A little dignity is all she wants...
This nice lady was referred by an endodontist after it was determined that #9 had untreatable external resorption on the palatal side. She was congenitally missing her maxillary laterals and had 6x8 and 9x11bridges. Both 8 and 9 had been previously endo treated.
Based on CBCT examination and probing depths, along with the location of the resorptive lesion, we had a high confidence that she would have defects in both the facial and palatal walls of the socket after tooth removal:
She is a rather high dental IQ patient, and her first question was if we only remove one of the bridges when we take out the the failed tooth, how can we possibly match something to her other bridge while she is healing? She was also concerned about trying to match the porcelain of a final prosthesis to her existing bridge on the other side. Knowing that she was going to have an extended period of time in some sort of provisional restoration while she heals from her graft, and then later her implant, she requested we remove both bridges so that her provisional would look uniform and allow her to "go to work and function with a little dignity."
I printed a model and measured 6x11, with the idea that I might be able to mill a provisional bridge for her:
It was very very tight, but worth a try. We selected TelioCAD B1 in a B55 block size. I reserved 3 hours of time for this procedure, and right off recorded a preoperative biocopy of her existing restorations. I removed her bridges, refined her preps, and reduced #9 to the gingiva. At this point I imaged the preps and 4.5.1 had no trouble merging the biocopy with the prep folder.
While the bridge was milling I removed the root, placed membranes facial and palatal, and grafted:
The bridge milled well, but you can see there were some compromises I made in order to complete the case this way, namely I couldn't get the entire facial of #9 in the block
I was able to contour and enhance this a bit so that it was not an esthetic concern for her
I was very happy that I could leverage CEREC and CBCT in a way to help me provide what the patient wanted. She was very happy with the result of her provisional, and told me that she felt she would indeed be able to conduct herself with dignity through the process.
I wish I had scheduled a little more time so that I could have contoured the provisional a bit more to improve the line angles and embrasures. I am tempted to mill another one and do just that so that when she comes in for her suture and membrane removal I can swap it out for her.
Nice Job JB
One of the things about having the in house ability is allowing you to rethink these cases. The provisionalization- not that is simpler, but it allows doing things you would probably not do if there was a lab involved from a cost or time standpoint
Seriously impressive. I agree. Mill another provisional. You’ve got the time and decreased pressure to contour it as you see fit. You’ll feel better knowing you went above & beyond and the patient will know beyond a shadow of a doubt what we on this site already do; you’re one helluva clinician and have only her best interests at heart.
Just curious if she actually likes the excessive bulk and round contours that her prior restorations had. I wonder what she would think about a flatter incisal-gingival contour and normal Buccal-Lingual thickness. If she is game it could be worth a test drive during these healing phases. The alteration in lip support might bother her though.
Nice case and documentation. What is the final treatment plan for her? Cases like this can be so hard to plan and to temporize its nice to have a patient aware of this and want it to look good.
Nice work Jeremy....I wondered if you considered relieving the pontic a bit more over #8 site to prevent pressure on the graft site? It may be passive already, just looks like pontic is contacting the site.
BTW...do you have inLab and XL milling unit I guess?
Nice job Jeremy. I agree that a new provisional would be nice, but, in line with Gary’s comment, I would get a really nice wax up done, thinking Bill Marais, and use this as an opportunity to test drive a new smile.
Thanks guys
I’m definitely going to work on a second provisional.
Like Gary said, I’d like to improve on the esthetics, but she says she has lived with her prosthetics for over 20 years and is used to them. Maybe a nicer provisional will help her see that some small improvements can make a nice difference.
The plan is to place an implant in the grafted site, assuming that I am successful in that endeavor. Then I can cantilever off that over the missing lateral, make a new 6x8 bridge, and a single unit #11.
There is more room than there looks under that pontic and there is no tissue pressure; I designed it so that I could retrieve the sutures and membrane without removing the provisional if desired. Hopefully, anyway.
Nice. Will be fun to follow this case to completion here in the forum. Agree, a new smile design would be awesome and open her eyes to the possibilities.
I forgot to mention that we are also treating her lower arch with clear correct to even and retract, making some more restorative space is the primary goal
