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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.
I was at first resistant to becoming zirconia enabled. I had convinced myself that I know how to prep and I didn't need it. I don't do that much zirconia yet, but I am doing one now on a lower left second molar. The thinnest area on the occlusal is 0.8 mm and I couldn't reduce any more because of pulp horn proximity. When I need it, I NEED it. I'm not getting into staining them and making them look like real teeth just yet but CEREC Zirconia C3 unstained and uncolored looks pretty good on this lower second molar I am doing. I am not sorry I pulled the trigger on the Trainer promotion Sirona offered at the end of last year.
In previous posts, I have mentioned how much I love guided implant surgery. It takes a lot of the guess work out of the process, and also reduces the "pucker factor" associated with implant placement. When planned properly, it is generally a very smooth and seamless process, resulting in a good experience for the dentist and the patient. However, despite the fact we have planned everything in advance, we still need to remember to check along the way and make sure nothing has changed or gone wrong, including user error, which is what happened here! I have generally placed Camlog implants due to the ease of their guided system...however, in this case I decided to try Straumann, mainly because of the posts I have seen here and feedback I received from some friends of mine. I stayed away from the system because of the keys required, but I have to admit they were not nearly as big of a deal as I thought they would be.
Patient presented with tooth #4 fractured and unrestorable:
So, I extracted tooth #4 in July 2016 and grafted the site:
The patient opted to wait until last week to come in for implant placement...we planned a Straumann bone level tapered implant 4.1X8 to go right up to the sinus. Here she is prior to surgery:
With the guide in place I began my osteotomy...this is where I screwed up! Being used to Camlog, where you ordered one set of burs, and having this be my first surgery with Straumann, I didn't notice there is a guided bur with 1 line, 2 lines, or 3 lines, correlating to the different lengths:
Even though we are going with a guided surgical protocol, I still always take a check film along the way...thankfully, I grabbed the 1 line drill and not the one with 3 lines! As you can see, I was way short of my desired location(instead of into the sinus if I would have grabbed the other bur), so I had to step back and figure out what happened.
Obviously, this was me being a knucklehead and not an issue with the guide or the system. So, I switched to the 2 line bur that I was supposed to use, and finished my osteotomy, which left me ready for placement at the desired depth:
I placed the implant fully guided-I really liked the way the implant engaged the bone:
And then 1 final PA with the healing cap in place, showing the implant right up to the floor of the sinus where I had planned it:
The patient is aware of the need for a new restoration on #5...
So, keep in mind that although we have planned everything in advance, it is still wise to proceed cautiously and take periodic radiographs to ensure you are following the planned treatment. I have spoken with some dentists who don't take a radiograph until the implant is in if they are placing them guided...this case hopefully shows a good reason to take a check radiograph along the way and make sure you are on the right path, especially if you pull a bonehead move like I did. For the few seconds it takes, it can save you a lot of time and risk later on!
This is a case were we sometimes have to meet the patient at their primary need. He presented to me to" fix his front teeth." There is a lot to deal with here, hygiene issues, assessment of diet as patient is high caries risk. Yes we discussed a lot of options and the need for change in order for anything to be successful long term. Ultimately we decided that we would crown the canines and the goal is to place two implant in the anterior segment and restore #7-10.
Here is initial presentation:
Set the case up to mill the interim bridge with Telio Cad:
My plan was to grind #7-10 down to the gum line, prep #6,11 and get a provisional bridge milling and then come back and extract the teeth. Lesson learned here was that I should have taken the teeth down even more to allow for a better design of the interim bridge.
Next was to design the case - I did utilize biojaw in this case and the harmonic positioning. This may not be the final restorative position, but you can see how it placed the proposals well in front of the extraction sites, given the position of the canines. The case required a Telio Cad block B55. I have attached the rst if anyone wants to play around and design the case.
While that was being milled it was time to extract the teeth, utilization of the Benex allowed for atraumatic extraction
I did opt to place bone graft as well - curious how others would have handled this
After grafting it was time to seat the bridge - I certainly needed to spend more time contouring and need to work on making the embrasures look better. Many lessons learned, hope this helps someone out in the future with this type of case. The patient was happy given the initial presentation and it's at least a start point for this case that is certainly a work in progress.....
