One thing that I had a hard time with prior to placing my own implants was dealing with second molars and how they were placed. I love seeing a radiograph with an implant perpendicular to the floor, but the bottom line is that is just not how teeth line up in the mouth. The Curve of Spee is made up of the combined angulation of the teeth roots and crown in a mesio-distal dimension. On the lower all teeth lean to the mesial with the second and 3rd molars REALLY leaning forward. On the lower, per the Curve of Wilson, the molars tip to the lingual. It all starts in your pre-prothetic planning. Look at the contra-lateral teeth and get an idea of where they are tipping then mimic that.
This is best visualized in the scan. Here you can see my implant is in the center of the proposal and leaning both mesial and lingual.
Back in the mouth I like to use an Isolite for suction as well as Guide Stabilization. I use Lido with 1:50K for heme control prior to my punch and to lift the periosteum.
The graft is 2 months out and is still ossifying. But we have our angulation pin in the right place
Guide Series, for some reason I got a small sleeve, so I used my last drill without a handle and looked out for the 22mm laser mark.
We need to manage torque. As you know a ratchet has unlimited torque. So I got the implant down after the hand piece atalled out at 45 NCM. Then I back it out about 3/4 of a turn then go to the wrench.
We all have our “magic number” but I like my implants to be in around 35-50 Ncm. In this case we are right at 50 which is not hard to get in D2 bone. Even though the graft looks light, we had great torque.
Indexed. Not the Mesial and Lingual tip.
Oversized healing cap. This is a 5.2 by 10 and the healing cap is 5.7. This acts like a tissue former.
After 2 months we replaced the 5.7 healing abutment with a contour healer, look at the size of the tissue cuff!
We get this nice wide area where our impression material can then get in there. I did not use a custom Impression coping, but the lab was able to fill in this area nicely.
The lab had an easy time with this case, Implant is in line with the central fissures of the adjacent teeth and the abutment is centered in the middle of the crown with no mesial or distal cantilevers.
Stock, un prepped abutment. No finishing or anything. Look at that tissue! Torqued down nice at 30 Ncm.
Final decent emergence, a little supra eruption of the upper. But if you ignore the fact that this is a 2nd molar, this really is a great first case for new implantologists. Lots of bone, lots of good tissue, this patient could open big. So as long as you know where the nerve is don’t discount molars as an option as an easy case.