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Talk To The Left Hand Cuz You Ain't Right: Managing Insertion Torque with Legacy4 Implants Case Study by: August de Oliveira, DDS Here is another non ideal case that does have a "teachable moment", which is managing insertion torque. Everyone has a "happy number", most like 35Ncm, some like 50. I know a few old timers that would like almost no torque! They always refer back to press fit implants. I am happy if I get between 35 and 50. So here is a case we did yesterday. Tons of bone loss, close to the nerve, goodie! I planned in CEREC for an optiguide. I usually don't use CEREC for free ends, but thought I’d give it a go. I took models as I did not have time to scan in the mouth and used the buccal bite. We did an OK job with design. We planned two Legacy4 7.00mmD implants, one 10mm and one 8mm in length to be splinted.


Talk To The Left Hand Cuz You Ain't Right: Managing Insertion Torque with Legacy4 Implants

You know the deal, Optiguide with the Large Diameter Guide Sleeves. Good amount of attached tissue, so we punched. Really smooth surgery. Isolite for suction and to hold down the guides.

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Talk To The Left Hand Cuz You Ain't Right: Managing Insertion Torque with Legacy4 Implants

Tough to see in any PA, but there is a prominent submandibular fossa that limited out length, not the nerve. 10mm in the 19 position and 8mm in the 18 position. Drilled up to the 5.7mm drill.

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Talk To The Left Hand Cuz You Ain't Right: Managing Insertion Torque with Legacy4 Implants

On the lower, I am usually not a fan of any implant greater than 5.2mmD on a healed ridge. But we did a lot of grafting and we scraped out a lot of soft tissue in the sockets, so I was not convinced we were completely healed in the ridge, so we went wider for stability. Tried in the implant before using the crystal bone drill and could not even get it in. Again, these are Legacy4s with the greater platform switch.

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Talk To The Left Hand Cuz You Ain't Right: Managing Insertion Torque with Legacy4 Implants

Here is my sequence for torque management: The implant is placed using a hand piece that torques out at 45Ncm. I just use the Ratchet to index, maybe 1/8th of a turn, just to get the "flat" on the fixture mount buccal or lingual. Then I measure torque. In this case I used the variable torque wrench and we were between 50 and 60. Not bad, but above my comfort zone of a Max of 50. Let the implant sit for 5 minutes (take an x-ray, fill out your chart, sit around and stare at the wall), then reverse torque the implant about 360 degrees.

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Talk To The Left Hand Cuz You Ain't Right: Managing Insertion Torque with Legacy4 Implants

Now set the torque wrench at the amount you are happy with. In my case, I wanted about 45 Ncm. So I set the torque wrench and magically, we indexed just over 45, which I reversed back to index. So I am most likely around 40 Ncm. Not in love with #19 distal, but we were close to the nerve/fossa. Will see how things heal on the mesial, I may do some recontouring. Due to the height of bone on the medial, I couldn’t fit a contour healer and was out of my 3mmL 5.7mmD healing collars so I went with the freebie healing caps. Again, another "meh" case, just to show the good, the bad, and the ugly. Will splint the crown and show the finals.

Dr August de Oliveira graduated from dental school in 1997 from the University of Washington and completed his General Practice Residency in Los Angeles in 1998. Dr de Oliveira has been lecturing on 3D technology since 2004, when he started as a CEREC Basic trainer. Since 2008 he has been involved with Implant Direct’s R and D department developing Guided Surgery Software and Hardware and testing their CAD Milled Bars and Substructure Department. Dr de Oliveira has written two books on Implantology: Implants Made Easy and Guided Implantology Made Easy. He has been involved with beta testing Sirona’s Sidexis Program, as well as developing the Opti and CEREC Milled Surgical Guides. Dr de Oliveira lectures nationwide for Sirona on the Galileos Cone Beam system and Sirona Guided Implant Surgery. He also teaches for Implant Direct at their Las Vegas Educational Facility and with the Engel Institute in Charlotte NC. Dr de Oliveira lives and practices in Los Angeles CA.

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Talk To The Left Hand Cuz You Ain't Right: Managing Insertion Torque with Legacy4 Implants