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After seeing all of Kris' cases and hanging out with her mentoring lvl 2,4 and accept two weeks ago, figured I'd do my best to try and post a good before and after.
Patient has had a hx of throat cancer and treatment did a load on his dentition. So trying to start somewhere. He wanted to fix his front teeth if we could first. With malposition of existing lowers, decay had taken its toll. 23,24 fillings and 25-27 crowns. Had to more aggressively prep #27 to "turn" it into the arch form. Think we ended up with a pretty good result. Biojaw was extremely useful here, which is why in my opinion 4.4 is so good. Great case to finish the week!!
Props to my assistant for staining and glazing.
I've been using Lustre Gel for almost a year and did not have good luck at all adding the gel in purple phase and firing on P3 because when I would fire all of the glaze would melt to the bottom and pool at the cervical edge. I recently read a post, saying that P3 was ok because of how the cycle worked, so I figured I would try again. My crown turned out really really shiny but has a melted appearance and literally all of my color, especially the blue, went straight to the cervical. I removed it, re-stained/glazed and placed it on the 10 min cycle that GC recommends. So just a warning, if you want to add a lot of color, be careful with P3 because it is easy to melt it all together...
Here was my end result... I'm loving her new smile! #8 Bioreference with e.max A2 HT and Lustre Gel for the stain and glaze.
This case is one of my favorite things to do with the CEREC machines because it is a service that no one without a CEREC could ever imagine doing in such an efficient way. It is also extremely predictable, and cost-effective for the patient to boot. This is a patient that has floated in and out of the practice, never really getting comprehensive treatment done, but always with some sort of restorative need. Today was an extremely busy surgical day, so when I saw her show up on my schedule as an emergency appointment, I wasn't really sure what I could do to help her. Luckily we could work her in and deliver definitive treatment to the area today.
Patient presents with an existing occlusal alloy in tooth #19 with recurrent decay that undermined the distal marginal ridge. The tooth cracked around the alloy in such a way that direct replacement with resin would prove to be very time consuming, and clinically deficient. A full coverage restoration would be extremely aggressive treatment. I presented the patient with a treatment plan of replacement of the alloy with a milled hybrid composite inlay.
I removed the alloy, prepped with draw, and imaged. No opposing model needed
While the model was processing, I removed the last bit of decay that would have caused an undercut, knowing it will fill in with bonding cement. I also prepped the buccal pit that was stained. Perfect initial proposal, got it in the mill and moved on with my day. 15 minutes later, the restoration was ready to bond, I sat down, bonded it, checked occlusion and left the room. Total time with the patient, 45 minutes.
I love doing these hybrid inlay restorations, as it shows the patient how we really are focused on the best treatment for them. I never looked at the tooth and said, hmmm should I try to save it and do a resin, or should I just prep for a crown? In my previous practice lifestyle, I would have immediately started considering prepping for a crown and never looked back. Now this patient has a minimally invasive restoration at a fraction of the cost. I love sharing these cases with docs during trainings; you can see the lightbulbs turn on in their brains. The CEREC system has done a number of things for me, but most importantly, it has reprogrammed my brain to look at restorative situations in a much different light.
I wanted to start a discussion on this case. Many of you know this individual and she was going to be our patient in the upcoming Live Implant Seminar in May. A bit of background, this patient had an existing root canaled tooth on #7. Here is the preoperative clinical situation:
There was a vertical root fracture and the tooth was going to be lost. The patient had the tooth extracted and implant placed after a surgical guide was fabricated for the patient after we did the integration between the CEREC and the Galileos. After implant placement by the local periodontist- the patient presented back to the office for provisionalization. We figured the best way to provisionalize immediately post surgery was to bond in a single wing maryland bridge as the surgeon felt the implant was not stable enough to support an immediate restoration. The Maryland bridge was bonded wiht a single wing so as to allow the patient clensibility of the area and satisfy her esthetic needs:
Well unfortunately this case didnt last long. Soon after the initial implant placement, the implant was lost due to pain and infection. The implant was removed and the area was grafted and a new maryland bridge placed. Fast forward to today as Im getting ready for the May Live Patient Implant seminar and doing the prep work. I took a follow up photo and this is what I see and I sent to Farhad:
Its been several months yet the area is still not healed. There is irritation at the tissue and to complicate things further, the patient is pregnant so taking an xray is not an option currently.
So my question to you all is - how would you handle this in your offices? Unless this resolves in a few weeks, the patient will not be our patient for the implant seminar and I will get a new patient. But I figured this would be a good case for discussion among the group. If we dont use her in May, we can use her in the fall seminar.
Regardless, all of this will be covered in the seminar including how to fabricate the maryland bridge, how to fabricate a screw retained provisional and really every step of the implant process. But I figured it would be a great topic to stir up some discussion and talk about the potential complications of implant surgery and more importantly how to manage these complications.
Im sure Farhad will chime in here but Id love to get a vast array of opinions.
- Would you place an immediate implant after extracting #7?
- Would you be comfortable loading the implant? What is your criteria on whether to load immediately or wait?
- How would you handle the complication of having to have the implant removed? how long would you wait to place a new implant?
- If you saw the tissue that you saw in the final photo- what would your next step be?
I think we learn more from failures than from successes. Im hoping this can be one of those instances.