Thoughts and ideas welcomed.....
I was uploading photos last night when my husband was looking over my shoulder and said "Oh I can't wait for you to do that case! What a difference it will make for her." He was certainly surprised when I told him that this was my final photo, not my before picture...
He thought I was kidding until I showed him the before picture. He asked my why I just didn't redo the centrals as well...
I am always intrigued to discover what a patient sees about themselves when he/she smiles. In this case, she saw the lines on her laterals that were staining, but did not have any concerns with the esthetics of her two front teeth. Of course, as a dentist and someone who loves front teeth, my concern was the centrals. We talked about them, what could be improved, but again it just wasn't her priority. Will they need to be replaced someday- absolutely, but first I need to gain her trust. So I did some simple bonding on #7 and #10 using the same techniques that I do when I stain and glaze my Cerec crowns. I love using Cosmedent's Creative Color Tints and opaquers to mask any lines and help blend composites in nicely. Just like I would bevel to hide the margin on an onlay, I also bevel my margin on the facial to hide that dreaded line that composites tend to show. I know how to contour much better now, because I do them over and over on my anterior crowns trying to make them appear natural and this translates to my composite work. I also take time to really make my margins smooth and I polish heavily to help prevent staining. These techniques are simple and fast but can make a huge impact on the result.
There has not been a single day that I have regretted my journey in the Cerec world and this is why. Everyday I feel like I can apply the skills that I learn here on this board or from this community. Everyday I feel like I am becoming a better dentist and my journey is far from over.
The esthetic bevel has been talked about numerous times on the forums from the stand point of being conservative and allowing restorations to blend in to the remaining structure. But on of the benefits of this conservation of tooth structure is keeping the structural integrity of a compromised tooth. This patient walked called in with an emergency of a fractured tooth. The virgin tooth #13 fractured the lingual cusp below the gingiva.
The options were try and save the tooth or remove and implant. There was still a lot of good tooth structure to work with as long as we didn't mow down the facial aspect. In comes the esthetic bevel. The lingual gingiva was removed with a diode laser to assess how deep the fracture was. Upon exposure and probing it was found a margin could be placed without impinging on the biological width. The root canal was accessed, instrumented and filled.
After this a build was placed and the tooth prepared for full coverage utilizing the esthetic bevel to keep as much of the buccal tooth structure as possible.
When doing a high and dry margin like this on the facial aspect make sure not to make the margin straight across. There is a slight wave to the margin. The eye notices sharp delineations and straight lines. By making the margin smooth but uneven it tricks the eye. To make the bevel either use a football diamond or a large chamfer bur.
Fractures generally occur from working side interferances. Thus buccal cusps on maxillary teeth and lingual cusps on mandibular teeth. By keeping the extra buccal tooth structure we reduce the risk of fracture from excursive movements. This danger to preparing the buccal aspect to the gingiva is weaking the tooth and leading it to fracturing at the gum line making the tooth unrestorable in the future. The extra tooth structure acts as a buttress to fortify the tooth from future fracture.
The material of choice in this situation needs to have enough translucency to allow the bevel to blend in. For this case an A2 MT Emax was used. Care needs to be taken during cementation to prevent staining of the margin. Make sure to etch the enamel for a full 20 seconds. Lack of adequate time with etchant will cause premature break down of the margin. Also allow the bonding agent to have time to penetrate well enough so follow the directions of the manufacturer for the proper length of time to allow it to work it's magic. And finally seat the restoration clean off the excess with a greg 3/4 or similar instrument. Press down firmly on the restoration, you should see a little more material express out. Tack cure if that is your preference or allow it to gel. Clean the interproximals but leave the facial alone. Apply glycerin gel to the margin over the little bit of material left. Do your final cure. Now clean the excess with a fine diamond. This will give you the most protection for the margin and prevent future staining.
Maintaining the extra tooth structure now gives the added strength to the tooth to allow it to have a much better prognosis than if the buccal tooth structure was removed for esthetics.