CASE PRESENTATION
CEREC Implantology:
The Single-Tooth Implant
The Single-Tooth Implant
This case is an example of how my digital CEREC implantology workflow is used to replace a hopeless tooth with a dental implant and restore it with CEREC technology. The patient is a 48-year-old woman who avoided replacing a hopeless maxillary canine for many years. Unfortunately, bad dental experiences had left her unable to improve her current condition, which included multiple missing posterior teeth and residual roots. She was left with no choice but to replace a fractured nonrestorable upper left canine. I temporarily recemented the existing crown, bypassing the fractured post, but it was apparent that this would likely recur.
I used digital imaging with Schick 33 (Dentsply Sirona) as a communication tool to clarify my clinical decision making and help the patient understand the existing dentition and potential problems. The patient agreed it was time to replace this tooth with a longterm solution. Several medical concerns prevented any earlier intervention, but her condition improved, and she was cleared for bone regeneration and implant dentistry.
Corroborating clinical evaluation with Schick 33 imaging established the hopeless diagnosis and a GALILEOS scan (Dentsply Sirona) confirmed the diagnosis and implant treatment plan. We discussed all the risk-reward options available, and decided the best option was an implant. This treatment plan was optimal because the adjacent lateral and premolar teeth were never treated, and it is best to preserve healthy teeth when possible. A SIMPLANT tooth-borne SAFE Guide was designed and fabricated to aid in the implantation of Nos. 11 and 13. It was apparent that No. 13 would require buccal bone grafting to improve the prognosis of any implant placed in that site.
I fabricated a unilateral acrylic removable replacement for No. 11 before scheduling its removal. Local anesthesia was given, and the root was atraumatically removed. The resultant buccal plate was inadequate to house an immediate implant, so a mineralized PUROS cortico-cancellous allograft was packed into the socket. A resorbable collagen membrane contained the graft, and the flap was advanced to achieve primary closure. A unilateral acrylic partial was inserted as an interim prosthesis to replace No. 11 only. While this graft was maturing over a period of 4 months, I elected to perform a horizontal buccal bone graft at the No. 13 site.
Using local anesthesia and with the aid of a wellfitting SIMPLANT guide, I performed a flapped, guided implant placement with a 4.2 × 11-mm Astra Tech Implant System EV (Dentsply Sirona). Using an Osstell Resonance Frequency Analyzer, we found the implant stability quotient was indicative of very high initial stability and suited to be immediately restored. The implant was placed precisely where it was virtually planned and allowed the use of a stock contoured abutment for its restoration—a direct benefit of the CEREC implantology workflow. A TiDesign EV 4.2 abutment (Dentsply Sirona) was torqued in at 25 Ncm, and the access opening was filled with Teflon tape and covered with resin.
An Ivoclar Telio provisional crown designed and milled using CEREC was retentive enough to be temporarily cemented. I kept the crown out of occlusion in centric occlusion and in lateral excursions. Two interrupted gut sutures held the flap in position and the patient was dismissed. Total surgical and restorative treatment time was 90 minutes.
Four months later, a GALILEOS scan was obtained to evaluate the result of the buccal bone graft at the No. 13 site. This revealed that the buccal defect was restored adequately and was ready to receive the planned 3.6 × 11 mm implant. A definitive CAD/CAM crown was created and inserted on the original abutment placed during the prior visit. The scan also affirmed that the No. 11 fixture was completely housed in bone and well-integrated. These types of results have the potential to last a lifetime, and that is the expectation I have for this tooth replacement.
SCHICK 33
Schick 33 intraoral sensors provide remarkable resolution through market-leading technology for consistently detailed images and advanced diagnostic capabilities. Designed to withstand the rigors of daily practice life, the silicon-coated cables are the industry’s only in-office replaceable cable. With 3 sensor sizes, 3 cable lengths, and limitless image enhancements available, the Schick 33 sensor is a versatile choice for nearly all clinical situations.
I used digital imaging with Schick 33 (Dentsply Sirona) as a communication tool to clarify my clinical decision making and help the patient understand the existing dentition and potential problems. The patient agreed it was time to replace this tooth with a longterm solution. Several medical concerns prevented any earlier intervention, but her condition improved, and she was cleared for bone regeneration and implant dentistry.
Figure 1—Schick 33 preop image of No. 11 prior to
bypassing the fractured post for an interim restoration
Figure 2—Initial GALILEOS cross-sectional view of
tooth No. 11
Figure 3—Residual socket and buccal bone defect
post-extraction of No. 11
I fabricated a unilateral acrylic removable replacement for No. 11 before scheduling its removal. Local anesthesia was given, and the root was atraumatically removed. The resultant buccal plate was inadequate to house an immediate implant, so a mineralized PUROS cortico-cancellous allograft was packed into the socket. A resorbable collagen membrane contained the graft, and the flap was advanced to achieve primary closure. A unilateral acrylic partial was inserted as an interim prosthesis to replace No. 11 only. While this graft was maturing over a period of 4 months, I elected to perform a horizontal buccal bone graft at the No. 13 site.
Figure 4—SIMPLANT SAFE Guide for Nos. 11 and 13,
intraoral view
Figure 5—Astra Tech Implant System EV, 4.2 × 11
mm, placed in grafted bone
Figure 6—Provisional crown cemented onto
TiDesign EV stock abutment
An Ivoclar Telio provisional crown designed and milled using CEREC was retentive enough to be temporarily cemented. I kept the crown out of occlusion in centric occlusion and in lateral excursions. Two interrupted gut sutures held the flap in position and the patient was dismissed. Total surgical and restorative treatment time was 90 minutes.
Figure 7—Healed peri-implant tissue, abutment
ready to receive cementation of definitive crown
Figure 8—Definitive CEREC crown on No. 11
Figure 9—GALILEOS cross-sectional view of wellintegrated and restored Astra Tech Implant System EV
GO-TO PRODUCT USED IN THIS CASE
Schick 33 intraoral sensors provide remarkable resolution through market-leading technology for consistently detailed images and advanced diagnostic capabilities. Designed to withstand the rigors of daily practice life, the silicon-coated cables are the industry’s only in-office replaceable cable. With 3 sensor sizes, 3 cable lengths, and limitless image enhancements available, the Schick 33 sensor is a versatile choice for nearly all clinical situations.
ANTHONY
RAMIREZ, DDS, MAGD, DICOI
Dr. Ramirez specializes in cosmetic smile design and digital implantology in his practice in Brooklyn, NY. In practice since 1983, Dr. Ramirez is a Master of the Academy of General Dentistry, a Diplomate of the International Congress of Oral Implantology, a key opinion leader for Dentspy Sirona, a CEREC Doctors mentor and trainer, and an attending physician at New York Presbyterian Brooklyn Methodist Hospital. Dr. Ramirez uses 3D CBCT imaging and CEREC CAD/ CAM technologies to promote a fully integrated digital dental practice and to improve quality of life for his patients.
Dr. Ramirez specializes in cosmetic smile design and digital implantology in his practice in Brooklyn, NY. In practice since 1983, Dr. Ramirez is a Master of the Academy of General Dentistry, a Diplomate of the International Congress of Oral Implantology, a key opinion leader for Dentspy Sirona, a CEREC Doctors mentor and trainer, and an attending physician at New York Presbyterian Brooklyn Methodist Hospital. Dr. Ramirez uses 3D CBCT imaging and CEREC CAD/ CAM technologies to promote a fully integrated digital dental practice and to improve quality of life for his patients.
