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Case Presentation
Peter Gardell, DDS
The pursuit of function, form, and esthetics is a driving force for clinicians. Our current dental landscape has advanced to the point where we can predictably design the tooth replacement process prior to even lifting a scalpel. Now, we start with a prosthetic vision and work backwards so that our final solution does not look like a crown or an implant, it looks like what we aim to replace—a tooth.
Digital Planning and Placement
A patient presents with a nonrestorable central incisor. An implant is indicated, but because the preop periapical x-ray (Schick 33, Dentsply Sirona) reveals a very thin buccal plate, we determine that a socket shield is needed to predictably maintain the soft- and hard-tissue profiles. We section the tooth using a surgical guide, a surgical trephine bur (Salvin Dental), and a Lindemann bur. The CEREC chairside system (Dentsply Sirona) is used to design and fabricate the 2 surgical guides: one for guiding the trephine bur and another to create the osteotomy for the tapered implant.
The trephine plan follows the long axis of the failing tooth, leaving a uniform thickness for the residual root fragment. The implant plan does not need to follow the same path—in fact, the cingulum is the desired location, affording the most flexibility when restoring.
The trephine guide is placed and the 4.5-mm trephine bur is guided, following the plan without deviation. The trephine is able to produce a thin uniform thickness, which is difficult to accomplish without a guide. When brought to length, the Lindemann bur is used to complete the sectioning. The fragments are removed without disturbing the desired buccal fragment.
The 4.1-mm implant is placed, followed by placement of a cancellous allograft material (OraGRAFT, LifeNet Health) in the gap between the bone and implant. Immediate loading is not attempted in this case, so a Maryland bridge is fabricated with CEREC out of Tetric CAD (Ivoclar Vivadent) and bonded into place. The Isolite system (Zyris) helped to control moisture and create visibility.
Uncover Visit
After 12 weeks, the implant is uncovered. A scan post is placed and the implant site is imaged. This is used to fabricate a screw-retained provisional with a meso bloc (Telio CAD, Ivoclar Vivadent). After the soft-tissue has matured, it is imaged and then the final prosthesis fabricated. A custom abutment is made with a Straumann Variobase for CEREC – TAN and a meso bloc (inCoris ZI, Dentsply Sirona). The zirconia is infiltrated to mimic a true dentin shade. The veneer crown is then fabricated with an MT block (IPS e.max, Ivoclar Vivadent) so that the warmth of the dentinal shade abutment shows through and creates a lifelike result.
Go-To Product Used in this Case
Schick 33 provides industry-leading image quality that can make substantial improvements to diagnosis and patient acceptance, offering unprecedented resolution for consistently detailed images and advanced diagnostic capabilities. Kevlar-reinforced, silicon-coated cables help keep your sensor up and running. With 3 sensor sizes, multiple cables lengths, and limitless enhancement capabilities, Schick 33 is designed to suit your patient's needs, as well as your practice and personal preferences.
About the Doctor
Dr. Gardell graduated from NYU College of Dentistry and has a technology-based practice with an emphasis on cosmetic dentistry in Stamford, CT. He has been using CEREC in his practice since 2005 and he successfully completed the CON process in the state of Connecticut and, in 2010, installed the first GALILEOS in the state. Through his work, the laws requiring a CON have been changed, so that it is not required any longer. He has been a beta tester for the CEREC chairside system since 2009 and has been involved in the beta testing of the Digital Encode workflow for implant systems from Zimmer Biomet. Dr. Gardell has lectured nationally on topics ranging from CEREC and GALILEOS to implants, and practice integration.
