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Case

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Augmentation and regeneration of the alveolar ridge

Restoring an area to proper form and function ‫‏‬Dr. Ara Nazarian

XX With a case study, Ara Nazarian illustrates the steps to replacement of a non-restorable tooth. Today, patients increasingly present with endodontically treated teeth that have failed for various reasons—fracture, recurrent caries, or periodontal problems. In the past, the common dental treatment would be to prepare the adjacent teeth for a three unit bridge. However, with implant therapy gaining more popularity among patients and providers, the request to have implant treatment has increased. It is my opinion that implant tooth replacement is the standard of care, and every dental provider needs to learn how to replace missing teeth using this modality at XX XX some level. This article discusses the steps taken to remove a non-restorable tooth, graft the area, and then replace it with an implant and corresponding abutment and crown restoration.

approximate location of the mucogingival junction to balance the beak. In other words, the beak grasps the tooth, while the bumper is the fulcrum to provide leverage and stability for the beak and wrist movement.

Restoring an area to proper form and fun

Using only wrist movement, a steady and gentle pressure was applied toward the buccal utilizing the Physics Forceps. Approximately within 30-60 seconds, the internal force or “creep” built up allowing the bone to slowly expand and the periodontal ligament to release. Once the With a case study, Ara Nazarian illustrates the steps to repl tooth disengaged from the socket, the tooth was removed with a maxillary forceps (Figure non-restorable tooth 2). Bone grafting material (Foundation™, J Morita) was placed into the socket (Figure 3) and oday, patients increasingly present sutured (Figure 4) to prevent any dislodgement. The surrounding cells and capillaries infiltrate with endodontically treated Foundation. As the extraction socket heals, is filled augmented bone. Foundation is teeth that ithave failedwith for new various reasons—fracture, recurrent caries, or small and medium sizes. shaped in “bullet” form for easy placement. It is available in both

T

Restoring an an area area to to Restoring proper form form and and function function proper

A 44-year-old woman presented with a severely broken down maxillary right first premolar (tooth No. 5) (Figure 1). The decay, already present in this tooth, had extended far below the free periodontal problems. In the past, the common dental was treatment would be(Figure to Approximately 12 weeks after healing, the area inspected 5) and a new radiograph gingival margin to the crest of bone and into the furcation. All risks, benefits, and alternatives prepare the adjacent teeth for a threewas taken to visualize the underlying There was with adequate were reviewed with the patient regarding treatment. The patient understood that the tooth would unitbone. bridge. However, implantwidth and height to place an 5 (AB Dental USA) dental implant that would replicate the premolar using a 3.75 mm need to be extracted; however, she did not want a bridge restoration for the final prosthesis. therapy gaining more popularity Witha acase casestudy, study,Ara AraNazarian Nazarianillustrates illustratesthe thesteps stepstotoreplacement replacementofofa a x 13 mmFigure With 1: Clinical view of non-restorable tooth among patients and providers, the implant. Instead, she insisted on having the tooth extracted, and the area grafted followed by implant non-restorabletooth tooth No. 5 non-restorable request to have implant treatment placement and restoration. The patient’s medical history was non-contributory. has increased. It is my opinion that oday, patients increasingly present

T Once the patient was fully anesthetized, the gingival tissue was slightly reflected with aT

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oday, patients increasingly present with endodontically endodontically treated treated with teeththat thathave havefailed failedforforvarious various teeth mucoperiosteal elevator to separate the attachment. With the handles of the Physics®reasons—fracture, Forceps reasons—fracture, recurrent caries, recurrent caries, or or periodontal problems. past, problems. In In thethe past, thethe (Golden Dental Solutions) wide open, the beak was set into the depth of the lingual or periodontal palatal common dental treatment would common dental treatment would be be to to sulcus on solid root surface. A secure purchase point on solid root surface was criticalprepare to prepare adjacent teeth a threethethe adjacent teeth forfor a threesuccessfully rolling out the tooth. When necessary, it is not uncommon to create a small trench unit bridge.However, However,with withimplant implant unit bridge. therapygaining gainingmore morepopularity popularity therapy with a small, flame-shaped diamond bur to engage the beak more securely on solid root Figure 1: view of non-restorable tooth 1: Clinical view of view non-restorable amongpatients patientsand andproviders, providers,thethe Figure Figure 1:Clinical Clinical of non-tooth among No. 5 5 surface. Once the beak was placed, the bumper was positioned on the alveolar ridge atrequest the requestto tohave haveimplant implanttreatment treatment No. restorable tooth No. 5 increased. opinion that hashas increased. It It is is mymy opinion that implanttooth toothreplacement replacementis isthethe implant standardof ofcare, care,and andevery everydental dental standard provider needs learn how replace provider needs to to learn how to to replace missing teeth using modality missing teeth using thisthis modality at at

