This That And The Other Thing: Managing Uneven Bone

Here is a case that turned out OK. Not in love with the tissue. Patient presented with a loose bridge from 27-31! Done by my past, non implant self, about 12 years ago. In retrospect I am surprised it lasted that long! #31 has recurrent decay into the pulp and needs endo. We have a deep and long pontic space and we know there has to be some lack of tissue as well as a sharp ridge. We also know that the implant crowns will look “long” unless we add some pink porcelain. Looking at his occlusion (which again I am surprised this bridge lasted so long) I want to splint the implants.

You guys know how to get a model out of CEREC right? Here is a stone model we took from an alginate. Just draw a little circle somewhere on the model, it can be an inlay or a crown and just don’t care about the proposal, just right arrow to the mill preview and export the whole thing. SICAT will cut away the teeth. Since it was multiple teeth and we needed to do endo on #31 I decided on an optiguide.

 

 

Very sharp and uneven bone. Planned the implants underneath the pontics of the teeth. Make sure you take away the model and just display the guide sleeves to make sure that they don’t overlap. I planned my implants sub crestal and planned to do some ridge recontouring after the implants were placed.

Did the endo first on #31 and did buildups on both 27 and #31. We are deficient in keratinized tissue on the buccal but have a lot on the lingual. This patient had some limited opening so we could not fit the isolite. Since we took off the crown on #31 which was our seat, we really had to rely on holding the guide down on the contra lateral side to make sure it did not rock.

Finished endo. There was a huge PARL and the sealer really did a big puff. You can see in the image how sharp that ridge was and where the buccal extent of the osteotomy should be. Just for fun I decide to place the 3 4.7 by 10 legacy 3s through the guide. I know my guide is 22mm tall and the implants are 10mm long. The mount is 12.6mm so with the implants I should have about .6mm sticking out. Not very exact but wanted to give it a go.

Three 4.7 by 10mm Legacy 1 implants were used. Could I have gone skinnier? Sure but I know I am splinting and I know I am using pink porcelain so I am not worried about cervical emergence profile as it will be one long “mini-hybrid” . Placed through the guide with about .5 sticking out and used the ratchet to index. From the get go I knew I was in dense bone so I used crestal bone drills on all sites.

 

 

 

 

 

 

 

So here is a problem we have a lot with punches. You can’t contour the bone as you are not accessing the ridge. In the radiograph it looks like I really sunk those implants too far. But in the cross sectional you can see that lingual “fin” of bone. In some systems you can use a bone reduction guide, but what I try to do is get my implants all covered in bone (#31 I do have one the platform shift exposed) and then, very carefully, use a carbide 557 to level the bone with the healing caps on. Sutured the flap with horizontal stitches on the buccal and just loose verticals (sorry hard to see under the pontics in the next shot). Made a temp engaging 27 and 31, not the implants and kept the space under the pontics cleansable. Not my best stuff, but I will re-eval the tissue at 3 months. May need to get a FGG after the tissue settles in.