Dental Implant/Crown - Guided tooth #14 CEREC

Welcome back everybody. This video is going to be a little bit longer than the last one was. I think it's going to be maybe 20-30 minutes, we'll see. So what we're looking at is kind of a recap of the article that I had an opportunity to publish. We're talking about an immediate placement using a surgical guide of a dental implant and then immediately scanning that implant with CEREC and designing the crown. Now we didn't immediately place the crown on it, but we immediately did the scanning. So this is the situation here. You can see it was tooth number 14 here, non-restorable. Now we could have tried to push the borders and do our best to see if we could restore it, but ultimately we decided to go ahead and eliminate that tooth. The plan is basically to remove each of these wisdom teeth and this guy here, that guy there. So this dental implant was placed back at the end of 2016. So you'll see some good follow-up. Anyway, here is the end result. You can see this is an Emax dental implant with a titanium base, the Thai base from Dentsupply Serona. This is a Nobel Active from Nobel Biocare. That's a 5.0 by 10 millimeter implant. Turned out really, really well. I've actually placed this implant myself. I've done a lot of implants over the years. Recently though, I've been referring most of my dental implants to oral surgeons and periodontists who are in my office. They're my surgeons and periodontists because I'd prefer, if I were in that situation, to have a specialist do it, if available. Not to say that general dentists are not capable of placing just as high of a quality of implant or going through just as high quality of an implant placement surgery as a periodontist or oral surgeon. But we like to refer to a specialty as much as we can in this office. It frees me up to do more general dental work where possible. So again, this is the final outcome here. You can see a really solid bone height coming up over the edge of the implant. That's what I like with a platform switch from the surgical platform to the restorative platform. Turned out really, really, really, really good. All right, so let's dig in here. So I had this patient in for a consultation. This happened to be a relative of one of my office co-workers, I guess. So this is a Simplant software where we actually got a cone beam X-ray, a cone beam CT from, let's see, it was a Planmeca machine from one of my buddies who lived up the street. And so we got that X-ray and I actually uploaded it, which office? I think we used Glidewell. Glidewell Lab did this with me. Anyway, so they requested a series of models. They imported the 3D X-ray and brought the two together. And we have all the views and angulations. And we talked, we had a conference call where we talked about what size of implant we wanted to place, where we wanted it to be. And this is basically that process. So ultimately, on that conference call, I logged in through either GoToMeeting or LogMeIn. And I worked with a technician to place that implant in an ideal location based on where the bone was, the height of the sinus you can see here, as well as the angulation of the roots that were there. Again, a couple more pictures here. We ultimately decided to do a 5.0 by 10 millimeter implant, even though this indicates maybe a slightly larger one. But yeah, this is the pathway of insertion for the dental implant. It's pretty simple. I know many of you, many of the docs that I'm affiliated with also do all of this planning on their own with software they have either in their own office or in their personal possession. It's pretty simple, pretty straightforward. Just like, you know, CEREC, when you get using it for a while, it becomes pretty simple. So within a couple of weeks, we were able to generate a 3D printed guide. And you can see they generated the model with the tooth extracted and the guide with the sleeve. Now these sleeves come in different sizes. So make sure that you have the right key kit for the right sleeve or that you order the right sleeve for the kit that you have, the implant placement key kit. You'll notice this particular key is not the right size for this particular sleeve. Or in other words, they sent me the wrong sleeve size for this kit. This worked just fine. It ultimately was not a big deal. With a little bit of play in there, we were able to place the implant still in a way that worked out just fine. But in some situations, this kind of play would not be okay. You know, in an ideal world, this key would slide in very, not very tightly, but very, it would approximate these walls very securely so that there was never any doubt what the angulation on that implant should be. And then of course, you have the drills that are set to a specific depth that you can alter. This of course is a guide, surgical guide. You can see little windows here to ensure that the guide is seated all the way on the models. And then in the mouth, when you put it in the mouth, you can also see those windows, look through the windows to see that it's seated all the way on the teeth. Here is just the key with the drill in place. So you can see how that sits and fits. And then here is the beginning of the process. So here's the tooth in place. You can see we got a bunch of granulation tissue, gingival granulation tissue that had grown up in there. You can see some of the white blanching where I had anesthetized the gingiva there on the palate. Step number one was to go from here to dechlorinate the tooth. So I actually cut the tooth off at a high speed, dechlorinated the tooth, and then I sectioned through the roots. That was step number one. Once the tooth is dechlorinated and the roots are sectioned, now we have access to this interfurcal bone, the bone that's in between the furcation. Here you can see the guide in place. We can actually see through it slightly. And then this is the drill all the way to the depth that I wanted to take it to. Notice the key is not in place. This is just the drill. And so here's a couple of different views of that dechlorination. I think these are the same image. I'm sorry, I didn't mean to duplicate those. But basically I took the handpiece and I cut it off and I sectioned it just so we could get direct access. I did not want to take the