Hey Doc...The surgeon says I'm ready for my new crown!

8 years ago

So my patient coordinator says her step mom is in need of a second opinion about her front tooth. I tell her to send her over and sure enough, she has a old, loose PFM that is failing and there is inadequate ferrule and simply has a poor long term prognosis.

She is mortified about esthetics and how this implant will look (despite her many other dental concerns). I don't place implants yet, but walk her through the process and give her the recommendation for the surgeon I work with, etc., etc. Fast forward to about 16 months ago, she shows up at my office saying the surgeon says she is ready to go. I'm a bit lost now because I hadn't heard anything from my surgeon and our plan was to make her a custom healer at the time of surgery. Anyway, she ends up seeing a different surgeon in town, has extraction of #9 and immediate implant placement with a Straumann 4.8RC. Now fortunately, this isn't the end of the world in this case. Implant was placed pretty well, it is a tibase compatible system but there were some challenges that I had to deal with that took some extra time and extra cost (thankfully I have a CEREC otherwise the costs would have been even more). So here's a pic and radiograph of how she presented with the implant in place .

As you can see from the initial photo, I have some gingival asymmetry to address, so we discussed that I would be placing a provisional crown to help shape the tissue and make the final result more esthetic. She had a minor freak out moment until I explained that her provisional implant crown wasn't removable like her flipper :) So I choose to use Telio CAD as a provisional. For those of you that don't restore implants yet, I would highly recommend Level 3. This by itself has paid for my CEREC several times over. Plus, having full control of the outcome it nice too. I used to hate making an implant provisional chairside. It is time consuming and tedious. But with CEREC, this become quite easy and predictable. Yes, it cost me about $150 in parts for the variobase and for the TelioCAD block, but I'm still ahead even after the cement retained crown that will cost me a little less than $180.

As you can see from the radiograph, the implant is countersunk about 0.5-1.0mm. It may be a bit exaggerated from the angle of the PA. I was able to seat the scanpost completely, and then we designed Screw Retained Crown on the CEREC. Sorry I can't pull up my design right and show you a screenshot of it, but usually I make the facial emergence profile a little concave for everything touching the tissue with my anterior implant abutment or crown. In this case, I matched the shape of tooth #8 in my proposal at the gingival third so that I would get the tissue to move apically to my desired location. Everything above my depicted line was concave and not blanching the tissue. I will say I did have to make releasing incisions on the mesial and distal interproximally to get the tissue to release enough to seat provisional crown completely

One important step with using Telio CAD is that you need to use SR Connect on the intaglio surface of the implant crown. This is an methyl-methyacrylate(MMA) liquid that is light cured in order to optimize the bond of the Telio CAD to the tibase. Still sandblast the tibase, use your Monobond Plus and cement with the Hybrid Abutment HO cement by Ivoclar Vivadent. Sam has an excellent video showing the full process.

Here is the Telio CAD provisional seated about 1 month post. Not perfect but much better.

At this point, things are more predictable and easier to deal with. This wasn't an ideal case. The patient is in some serious need of soft tissue grafting in a number of areas. Wasn't interested in ortho and wouldn't let me recontour a few of her other teeth to help with some line angles, but overall given my restrictions, I was able to make her happy and deliver a nice result. This would have been a lot more unpredictable and expensive without CEREC.