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I saw a comment on the boards the other day that asked this question. It was funny because I am going through a case right now that I had some issues with this.
I don't exactly know how to answer the question to be honest. There are many different things i've heard.... things like the blanching goes away in 20 min or less,etc... The way that I have done it in the past was just by "feel". That is... I want to put pressure on the tissue and I can usually feel if it's too much by how it seats. If I have trouble, then I will adjust. It also will depend on anterior vs posterior and how much tissue I need to move.
Here is a case replacing 2 congenitally missing lateral incisors. He has been wearing a flipper for over 10 years and finally wanted some teeth. Here is the initial preop photo...
After doing the plan, we placed the implants guided in the site
I let heal about 3 months. Since he had a flipper, I just used healing caps that were flush with the tissue and adjusted his flipper for the provisional.
Here is how the tissue looked at full healing:
As you can see, I have a lot of tissue to move, especially on tooth #10. Now, here is the mistake that I made. I tried to move it too quickly. Meaning, I pushed on the tissue way way too hard. It was difficult and painful for the patient (I did not numb up). #7 was still painful, but not that bad because I didn't have to go as far...
Here are the initial provisionals:
How do I know I pushed too much too fast? Here is an iphone picture my assistant sent me two days later (it's her brother in law)
Yikes.... I had to have the patient in immediately, get the provisional out, recontour it quite a bit and put it back in. That with a chlorohexidine rinse healed the problem in about 4 days.... Here he is as of Monday:
So.. be careful. If you need to move the tissue a lot, do it in a couple stages and not all at once. You may get lucky and it will work... or you may end up having a significant issue like I did on this case.
Just another case with another custom healing abutment. It is aour standard protocol now in most cases. I am doing a presentation this week so I figured I would post this. The final crown was made from the initial scan at the time of surgery. I literally removed the healing abutment and placed the crown. Also the bone was profiled at the time of surgery
Comparison of the gingival 1/3 of the custom healing abutment and final crown
I had my Form 2 printer delivered last week and it's been so much fun playing with it. This patient presented with fractured teeth @ #20 and #21 with missing 18,19. We decided on a plan to extract the roots 20 and 21, place implants @ #19 & #21 and make a 3 unit bridge. In the past, I would have sent for a Sicat guide or made 2 CG2's, but I want to go over the workflow for a printed guide since I have a new toy.
First, the patient (or a model in this case) is scanned with CEREC and a bridge designed so that I can incorporate my plan into Galaxis with one .ssi file.
The implants are planned in the usual way, including setting D2 and choosing a CG2 sleeve. The CMG.DXD file is then exported in the same way as you would for milling a guide. Since I don't have inlab, I sent this file via dropbox to Frankie at AA Dental and in a day, he converted my file to a .STL file.
In the preform software that comes with the printer, I was able to add supports so that it prints properly (these can be edited away from critical areas).
Once the supports are removes (kind like the sprues on a milled guide), the guide was tried on the model. It really is very easy to remove them.
This entire process took a day and cost about $20 for the stl conversion and about $7 in material. Just another option with a pretty easy workflow. It's also fun to play with!
I would like to upload our proposed implant position from galileos implant viewer where we have added our cad/cam scan w/proposed restoration and placed a BioHorizon implant for review. What would be the best way to export, i.e. what format file? And then, pending and changes to the implant plan I would like to upload the proposed guide from the cerec software.
Margaret Wetherell, CDA/CDT
I wanted to share my experience from some of these larger cases I have completed recently. First off, Level 4 was a huge help and I cannot give that course enough credit. Sam, Mike, and Mark do a great job updating the content and making sure to cover as much as possible. Everytime I mentor a Level 4 course I pick up something new that I can use when I get back to the office.
I took photos throughout the process, but don't want to overload with too many on this thread. What I did want to point out was how the process of Cerec and milling gets you about 80 % there. The mill likes to mill rounded angles so even with copying the waxup/mockup you will still have some work to do post milling. The models were ordered by exporting the case after margination as a .dxd file. Upload to Infinident and they will send nice solid models as well as trimmed models in about 3-4 days. Cost about $25. They can also send an opposing. Most of these cases I'll rely on the biocopy and never order the opposing.
Tips to make this process flow:
1. Get a good waxup from your lab. Most of the time they will waxup in grey or blue to allow contours to pop. A siltec stint or any putty stint should be made as well.
2. Transfer that to the mouth. I dont like trying to stitch the preps in the mouth to a waxup off a model. Have the patient work out the occlusion and copy that for your biocopy.
