Torquing by the book? Time to reconsider…

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It has been my experience that small diameter implants (3.5 or less) in the anterior maxilla can deintegrate easily when the final abutment is being torqued down.  Whenever this has happened it has been the result of torquing to a full 35 N.cm as recommended by the instruction manual that may accompany many implant systems.  However, what has really worked for me is to torque down to 20-25 N.cm and call it a day.  The abutment usually does not become loose after the crown is placed in function and the case is finished just fine.  Since we are talking of the anterior maxilla most cases will go through a temporary phase and this would still give the clinician a second chance to test out the torqued abutment and give the implant more time to integrate fully.

Whenever I have gotten the call that it seems that the implant just moved on torquing (usually because the abutment loses it’s correct position by rotation of the implant) there are usually three choices to proceed.

  1. Reposition implant as closely as possible to it’s original position.  Leave the final abutment on.   Cement final crown temporarily or replace the temporary crown that was on.  PUT THE TOOTH OUT OF OCCLUSION.  And hope for

    Untitled.jpgreintegration…  (this can and does work )

  2. Remove it, debride the socket and regraft and replace implant after graft healing  
  3. Remove the implant and place a wider implant, wait for integration and remake final abutment.

When this happened to one of my restoring dentists, my solution was to remove the implant. Gently examine the socket. Then replace with an implant of the same width but longer (16mm instead of the previous 13mm).  I could not place a wider implant due to space restrictions in the esthetic zone.  I indexed it in the same way and also eyeballed the vertical depth to as close as possible to the previously placed implant. This allowed me to use the already fabricated final abutment and crown (taken out of occlusion) during implant reintegration.  So please be prudent when torquing down implants to the exact requirements by the implant company. If in soft bone, working in the anterior maxilla, implants within sinus grafts, or working with narrow implants (<3.5mm) you may just want to hand tighten the final abutment (8 newtons of force) or just go up to 20 Ncm. Also keep some long (16mm) implants in your inventory for a rainy day like the one I was having.  In the posterior mandible by all means you can swing off that torque wrench and I won’t mind!  

 

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