Blog Recent Articles
We all have this happen to us, our schedule laid out the way we want for a productive smooth running day, then something happens to throw a wrench in it. My Wednesday morning I had a crown on #8 to start the day and then an implant right after that. The crown patient came in with the crown #5 off at the gum line.
Now we have a problem. I only have one room set up for implant surgery. I don't have time to make a guide for this case, get the tooth out and place the implant before my next patient comes in and needs her implant placed. So the decision was made to go ahead and extract and place the implant free hand. Normally implant surgery is done with a guide in my practice. There are times that either the guide doesn't fit or fabrication of the guide is not feasible. This is why it is important for doctors to have the surgical abilities to place an implant free hand.
The plan in this case was to split the roots and place the implant in the interseptal bone to get primary stability.
The roots were sectioned with a high speed hand piece with a long shank surgical bur. This serves to purposes. One is to make the removal of the roots easier. Secondly it also gives a guide for the drill to not kick buccal or lingual during preparation of the osteotomy. Now all we need to do is manage the mesial distal position during the osteotomy preparation. Having the CBCT did however help show where we needed to section the tooth and how deep to go to make sure that the tooth was sufficiently. Unfortunately due to the time constraints trying to get the case done before my next patient gets here I didn't get a photo of the sectioning. Once the osteotomy was finished the roots were removed atraumatically. The implant was then placed with 35+ncm of torque and the root areas were grafted with cortical/cancellous
Could this case have been done guided, sure but I would have either had to reappoint the patient(they are not the most reliable patient) or run behind and make my next implant patient wait. As it was the patient got the tooth extracted and the implant placed and we were on time for our next patient. Guides are great but ultimately the surgeon needs the skills to know how the surgery should go even if they don't have a guide.
I have been posting a lot lately on infiltration... tried it today on a zirconia abutment (Incoris F0 Meso). There is a of pictures here.. but I thought I would post a full protocol!
Initial Situation. Heroic "try" with aggressive prep. We knew it would not work long term... was done 9 years ago
Implant plan on #12. Based on the plan and screw access, I knew I was going to do a screw retained restoration.
Healed implant 5 months later ready to restore:
Took images into CEREC
Final design... notice position of screw access compared to initial Galaxis plan:
Infiltrated with A3 Vita Liquid:
Sintered in SpeedFire:
Torqued into mouth:
Just an update on infiltration. I have been messing around with the Vita YZ HT liquids based on a couple recommendations. Like everything it's a work in progress, but I like it a lot. Seems to be pretty intuitive and the colors really come out nicely. I think there are some good methods to lower the value of zirconia using a couple different recipes...
Here is just a really quick one I did this afternoon between patients messing around. It was an A2 block with A3 shade in the intaglio and cervically. An A chroma shade in the fissure and Blue on the cusps and ridges. I got the "A chroma" a bit sloppy and I think i'm going to try the pens on this to make it cleaner.
It's definitely got some potential for sure! This is obviously just polished.
The mantra goes "pink esthetics before white esthetics" and I thoroughly agree. What our scalpel-wielding friends can achieve for our patients is truly remarkable. Here's an anterior restorative case with combination clinical/esthetic crown lengthening that simply would not have been possible without perio surgery:
I can see the issue because of your excellent photography but I submit that it is not noticeable to the naked eye at conversational distance and nobody cares about this but you. However, if you can sell it to the patient, God Bless You. The people I see would laugh me out of the operatory.
What Parameters are you using?
I think Mike said that the key to the movements was the midline point of the incisors for movement and setting the arch into the articulator.
