The Magic Triangle

The Magic Triangle

“Master the angle, find the island — and the case turns from challenge to art.”

Heading off to Madeira Island to do some cool cases with my friend Jeanne! This island feels like the tropics — it reminds me of the Caribbean, of Venezuela! I always told Elena that I’ve always had the feeling I was born on the wrong side of the world. My body breathes the tropical forests, the beaches, the sun, the people, the food, the fruits, and the joy of living! So Madeira pretty much resembles all that, and for two days I’ll be operating on some patients with Liliana — but for sure I’ll still find some time to absorb a bit of that sun!

One of the cases is something I see many people struggling with — even top surgeons sometimes don’t get this one right: the upper premolars, especially number 5.

Number 4 is often easier because there’s apical bone, and since 80% of the time you have two roots (with the palatal one pointing to the basal bone), in immediate implants you could practically be drinking a coffee, flirting with the dental nurse, and still get it right!

But number 5 is alive!

(Yes — allusion to the old Disney movie where they say “Number 5 is alive!” Probably a joke for the 50-year-old crowd 😄).

Number 5 usually sits under the sinus already, so there’s almost no apical bone left — except for what I call the magic triangle: a small island of bone just behind the apical portion of the premolar.

A hidden bony tropical paradise — and that’s where the money is! 💰🏝️

This island is, in most cases, the confluence of the anterior sinus wall cortical with the palatal and buccal corticals. So, if you hit that spot and engage this confluence, stability will be high enough for immediacy and even immediate loading in some cases! Moreover, because the root is slim, there’s room for mesial-distal engagement, which further enhances stability.

Now, I had one premolar in my own mouth that was a perfect example of this. A great Easter almond just did its job and broke my tooth in seconds.

Diagnosis: vertical root fracture.

So — take the sucker out, and off we go for a dental implant!

But my dentist friend missed the spot! Why?

Because in this island, you have only one chance to dock the boat — meaning the drilling protocol is of much importance. Crucial, I would say.

If you don’t get it right with the first drill, forget it — it’s going to be a delayed implant placement for sure!

The more burs you use in the system, the higher the chance of failure. So, a 3.75 to 4.0 mm implant is what you want — with an apically tapered macrogeometry and self-threading capability. Two drills, and off you go with the implant!

Remove the root without breaking the buccal bone.

And yes — don’t underestimate these teeth, because if you break the buccal bone: bye-bye implant, bye-bye crown, bye-bye immediacy, bye-bye money island!

Cut the tooth if needed. If you break the tip, go very gently so it doesn’t end up in the sinus or in the buccal submucosal space (a worse scenario — then it’s oral surgery one-to-one, and bye-bye implant dentistry).

After that, treat the case as if it were a central incisor immediate implant.

If you place your spear drill into the socket, it will immediately fall into the apex — but you don’t want to drill there!

Instead, gently sound the palatal wall and enter (depending on the case) 3 mm coronal to the apex, at a 45-degree angle to the buccal, so the drill engages the island.

Then use the 2 mm sharp bur to enlarge the osteotomy at the same 45-degree angle, at 1200 rpm.

(Please — a sharp and steady 2 mm is mandatory. If it vibrates, you can break the island — and “caput” 💀).

Next, use the final conical bur (2.8 mm) at 2000 rpm, entering at a 45-degree angle and then quickly adjusting to 0 degrees for prosthodontic alignment.

With this bur, you’ll feel the sinus cortical, but it only cuts at the tip with light apical pressure — giving you perfect control as you approach the sinus. You’ll feel resistance, then suddenly less — that’s your cue to reduce pressure and let the bur gently fall into the sinus.

Now insert your implant slightly toward the buccal (about 20 degrees), and while inserting, adjust back to 0°.

(Very aggressive designs can tilt buccally — tight fist 👊).

Let the apex find the cortical hole and seat perfectly on the tropical island.

🏝️

And that’s it — you’re in the tropics. Enjoy it!

Meanwhile, I’ve just arrived in Madeira to place this implant… and go for an espetada!

Have a great November!

André