I did this 2 years ago when emax abutments first came out. I can't believe its been that long. I thought it was worth while to post since I'm back in the posting mood. I really like how 10 turned out but I'm not too happy about the shape of 8. Way better than his previous guarded smile but I needed to do some contouring with a lab handpiece. Fortunately the lip hides it well. I think I used A1 LT but it might have been B1 LT. I'd have to check the notes. It was one of my first emax custom abutments instead of zirconia. Oh well. One of the great things about taking pictures after you think you nailed it. It keeps you going back for more.
Another Cerec doctor asked me to borrow some blocks because I tend to store a fair amount of shades and the doctor needed a B1. To be fair the doctor did ask what shade I wanted in return in which I said it didn't matter- so what do I get back... C4. I've been doing Cerec for almost 10 years and I didn't know C4 was a choice! Today was my day though and I finally got use them!!! Yay!!!!
e.max crowns #7 & #10 using C4 HT block with Variolink Esthetic cement- shade: warm. E.max stain colors are sunset, cream and gray.
This is a case that I have been meaning to post for a while. It really shows the importance of proper surgical training to make sure that you have a good feel for what drilling in to bone feels like and also when something just doesn't feel correct.
The patient in this case is an elderly gentleman that was edentulous posterior to the bidcuspids. Due to a nerve injury suffered during military service he is incapable of having anything past the bicuspid area. He had two existing bridges. One of which was the area of concern. There was recurrent caries under both abutments 5 and 8 respectively.
The plan was to remove 5 and 8 with concurrent placement of implants in the area of 5,6 and 8.
As you can see there is not a lot of wiggle room for #6 implant. I got a guide done by codiagnositcs. The reason I used them was I had already gotten the CT scan and didn't have the bite plate at the time. I didn't want to rescan the patient so with this method I was able to get a guide fabricated without having to rescan. The stone model was digitized and used to fabricate the guide. I also wanted to try out other options that are available to use. So I extracted the teeth a traumatically. Now as can be seen on the CT cross section of #8 there was not a lot of buccal bone. After extraction and inspection of the extraction sites is when things didn't feel right. I had planned on flapping to help build up the area of 6 but upon inspection of 8 the buccal wall felt "weak".
So I flapped it and with just the action of gentle reflection of the facial tissue the buccal plate at the coronal aspect peeled away with the tissue.
So now I am definitely having to graft. I verified the fit of the guide.
I then went ahead and started the osteotomies for the three locations. The two in the extraction sites went very smooth. The one for #6 didn't feel right when I drilled into the area. So I removed the guide and looked at where the osteotomy was. Low and behold it was lingual to the designed location.
What appeared to have happened is with no distal support for the guide the drill deflected off the hard ridge and gained purchase lingual into the palatal bone. This is where having a good grasp of surgery helped. The feel of the drilling into the bone did not feel right given the density of the ridge and then of course when probing the site it really didn't feel right. If this case had been done flapless it would have been very likely to place the implant and get good stability, however the implant would have only had the apical third completely in bone the coronal two thirds would only have had bone on the facial, mesial and distal. Just enough to integrate but not enough for long term success. I tried to free hand the osteotomy but with the damage to the lingual aspect all I got was a nice through and through defect to repair.
I went ahead and punched a few holes in the buccal plate to allow for medullary bleeding. I then placed the implants in the extraction sites.
So now the reconstruction of the facial area needed to happen. First we mix some a-PRF with cortical cancellous bone and Bioss.
Then our membranes are placed. This is the sandwich technique that Farhad talks about.
Then we suture it closed and allow it to heal. I buried the implants to after it healed we had to uncover and let the healing abutments settle in. Here is the site after healing. Note the thickness of the buccal area after grafting.
Now we just need to temporize while the lateral wall grafting continues to settle in and stabilize. I want to give it a good 6 months before going back in to place the implant in the site of #6. So once the sites are uncovered we reline a shell temporary and recontour it to give good tissue and papillae support.
Now we wait. Once the bone has healed I will get a new scan and fabricate a guide to place the implant in the location of #6. With good stability we will reline the temp at the day of surgery. Then the restoration will happen.
The big take away from this is while guided surgery is definitely a huge benefit for us and our patients we as surgeons still need to have good surgical knowledge to be able to evaluate what is happening during surgery to make sure it is going as planned. And if not how to handle the complications that can arise.
Here is a case that I posted about a year ago that we are now ready to restore. It was a difficult case that we have been working on for awhile and I thought I would post it since it is turning out better than expected.
This patient came to me as a new patient on a second opinion referral to evaluate #10 for an implant. Here previous dentist said she was not a candidate for implant due to no bone and wanted to do a bridge.
Here is her preop situation:
We extracted #10 and waited two months to go back in for bone grafting. We used bone morphogenic protein and a titanium mesh technique (non-demineralized allograft and growth factor).
After 6 months we removed the mesh and placed a 3.3 Straumann Bone Level implant in the site.
When we went to form the tissue with a Teliocad abutment block, we could not get the titanium base to seat due to bone interference (normal with a narrow diameter implant and titanium base).
Since she had a lot of room, we used the Straumann Guided bone profiler and removed some of the shoulder of titanium base for the provisional
After 3 weeks of healing, here is the final tissue position/healing ready to restore.
I imaged today for the final and the scanpost seated with zero issue due to the bone profiling. I will post the final after seating next week.