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Fast, functional aesthetic solution for anterior tooth trauma

Gentle extraction preserving the vestibular lamina. (Photograph: Dr Martin Weber, Germany)

Wed. 9. January 2019

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CEREC and oral surgery? In times when patients go to a practice to receive complete, aesthetic, state-of-the-art treatment as quickly as possible, I think they go together very well. I did not always think so. Certainly, CEREC was always interesting; I have used it since 2003, but I did not always find the results convincing. In 2014, I had a closer look at an event in Salzburg, Austria, and learnt two things: the system had been further developed, and in particular, the precision had been improved considerably. It fits well in my practice; I use it almost every day because I have many patients who have busy jobs and do not have much time. I experience a great workflow in the practice that gives me maximum flexibility. Depending on the indication and the patient’s wishes, I can decide whether to make the restoration myself or outsource it to a laboratory, which I often do for more elaborate bridges. Then, I send the scan directly to my partner laboratory via Sirona Connect—that is very reliable.

I mainly use conventional ceramic materials (VITA ENAMIC, VITA Zahnfabrik; CEREC Blocs C PC, Dentsply Sirona; IPS e-max and Telio CAD, Ivoclar Vivadent; and Celtra Duo, Dentsply Sirona) to treat my patients. The possibility of using implants in the premolar and molar region with screw-retained all-ceramic crowns is especially interesting. Sintering or crystallisation in the CEREC SpeedFire furnace is fast and fits smoothly into the workflow.

The advantage for my practice, where I also employ two other dentists, is obvious. We produce laboratory tasks right in the practice and have the entire workflow under control, and our patients are satisfied. They are still really impressed by the technology today. They are treated immediately, have no problems thanks to the precise fit, and feel like they are involved because they can watch us create the design and view the planning process live in CEREC. And yes, patients do talk about that with their friends and family. This case study shows how the digital processes, including implant planning, with CEREC work.

Treatment of an anterior tooth trauma with an immediate implant

The female patient, born in 1989, came to my practice with problems at tooth #21 caused by a childhood trauma. The gingival margins were reddened and bled when probed. The intraoral radiograph showed posttraumatic resorption of the root, and the tooth could therefore not be preserved (Figs. 1 & 2). The tooth was to be replaced by an implant with an all-ceramic crown immediately after extraction. To plan the procedure, a 3-D radiograph (Orthophos XG 3D, Dentsply Sirona) was taken. It was important to assess the available horizontal and vertical bone and evaluate apical osteolytic processes after the failure of endodontic treatment and in the region of the crestal bone due to progressive dentinal resorption. The integrity of the vestibular lamina was preserved, and there was sufficient apical bone to allow immediate implantation with immediate loading (Fig. 3).

After scanning the upper jaw, tooth #21 was deleted in CEREC to simulate the initial postoperative situation. The prosthetic proposal for tooth #21 was used to optimise implant planning and to produce the surgical guide (Figs. 4 & 5). In the implant planning software (Galileos Implant, Dentsply Sirona), the prosthetic proposal was superimposed over the CBCT data for the optimal positioning of the implant. In this way, sufficient vestibular distance was ensured, and the correct size of the implant for optimal primary stability could be selected (Fig. 6).

When extracting tooth #21, it was important to preserve the vestibular lamina to allow immediate implantation. For this reason, the Sharpey’s fibres were carefully severed with a periotome, and the tooth was gently removed (Fig. 7). The tooth had pronounced dentinal resorption, confirming the previously made diagnosis (Fig. 8). The SiroLaser Blue (Dentsply Sirona) with a wavelength of 970 nm was used to disinfect the alveolus. An OsseoSpeed EV 4.8–15 mm implant (Astra Tech Implant System, Dentsply Sirona) was inserted immediately using a surgical guide (SICAT OPTIGUIDE, SICAT; Fig. 9). At > 35 Ncm, sufficient primary stability was achieved.

After the intraoperative scan with a ScanPost (Dentsply Sirona) to complete the temporary restoration, the vestibular alveolus was filled with a bone substitute material (Figs. 10 & 11).

Designing the temporary screw-retained crown included processing the composite crown (Telio CAD) produced with CEREC and extraorally attaching the TiBase (Telio CAD, Ivoclar Vivadent on Dentsply Sirona TiBase). The crown was screwed in situ, and the screw channel was sealed with composite (Figs. 12 & 13).

The situation after the temporary restoration (Fig. 14) was aesthetic and free of inflammation. The temporary was positioned 0.5 mm short of occlusion. The patient came for a follow-up after one week. At this visit, we used the soft laser (SiroLaser Blue, wavelength of 660 nm) to activate wound healing (Fig. 15).

Four months after this treatment, the patient came to the practice for the final restoration. We had previously sent the scan to the partner laboratory via the Sirona Connect portal. There, the abutment was designed with the inLab software (Dentsply Sirona), milled and attached with a titanium base.

The temporary was then removed, and the abutment was inserted using a transfer key. The vestibular contour was completely preserved (Figs. 16 & 17). After sealing the screw channel with a PTFE strip, an all-ceramic, custom-veneered crown was inserted for a perfect aesthetic outcome of the anterior tooth (Fig. 18).

Coordinated system supports the workflow

For this case, I used the digital workflow from Dentsply Sirona. After having tested different systems, it proved to be especially efficient and easy. The individual steps, from imaging and diagnosis using the scan, ordering the surgical guide and planning surgery up to producing the temporary restoration and the final prosthesis, are very well coordinated. The interface to SICAT is included in the planning software and enables one-click ordering. Even if I do not use a surgical guide for every implantation, I find it to be very useful depending on the indication.

I also use laser in my practice depending on the indication. In the case of this patient, there was an inflammatory process at the tooth (granuloma). With the laser, I can achieve thorough disinfection of the alveolus and also activate wound healing.

I found that the CEREC Software 4.5.2 has brought another major advance in the accuracy of fit compared with the preceding versions. In addition, it is fast and reliable. The optimised processes proved to be especially advantageous for implants, as in this case. I particularly appreciate the option of implementing screw-retained solutions with CEREC. In my practice, I place more than 100 implants a year with CEREC— I generally use screw-retained crowns. They considerably reduce the risk of peri-implantitis owing to the absence of cement.

For implants in the anterior tooth region, I produce long-term temporaries with CEREC. They have the significant advantage in that they do not look like temporaries, do not feel like temporaries to patients, and thus ensure better quality of life. The patients are also convinced of this. The follow-up radiograph (Fig. 19) before the final restoration with a custom-veneered ceramic crown showed good osseointegration of the implant. The gingivae were externally completely free of inflammation.

Discussion

Given the great aesthetic demands and the need for rapid results, thorough consideration must be given to the options available for treating anterior teeth. In my view, conservation by means of conventional techniques was not possible in this case owing to the comprehensive and advanced internal resorption of tooth #21 due to previous trauma. Upon extracting this tooth, it was particularly evident that it was not worthy of conservation (Fig. 8). The young age of the female patient and the integrity of the adjacent teeth meant that a bridge was ruled out as an alternative. In light of the favourable anatomical situation with fully conserved vestibular bone lamella, immediate implantation was the optimal treatment option for improved conservation of the bundle bone and, along with it, the hard and soft tissue. The fixed provisional crown supported the soft tissue, was aesthetically pleasing and offered the patient a highly satisfactory solution. Moreover, the digital workflow offered the patient additional comfort (impression without a tray).

Editorial note: A list of references is available from the publisher. This article was published in CAD/CAM - international magazine of digital dentistry No. 03/2018.

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