Hey Doc...The surgeon says I'm ready for my new crown!
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.
Final restoration: (Photos are 15 months post op)
Utilized IPS e.max MO-2 abutment block (fired on P7)
IPS e.max B1 MT
Nice work Dan! Great Documentation as well. I can not agree with you more about Level 3. Still one of the best courses for the money there is. I gotta get on posting some cases. 
Very, very nicely done Dan !
Now comes the really hard part - convince the oral surgeon to get on the CEREC guided surgery band wagon ......
Winnie
All that worrying for nothing. Great job and nice documentation. She probably has no idea what the temp/tissue shaper did for her.
On 5/17/2017 at 11:35 am, Sameer Puri said... Dude!!!!! Spectacular procedure and documentation.
+1 Nailed it on all counts!
On 5/17/2017 at 11:58 am, Askold Wynnykiw said...Very, very nicely done Dan !
Now comes the really hard part - convince the oral surgeon to get on the CEREC guided surgery band wagon ......
Winnie
Isn't that the truth Winnie! But that's why my present to myself is Garg's implant continuum. Just need to find time in 2017. I'm excited to take my journey to the next level with the full integration of Gaileos and CEREC.
Perfection!
not to mention a great xray... that implant is HUGE (im hoping there was ample b-l bone to place it in).
- david
Beautiful result.
Funny, rewind a few years and that implant coming back to me from the surgeon would be everything I would hope to see.
Shows how quickly the bar gets raised year by year.
Beautifully executed. Just 2 points:
1.) The surgeon made the wrong decision to place a 4.8mm implant n this site...A 4.1mm implant is more appropriate for this site.
2.) I would advise against doing releasing incisions in the esthetic zone to seat restorations. You risk loosing papillary height with that approach.
Obviously both of these points did not affect this case adversely.
Farhad
Farhad,
I definitely agree with you that he put too large of an implant in. Since it was an immediate, I speculate he was wanting more threads to engage the extraction socket. Regardless, I concur and think you're right on the money.
So what would have been a better option to seat the restoration when we run into cases like this? I know this is the second time this week you have mentioned not making releasing incisions to seat a case like this? Thanks!
Dan
On 5/17/2017 at 5:52 pm, Daniel Wilson said...Farhad,
So what would have been a better option to seat the restoration when we run into cases like this? I know this is the second time this week you have mentioned not making releasing incisions to seat a case like this? Thanks!
Dan
Dan,
First you have to distinguish if bone is in the way or soft tissue. Bone cannot be displaced (even with a releasing incision) but soft tissue can.
1.) If bone is in the way: Use the bone profilers to profile the bone. If there is not enough keratinized tissue left then a small flap is necessary to profile.
2.) If only soft tissue is in the way: Releasing incisions will lead to the papillae not being adapted to each other, hence leading to secondary intention healing, which in turn can lead to blunting of the papillae. This is not a big deal in posterior sites but can be in anterior esthetic sites. If there is enough keratinized tissue then the same bone profilers can be used to profile the soft tissues as well. The other option I use frequently is to expand the soft tissues with successively larger stock healing caps (usually 2 different sizes) and then to slowly screw the restoration in. Soft tissues will displace.
Farhad
Amazing tissue management and gorgeous result. Is the Telio cad cemented to the Straumann variobase and then the entire unit screwed in? Thanks for the reminder to use SR Connect!!
On 5/18/2017 at 10:40 am, Carmela LaFalce said...Amazing tissue management and gorgeous result. Is the Telio cad cemented to the Straumann variobase and then the entire unit screwed in? Thanks for the reminder to use SR Connect!!
Thanks Carmela!
For all of my provisional implant crowns, I will do screw retained crowns. It really doesn't make sense for me to mess with cement especially while tissue is healing. So, yes, I create my Telio CAD crown and bond it to the Variobase (or Tibase) extraorally and screw the Variobase and Telio CAD as one unit.
