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My First (Restoring) Implant Case

Discussion in 'Case Presentations' started by patmo141, Mar 27, 2012.

  1. patmo141

    patmo141 Member

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    Ok, here goes. My first ever real case presentation. I'm very excited to get the opportunity to restore some posterior implants at school. This case is just getting started and I need to get in the habit of good documentation so consider this a practice run. I'm a 3rd year dental student and the implant placement and surgical phase of this will be handled by our perio department here at school. We use Straumann tissue level for the most part in the posterior but the final decision will be made after CT scan and consult with perio department.

    Healthy 39 yo male. No contributory medical history. This patient was transferred to me with all his restorative work complete and his chief complaint was "I want the spaces in the posterior filled, and I would like to whiten and possibly take care of the chips in the front."

    I'll post more pictures as we go on :) No need to go easy on me, this is my first case presentation and my goal is to get feedback. One small disclaimer...I took these clincal photos by myself (no one to blow air) with a Pentax Optio W80 which was included in our instrument distribution (a water resistant point and shoot camera). Some of the model shots were with a Canon T3 w/ Ring Flash and 100mm macro lens.

    [PICASA="104261288860868281952"]CasePresentation[/PICASA]


    Some questions that I see popping up....

    Q: OMG is he wearing a night guard appliance?
    A: Yes, it was given to him about a year ago by his previous student dentist. Headaches, neck aches and facial muscle pain and muscles of mastication soreness have all been reduced. Patient also reports lowering stress in his life.

    Q: Hmm..those cervical toothbrush/abfraction lesions look suspicious. What's the plan there?
    A: Patient reports no sensitivity and we have established appropriate brushing technique with soft bristled brush and proper stroke (although I suspect the problem was more the bruxism). All are carries free. We will be monitoring them.

    Q: I see some rotated teeth, was orthodontics discussed with the patient?
    A: Yes, patient declined.

    Q: The ridge looks a little narrow/sharp near #19, are you considering augmentation?
    A: TBA CT Scan, probably so.

    Q: Are you worried about the supererruption of #3?
    A: Yes, we will may end up using a custom or prepable abutment to gain some clearance and probably a little enamel-plasty.
     
  2. amadent

    amadent http://amadent.net/Home.p

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    cant see your photo's
     
  3. rkm rdt
    Artistic

    rkm rdt Well-Known Member Donator

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    Never practice dentistry during Earth Hour ! :D
     
  4. corona

    corona Member

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    looks white .....oh wait theres no pic . wheres the pic???
     
  5. patmo141

    patmo141 Member

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    Hmm, it's supposed to be a slide show. i could see it, I changed the permissions. Now I think it should be good.

    -Patrick
     
  6. CatamountRob
    Amused

    CatamountRob Banned Member Donator

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    I still only see text....
     
  7. Jo Chen

    Jo Chen Active Member

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    Nice documentation and a great idea to ask on this forum for feedback. The team approach is touted by many speakers but most of the time the tech is forgotten.
    Remember to make the occlusal table a little narrower buccal/lingual for implant restorations, this should already be reflected in the diagnostic wax up. The pictures do suggest a narrow bony ridge. If you have enough bone height this could be flattened during surgery. A saggital slice from the CT will clue you in how much height is available and how much the ridges can be flattened.
    May I suggest making a CT appliance with radio opaque teeth, this would help in determining the tissue height, not just the relation between bone and planned restoration. Make sure the radio opaque material touches the tissue.
    #30 might need to be planned as a screw retained crown.
     
  8. patmo141

    patmo141 Member

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    Jo Chen, is the slide show working for you here in the forum?

    -Patrick
     
  9. Jo Chen

    Jo Chen Active Member

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    Yes, perfectly.
    Some of my brethren may not be up to date with their technology.:D
     
  10. subrisi

    subrisi Member

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    I have the newest I pad here and I don't see pictures. So it can't be out dated technology.
     
  11. rkm rdt
    Artistic

    rkm rdt Well-Known Member Donator

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    I see the pics now and they are excellent.