implant tooth replacement is the standard of care, and every dental provider needs to learn how to replace missing teeth using this modality at some level. This article discusses the steps taken to remove a non-restorable tooth, graft the area, and then replace it with an implant and corresponding Figure 2: Extracted tooth Figure 2: Extracted tooth abutment and crowntooth restoration. Figure 2: 2 Extracted A 44-year-old woman presented with a severely broken down maxillary right first premolar (tooth No. 5) (Figure 1). The decay, already present in this tooth, had extended far below the free gingival margin to the crest

Figure 3: Placement of graftingofmaterial Figure 3: Placement grafting

Figure 2: Extra

Figure 4: Graf

material

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Restoring an area areato to > Restoring an Restoring an area toand proper form and function proper form function proper form and function Augmentation and regeneration of the alveolar ridge

‫‏‬Dr. Ara Nazarian With a case study, Ara Nazarian illustrates the steps to replacement of a With a case study, Ara Nazarian illustrates the steps to replacement of a non-restorable tooth non-restorable tooth

T T rea to

oday, patients increasingly present

patients increasingly Aoday, 2.0 pilot drill waspresent placed withmm endodontically treated into the site and advanced to a depth of 15 mm measuring from with endodontically treated teeth that have failed for various the that tissue surface. This additional 2 mm was the same depth of the tissue height to bone. In teeth have failed for caries, variousor reasons—fracture, recurrent other words, 13 mm for theorosteotomy in bone and 2 mm for tissue thickness was created to reasons—fracture, recurrent caries, periodontal problems. In the past, the periodontal problems. In the past, the A parallel pin gauge was placed in the site of the osteotomy, and place adental 13 mm long implant. common treatment would be to common dental treatment would be to an x-ray toteeth check angulations of the pin between the adjacent teeth within the maxilla. prepare the taken adjacent for the a threeprepare the adjacent teeth for a threeunit bridge. However, with implant Using a rotary tissue bridge. However, withpunch, implant stepsunit to replacement a a 4 mm outline was created over the initial osteotomy and the tissue therapy gaining with morea of popularity plug removed curette. drills sequentially utilized to increase therapy gaining more popularity Intermediate Figure 1: Clinical view ofwere non-restorable tooth Figure 2: Extracted tooth the size among patients and providers, the Figure 1: Clinical view of non-restorable tooth Figure 2: Extracted tooth among and providers, thecompleted, No. 5 of thepatients final osteotomy. Once a 3.75 mm x 13 mm 5 (AB Dental USA) conical groovy No. 5 request to have implant treatment request to have implant treatment implant (Figure placed has increased. It is 6) mywas opinion thatin the osteotomy using the enclosed Clip Carrier (AB Dental USA) has increased. It is my opinion that implant tooth replacement is the until increased torque was necessary. The ratchet wrench was then connected to the driver implant tooth replacement is the standard of care, and every dental standard of and care,the andimplant every dental adapter torqued to final depth reaching a torque level of 65 Ncm (Figure 7). providerneeds needstotolearn learnhow howtotoreplace replace provider A 5 mm healing abutment, included with the implant, was handtightened to the implant missing teeth using this modality missing teeth using this modality at at (Figure A article postoperative radiograph was made of the implant and the healing abutment. The some level.8). This articlediscusses discussesthe the some level. This steps taken to remove a non-restorable implant evaluated clinically after one week. The patient stated she had no post-operative steps taken towas remove a non-restorable tooth, graftthe thearea, area, andthen thenreplace replace tooth, graft and discomfort or swelling.