3. Any teeth more than 2, I do in 2 visits. Its just too stressful for me. Order a model and work on your own time.
4. Contour and prepolish then crystalize. (obviously if using Emax)
5. Then add characteristics with stains and fire. Finally glaze. If I separate these steps it just helps visualize the outcomes.
Preop Situation. Patient wanted spaces closed and new partials made to allow her to eat. Ortho was declined even though at a young 78 she probably could have done it. Emax A2 MT
Test Drive. She wore these for about 3 weeks. Had to adjust occlusion once.
Initial Milled Models crowns on models from Infinident
Contouring and Prepolish. Used all burs from Cerec Doctors Kit
Stain and Glaze:
Several old restorations needed attention. Patient's OH is unfortunately not as good, but he is improving. His dexterity is not great due to medical condition. Electric tooth brush hopefully will help him. Posterior teeth were not built out to fill buccal corridor because he did not want to redo his LPD. So had to compromise. Also, had to compromise with him on shade. I did not want to go that white. Emax MT A1
Hopefully this shows how important these post milling steps are. Do yourself a favor and if you really want to start doing some anteriors, check in to Level 4, totally worth your time.
Quadrant dentistry is fairly predictable. You take a quadrant scan, take a buccal bite, design your crown, adjust your occlusion on the CEREC software, deliver your restoration and boom, everything is good.
Where we start to doubt this process is for larger scans. Full arch scans that everyone has taken result in inconsistent occlusion. You take the buccal bite on the right side, the occlusion is heavy on the right side and the left side is wide open. Conversely, you take the bite on the left side and the right side is wide open.
So you take a larger buccal bite and hope that corrects the problem. Well, not really as you can see from the screen shot below:
So how do we improve on this? Is it where you take the buccal bite? Or is it something else? We decided to do some investigation and see if there were steps we could take to get the occlusion and the models- as accurate as possible. I would love to hear your comments and feedback on the situation.
So my patient coordinator says her step mom is in need of a second opinion about her front tooth. I tell her to send her over and sure enough, she has a old, loose PFM that is failing and there is inadequate ferrule and simply has a poor long term prognosis.
She is mortified about esthetics and how this implant will look (despite her many other dental concerns). I don't place implants yet, but walk her through the process and give her the recommendation for the surgeon I work with, etc., etc. Fast forward to about 16 months ago, she shows up at my office saying the surgeon says she is ready to go. I'm a bit lost now because I hadn't heard anything from my surgeon and our plan was to make her a custom healer at the time of surgery. Anyway, she ends up seeing a different surgeon in town, has extraction of #9 and immediate implant placement with a Straumann 4.8RC. Now fortunately, this isn't the end of the world in this case. Implant was placed pretty well, it is a tibase compatible system but there were some challenges that I had to deal with that took some extra time and extra cost (thankfully I have a CEREC otherwise the costs would have been even more). So here's a pic and radiograph of how she presented with the implant in place .
As you can see from the initial photo, I have some gingival asymmetry to address, so we discussed that I would be placing a provisional crown to help shape the tissue and make the final result more esthetic. She had a minor freak out moment until I explained that her provisional implant crown wasn't removable like her flipper :) So I choose to use Telio CAD as a provisional. For those of you that don't restore implants yet, I would highly recommend Level 3. This by itself has paid for my CEREC several times over. Plus, having full control of the outcome it nice too. I used to hate making an implant provisional chairside. It is time consuming and tedious. But with CEREC, this become quite easy and predictable. Yes, it cost me about $150 in parts for the variobase and for the TelioCAD block, but I'm still ahead even after the cement retained crown that will cost me a little less than $180.
As you can see from the radiograph, the implant is countersunk about 0.5-1.0mm. It may be a bit exaggerated from the angle of the PA. I was able to seat the scanpost completely, and then we designed Screw Retained Crown on the CEREC. Sorry I can't pull up my design right and show you a screenshot of it, but usually I make the facial emergence profile a little concave for everything touching the tissue with my anterior implant abutment or crown. In this case, I matched the shape of tooth #8 in my proposal at the gingival third so that I would get the tissue to move apically to my desired location. Everything above my depicted line was concave and not blanching the tissue. I will say I did have to make releasing incisions on the mesial and distal interproximally to get the tissue to release enough to seat provisional crown completely
One important step with using Telio CAD is that you need to use SR Connect on the intaglio surface of the implant crown. This is an methyl-methyacrylate(MMA) liquid that is light cured in order to optimize the bond of the Telio CAD to the tibase. Still sandblast the tibase, use your Monobond Plus and cement with the Hybrid Abutment HO cement by Ivoclar Vivadent. Sam has an excellent video showing the full process.
