Implant position: opinion?

Matt Helm DDS comments:

Well now, that is quite a difference. Had you seen this from the very beggining, you would have known that this implant is just FINE, no CBCT needed! This whole discussion would have beecome moot. This experience should be a learning oportunity for you. Yes, YOU SHOULD, AND MUST become better at taking your own x-rays! (Stop calling them Rx's in English. Rx in English means prescription, as I said before. PA, for "Peri-Apical" is the proper term in english for a dental x-ray.) Lesson 1? It is ALWAYS worth the effort to take one little, simple, PA (periapical, "ortoradiala" in romanian) x-ray! It is the easiest, fastest thing to do, and it always gives you a better, more accurate view than any pan. Lesson 2? It is WORTH your effort to learn to take better PA's YOURSELF. In fact, it is a must! Whenever I need a very accurate view, or a particular view (like a disto- or mesio-centric angle to "rotate" the tooth or implant) I ALWAYS take my own x-rays, because I Know that no one will take them better, not even the best dental assistant! It's not hard to learn and you really should know how to take your own x-rays. Oh, and I don't rely on the rings, because they always give a distorted (slightly elongated) view. Those rings were invented for "dummies" and inexperienced dental assistants who have no idea how to take x-rays. Here is the surest technique for accuracy, to ensure that you get the exact view and proper angle: after placing the film in the mouth I then place the patient's finger on it to hold it (I always place the patient's finger myself), and then if I have any doubts as to the angle of the x-ray tube, I always place the fingertip of my right index finger (keeping my finger straight) on the occlusal of the tooth and angle my finger to visually see the exact bisecting line of the angle between tooth and film, and I place the tube with my left hand perpendicular to my finger. This way I get an exact PROPER angle and, therefore a most accurate view. I use a similar technique when taking disto- or mesio-angular shots. This simple but effective technique has never failed me in all my decades of practice. All you need to do is to study a little bit a textbook on periapical x-rays and understand all the angles, because it's a very simple question of basic geometry and image projection. And you don't know it only because no one ever explained to you how an image is elongated, shortened, or rotated on the film. But once you visually see it then it becomes the easiest thing in the world. Most certainly you didn't have the excellent radiology professor that I had. :) But with today's internet, even a simple search on Google images should bring up all kinds of images showing the different effects that different x-ray tube angulations have on the final image. Do the following simple exercise to visualize what I'm talking about. Take a pen and hold it vertically in front of your eyes. Now lean it (incline it) towards you or away from you. See how the length of the pen shortens? Likewise, take any flat object and hold it perpendicular to your line of sight. Now rotate it just a little left or right. See how you are now looking at a different angle of the flat object and it's diminished in size laterally? Those are the same principles as in x-rays. Otherwise said: if you angle the x-ray tube too much vertically, you will get a shortened view of the tooth. If you don't angle the x-ray tube enough vertically, you will get an elongated view. If you angle the x-ray tube more from the left or from the right, and the x-ray tube's long axis is not perfectly perpendicular to the tooth, you will get a disto- or mesio-angulated shot. You esentially "rotate" the tooth. This is useful in visualizing BOTH the mesiobuccal and mesiolingual canals in a lower molar, and that's just one example. There are many others. This x-ray that you posted is good, exept that it's cut! But it is properly angled with the long axis of the x--ray tube perpendicular to the interdental space, which is exactly what you wanted to see in the first place. Hope this has been helpful and educational. :)

Oanca Alexandru comments:

Dr.Matt,multumesc(thanks) for sharing your experience and time trying to make me better.I decided to slow down a little ,because i started to do a lot of operations,and forgot on focus on basics,like in this case.i follow mentors ,like now i am on an online course for 8 weeks about Khoury tehnique,i got sick of biomaterials.After i finish this i will start studying again the basic of implantology and i think my problem is pre planing:(.Next time i post here it will be my own PA ,and for sure better quality.Thanks again.Wish you well Doc.Numai bine cum se zice in Romania:)

Matt Helm DDS comments:

Nu ai pt ce! Placerea mea! And remember, when in doubt, always return to basics. They'll never steer you wrong. And yes, details matter and graba strica treaba, otherwise known as haste makes waste. Here's another good maxim for Dentistry: if you don't have the time to do it right the first time, how in the world will you ever find the time to re-do it? I love this last one, because it's so darned true. Ti-am lasat mailul meu printre randuri mai sus, in raspunsul meu dupa primul tau raspuns catre mine. Scrie-mi oricand vrei. And yes, I insist on the deails that lead to excellence because I'm a brash, rash, take-no-prisoners New Yorker. :)) I own bragging rights to NO gross failures in my many decades of practice! NONE, in any kind of treatment, from operative to prosthetics, with all kinds of endo and surgery in-between. I have plenty to share and teach, and I love to freely impart my knowledge, as you've seen, because I've been lucky and was blessed with tons of talent. (I was also a dental tech before dental school.) One suggestion: keep it simple. We Americans call it the KISS rule, for "Keep It Simple Stupid", LOL. Don't go crazy with too many biomaterials, too many surgical kits, too many different techniques, or too many different implants. Although the temptation is there, you'll get better results if you find one or two that you feel works best in your hands and stick to it. As for planing, absent fancy software and surgical guides (and even when you do have them) making a pre-op wax-up and a clear omnivac stencil over it (gutiera transparenta) will always steer you in the best possible direction. It will clearly show you where your restorations need to be and therefore where your implants need to be placed. Mind-you, I'm not a great fan of all-on-four, and I accept it only when there seems to be no other alternative, which is rare. I have found that, at least in my hands and my way of doing things, a clear omnivac over a model wax-up of the planned restoration not only visually clarifies things greatly, but can also be used as a surgical guide whenever in doubt. Good luck, and keep at it. You're doing very well. Salut si SANATATE, caci e mai importanta decat toate! :) PS: Kudos in plus daca stii cine a fost Matt Helm. ;)

doclock comments:

Not a good outlook for #6. Consider removal of #6 and a fixed screw on bridge.