nd function

he

e tooth

al

with2: implant andcorresponding corresponding Extracted tooth ititFigure with anan implant and abutment and crown restoration. abutment and crown restoration. 44-year-oldwoman womanpresented presented AA44-year-old with a severely broken down maxillary with a severely broken down maxillary right first premolar (tooth No.5)5) right first premolar (tooth No. (Figure 1). The decay, already present (Figure 1). The decay, already present in this tooth, had extended far below in this tooth, had extended far below the free gingival margin to the crest the free gingival margin to the crest of bone and into the furcation. of bone and into the furcation. AllAll risks,benefits, benefits,and andalternatives alternativeswere were risks, reviewedwith withthe thepatient patientregarding regarding reviewed treatment. Thepatient patient understood that treatment. understood Figure 4:The Graft material securedthat Figure 4: Graft material secured with sutures the tooth wouldneed needtotobebeextracted; extracted; the tooth would with sutures however, however,she shedid didnot notwant wanta abridge bridge restoration for the final prosthesis. restoration for the final prosthesis. 14 Instead, Instead,she sheinsisted insistedononhaving havingthethe tooth toothextracted, extracted,and andthe thearea areagrafted grafted

Figure 3: Placement of grafting material Figure 3: Placement of grafting material

Figure 5: Healed ridge

Figure 5: Healed ridge Figure 5: Healed ridge

Figure 4: Graft material secured sutures Figure 4: Graft material secured with with sutures

Figure 6: 5 AB Dental USA implant

Figure AB Dental implant Figure 6: I56:ABI5Dental USA USA implant

to to release. Once the the tooth to to create a small trench with a small, ligament release. Once tooth create a small trench with a small, ligament the the flame-shaped diamond burbur to to engage disengagedfrom fromthe thesocket, socket, flame-shaped diamond engage disengaged thethebeak more securely onon solid root waswas removed withwith a maxillary beak more securely solid root tooth tooth removed a maxillary surface. waswas placed, Bone grafting surface.Once Oncethethebeak beak placed, forceps forceps(Figure (Figure2). 2). Bone grafting

When the patient returned 3-months later, the healing abutment was removed and a SmartPeg™ (Osstell®) was attached to the implant to confirm osseointegration. Using the hand-held probe of the Osstell ISQ® unit, the SmartPeg was stimulated magnetically, without actually being connected to it–or even touching it. Positioning it from buccal to lingual and mesial to distal, readings of 82/84 were recorded on the unit. An ISQ (Implant Stability Quotient) is a measurement scale for use with the RFA (Resonance Frequency Analysis) method of determining implant stability. It’s a mapping of resonance frequencies (kHz), presented as a clinically useful scale of 1-100 ISQ. The higher the ISQ value, the more stable the implant. Utilizing a Clip Impression Transfer (AB Dental USA), an impression was taken of the implant with no affixing screw (Figure 9). Suitable for closed tray method, there is no need to remove it or to insert the transfer as it remains in the impression throughout the process. A heavy and light bodied polyvinyl siloxane impression material (Take One® Advanced™, Kerr) was used in a fullarch impression tray. Once the impression material was set, it was removed from the mouth, picking-up the Clip Impression Transfer) and sent to the lab for custom abutment and crown fabrication (Figure 10). When the patient returned for the seating appointment, the Inclusive® (Glidewell) titanium abutment (Figure 11) with corresponding BruxZir® (Glidewell Dental Lab) crown was placed, and another x-ray was taken to verify an accurate fit. Since there were no open margins, and the contacts and occlusion were good, the crown restoration was seated using Maxcem Elite™ (Kerr) cement (Figure 12). Once the cement reached its gel stage, it was quickly cleaned off and any excess removed. The patient was very pleased with the end result and was pleased to have all the services (extraction, grafting, dental implant, abutment and restoration) at one location. Today, patients like to get all their services under one roof. They know, trust, and feel comfortable with their 15


>

Augmentation and regeneration of the alveolar ridge

Restoring an area to proper form and function ‫‏‬Dr. Ara Nazarian

XX XX XX XX

dental provider and usually prefer him/her to perform all their dental procedures necessary to XX XX reach optimum dental health.