I'm no expert on this so let's see what others say, but wow, great job and great photography. The lateral incisors are begging to lose that labial flare.. perhaps go after those next to make a difference
This happens in all of our practices. A long time patient schedules an appointment yesterday for a "chipped tooth" I walk in to the op and see the case below. As you can see cerec handled the case as we would all expect. I spent time discussing the options with the patient to include:
1) extraction, implant, abutment and crown
2) extraction, Chairside FPD
3) endo, post/core, crown
As I presented the options, I even stated that option number three is becoming outdated in its philosophy and that dentistry as a profession is moving away from the less predictable long term prognosis of the endo/post/ core. I also stated that I did not like option two because of the uncertain condition of #9. The patient chose option #3. I know him very well and as I stated, he has been a patient of mine for twenty years. So I asked him why he chose that option. His answer, "I am 80 yrs old, I have had 17 surgeries in the last 9 years, and I just don't want another one if I can avoid it." Can't argue with that at all. So the question is, what would you guys have done? With all of the technology we have at our fingertips, are we forgetting traditional dentistry?
It's not too often these days where I completely inherit and implant case. When I do, it's generally just a posterior implant that the patient has not restored yet for some reason. This one was a bit different. Was an implant placed on #8 and a crown on #9... ouch ;)
The patient suffered a trauma at work a year and a half ago. He had to have endo on #7 and #9 and tooth #8 was extracted. I asked if the implant was placed immediately and he said no... the implant was placed by the periodontist after 6 months of healing. He moved into my area 2 months ago and found his way to the oral surgeon I work closely with on referral. He then was referred to me to restore the implant and tooth. For the last year or so, he has been wearing a provisional acrylic cantilever bridge that was not even temporarily cemented, but held into place with denture adhesive. Here is how he presented to my office (he took his own temp off):
So, before I could even think about the restorative challenges on this case, I needed to take a 3D to evaluate where the implant was placed. Good news and good start because the Periodontist had excellent implant placement (Straumann BL 3.3)
Now I had to start thinking about the restorative challenges that we were facing. I could identify two right off the bat:
- The midline papilla was mostly lost and blunted. He did have a little on the lingual that I could play with, but I knew right away that I was going to have a long midline. It would have been nice if an immediate provisional was placed to hold the papilla right off the bat.
- The space was very asymmetric. That is, if I wanted the midline to be correct, the spaces were going to be far enough off that I would likely have to leave an open contact with tooth #10 to get proper proportions.
To verify my findings, I did a little planning before scanning the patient. Here are pictures of where I envisioned the midline, the asymmetric space, and where I planned the teeth to be:
So the next appointment we went ahead and scanned the patient for the restoration.
Designed the final restorations. I split #8 into a zirconia abutment and veneering structure. Both Crowns were e.max CAD V3 Impulse (had some left over before the introduction of MT)
Here was seat day yesterday:
The patient and I were both pretty happy with the final result... especially with how we started. After the first of the year we are going to reshape #10 and bond with composite and also restore #7 with a veneer to even out the color and shapes.
Now... 2 mistakes that I made on this case
- I made it very difficult from a color prospective milling an F.5 zirconia abutment (very white). I should have milled an F2 shade zirconia because it would have been profoundly easier to match the two teeth from a color prospective. The crowns were thin on the facial and #8 was clearly whiter than #9 due to the substrate underneath. I had to play around with resin cements (-3 value on #8 and +3 value on #9 were the final) to make this work. It was a pain in the neck.
- Since the implant was slightly lingual I had to create proper emergence on the facial by pushing on the tissue with the abutment. I over did it just a little bit and made the gingival crest slightly apical than where I would have wanted to be perfect. I did have a concavity there and maybe it will bounce back (this was immediate seat), but we will see. If not... no worries. Low lip line
Long story short... fun case , happy patient. Looking forward to finishing up the case next month
I have been doing all my single stage surgeries with custom healing abutments since Enamic became available. It has been a learning process and took some time to incorporate the digital workflow for the implant procedure. It takes us about 30 minute longer but saves more time from final Imaging. For posterior teeth I can make the final crown from the initial impression. For anteriors you have to evaluate to see if you need to re image. I posted this for discussion, I love this workflow. This custom healing abutment and crown had an emergence profile that I felt was too broad. Love to hear how others would shape the gingival portion.