#DentalER Case: Same Day Extraction tooth #14, Bone Graft, Membrane, Same-Day CEREC Zirconia Bridge

Hello, good afternoon. I'd like to share a great case with you. This actually was a case from yesterday. I had a patient present with this panoramic. She was complaining of pain. You can take three guesses and guess where the pain was coming from, but you'd probably be wrong. The pain was actually coming from tooth number 14. She was complaining of a sharp, shooting pain every time she bit down and kind of a nonstop, dull, aching pain that seemed to be getting worse, although it had accelerated over the past few days. We took this panoramic, did a little bit of testing, looked at tooth number 14. On the periapical, we're not seeing anything that indicates any real significant pathology radiographically around the apex. This looks fairly normal to me. Large amalgam filling, like you can see here. Fairly deep. We talked about some options. Option number one, after determining that the tooth was not fixable because of the fracturing, which I'll show you. Option number one is taking the tooth out, looking at a bone graft, a membrane, preserving that bone for the future, and looking at a dental implant down the road. We talked about her likely meeting a sinus lift due to the low height of the maxillary sinus in this area, at least to accommodate a dental implant. So that was option one. Option two, take out the tooth, still bone graft the area to maintain that bone volume, and then look at a dental bridge, which we could do in one day. And, of course, the option three would be take it out and put in a partial with or without a bone graft. And then the fourth option, eliminate the tooth and do nothing. Here's the scan. As you can see here, we opted to go ahead and move forward with a bridge. So the tooth, occlusal buccal fracturing, mesial occlusal, occlusal distal, and then you've got a big piece missing here from the lingual. Here's another view. Sorry, we've got a little bit of incomplete scanning here in these areas. But, yeah, fairly substantial cavity underneath this old amalgam restoration and some significant fracturing. Now, had the tooth been fixable, I definitely would have recommended trying to fix it. Oftentimes we try to fix it and we realize ultimately that it's not, whether the fractures are too deep or the caries are too extensive. But in this case, it was pretty clear because the whole lingual portion of the tooth was shifting when I put pressure on it that that tooth was fractured beyond repair. So extraction was the only option. So the bridge is what we opted for. Normally when I do this, what I'll do is I'll go ahead and I'll, in this case we did a biocopy, biogeneric copy of the three teeth in this area so that we could minimize the need for postoperative adjustment on the bridge occlusion that was. So I'll go ahead and anesthetize the patient. I'll scan the quadrant that we're working with and then I'll prepare the teeth. After the teeth are prepared, then I'll take the tooth out. But first we get the bridge designed. Now the rationale for that is if I can take the tooth out virtually first in the design process, then I can get the bridge designed, get the bridge in the manufacture process while I work on taking the tooth out. Now it's good that we did that because it ended up being a fairly surgical extraction. And then we opted for the bone graft and the membrane, which took some time. So we were able to probably save her an hour because I had the time to devote to her an hour just because we numbed her, scanned, prepared the teeth, and then extracted the tooth virtually as you can see here. These are the prepared teeth you can see. We extracted the tooth virtually by using the replace tool. You go back one step, there's a replace tool under the edit model step where you just encircle the tooth kind of like drawing the margin and you hit replace and it'll flatten that portion of the tooth. Assuming you have it encroached on your margins, you can remove that tooth virtually. And then I take the remove tool or the minus tool and I just create a little divot down into that extraction site so that there can be a little bullet-shaped pontic to allow for the gums to form. Now there's a little bit of guesswork here, but usually if you create 2 or 3 millimeters, maybe even more than that, going down into the extraction site, if you bone graft and get the membrane kind of nestled up next to that bullet shape, in my experience you end up with a really nice pontic form after the gingiva responds. But it's hit or miss. I have offered and told patients that if the pontic, if there's space underneath it and we need to redo it, that I'm happy to redo it within the time frame of a year. If you want to do that, I'm happy to do it. I haven't ever had to redo it. We always tend to guess really, really close. The ones that have a little gap, the patients don't seem to mind too much because it tends to be a little more cleansable. So here is the bridge design. You'll notice it is a biocopy. I basically just biocopied and then once we got the connector thicknesses, as you can see here, this is a little thin, we widened the connectors out by just using the anatomic shape tool to broaden the mesial, I'm sorry, the buccalingual width of those teeth while not changing the occlusal height of those teeth to allow for contact the connector thickness that we need. There's a facial view. Here is the bridge itself. So remember, like I mentioned before, I anesthetized the patient, I prepared the two abutments and my choice, my bridge preparation armamentarium really involves three burrs. It's an 8-5-6-0-1-8 coarse burr on a high speed and then usually after I do the initial preparation which I use that for all the reduction buccalingual, mesial, distal and occlusal and I'll use a round burr and it's often times a size 6 round burr on a low speed handpiece to excavate any carries and then I follow up with an 8-5-6-0-2-5 so 8-5-6-0-1-8, round burr number 6 on a low speed and then 8-5-6-0-2-5, fine. The 8-5-6-0-2-5, fine is what I use to kind of refine my margins and I usually place them equigingibly right at the gingival margin. Then I virtually extracted the tooth designed the bridge, got the bridge in the manufacturing process then started taking the tooth out while the bridge was being made because zirconia, a zirconia bridge takes the machine about 45 minutes to mill and then about an hour to go through the sintering cycle. So there's the bridge and then here is the post-op of the x-ray with the bone graft and the bridge in place. So it was a great great opportunity to serve this patient It was really nice to be able to get her completely wrapped up in one appointment The couple of previous videos that I showed were actually the bridge being milled and also coming out of the furnace it's red hot when it comes out of that CEREC speed fire but this is a great opportunity to serve this patient Is it something that I'm comfortable doing during this time frame of the pandemic and the coronavirus? Sure. To be able to take the tooth out that's causing the patient pain and replace it at the same time personally I feel we're already taking that risk of exposing ourselves to the patient and the patient to us for a justifiable need so why is there any additional risk during the same appointment at the same time, the same day to go ahead and deliver a permanent prosthetic rather than a temporary and then she has to come back and we reuse more PPE, etc. etc. etc. So a great opportunity to provide this patient a service in the same day give her a restoration that's going to be long lasting and permanent without having to wear a temporary So thanks again for watching Hopefully you've enjoyed this Hopefully it wasn't too quick or too slow or too much or too little I sure appreciate you taking the time to check in with me. Thanks. Bye