Posted October 7, 2015Ok, getting back into it after C30! Have not been posting lately as I have been working on the Second Edition of Guided Implantology Made Easy and also beta testing Cerec Guide 2 which we could not post until now. So I will be posting case after case her over the next few weeks.
http://www.Digitalenamel.tvHere is a case that we see a lot in the general dental office. This patient’s upper right central incisor was fractured close to the bone. Obviously the patient could not be without a tooth, treatment planned an immediate implant with a Telio CAD screw retained temporary.
We combined CEREC and Galileos scans as well as a ohoto of the face using the Smile Design feature of CEREC 4.4. This is truly a virtual patient we have not only hard and soft tissue information but also we know how this patient’s lip will interact with the temporary and future crown. We combined the CEREC data with the Galileos scan as a .ssi file.
A 4.7 by 16mm Legacy 1 Implant was treatment planned to be placed, fully guided, using CEREC Guide 2. The Pilot drill path, the yellow pole in the image, helps not only to exaggerate the angulation of the implant but to also help determine the eventual position of the screw access. You can see in the cross sectional screen that the screw hole will come out the incisal edge, so the final restoration will be an abutment and crown.
The CEREC Guide 2 plan was exported out of Galileos version 1.9.2 and imported into CEREC 4.4 as a .cmg.dxd file. There are many features in CEREC where we can modify the guide. We can modify the thickness and extent of the guide as well as how much support can be provided for the guided surgery keys.
The planned guided can me positioned in the new Sirona Maxi block to maximize tooth coverage and thus support. Also windows can be placed in the guide and the edges of the guide can be smoothed for patient comfort.
Three major changes come with CEREC Guide 2 when it comes to your milling unit. carbide burs are used instead of diamonds and as a result some MCX or MCXL milling units may need a left motor upgrade. Also the screen pictured will need to be purchased to catch the large amount of acrylic shavings.
The fit of these guides rival that of Sicat Optiguides. And although there is no metal sleeve, the guided surgery keys fit quite well.
The upper right central incisor was removed with periotomes and the ostoetomy was started first with a lance bur then with a pilot drill. I always place the pilot back in the osteotomy and take an xray to make sure I am on course even if I am doing the case guided.
The guide was soaked in chlorhexidine for 30 minutes prior to surgery so I felt comfortable placing the implant through the guide. You can see in the xray and the photo that the implant was placed in an ideal position.
The implant fixture mount was then replaced with a scan post and the patient scanned in CEREC for a Telio CAD temporary restoration. And although the screw will be through the incisal edge, I felt comfortable with my bonding technique to seal this. However, the final restoration will consist of a custom abutment and crown.
One trick I learned was to use a long open tray screw to help block out the access of the Ti Base while cementing the acrylic portion. Multi Link abutment was used along with an acrylic coupler to help bond the composite cement to the acrylic crown framework.
Temporary glaze was used on the restoration and the access was filled with teflon tape and composite. Although we have some immediate recession due to the procedure, I expect these areas to fill in over the next few months as we wait for osseointegration.
We got a little tissue rebound but I am not happy with the recession. Burned out the Ti Base with the Telio CAD on the Empress Glaze Setting. Imaged with a scan post.
As the screw hole was right on the incisal edge we decided to go with a separate abutment. Its nice in 4.4 we can now position the sprue but we still cannot on screw retained crowns. Note the Supra gingival margin.
Here is the final. Note the SUPRA gingival margin. Hope we get some papilla filling in around the crown. The next immediate I will try to go smaller and also try to avoid damaging the papilla.