roots out until after I had created that osteotomy with the implant drills. I wanted to make sure I maintained that bone or maintained the guide. Sometimes if you have this point of interfurcal bone and you're trying to drill right through the point, the drill will slip off down into one of the extraction crypts. So I wanted to make sure that we had basically a more flat surface with the roots in place so I could drill straight down through that, even through the root part of the roots to get into that bone in a much more, I don't know, a little easier I guess is what I'm trying to say. Okay, so here again is the guide in place. We can see the, of course, the sectioned roots. And this is the drill in place again. And you can see this is through a mirror. Here's the other angle of the drill which we can see. Pretty clear, easy access. You know, this situation, this indication was pretty straightforward because it was a first molar. It wasn't too difficult to work with. Here it is with the guide removed. You can see the drill is going down in between the roots. Of course, it did cut through some of the roots, but if you have a nice sharp drill, cutting through tooth structure is not that difficult. Just make sure you're sharpening or replacing those drills as needed. Pretty straightforward, pretty simple. Again, maintaining these roots in place in this situation allows us a much more stable pathway rather than, like I said, having a point of bone and then trying to catch your drill on the tip. It's going to slide down into those extraction crypts. So if we maintain those roots in place, we have a much more flat surface to work with. And so I can grab a purchase point and go straight down. Now, you know, if we have the guide and the key, yes, that obviates some of the challenges because you have that key which, you know, is a cylinder which is going to allow that implant a much straighter pathway. But this was the way I chose to do it. Sorry this is a little blurry. I didn't realize this image was too blurry until I had, you know, dismissed the patient and whatever. It's the only photo that I have. You know, you can see here we've got the osteotomy and we've removed the roots. So here is, you know, the distal buccal root. Here's the mesial buccal root form right here. And then here is the palatal. And then of course we've got the little osteotomy site there. Pretty simple, pretty straightforward. It wasn't difficult. Honestly, when you have a guide and a key and depth guides and you've planned it all, it makes it very, very simple. Now, could I have done this freehand? Yes. And to be honest, this is the only implant. No, I take that back. I've probably placed maybe five implants with a guide. Most of them I did freehand. So, you know, take the tooth out, put in an initial pilot drill, take an x-ray and such. And yes, this was much, much simpler from the standpoint of less stress for me, but it did require a whole lot of preparation work up front. Tons and tons and tons. And there was a hefty cost because I used the lab. Now, if you've got the capability to do this in house, mill your own guide and you've got the time or the assistance to devote to it, yeah, this is definitely the way to go to do it guided. Guided surgery is definitely the way to go. Again, if you have the time and or the assistance to devote to doing all the legwork for you. So again, I apologize. It's a little bit blurry, but you can see, you know, the osteotomy and then the roots were all extracted here. So this is the implant in place. You'll notice the rim of the bone here and the interferical bone. This implant is actually placed a couple of millimeters below the bone level. So if we were to measure this height down to where the implant's placed, it's a couple of millimeters. You know, because it's in an angle and this is straight on, it's hard to see that. Personally, I prefer to have my implant platform below the level of the crestal bone, even once it's totally healed. That way, in my opinion, you get a better emergence profile. If you have the implant platform at the bone and we always get a little bit of resorption after an implant is placed or a tooth is extracted, there's some degree, half a millimeter or whatever. So I'd rather have, number one, that little extra leeway space to deal with. And number two, I'd rather have a lower implant so I can build a better emergence profile coming up through the gingiva rather than having, you know, an implant at this height and then the crown having to go straight out to the side. We're much better off going up, if you will. All right. So here is the implant in place. You can see some of the osteotomy. That's probably where the palatal root crypt is that's showing a little bit more radiolucent there. Of course, before extraction and then implant in place, you'll notice how deep I buried that implant. Let's change colors here. How deep I buried that implant relative to the height of the adjacent bone. It's significantly lower. And I was expecting to get some bone height change. You're always going to get some bone height change. But even if I get two or three millimeters, we still have plenty of bone to develop a nice, solid emergence profile for that implant. So here is the scan body in place. And what I like to do, you'll notice it's pretty clear. I try not to blow air directly into those extraction sites. What I like to do, you ever heard of a comprecap? C-O-M-P-R-E-C-A-P. That's basically a cap-shaped cotton roll. And that'll go down in there and suck all that blood out. And then you can scan real quick. Or you can just use cotton balls or cotton rolls. But I would recommend against blowing air directly into an extraction site. Anyway, we place the tie base. And you'll notice, you can kind of see it here. Here's the notch in the groove, which is so critical we orient correctly. You want to make sure you know exactly where that is on the plastic scan cap and on the tie base. And I apologize, I didn't get a picture of the tie base without the cap in place. But we can see that this cap is placed all the way down against the tie base. And it looks like the groove is lined up. At least we hope it is. And it was. So here's the scan in place. Let's go back. You'll notice that this arrow, you see the pyramid is pointing