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38 | cerecdoctors.com | quarter 2 | 2013
Life-changing
‘Someone toldme I had a beautiful smile and I started to cry.’
the sentence above was a text i
received the other day from a patient. We
touch our patients’ lives every day. Some-
times it is just alleviating their physical
pain. Then there are those times we can
really change a life. A person’s smile
changes how they feel about themselves
and how they present themselves to the
world. So, when my orthodontist called
me up and asked me to help out a girl
who was missing her laterals, I agreed.
C A S E S T U D Y | | | b y D a r i n O ’ B rya n , D . D . S .
Case study
The patient is in her early twenties, with
congenitally missing laterals (Fig. 1). She
had metal-wingedMaryland bridges that
kept de-bonding. She would hold them
in place with her tongue, causing the
metal wings to score the lingual of the
centrals and canines (Fig. 2). I saw her
for a consultation, and discussed her
options. Together, we opted for implants
in the lateral incisor areas and then thin,
full-coverage crowns on the centrals
and canines. With the prior removal of
bicuspids for orthodontic treatment,
the patient was left with dark buccal
corridors. We discussed veneering the
bicuspids to broaden her smile. Photos
and diagnostic models were taken, and a
CBCT scan was done with
a bite plate to help with
surgical guide fabrication.
The models were
1
duplicated to allow for a wax-up to be
done and also a guide to be fabricated
based on her presenting dentition. Based
on the lip-at-rest photo (Fig. 3), 0.5 mm
of incisal length would be added and
gingival re-contouring would be done
to lengthen the teeth without giving a
“toothy” look to the smile.
The original model was scanned with
the CEREC Bluecam, as was the diag-
nostic wax-up. This was done in Biocopy
to allow for transfer of the wax-up over
the existing dentition model (Fig. 4). The
two implant crowns on #7 and #10 were
then designed in the edentulous spaces
while leaving the preoperative condi-
tions on the other teeth (Fig. 5).
By leaving the preoperative condi-
tion, the designs could then be uploaded
to the CBCT scan (Figs. 6 and 7). With
this information, it was determined
where the final lateral incisor position
would be, thus allowing for planning the
I decided to utilize Astra implants and
TiBase custom abutments in this case. By
planning out implant placement based
on the restorative plan, we get a much
more predictable esthetic result.
Once the placement of the implants
was determined, the models, scan plate
and CBCT data were sent to SICAT in
Germany for a classic surgical guide
fabrication. Guide fabrication takes six
working days from the time it arrives in
Germany. Once the guide was fabricated,
2 3
4 5
implant placement based on the restor-
ative plan. By having a 3-D representa-
tion of the bone, I was able to determine
the size of the implants needed and also
at what depth to place them. We judge
the depth by the emergence profile we
want from our restorative design and the
type of abutment we want to use. The
top of the implant needed to be at least
2 mm from where the proposed margin
for the crowns would be (Figs. 7 and 8).