Ceri Owen-Roberts shows how he uses digital technologies to support planning and delivery of implant treatment in a young female patient.
Case presentation
A 24-year-old female patient was referred to me to help restore her failing anterior dentition. She had experienced a bike accident three years previously, which had caused trauma to the UL1, UR1 and UL2. All three teeth had undergone endodontic treatment, but two years later, external replacement resorption of the UL1 had been noted by the general dental practitioner (GDP). The referral to me in November 2021 was a request for the placement and restoration of a dental implant.
As is often the way, the patient had just got engaged and was due to get married nine months later. She wanted her dental treatment to be completed and healed for her wedding.
Aside from the three traumatised upper anterior teeth, she presented with otherwise unrestored and healthy dentition. She was a non-smoker, was fit and well and no abnormalities were detected during the intra- and extraoral examination.
Potential treatment options had been discussed in detail with the referring dentist, so we simply had to confirm suitability for implant treatment and conduct the necessary surgical and restorative planning.
We used the ITI’s SAC (Straightforward, Advanced, Complex) classification to determine the complexity of the case. This case was categorised as advanced due to the horizontal bone loss following tooth loss and the high aesthetic demand with a young, very cosmetically aware patient. We planned for a type 2 implant placement, which involves the complete healing of soft tissue and partial bone healing prior to implant surgery.
Treatment
The UL1 was extracted atraumatically and an immediate denture was provided. All the standard post-operative and oral hygiene instructions were given to the patient, who wore the denture for the next eight weeks to allow for healing.
When the patient returned, a CT scan was taken with a Planmeca ProMax 3D and intraoral images were taken using the CEREC Omnicam. These were uploaded to the Straumann Co-DiagnostiX software, which enabled planning for a guided surgical approach.
A Straumann BLX 3.75 x 10mm implant was chosen for greater primary stability and placed as per the plan. To achieve this, a two-sided flap was raised. Autogenous bone was taken using a safe scraper and mixed with cerabone, which was in turn placed over the exposed buccal bone. This was covered with a single layer of Jason membrane (Botiss), before periosteal release and tension free primary closure was achieved for submerged healing.
The patient was reminded of all standard post-operative instructions and went away for two months for healing. Once she returned to the practice, soft tissue contouring surgery was performed using a modified roll technique, a temporary crown was provided at this stage and soft tissue remodelling was performed over several visits to the practice, using compressive techniques. An open tray impression was then taken with a customised pick-up and a final crown as delivered – this was zirconia cemented to a titanium base, layered with ceramic and shade communicated using a cross polarised filtered flash and the eLAB technique. Providing an objective shade quantification that removes the guess-work, the elab software uses artificial intelligence and advanced image processing to communicate to the lab the values of the red, yellow and grey from the raw photo image. Using the cross polar filter removes the reflective glare and allows communication and visualisation of the underlying dentine.
The patient was delighted with the outcome, especially given that we were able to restore her smile in time for her upcoming nuptials!
Case reflections
This case demonstrated the excellent shade matching that can be achieved using the eLAB technique, for exceptional aesthetics that patients appreciate. It also shows the predictability and accuracy that can be delivered with guided surgery and cutting-edge software like Co-DiagnostiX. In addition, it shows the soft tissue structure that can be gained by using a well-designed provisional crown during the healing stage.
For colleagues looking to develop their skills and take on a similar kind of case, the SAC tool should always be utilised to determine the complexity of the treatment required. This helps to ensure predictable planning and soft tissue management, while also supporting the decision-making process for the surgical procedure. I knew very quickly that the above case would be advanced and likely require augmentation and soft tissue techniques. This would be particularly important to know early on for anyone expanding their capabilities and taking on such a case for the first time.
It is just as important to have a strong working relationship with the laboratory for these cases. I worked with PCG Dental (Bristol) for the presented case, who ensures close collaboration with digital communication. This also made sure that we avoided what could have easily been an aesthetic failure for a young patient. Instead, we were able to predictably deliver a functional restoration with no compromise in aesthetics – and in time for her big day!
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