You Get What You Get and You Don’t Get Upset

Here is another case in which I had to bail and graft on one of the planned implants.  Which I think is another good learning point, recognizing when things are not going well and knowing when to come back when you have the bone:

One of my favorite patients moved to Vegas.  Had some teeth extracted for perio reasons and grafted about 6 months ago.  Wanted me to to the implants, came in and we rushed a Radiographic Guide with some Barium Sulfate teeth:

The lab did a great job, Barium Sulfate denture teeth with a Vacuuform.  When I have more than two teeth missing next to each other, its easier to go with Barium Sulfate than making the the teeth in CEREC:

The Surgical Guide is a modification of the Radiographic Guide, so make sure the Radiographic Guide fits well:

The original plan was one implant per tooth, bone seemed good, but we shall see:

Popped in with the 2.3mm pilot.  The 2.3 to me, is almost diagnostic of the quality of bone I have.  If I have resistance I know I am dealing with good bone.  #10 and #13 had great bone, but #11 I just popped in.  In Guided Surgery when that happens the first thing you worry about is if you perfed the buccal plate.  So I flapped to see what was up:

On the cross sectional image everything seemed cool.  But look at the radiographic appearance of the graft, very radio opaque.  I am not sure he was grafted with but it all came out when I flapped, you can see in the upper left the graft ob my periosteal elevator.  This is just after the 2.3mm, I scraped out all the graft and found that none of it “took”.  I went ahead with the 2.8mm drill hoping I could treat #11 like an immediate, but you can see with the angulation pin that the thing was wobbling, no stability.  No bueno!

Went ahead and placed implants in the #10 and #13 positions.  I would have liked three implants but discussed a bridge with the patient.  I will have group function on it, but would have liked an implant in the canine area, but the patient was happy he saved a few grand.

MFDBA, doing this two stage.  Membrane and resorbable sutures as the patient lives in Vegas.  I think we will still have a great result, but would have liked 3 implants instead of 2.  With the new graft, I may end up placing an implant in 11 down the road if we have any occlusal issues.  But I think the lesson here is that you need to be prepared to flap, visualize and bail/graft if necessary.