    I like screw retained as well, especially when there is an adjacent pfm ( you could remove the implant crown to access the pfm if it ever fractured)

    One issue that I see often is with the interproximal embrassures. How do you close the spaces when there is loss of tissue or when the adjacent teeth tilt towards the edentulous area?
    Maybe not so much in this case but there still will be a slight potential food trap regardless of the path of insertion. You can't always modify the adjacent contacts as is the case with the mesial of the pfm.
     
  12. paulg100

    paulg100 Active Member

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    Working fine here, looks good pat.

    and Id say your right about the upper 4. Thats abfraction, not abrasion, especially considering the occlusual wear.

    So you in dental technical school right? im amazed your covering and documenting cases in detail like this.

    This is soooo much more than the guys get to do in the schools in the UK.
     
  13. Rex Kramer
    No Mood

    Rex Kramer HMFIC

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    Patmo141, here is an article I published online back in 2004 on embrasure problems we see in the lab all the time that is easy to prevent.

    fyi this site no longer is up this just a link to an old article:

    RestOraDent

    rex
     
  14. rkm rdt
    Artistic

    rkm rdt Well-Known Member Donator

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    That's a great artical Rex! Discing (sp?) is probably the best way to address this as you say however how would you deal with the adjacent pfm?

    Should that be considered when determining the angle / axis of the implant?
     
  15. Rex Kramer
    No Mood

    Rex Kramer HMFIC

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    I just put those pictures on a postcard and sent them out to my accounts, they get it right off and I never see it again from those guys....

    Funny how a picture really is worth a thousand words... once they SEE the tilted tooth as we see it...they dont forget

    rex
    -
     
  16. Al.

    Al. Well-Known Member

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    Great link Rex, that is also the most common problem I see along with the upper that has dropped.
     
  17. Rex Kramer
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    Rex Kramer HMFIC

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    Hey thanks for the comments guys... yea Al the opposing dropping into edentulous space is common here too.... frustration at times..its like they dont even notice it... lol

    rex
    -------
     
  18. patmo141

    patmo141 Member

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    @Jo Chen
    The protocol at the school is to place a gutta percha marker in the center of the acrylic where the restoration is planned. So I probably will not have the "down to the tissue radiopaque teeth" that you are suggesting. I don't have a whole lot of say in the matter but I can definitely ask. Pictures tomorrow if I get the appliance back from the lab (we wax it, they fab it).

    I'd like to hear more about the screw retained option in this particular site (#30). Here is what I'm thinking now without having the CT scan yet.

    Assume we flatten the ridge to the red lines shown in the photos, and disk 0.5mm off the opposing. That leaves us with 7.5mm clearance. The standard tissue level implants we use have 2.8mm necks and the shortest abutment is 4mm. That leaves us with 7.5 - 6.8 = 0.7mm of clearance (not enough). So I need an extra 1 - 1.3mm. I feel like I am right on the borderline between just reducing a prepable abutment vs having to go screw retained (minimum abutment height after modification is 3mm according to the Straumann manual). So, if we are cool with 1.7mm clearance and the absolute minumum reccommended abutment height, we can get away with stock parts modified in the mouth.

    @Paul
    I'm in Dr's dental school (the dark side). Hopefully we can still be friends :) Case documentation is an increasing aspect of our curriculum and while it can be a pain sometimes, I'm really glad they are pushing it.

    @Rex
    Thanks so much for the suggestion. It's interesting, I have the supereruption on one side, and the tipping on the other. We disk for cast RPD's I see no reason why we couldn't to improve embrasure form and gingival health in implant scenarios as well. I'll bring that up to my professors. Plus, the rotation plus abraction/abrasion lesion of #20 is going to really exacerbate the embrasure issue which is really apparent in this photo.

    alh3.googleusercontent.com__RG91EAKcJIQ_T3IoaDlcicI_AAAAAAAAAjM_lf_2hAQoY0c_s720_IMG_1482.JPG
    alh3.googleusercontent.com__RG91EAKcJIQ_T3IoaDlcicI_AAAAAAAAAjM_lf_2hAQoY0c_s720_IMG_1482.JPG
     
  19. patmo141

    patmo141 Member

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  20. Al.

    Al. Well-Known Member

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    Did you use baseplate wax?
     

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