Archived Newsletter Re-Post.
The AOX Newsletter • February 2024 #7
We’ve all seen it.
And if you’ve done enough All-On-X cases, you’ve done it too.
I know I have.
Despite my best efforts, I cannot argue with that post op scan. Those glaring implant apices staring at me, seeming so obviously to touch. How did I not feel that intra-operatively?
At first I tell myself it’s the angle of the scan. But I know deep down, my implant apices are simply in direct contact – titanium to titanium.
While this isn’t common in my hands, it definitely can occur from time to time.
It is more common in atrophic cases where bone availability is minimal and when implant configurations such as the “M” or the “Inverted V” are used.
So, if we find ourselves in this situation, is it a problem?
Should we even care?
The short answer is, no it is not a problem.
The long answer is more complex. And yes, we should care.
Here’s the deal...
Implant apices can touch and still integrate properly.
I have seen it many times from other practitioners as well as in my own cases.
I have known many well respected AOX surgeons with post-op panorex images that show kissing implant apices.
So I wouldn’t stress, worry, or remove an implant simply because it is touching the apex of the adjacent implant.
If this is the case, then why should we be concerned at all?
- When placing our implants, if they do come in direct metal to metal contact – we increase the chance that as we complete the final torquing of our implant – the implant may spin out and lose all torque. This occurs as a result of the implant hitting the adjacent hard metal stop and not being able to progress further down the osteotomy.
- If there is an infection with one implant, or an indication for removal of that implant, this can also negatively affect the implant with which it is in contact. Now we potentially have a problem with two implants, instead of just one implant.
- Style points. Whether it matters clinically or not, style points always count. Touching implants don’t win extra style points in my book.
For the reasons listed above, I always strive to avoid direct implant to implant contact. This is the best scenario.
However, sometimes it happens. And when it does – I don’t lose sleep over slight apical to apical implant contact. Typically, in the grand scheme of things, this doesn’t really matter.
But the style points – the style points always matter 🙂
Matthew Krieger DMD
P.S.
*I will clarify that I am referring to the apices of adjacent implants being in contact as they would be in an “M” or “Inverted V” configuration. If the entire body of one implant is positioned right next to another, without sufficient bone availability – this very likely will cause an issue with integration and is a different scenario.
“Art is all in the details.”
Christian Marclay
Q & A with Dr. K
“How do you ensure your implant angles are at exactly 17 or 30 degrees for restoration with MUA’s?” |
I don’t.
More so than an “exact” angle – I am concerned with maximizing A-P spread and achieving symmetry within the arch.
In the maxilla, I normally follow the trajectory of the sinus in order to maximize A-P spread.
Within reason, whatever angle the anterior sinus wall slopes at, I will mimic with my implant angulation. I then select the appropriate abutment to match that angulation.
Remember, that while I do attempt to have implants “somewhat” parallel following MUA placement – there is a level of restorative flexibility with abutment divergence. Furthermore, implants do not need to be, and actually should not be, “perfectly” parallel for an optimal prosthetic outcome.
The mandible is usually more straightforward from an anatomic standpoint and is almost always a 30 degree posterior abutment in my hands. Clinically, I want to have my implant exit point sit over/above the mental foramen. An angulation close to 30 degrees usually accomplishes this goal.
In both scenarios, I am utilizing intra-operative Graphite Guided Surgery to indicate and execute my implant trajectory.
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