Figure Figure 7: Dental Dental implant implant placed placed Figure Dental implant placed 7:7:7: Dental implant placed Figure Dental implant placed Figure 7: Dental Figure 7: Dental implantimplant placed placed

Figure Figure 10:10: FullFull arch arch impression impression

Figure 10:Full Fullarch arch impression Figure 10: impression Figure 10: Full arch impression Figure 10:Full Fullarch arch impression Figure 10: impression

place placeananimplant implantthat thatwould wouldreplicate replicate place an implant that would replicate place an implant that would replicate the the premolar premolar using using a a 3.75 3.75 mm mmx x placean animplant implant that that would would replicate place replicate the premolar using a 3.75 mm the premolar using a 3.75 mm xxx 13 13 mm mm I5 I5 (AB (AB Dental Dental USA) USA) dental dental the premolar premolar using using aa 3.75 3.75 mm the mm x 13 mm (AB Dental USA) dental 13 mm I5I5 (AB Dental USA) dental implant. implant. 13 mm I5 (AB Dental USA) dental 13 mm I5 (AB Dental USA) dental implant. implant. A A2.0 2.0mm mmpilot pilotdrill drillwas wasplaced placed implant. implant. 2.0 mm pilot drill was placed AA 2.0 mm pilot drill was into into the the site site and and advanced advanced totoaplaced adepth depth A 2.0 mm pilot drill was placed A 2.0 mm pilot drill was placed of of 15 15 mm mm measuring measuring from from the the tissue tissue into the site and advanced to a depth into the site and advanced to a depth intothe thesite site and and advanced advanced to to aa depth into depth surface. surface. This This additional additional 2 2 mm mm was was 15 mm measuring from the tissue ofof 15 mm measuring from the tissue of15 15mm mm measuring measuring from from the the tissue of tissue the thesame same depth depth ofofthe thetissue tissue height height surface. This additional 2 mm was surface. This additional 2 mm was surface. This additional 2 mm was surface. This additional 2 13mm was totobone. bone. In Inother otherwords, words, 13 mm mm for for the same depth the tissue height the the same same depth depth ofof of the the tissue tissue height height the the osteotomy osteotomy in in bone bone and and 2 2 mm mm for for sameInIn depth ofwords, the tissue height 16 the bone. other words, 13 mm for toto bone. other 13 mm for to bone. In otherwas words, 13tomm for tissue tissue thickness thickness was created created to place place to bone. In other words, 13 mm for the osteotomy bone and mm for the osteotomy inin bone 222mm for the osteotomy inimplant. boneand and mmpin for a a13 13thickness mm mmlong long implant. A Aparallel parallel pin the osteotomy in bone and 2totomm for tissue thickness was created place tissue was created place

Figure Figure 8:8:8: Healing Healing cap cap Figure 8: Healing cap Figure Healing cap Figure Healing cap

Figure Figure 9:Figure 9: Clip impression impression transfer transfer 9: Clip impression transfer Figure 9:Clip impression transfer Figure 9:Clip Clip impression transfer

Figure Figure 11:11: Inclusive Inclusive abutment abutment placed placed

Figure Figure 12:12: BruxZir BruxZir crown crown placed placed

Figure 8: Healing Figure 8: Healing cap cap

Figure 11:Inclusive Inclusive abutment placed Figure 11: abutment placed Figure Inclusive abutment Figure 11: Inclusive abutment placed Figure 11:11: Inclusive abutment placed

