Page 40 - CEREC Q1 | 2014

38 | CERECDOCTORS.COM | QUARTER 1 | 2014
we have a smooth, convex surface that is
easy to clean for Larry.
You may wonder why we would go
through the intermediate e.max abut-
ment step. The simple answer to this is
to allow me to control the environment
better than if I used a stock abutment to
elevate the margin to the point where
a single e.max block could be used. I
would be locked into a less-than-ideal
emergence that could compromise my
final outcome. Using a lab to create a
custom abutment was an option, but
that would have had a dramatic effect
on the costs to restore this case.
The e.max “custom” abutment also
opened the door to where I could think
about how I could get the best result by
playing with the different materials out
there. I could use an LTA-3 block for the
abutment to mimic the dentin, and an
HT A-2 to mimic the enamel. A natural
depth can be created in the final resto-
rations. Many benefits are realized with
minimal time and expense.
The next step in Larry’s implant journey
is the crown on #5. This has split, and the
tooth needed to be removed and replaced.
My personal preference is to avoid
splinting natural teeth to implants. I was
also concerned with the loss of bone that
would happen once #5 was removed. I
thought there would be a high probability
of a compromisedesthetic result long term.
A cantilever bridge off of the implants
couldbemade to functionwell, but the risk
of decreasing esthetics over time removed
it fromthe top of the treatment option list.
The decision was made by Larry to
have #5 removed and an implant placed,
and I began to write the referral out.
That’s when he spoke up and said he
didn’t want to go anywhere else. Larry
is observant, and he had seen how the
technology in the office had benefitted
him, e.g., CEREC to restore his teeth and
cone beam to help diagnose the fracture
present in his premolar.
We have had discussions in the past
about how we offer implant placement
in the office, but only when I can utilize
the technologies and perform it guided.
We talked about the benefits this process
gives to my patients and to me.
To Larry, these points were important
enough for him to choose to have his
new implant placed in my office and not
return to the oral surgeon.
An impression was made of Larry’s
upper jaw, and a scan performed of his
upper arch, lower arch and buccal bite.
This information was used to plan out his
case: first the ideal proposal was created
with esthetics and function dictating posi-
tion. This ideal proposal is then imported
into the Galaxis software and can be used
to help dictate the position of the planned
implant (Fig. 5). The cone beam allows
you to visualize the true bone profile and
the critical anatomy of the area.
In Larry’s case, there was still a thin
bone wall on the distal of the broken
premolar. This is a concern since after
the removal of the tooth, there is a high
probability that this bone sliver would
resorb with healing.
Buccal plate was intact and the rest of
the surrounding bone was favorable for
implant placement without the need for
the ridge augmentation thatwas required
with teeth #3 and #4. The decision was
made to remove the tooth with imme-
diate placement of the implant.
Once the implant placement was final-
ized, the file was sent to SICAT, and an
Optiguide was ordered. The Optiguide is
amilledsurgical guidewhichhasamaster
sleeve that the keys of your surgical kit fit
into. The surgical guided kit used in this
case was the Biomet 3I Tapered Navi-
gator. The kit is a fully guided kit; so you
can also see in Figure 6 that on themaster
sleeve there is a notch. This allows for the
accurate timing of the implant. This is
important if model surgery is desired for
the cases in which you wish to fabricate
the temp prior to the surgery appoint-
ment and immediately temporize.
In our patient’s case, the decision
was made to temporize by fabricating a
cantilever bridge off of the implant #5.
The material used for this temp is LAVA
Ultimate. The post-op PA in Figure 7
shows the thin, distal wall of bone, the
cantilever restoration and the placement
of the implant. The cantilever allowed
for the implant to integrate without any
potential external forces. I was able to
develop an ovate pontic to help main-
tain the papillas during healing. (Main-
taining a papilla is much easier than
trying to redevelop one after it is lost.)
The healing of the surgical site was
once again uneventful and, after three
months, the case was ready to proceed.
At the uncovering visit, the provi-
sional was removed. In Figure 8, you
can see how the tissue responded. The
ovate pontic accomplished what it was
intended to do, papilla maintained and
soft tissue was healthy.
| | | G A R D E L L
Fig. 6: Notch on
master sleeve
Fig. 7: Post-op
radiograph
Fig. 8: Tissue
response
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8