Here is a another non ideal case that does have a “teachable moment”, which is managing insertion torque. Everyone has a “happy number”, most like 35 Ncm, some like 50. I know a few old timers that would like almost no torque! They always refer back to press fit implants. I am happy if I get between 35 and 50. So here is a case we did yesterday. Tons of bone loss, close to the nerve…goodie. planned in CEREC for an optiguide. I usually don’t use CEREC for free ends, but thought Id give it a go. Took models as I did not have time to scan in the mouth and used the buccal bite. Did an OK job with design. We planned 2 Legacy 4 7mm, one 10mm one 8mm in length to be splinted.
You know the deal, Optiguide with the Large Diameter Guide Sleeves. Good amount of attached tissue, so we punched. Really smooth surgery. Isolite for suction and to hold down the guides.
Tough to see in any PA, but there is a prominent submandibular fossa that limited out length, not the nerve. 10mm in the 19 position and 8mm in the 18 position. Drilled up to the 5.7mm drill.
On the lower I am usually not a fan of any implant greater than 5.2 on a healed ridge. But we did a lot of grafting and we scraped out a lot of soft tissue in the sockets, so I was not convinced we were completely healed in the ridge, so we went wider for stability. Tried in the implant before using the crystal bone drill and could not even get it in. Again, these are Legacy 4s with the greater platform switch.
Here is my sequence for torque management: The implant is placed using a hand piece that torques out at 45 Ncm. I just use the Ratchet to index, maybe 1/8th of a turn, just to get the “flat” on the fixture mount buccal or lingual. Then I measure torque. In this case I used the variable torque wrench and we were between 50 and 60. Not bad, but above my comfort zone of a Max of 50. Let the implant sit for 5minutes (take an x-ray, fill out your chart, sit around and stare at the wall ;}) Then reverse torque the implant about 360 degrees.
Now set the torque wrench at the amount you are happy with. In my case I wanted about 45 Ncm. So I set the torque wrench and magically, we indexed just over 45, which I reversed back to index. So I am most likely around 40 Ncm. Not in love with #19 distal, but we were close to the nerve/fossa. Will see how things heal on the mesial, I may do some recontouring. Due to the height of bone on the medial, I could not fit a contour healer and was out of my 3mm height 5.7mm diameter healing collars so I went with the freebie healing caps.
Again, another “meh” case. Just to show the good, the bad, and the ugly. Will splint the crown and show the finals.