Here is the Telio CAD provisional seated about 1 month post. Not perfect but much better.
At this point, things are more predictable and easier to deal with. This wasn't an ideal case. The patient is in some serious need of soft tissue grafting in a number of areas. Wasn't interested in ortho and wouldn't let me recontour a few of her other teeth to help with some line angles, but overall given my restrictions, I was able to make her happy and deliver a nice result. This would have been a lot more unpredictable and expensive without CEREC.
Final restoration: (Photos are 15 months post op)
Utilized IPS e.max MO-2 abutment block (fired on P7)
IPS e.max B1 MT
I am pretty sure I have posted a lot of this before, but I wanted to post the entire case now that I am finished. Many of you in the courses have heard me tell of a good friend of mine that had a nasty trauma to his front teeth. It was a very difficult case to treat, but I think we got a reasonable final and he is very happy.
Here is how he showed up in my office the Monday after the accident. He took a blow to the face and vertically fractured both 8 and 9 all the way down.
I referred to my surgeon who was able to extract the teeth, place the implants, and do pretty extensive bone grafting. The one major compromise that we had was that the teeth were extremely difficult to remove. Because he had to incise the midline papilla with his flap design, I knew that we were going to lose the midline papilla on the final (I was right). I could have prevented this by placing custom healers right away (or immediate provisionals), but the surgeon did not feel comfortable with me doing this. I also could have been more patient with the treatment and let the ridge heal before implant placement or done more extensive soft tissue grafting. However, he was a good friend and I wanted to get him fixed up.... perhaps a regret that I would have not done with other people....
Because he had crowns on 7 and 10, I was able to remove the crowns and create/mill a 4 unit provisional for the healing phase. This really saved me because he would have had to wear a flipper or essix. With his job, that would have been a disaster for him. He is in front of people all day.
He wore the provisional for several months and here he was 4 months later. Notice the swelling above #8... we were freaked out thinking we were loosing the implant. Thankfully it turned out to be a loose healing abutment.
We then started the restorative process with Provisionals to attempt to form the tissue a little bit (although I knew the midline was not coming back at this point). I just sectioned the pontics out and left 7 and 10 provisionalized.
After another month and a half wearing these, we moved on to the final restorations (split technique with infiltrated zirconia abutments and e.max MT crowns on all 4 teeth)
While not a perfect result, I think it worked out pretty good for him. Sometimes, a long midline is required with implants on both of the central incisors. He was happy and he doesn't show everything when he smiles anyway!
This is a Dental Lifeline Network Donated Dental Services case done for a disabled veteran. There is plenty that can be improved with this case. Ross Enfinger, Chris Aadland, Daniel Wilson, and especially Mike Skramstad would never post something like this. I accepted this patient because I saw an opportunity to gain experience doing a comprehensive esthetic implant case, but with lower esthetic demands than if this were a soccer mom. It is the best I could do under the circumstances. I received some coaching along the way from Farhad and Emil Verban. The patient presented with an edentulous space that was too narrow for a normal looking central incisor. Clear Correct generously donated their orthodontic services. The ortho isn't perfect but the patient is 40 years old with some serious space issues. The edentulous space was enlarged enough to provide some room with which to work. Straumann graciously donated the 3.3 x 10 BLT Roxolid implant, the healing abutment, and the Variobase. The osteotomy was carried out using a CEREC Guide 2 milled in house with Densah Osteotomy drills and the old Verban Drill stops. Emil loaned me one of his reduction gear handpieces, a pilot drill, and some drill stops--he wanted to spare me the expense of purchasing the drill stops which were available at the time because he was rolling out his new drill stops a few months after this implant was placed. I did purchase a set of his new drill stops. A membrane was placed under the reflected labial gingiva, FDBA was placed between the membrane and the ridge to increase the width of the ridge for better esthetics, the site was sutured shut and allowed to heal for six months. After the six month healing period, the implant was uncovered and a healing abutment was placed. After two weeks of healing, a fixture level impression of the upper arch and an alginate impression of the lower arch were obtained, models were poured, and the split custom zirconia abutment and e.Max crown were fabricated.
The pre treatment planning pictues
The custom abutment and implant crown. It was necessary to reduce the mesial of #9 because it was too large. I could have done a better job. Now it is too small with a cant.
The distal of #9 was rotated to the lingual. A veneer pretty much solved the cant and size discrepancy. It was necessary to polish out some orange peel in the glaze on the veneer. In the process, some of the white stain was lost. The veneer should have been restained and reglazed but we were running out of time. The result is still an improvement over what the patient presented with. The gingiva has almost covered the abutment margin.
Don't be too hard on the old man.