Implant breaching alveolar canal: best options?

If your patient has no paresthesia leave it alone. On their next visit document a normal neurosensory exam. Remember that X-rays are two dimensional, You can not properly locate the end of your implant and the nerve in two dimensions. Take more intra-operative X-rays so this doesn't happen. I'd say you were lucky here.

next time use an 8mm implant and you won't have to worry. Agree if symptomless ...leave alone

leave it alone top of ian canal is harder cortical bone most likely did not touch nerve

Platform too deep. No symptoms, leave it alone

I would refer the patient to an OMFS for 3D scan and his or her recommendation before Osteoinegration, just to protect yourself legally. I doubt it that anything would happen but it is the standard of care. Also the 3-D scan may show that the Roof of the canal hasn't been breached.

If this was noticed at time of placement I would back it out a quarter turn, but as others have said, 2D imaging is imperfect. As it is asymptomatic, I'd leave it. CBCT would help.

you may be actually lingual to the canal. Hard to tell with a 2D image but, since it's asymptomatic, you missed the nerve! Leave it alone.

You are not in the canal. Close but not in. Asymptomatic patient confirms it. But in the future remind yourself the standard of care is to have a three dimensional image, especially in a posterior mandible. From a legal standpoint you don't want to put yourself in a situation like this. Especially considering the alternative treatment would be to remove the failing crown behind the edentulous site and crown tooth #30 (which it clearly needs) Leave it alone.

Get a CBCT to demonstrate that the fixture has not perforated the canal. If you back the implant out which is not a bad idea, the implant may lose stability and fail. Dennis Flanagan DDS MSc

The implant is probably lingual. You may scan to determine the location for future reference. Not all perforations of the canal result in a sensory disturbance. The nerve, artery and vein travel down the canal in a twisted manner. The nerve is on the superior aspect of the bundle about 20%of the time. So it is possible to be in the canal but not affecting the nerve. If you choose to scan then you can subsequently act in an intelligent manner.

Two points. You must immediately have qa Catscan done, and get a written report from the company which normally has a specialist advisor. Determine whether you did or did not breach the superior cortical bone of the mandibular canal, and whether there is any proximity of the implant resting on the nerve. If so, back it out. If you have not perforated the cortical housing of the nerve, consider yourself fortunate, and the patient even more so. Lastly, do not worry about backing the implant out one turn. I have had to do that when I did not like the crestal position, and as long as the implant is buried under the gum, it will integrate from proximity to the surrounding bone and the normal process of bone healing next to an implant. I would wait 4 months before loading.

Thanks all for the kind guidance.I decide to leave it as such and wait for 4 months for integration.Can we expect any long term complication after loading?

For a case like this you will need to show a pre-op CT scan. for the lawyers, can you show that you took reasonable care in planning?. This I am sure is the standard of care, not doing it afterwards. Fantastic placement just wait and restore now the patient is comfortable without any complications, but I suspect you got lucky as the final outcome is a surprise to you! Looks like the mental foramen may be close by and of course the nerve bundle will be moving towards the facial which helps keep it away from osteotomies and don't forget that there may not be cortical plate protecting nerve in molar region.

Taking CBCT's are not the standard of care! The decision to take or not to take a CBCT is still up to the doctor. CBCT's do not place implants. One can still perfectly mess up a case when a CBCT has been taken. CBCT's are just another eye in the sky. They are not some magic surgical gizmo! I use them from time to time but they are not usually a requirement to perform a case.

one of the first things needed is to take a periapical radiograph that is perpendicular to the tooth, bone and implant. this is foreshortened and not accurate. over and over and over we all see poorly positioned sensors or films. radiographs are certainly not an end-all diagnostic tool but are essentially worthless if not clear, concise, and done with proper angulation. don't worry and keep trying. some great advice on this case.

remove the implant, give cortisone if you hot the nerve, place a icon short implant!

Krishan, real quick how did the implant end up 3mm subcrestal? Did you take any parallel pin/depth verification radiographs when developing your osteotomy? Or did this happen when placing the implant? Is that a nobel active? Thanks for having the courage to share your case. Mark

Hi.. the IOPA image is foreshortened. (You can see the lower border of the mandible). Hence, you should have atleast 2-3 mm between the implant and the canal cortex, if you take a proper IOPA. Nothing to worry about.

I agree with Dr. G. A good plaintiff's attorney will certainly use the standard's set forth by AAOMS Parameters of Care, should a misadventure result. Therefore, next time get the CBCT prior to implant placement.