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Fig. 3.5. Damage to the adjacent tooth and bone loss due to poor implant position.

Fig. 3.6. Implants placed too close together compromising gingival esthetics and periodontal health.

In order to prevent excessive tilting and improper angulation during implant placement, some form of paralleling technique should be utilized by the clinician, if the implants are being placed in a freehand fashion. The use of intraoperative periapical radiographs with a guide pin or implant pilot drill after the initial osteotomy is useful to guide the need for redirection of the implant osteotomy as it is prepared further for implant placement (Algorithm 3.2). Of course, the use of a CT‐generated surgical guide or dynamic navigation techniques may also be beneficial in reducing the possibility of iatrogenic injury to adjacent teeth. Furthermore, based on a landmark study [22], in order to minimize heat‐induced hard tissue injury and indirect damage to adjacent teeth, copious irrigation at a temperature <47 °C per minute must be maintained. However, as mentioned, it is not possible to irrigate the tip of the drill within the bone (note: internally irrigated drills had been used in the past, but became clogged with bone debris and were not very functional), so sharp, new drills should be used at the correct drill speed to avoid excessive heat generation.

Fig. 3.7. Periapical radiograph showing implants placed too close together resulting in bone loss.