Never blindly go guided
In previous posts, I have mentioned how much I love guided implant surgery. It takes a lot of the guess work out of the process, and also reduces the "pucker factor" associated with implant placement. When planned properly, it is generally a very smooth and seamless process, resulting in a good experience for the dentist and the patient. However, despite the fact we have planned everything in advance, we still need to remember to check along the way and make sure nothing has changed or gone wrong, including user error, which is what happened here! I have generally placed Camlog implants due to the ease of their guided system...however, in this case I decided to try Straumann, mainly because of the posts I have seen here and feedback I received from some friends of mine. I stayed away from the system because of the keys required, but I have to admit they were not nearly as big of a deal as I thought they would be.
Patient presented with tooth #4 fractured and unrestorable:
So, I extracted tooth #4 in July 2016 and grafted the site:
The patient opted to wait until last week to come in for implant placement...we planned a Straumann bone level tapered implant 4.1X8 to go right up to the sinus. Here she is prior to surgery:
With the guide in place I began my osteotomy...this is where I screwed up! Being used to Camlog, where you ordered one set of burs, and having this be my first surgery with Straumann, I didn't notice there is a guided bur with 1 line, 2 lines, or 3 lines, correlating to the different lengths:
Even though we are going with a guided surgical protocol, I still always take a check film along the way...thankfully, I grabbed the 1 line drill and not the one with 3 lines! As you can see, I was way short of my desired location(instead of into the sinus if I would have grabbed the other bur), so I had to step back and figure out what happened.
Obviously, this was me being a knucklehead and not an issue with the guide or the system. So, I switched to the 2 line bur that I was supposed to use, and finished my osteotomy, which left me ready for placement at the desired depth:
I placed the implant fully guided-I really liked the way the implant engaged the bone:
And then 1 final PA with the healing cap in place, showing the implant right up to the floor of the sinus where I had planned it:
The patient is aware of the need for a new restoration on #5...
So, keep in mind that although we have planned everything in advance, it is still wise to proceed cautiously and take periodic radiographs to ensure you are following the planned treatment. I have spoken with some dentists who don't take a radiograph until the implant is in if they are placing them guided...this case hopefully shows a good reason to take a check radiograph along the way and make sure you are on the right path, especially if you pull a bonehead move like I did. For the few seconds it takes, it can save you a lot of time and risk later on!
Great post Anthony... actually a bit of a relief, as scrolling down with the bur highlighted, I was expecting the osteotomy into the sinus... I mean, there's user error and then there's user error! Great result!
Mark
On 4/25/2017 at 10:28 am, Mark Stockwell said...Great post Anthony... actually a bit of a relief, as scrolling down with the bur highlighted, I was expecting the osteotomy into the sinus... I mean, there's user error and then there's user error! Great result!
Mark
I was too! Glad it all worked in the end. Great story and reminder of the dangers of "routine" things we do every day!
On 4/25/2017 at 11:54 am, Ernie Johnson said...On 4/25/2017 at 10:28 am, Mark Stockwell said...Great post Anthony... actually a bit of a relief, as scrolling down with the bur highlighted, I was expecting the osteotomy into the sinus... I mean, there's user error and then there's user error! Great result!
Mark
I was too! Glad it all worked in the end. Great story and reminder of the dangers of "routine" things we do every day!
Me too! I was kind of looking forward to some horrific pictures (implant in the orbit?!?) instead of that beautiful result!
Was if Farhad or Reznic who calls a guide the "circle of trust"? Great job Anthony. You are the man!
Kind of like carpenters who say "measure twice, cut once". The extra time double checking your technique is always worth it. Thanks for reminding us!
On 4/25/2017 at 1:31 pm, Yao-Lin Tang said...this is where " to be short better than long" :)
Oof... ;)
Mark
In my first year of guided surgery I would always take a check radiograph. I don't do that anymore although there is definitely nothing wrong with that approach. But I still always insert a depth gauge prior to inserting the implant to measure depth and angulation.
One tip: If you do want to take a check radiograph then buy couple of depth gauges and cut them to 12-16mm (so they are not sticking above the occlusal plane) and use these cut depth gauges for the check radiographs. You will make your assistant's job easier and you will get a more accurate radiograph.
Farhad
Anybody using other implant system and wants to unload their Staumman system? I am interested. Thank you.
Anthony-
Nice save. Your friends talked you out of camlog?
I have tried a few systems and always come back to camlog/conelog. The surgery (no keys, internal irrigation) is so easy and I really like the longer tube/tube prosthetics. Makes seating the abutments so much easier. With conelog, the conical connection is there if that floats your boat.....which it does for me, but I personally haven't seen the issues with bone loss in 7 years of camlog placement.
Still waiting on the 5/6 mm guided system from camlog (use BH for those now).
Anyways- not trying to hijack, but a bit surprised of the rationale for your switch. Were you having issues with camlog?
On 4/25/2017 at 1:31 pm, Yao-Lin Tang said...this is where " to be short better than long" :)
that's my tag line
Thanks Farhad...I have depth gauges with my surgical kit but I was using the rep's kit and he didn't have any in there so I improvised...great idea about cutting them down!
On 4/25/2017 at 12:35 pm, Daniel Butterman said...On 4/25/2017 at 11:54 am, Ernie Johnson said...On 4/25/2017 at 10:28 am, Mark Stockwell said...Great post Anthony... actually a bit of a relief, as scrolling down with the bur highlighted, I was expecting the osteotomy into the sinus... I mean, there's user error and then there's user error! Great result!
Mark
I was too! Glad it all worked in the end. Great story and reminder of the dangers of "routine" things we do every day!
Me too! I was kind of looking forward to some horrific pictures (implant in the orbit?!?) instead of that beautiful result!
I like that you were looking forward to it that...you are a sick man, birthday boy...
On 4/25/2017 at 5:47 pm, Brad Dorsch said...Anthony-
Nice save. Your friends talked you out of camlog?
I have tried a few systems and always come back to camlog/conelog. The surgery (no keys, internal irrigation) is so easy and I really like the longer tube/tube prosthetics. Makes seating the abutments so much easier. With conelog, the conical connection is there if that floats your boat.....which it does for me, but I personally haven't seen the issues with bone loss in 7 years of camlog placement.
Still waiting on the 5/6 mm guided system from camlog (use BH for those now).
Anyways- not trying to hijack, but a bit surprised of the rationale for your switch. Were you having issues with camlog?
Haven't decided on a switch and they didn't necessarily talk me out of Camlog...just encouraged me to try Straumann to see if I liked it. I have had good success with Camlog, so I don't really have too many complaints, but it is also the only system I have ever placed, so hard for me to compare. I will say that the implant felt like it engaged more aggressively than I feel like my Camlog's normally do...maybe it was just this case/bone, but just one observation. I am low on implant inventory so it seems like a good time to at least try some things out before I reload...
On 4/25/2017 at 9:02 pm, Daniel Wilson said... Great post Ponz! Are you sure you didn't photoshop this case?!?
Come on Anthony I thought you like working out those pucker muscles.
Great post on always check!
