One of the hardest things for our patients to deal with is tooth loss. What we view as a routine procedure, they view as a loss of vital tissue, functionality, and possibly self esteem. The emotional attachment between our patients and their teeth is sometimes stronger than the attachment of the periodontal ligament holding the teeth in their jaw!
In this case, a 28 yo F was seen for her new patient exam. She presented with retained deciduous maxillary right and left first molars #A and #J. Despite having a lengthy dental history, she was shocked and concerned to learn her primary teeth were still in place. In all her years going to the dentist, no one had ever told her it was abnormal to still have these teeth!
After discussing the risks involved in keeping these teeth much longer, which includes loss of attached tissue, maxillary sinus pneumatization, and bone loss, the patient decided to remove both teeth and replace with dental implants. There was little root remaining on the upper primary teeth, so we decided to proceed with the maxillary arch first, and will address the mandibular arch as a second phase.
My first step was data gathering. A CEREC scan and CBCT were taken in order to merge the data sets. In this case, I did not need to design ideal restorations, as I would use the existing teeth as the reference point for implant alignment. This case was not without difficulty: the apex of the implant in #13 position is closely approximating the floor of the sinus
Additionally, once the palatal root of #A and #J is removed, there will be a significant defect along the length of the implant.
Both of these intraoperative finding would pose significant potential for compromised results. Guided surgery gives us the ability to anticipate these situations ahead of time and control them on our terms. First, by controlling the depth of the osteotomy drills, I can ensure my drilling protocol allows the implant to slightly engage the floor of the sinus and gently elevate it as the implant goes to fully depth. Secondly, by guiding the direction of the drills, the implant will be delivered into the thickest part of the ridge, allowing me to graft over the exposed threads.
This data was sent electronically to Sicat for fabrication of an Optiguide surgical guide. This surgical guide requires only a merged CEREC impression with the CBCT dataset. There is no need for a physical model or any analog data. What this means is at least three of the teeth in the treatment arch need to be free of restorative material in order to merge the datasets reliably. The Optiguide can have multiple implant sites in one appliance, which saves time during surgery and significant costs by not needing multiple appliances. Until the advent of 3d printed “Digital Guides” from Sicat, the Optiguide was my go-to for multi-site implant cases.
Using the surgical guide allowed me to predictably place the implants in position that allows for ideal final restorations. Grafting took place at the same time as implant placement and primary closure was obtained. Once the implants had healed in the bone and soft tissue emergence profile was developed, CEREC scans were taken using the proper Scanpost, the restorations were designed, fabricated, and delivered. I fabricated full contour screw retained crowns in this case, which was necessary due to a lack of space for split abutment and crown.
This workflow allowed me to provide a highly successful solution to my patient, while still being very efficient with my time. After surgery, we had 2 short post operative visits, a scanning appointment, and final delivery. The case took less than 3 hours of total chairtime from start to finish, which means it was an incredibly profitable service for the practice. On top of all that, we gave the patient renewed confidence in her smile and self-esteem. Talk about win-win!