cutting the bone, very low rpm, the bone can be compacted and pushed into the already created lift. Actually I like engaging the septum with the implant tip to grab it, in that case a Nobel active is a nice way to go initially but since you will have nice grafting now I would use a Staumann transmucosal since it will be protected by the adjacent teeth, allow it to heal don't load it too soon. The real implants are worth the money , will Blue Sky Bio replace this for free?

Eric

06/27/2015

Thanks for the comments. Pt was advised of less than ideal results at placement and the implant is planned for removal, lateral lift and try again in a few months. Thanks again

CRS

06/28/2015

As an " all knowing " Oral surgeon I have a mandibular case that I just did and I had a questionable placement a few weeks ago. I am going to remove it also, the patient wants to keep it but I am visiting the restoring dds to get him on board. In the long run it will be better but I go thru anguish in the decision tree. It is how we learn. Applaud your decision good luck!

Tuss

06/29/2015

A paralleL sided or tapered implant in soft bone over the sinus may easily pop into the sinus when placed. If you're starting out etc then using another Straumann transmucosal would be wiser or maybe an Astra as it has a flared neck also. Switching implant systems hping for a better result is not a great idea. Get the implant bed prepared to accept an implant before you place a new implant and it should be fine as the space looks simple to restore.

Hank Michael

06/29/2015

All very professional feedback! Completely agree with removing the dental implant and doing it very carefully to avoid loosing it in the sinus. I also agree short implants have their place in implant dentistry - in the posterior maxilla it would be nice if they were splinted implants. In this case, I feel the lateral window technique with immediate or delayed implant placement is most appropriate. The nice thing about the lateral window is you can usually develop abundant bone for future implants in the adjacent teeth position - if it became necessary in the future.

PDM

07/01/2015

As mentioned by a previous poster, I would also recommend you refer this case to someone who is well familiar with later windows as that is what what you will need to do if you attempt to remove crest ally. What technique did you use for the crestal as I don't see any significant graft and the threads are not engaged in bone. The flare of this implant design may be the only thing that prevented this implant from being lost in the sinus.

Dr.Katta Sridhar Chowdary

07/08/2015

Hi! provided Patient's X-ray shows ABUTMENT TEETH adjacent to implant are having HUGE restorations.Following are my recommendations to you; 1.Leave your dental implant in place,Prepare abutment teeth and place a three unit Fixed Partial Denture. 2.Remove implant,do crown preparation with 25&27 and place temporary Fixed Partial Denture and replace with permanent one after through tissue healing.

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