roughly to the mesial, right? If we look at the next one, you can see that same angulation is pointing to the mesial. So this is the scan, of course. So at this point, with this particular scan, I just left it alone. I hit save, closed the case. I wanted to make sure the implant integrated fully and that we didn't have any post-op issues before we invested the time and the money in the implant process, although it's really nominal as far as cost is concerned. And then I put a little resorbable membrane and actually, whether I should have done it this way or not, it's certainly open for conjecture, screwed the healing cap into the membrane or made a little hole and punched that in there so that the cap itself, the screw, the healing abutment, held in the membrane. And here you can see a bunch of gel foam and Surgicel that's just helping to maintain a clot. And then a bunch of little sutures, some gut sutures. So here it is in a nutshell, from step one where we did the diagnosis to step two, getting the guide and then actually decorating the tooth and placing the implant to scanning to the healing process. There it is. That's it in a nutshell. Once everything healed, here is the restoration that we made. And this was all made in-house. This is a Tybase. It's an NBA 5.0L. Let me write that down. NBA. And that matches the regular platform of the Nobel Active 5.0L. And that 5.0L, you know, if you've seen any of my other videos, fits on a 5.0mm implant interface and a 4.3mm implant. So anything regular platform takes the 5.0 implant. The 5.0 Tybase, I'm sorry. So it turned out pretty well. You can see a little bit of staining and glazing in here. Just a little bit of stain. We got a little bit of some of the yellow oranges and browns down along the gum line here. You'll notice the emergence platform here is really bulbous. I really like that type of an emergence platform profile. It tends to lend itself to a little more cleansability. I try to avoid concavities that are below the gingiva because it's impossible to get a dental floss or a toothbrush and difficult to get a toothpick or scalers or curettes into a concavity. So try to avoid those if you can. Yeah, so this is Emax. Sorry, this is an Emax restoration. Here it is in place. Now you notice that it's a little bit opaque and the shade may be a little bit too yellow. However, when you compare the yellowy here that you have to that, it looks pretty darn similar here. Where we get thrown off a little bit is all the gray from what looks like decay developing down in the grooves of these two teeth. So all in all, I think the restoration turned out really well. It looks good. You know, gingival, the contour looks a little higher than the adjacent teeth. Palatally, eventually, he developed a little bit of a gap there, which, you know, all that requires is a quick redo. I guess that's the last slide. But in the end, this case turned out really, really well. So this was done about two and a half years ago. And a couple of closing comments. You know, there's definitely a benefit to having a general dentist placing an implant in the more complicated restorative situations for those of us that have had the appropriate experience and training. Because I can now place it knowing that I want this emergence profile. I want this height of contour versus where's the bone? There's the implant. You know, oftentimes we have to sacrifice what may be, well, how do I say this? We don't want to put it in an unideal place, but we want the ideal place to prefer the restorative side of the equation rather than just the surgical side, if that makes sense. So rather than placing it in the best bone, which might be on the buccal or the lingual or the palatal, we want to place it in the best location that will allow us to create a nice long-term outcome aesthetic restoration. So in the end, whether it's using a little composite to seal it, a screw-retained crown, which I prefer in the molars, or if you use a cement-retained crown and make sure you clean up all the excess cement, direct, not direct, in-the-office restorations done with your CEREC machine and CAD CAM, planned ahead, etc., etc., can create really nice outcomes. I definitely recommend if you haven't tried a guided surgery and you've got some implant experience, definitely give it a try. I know that's the way the industry is leaning. I know there are docs all over the place, general dentists and surgeons alike, that are doing everything guided, which simplifies their life. Only drawbacks that I can see potentially are cost associated with it and the time involved, whether you're printing, whether you're running them through a scan, which there potentially could be some issues with the radiation, which hopefully we're getting past. Really, I see the time and the cost of either working with a lab to generate the pieces and parts that you need, or dedicating the staff or yourself to being able to create the guides that you need. In the end, yes, you're probably going to end up with a more precise, more specific, and potentially a higher success rate long-term. So I definitely recommend trying it if you haven't. This was a great case. Learned a lot from this case. Definitely will do it again. Our plan is to upgrade to a cone beam here in the not-too-distant future and then eventually get a little 3D printer. But yes, with CEREC, you can mill guides, again, if you have the time and people you want to devote to it. So maybe we'll try that first. I think that might be cheaper than investing in a 3D printer. Anyway, thanks for your time. Please let me know. I always welcome comments. In the last video I posted, there were a couple of comments about why on earth would you do this, restore this tooth, first taking it out and implant. We had some discussion about, well, this particular situation was unique because of the cancer situation and the chemo and the radiation therapy and the need for hyperbaric oxygen therapy. So please don't hesitate to ask questions, provide comments. I'm happy to give you my input. I certainly don't know everything. I've got some experience and hopefully through these videos, you can gain from my experience. But I definitely welcome your input, feedback, and any questions that you have. So thank you for your time. Enjoy your day.