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This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case Case Study by: August de Oliveira, DDS

Here is a case that turned out OK. Not in love with the tissue. Patient presented with a loose bridge from 27-31! Done by my past, non-implant self, about 12 years ago. In retrospect I am surprised it lasted that long! #31 has recurrent decay into the pulp and needs endo. We have a deep and long pontic space and we know there has to be some lack of tissue as well as a sharp ridge. We also know that the implant crowns will look "long" unless we add some pink porcelain. Looking at his occlusion (which again I am surprised this bridge lasted so long) I want to splint the implants.


This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case

You guys know how to get a model out of CEREC right? Here is a stone model we took from an alginate. Just draw a little circle somewhere on the model, it can be an inlay or a crown and just don't care about the proposal, just right arrow to the mill preview and export the whole thing. SICAT will cut away the teeth. Since it was multiple teeth and we needed to do endo on #31, I decided on an optiguide.

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This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case

Very sharp and uneven bone. Planned the implants underneath the pontics of the teeth. Make sure you take away the model and just display the guide sleeves to make sure that they don't overlap. I planned my implants subcrestal and planned to do some ridge recontouring after the implants were placed.

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This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case

Did the endo first on #31 and did buildups on both #27 and #31. We are deficient in keratinized tissue on the buccal but have a lot on the lingual. This patient had some limited opening so we could not fit the isolite. Since we took off the crown on #31 which was our seat, we really had to rely on holding the guide down on the contra lateral side to make sure it did not rock.

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This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case

Finished endo. There was a huge PARL and the sealer really did a big puff. You can see in the image how sharp that ridge was and where the buccal extent of the osteotomy should be. Just for fun, I decide to place the three 4.7mmD by 10mmL Legacy1s through the guide. I know my guide is 22mm tall and the implants are 10mm long. The mount is 12.6mm so with the implants I should have about .6mm sticking out. Not very exact but wanted to give it a go.

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This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case Three 4.7mmD by 10mmL Legacy1 implants were used. Could I have gone skinnier? Sure, but I know I am splinting and I know I am using pink porcelain so I am not worried about cervical emergence profile as it will be one long "mini-hybrid". Placed through the guide with about .5 sticking out and used the ratchet to index. From the get go I knew I was in dense bone so I used crestal bone drills on all sites.

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This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case So here is a problem we have a lot with punches. You can't contour the bone as you are not accessing the ridge. In the radiograph it looks like I really sunk those implants too far. But in the cross-sectional you can see that lingual "fin" of bone. In some systems, you can use a bone reduction guide, but what I try to do is get my implants all covered in bone (#31 I do have one the platform shift exposed) and then, very carefully, use a carbide 557 to level the bone with the healing caps on. Sutured the flap with horizontal stitches on the buccal and just loose verticals (sorry, hard to see under the pontics in the next shot). Made a temp engaging #27 and #31, not the implants and kept the space under the pontics cleansable. Not my best stuff, but I will re-eval the tissue at 3 months. May need to get a FGG after the tissue settles in.

Dr August de Oliveira graduated from dental school in 1997 from the University of Washington and completed his General Practice Residency in Los Angeles in 1998. Dr de Oliveira has been lecturing on 3D technology since 2004, when he started as a CEREC Basic trainer. Since 2008 he has been involved with Implant Direct’s R and D department developing Guided Surgery Software and Hardware and testing their CAD Milled Bars and Substructure Department. Dr de Oliveira has written two books on Implantology: Implants Made Easy and Guided Implantology Made Easy. He has been involved with beta testing Sirona’s Sidexis Program, as well as developing the Opti and CEREC Milled Surgical Guides. Dr de Oliveira lectures nationwide for Sirona on the Galileos Cone Beam system and Sirona Guided Implant Surgery. He also teaches for Implant Direct at their Las Vegas Educational Facility and with the Engel Institute in Charlotte NC. Dr de Oliveira lives and practices in Los Angeles CA.

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This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case  

This, That And The Other Thing: RCT, Uneven Bone, THREE 4.7mmD by 10mmL Legacy1 case

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