Figure 9: Clip impression Figure 9: Clip impression transfer transfer

Figure 12:12: BruxZir crownplaced placed placed Figure 12: crown Figure BruxZir crown Figure 12:BruxZir BruxZir crown placed Figure 12: BruxZir crown placed ®® swelling. swelling. seating seating appointment, appointment, the theInclusive Inclusive placed ®® swelling. seating appointment, the Inclusive seating appointment, the Inclusive swelling. ® ® (Glidewell) (Glidewell) titanium titanium abutment abutment (Figure (Figure When When the the patient patient returned returned seating the the Inclusive swelling. seatingappointment, appointment, Inclusive swelling. ® ® (Glidewell) titanium abutment (Figure When the patient returned (Glidewell) titanium abutment (Figure When the patient returned 11) 11) with with corresponding corresponding BruxZir BruxZir 3-months 3-months later, later, the the healing healing abutment abutment (Glidewell) titanium abutment (Figure When (Glidewell) titanium abutment (Figure When the the patient patient returned returned ®® ™™ 11) with with corresponding BruxZir 3-months later, the healing abutment 11) corresponding 3-months later, the abutment was was removed removed and andhealing a a SmartPeg SmartPeg (Glidewell (Glidewell Dental Dental Lab) Lab)crown crownBruxZir was was ® ® 11) with corresponding BruxZir 3-months later, the healing abutment 11) with corresponding BruxZir 3-months later, the healing abutment ™™ ® ® was removed and a SmartPeg (Glidewell Dental Lab) crown was (Glidewell Dental Lab) crown was was removed and a SmartPeg (Osstell (Osstellremoved ) was ) wasattached attached totothe theSmartPeg implant implant ™placed, placed, and andanother another x-ray x-ray was wastaken takentotowas ™ (Glidewell Dental Lab) crown was and (Glidewell Dental Lab) crown was was ®removed and toatoathe SmartPeg ® placed, andanother another x-ray was takentoto to (Osstell was attached the implant )®))osseointegration. was attached implant (Osstell placed, and x-ray was taken to toconfirm confirm osseointegration. Using Using the the verify verify ananaccurate accurate fit.fit.Since Since there there were were ® (Osstell placed, and another x-ray was taken was attached to the implant (Osstell ) was attached to the implant placed, and another x-ray was taken ®® hand-held hand-held probe probe ofofthe theOsstell Osstell ISQ ISQ open open margins, margins, and and thecontacts contacts verify an accurate fit.the Since therewere were to confirm osseointegration. Using thenono toto confirm osseointegration. Using the verify an accurate fit. Since there verify an accurate fit. Since there were to confirm osseointegration. Using the to confirm osseointegration. Using the verify an accurate fit. Since there unit, unit,the theSmartPeg SmartPeg was wasOsstell stimulated stimulated and occlusion occlusion were weregood, good, the crown crown no open margins, margins, andthe the contactswere hand-held probe the Osstell ISQ®®®and hand-held probe ofof the ISQ no open and contacts hand-held probe ofof the Osstell ISQ ® no open margins, and the contacts hand-held probe the Osstell ISQ no open margins, and the contacts magnetically, magnetically, without withoutactually actually being being restoration restoration was wasseated seated using Maxcem Maxcem and occlusion occlusion wereusing good, the crown crown unit, the SmartPeg was stimulated unit, and were good, the unit, the the SmartPeg SmartPeg was was stimulated stimulated and occlusion were good, the crown ™ and ™ unit, the SmartPeg was stimulated occlusion were good, the crown connected connectedtotoit–or it–or even eventouching touchingbeing it.it. Elite Elite (Kerr) (Kerr)cement cement (Figure (Figure 12). 12).Once Once restoration wasseated seated using Maxcem magnetically, without actually magnetically, was using Maxcem magnetically, without without actually actually being being restoration restoration was seated using Maxcem ™ ™ Positioning Positioning it it from from buccal buccal to to lingual lingual the the cement cement reached reached its its gel gel stage, stage, it it was was magnetically, without actually restoration was seated Maxcem 5 Elite connected it–or even touchingbeing it. Elite (Kerr)cement cement (Figureusing 12).Once Once (Figure 12). connected toto even touching it.it. ™(Kerr) (Kerr) cement (Figure 12). Once connected to it–or it–or even touching Elite ™ and and mesial mesialitto distal, distal, readings readings ofof quickly cleaned cleaned offoff and and any any excess excess (Kerr) cement (Figure 12). Once connected toto it–or even touching it.quickly Elite Positioning it from buccal to lingual the cement reached its gel stage, it was the cement reached its gel stage, it was Positioning from buccal to lingual the cement reached its gel stage, it was Positioning it from on buccal to lingual 82/84 82/84 were wererecorded recorded on the the unit. unit. An removed. the cement reached its any gel it was Positioning itto from buccal to An lingual and mesial distal, readings quickly cleaned off and and anystage, excess quickly cleaned off excess and mesial to distal, readings ofofremoved.

Restauración de una área con forma y función - Caso 3  

Restauración de una área con forma y función - Caso 3, Dr. Ara Nazarian

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