A work in progress.....
This is a case were we sometimes have to meet the patient at their primary need. He presented to me to" fix his front teeth." There is a lot to deal with here, hygiene issues, assessment of diet as patient is high caries risk. Yes we discussed a lot of options and the need for change in order for anything to be successful long term. Ultimately we decided that we would crown the canines and the goal is to place two implant in the anterior segment and restore #7-10.
Here is initial presentation:
Set the case up to mill the interim bridge with Telio Cad:
My plan was to grind #7-10 down to the gum line, prep #6,11 and get a provisional bridge milling and then come back and extract the teeth. Lesson learned here was that I should have taken the teeth down even more to allow for a better design of the interim bridge.
Next was to design the case - I did utilize biojaw in this case and the harmonic positioning. This may not be the final restorative position, but you can see how it placed the proposals well in front of the extraction sites, given the position of the canines. The case required a Telio Cad block B55. I have attached the rst if anyone wants to play around and design the case.
While that was being milled it was time to extract the teeth, utilization of the Benex allowed for atraumatic extraction
I did opt to place bone graft as well - curious how others would have handled this
After grafting it was time to seat the bridge - I certainly needed to spend more time contouring and need to work on making the embrasures look better. Many lessons learned, hope this helps someone out in the future with this type of case. The patient was happy given the initial presentation and it's at least a start point for this case that is certainly a work in progress.....
Thoughts and ideas welcomed.....
Nice case, your provisional result was excellent, even without the initial presentation. I have used the replace, and form tools in the optional edit model step to deepen and shape ovate pontic sites in these immediate bridge cases. Works well, and leaves enough tooth to easily extract.
Very nice Andrew.... I personally be concerned about the embrasure so much at this stage, but I see what you're saying. I like the fact it's protecting the extraction site, and given the allografting done, I'd lean toward keeping it off as you've done, and not necessarily develop ovate sites yet at this stage.... but certainly like you mentioned, it's not a final position, and hopefully the patient doesn't come to love the facial position of the incisors if you know what I mean. VERY nice consolidation of steps and provisionalization here....
Mark
Andrew, love the case and enjoy seeing the pitfalls presented. We've all been there, and yup, if this helps someone and gets a discussion going about a bread and butter dental challenge, I'm all for it!
I am concerned about the placement of the anterior teeth so far to the buccal. If you do go back and place implants, will you be able to restore in this new position that the patient has become accustomed to? I have no answer as I'm not an implant guy, I'm just asking the question.
I am also concerned about the method of decay and my guess is that you adequately addressed it with the patient, but didn't include it in your write up here. The first treatment this patient needs is the ability to stop the decay from harming his new bridge now that a seam/margin exists between the tooth and the temp.
But I am 100% in your camp to treat the chief complaint (his front teeth) as soon as biologically possible for a patient. Once you do that, yup, they may disappear, but most likely you will gain their trust and they will complete treatment knowing that you actually care about them as a human being!
No one asked, but I'm going to: Was the indication to extract the teeth? After you removed the decay its was good. Endo, core and crown.
@Ernie - It would be difficult and restore to this new position after implant placement - I will likely transition him into a new provisional after implant placement to work out the tooth position and function
@John - Benex is great when it works but it is not a 100% in my hands but I am by no means an expert, basics are you countersink into the root and then use fulcrum and leverage to slowly apply pressure and then they just jump out when it works correctly- have to be patient which is sometimes a challenge for my
@ Ricardo - yes the indication was to extract the teeth, possibly the central could have been saved with extensive dentistry but in my humble opinion the teeth were are all non-restorable
