Forgot cover screw and concerned about implant position: opinions?

Implant position is fine. Missing cover screw no big deal. You will just have a nice fibrous plug in there when you uncover to restore.

what is happening to UL5 ??

The implant position looks okay. You can still place a cover screw, just let patient know you want to place a tissue contouring healing screw. Good luck

I won’t loose my sleep over cover screw but next time have your assistant look from her side as well to verify the position. In this case distal could challenge you in prosthetic phase .Have the Lab go for wide contact to avoid food trap. Good luck for all the coming ones!

Although I do not place implants, I have restored them for 41 years. I lecture on implant complications for the restorative dentist.Using a tissue punch for the size of the implant should work. Cleaning out the implant without damaging the internal portion can be a challenge. I would still be very careful with titanium scalers and would recommend the glycine spray by Hu Friedy ,30% phosphoric for 30 seconds,followed by disinfecting with Cloysis mouth wash. The Cloysis will not damage the soft tissue attachments around the implant.

I think its an excellent placement. Its very prosthetically driven and I think you will have a great result. If its still fresh, you can always make an H- Incision and place a cover screw on the implant. Other wise no big deal :-) In future, if you ever struggle, trim off the mesial edge of the Lower left second molar to accomodate a nice mesiodistal width of the prospective implant crown ( with patient's consent of course. I think the implant certinaly is in an optimal position from a prosthetic point of view. Great work !!

Implant position is fine! For the sake of argument, the only way you could have "improved" it is by placing it about 1-1.5mm more distally and angling it slightly mesially, by "eyeing" an angle slightly shallower than that of the molar, by using the molar as a visual guide. But that's uselessly nitpicking for the sake of nitpicking. It would've resulted in perhaps a "prettier" x-ray, but that's all. The advantage to your placement is that you will most likely be able to use a straight abutment. Use a tissue punch ASAP and install a healing abutment to avoid further build-up of fibrotic tissue inside the implant. You are also dealing with a failed RCT on the UL 5, a required RCT on the UL 6 (possible endo-perio lesion) and a required RCT on the LL 7, due to large distal penetrating caries. BUT, since the UL 5 and 6 don't look too great from a prognosis standpoint, I would consider extractions and implants in those sites. Good luck!

Why would you place a cover screw (rather than a healing abutment) if you have good stability? Have the patient back and place a healing abutment.

Remove and replace. Time to eat crow here

35 N is fine stability, place a healing abutment

The other doctors have given you good advice on this case. Some things for you to consider on future cases: I screw retain crowns unless there is a profound reason not to. On a case like this, I would absolutely use a screw retained crown. I am moving away from UCLA/PFM crowns. More often I use a stock abutment and request the lab make a zirconia crown with a screw access hole. I cement them extraorally so that I can clean up the cement. When I deliver the crown, rather than throw away the model, I box it up and ask the patient to keep it in their sock drawer. If the porcelain ever chips we can send the case back to the lab with the original model. At an implant CE course, the presenting surgeon told us that (as a service to the restoring dentist) before suturing, he takes an open tray bone/implant level polyvinyl impression. He uses the carrier as the impression coping, and it takes just a few minutes. He sends the impression and parts to the restoring doctor's lab and they make a temporary crown (billing the restoring dentist). The patient gets a nice temporary with ideal contours fabricated entirely outside of the mouth (a fabulous service indeed). I raised my hand and asked why we needed the temporary at all. "Why can't the lab just use that impression to make the final crown?" No one in attendance could provide an answer. So that is how I would have approached this case. Implant placement, open tray impression, cover screw (or healing abutment), suture. Crown delivered 3-5 months at the patient's hygiene appointment. Lidocaine infiltration, mid-crestal incision, conservative flaps, deliver screw retained crown, sutures and then close the screw access hole (Tephlon tape, opaque layer, composite).

I too have experienced the same problem with respect to Angulation.... The x-ray position always almost seems akward most times when you compare it clinically, in the mandibular posteriors due to the fact that mandible tends to go up towards the ramus.... Many times I have ended up going at awkward angles trying to get a good position in the xray.... However, when I started placing more and more implants I did learn to get the positions right everytime both clinically and radiographically.... So, no worries about the position... As far as the missing cover screw, it is not going to be a problem... Even if you find some bony in growth, that bone is going to be super spongy and it shouldn't be a trouble removing it.... When you are trying to remove the growth inside, if it is going to be soft tissue use ablation with heat or laser, if it looks like bone try using an ultrasonic scaler tip that is sharp, instead of air rotors and diamond burs..... Hope that was helpful....

Others have stated the obvious: aside from the missing cover screw, this appears to be an excellent placement! I’d skip replacing the cover screw at this point. Proceed with a punch exposure or similar , irrigate the implant body with chlorhexidine and remove all traces of blood from the inner aspect of the implant body, and place of a permucosal extension/second stage cover screw no more than 1mm above tissue level. This will allow gingival contoring to begin whilst the implant healing continues. In similar cases I almost always placed a stage 2 extension at placement where I had good primary stability. As another surgeon mentioned, taking an open tray impression at placement is also a time saver, thus you might consider evolving in that direction. Otherwise, under the conditions you have outlined, you have executed an excellent example of the best replacement option for this case, missing cover screw notwithstanding, and a few years from now when you’re retrieving an errant bone tack from a sinus when the cortical bone infractured as you tacked down the collagen membrane, you’ll quietly smile as this missing screw is relegated to a minor and almost meaningless incident. Prayers and all the best to you and your patient!!

You did a good job my boy !!!! In future, you could have a checklist for yourself, that your assistant will read to you before you place your sutures.......there is no blood supply in the concavity of the implant, bone will not grow there...and if there is some fibrous tissue, just use a spoon excavator and remove...... the upper bicuspid should be investigated as well as the upper third molar.

following on from this thread if the healing abutment comes off a few week later for what ever reason. How long after placement is it safe to go back and replace it. If too early then will the integration be effected? or is it better to leave till fully integrated then deal with the soft tissue over growth?

Option 2. No need to get one’s panties in a twist over this. Bone will not grow into the internal aspect of the implant, so just uncover when you normally would and put a healing abutment on at that time, and impressions a few weeks after that. Not a big deal.

May 22, 2018 at 10:10:47 WJ Starck DDS says: Option 2. No need to get one’s panties in a twist over this. thanks for comment.. ps I wear boxers!

@WJ Starck DDS: Good comment, good humor. I believe the lad was asking if osteointegration will be affected if he doesn't replace the cover screw timely. Thought I'd allay his fears, since he seems so inexperienced. As for the panties, a screw can be placed with them off much easier, n'est pas? )))

@Arrif Lalani: You should wear briefs. Sexier for the girls. Besides, with your jewels dangling around it's no wonder you can't think straight enough to know that osteointegration will not be affected if a cover screw or healing cap is off, but that in the case of a healing cap you shouldn't leave the implant uncovered because you'll get into other problems.

all excellent comments. Just a note abut the comments on decay, careful not to mistake decay from panographic artifacts . There are better more diagnostic x-rays for that.