Dr Rao Implant treatment on missing UL5
Dr Alfonso Rao is the Clinical Director of The Queen Square Dental Clinic in Bristol. Here he provides a review of an implant case he completed using the Carl Zeiss EyeMag Pro dental loupes.
A female patient aged 51 presented with a lost maxillary second premolar on the left side that had been caused by a failing root canal treatment and crown (fig. 1). A personal assistant, she was a non-smoker with good oral hygiene who kept regular dental appointments and consumed on average no more than 3 units of alcohol per week. Her medical history was clear apart from hay fever and an allergy to penicillin.
Her desire was to restore the upper left 5 with a fixed prosthesis.
Clinical Exam and Diagnosis
A clinical exam, using Carl Zeiss EyeMag Pro loupes revealed a class one occlusion with canine guidance on lateral excursions on both sides. There was a posterior support shim that held all posterior teeth. There were no signs of Para functions (fig. 2).
The soft tissue was of a thin gingival biotype, and the tongue, buccal mucosa and palate and floor of the mouth were all NAD. There was a BPE of 0 and 1 all round (fig. 1-3).
The hard tissue revealed a missing UL5, moderately restored dentition and buccal concavity. A radiographic investigation, consisting of a Pa and CT scan was conducted
and to complete the diagnosis stage a study model and full contoured wax up for the UL5 was made (fig. 4-8).
The space analysis revealed an 8.5mm interdental distance, the interocclusal space was 10mm and the buccal concavity was noted.
Following the clinical examination, radiographic survey of the area to be treated and examination of the articulated study models on a semi-adjustable articulator in ICP, it was possible to make a diagnosis: there was good bone volume, 11.7mm to the maxillary sinus floor, 5mm minimum width.
After completing the examinations and diagnosis the following treatment options were made available to the patient:
1. Leave the gap as it was
2. Provide a denture
3. Apply an adhesive bridge
4. Apply a conventional bridge
5. Implant treatment
The patient opted for the implant treatment and the consent details and information were provided and agreed to.
The treatment plan was outlined as below:
Diagnostic work out:
Study model, jaw registration
Full contour diagnostic wax up
Construction of rigid clear acrylic surgical stent
Endosseous implant placement (one stage)
Placement of Nobel Replace tapered groovy implant (4.3 x 10mm)
Open tray pick up impression
600 mg Clindamycin and Ibuprofen was given one hour prior to surgery. Then the surgical stent was tried in place (the gingival margin was at the same level of the CEJ of the adjacent teeth) and left in corsodyl for 20 minutes. The patient then rinsed with corsodyl for 60 seconds. 3ml Septanset 1:100,000 was used for buccal and palatal infiltration. A surgical flap was then designed with a 15c scalpel with a crestal and intrasucular incision. An incision was made on the mesial aspect of the UL4 (fig. 9-10).
Once the surgical stent was in place, osteotomy was achieved with a twist drill up to 4mm. The drilling sequence was completed in accordance with Nobel Biocare Replace protocol up to a 10mm depth and regular diameter (4.3mm) (fig.11-12).
The site was then prepared to 3mm below the gingival margin (and CEJ). The buccal bone was kept and no threads were exposed, also there was not any communication with the maxillary sinus. The implant was then placed with 40Ncm torque and the stability was checked (fig. 13). The healing abutment was placed 4.3 by 5mm (fig. 14), and the flap was sutured without any tension with interrupted sutures (Vycryl 4.0) (fig.15). Successful haemostasis was achieved and post-operative instructions were given to the patient, both verbally and written.
Pick-up impression with open tray
3 months after surgery impression were taken using the open tray technique, using a medium body polyether impression material.
Impression coping was used and a periapical radiograph was taken to ensure that it was correctly seated, a shade was also taken at this appointment, the opposite arch was recorded with alginate and the bite was registered (fig. 18).
A final crown was returned from the lab and checked to ensure correct shade, contact point, lack of damage and a good passive fit (fig. 19). On the lateral excursions and protrusion there were no contacts between implant crowns and antagonistic teeth.
The patient was happy the crowns and consented on the permanent fit. The implant crowns were then screwed on fixtures to 35Ncm and the screw heads were covered with PTFE and the access hole was restored with flow composite.
At the review appointment four weeks later, the patient reported no problems with the treatment. The flow and PTFE were removedand the screw was tightened again to 35Ncm. PTFE was used to cover the screw heads and composite was applied to restore the access hole. Finally, the occlusion and contact points were checked to a satisfactory degree (fig. 19-20).
This treatment was completed using the Carl Zeiss EyeMag Pro loupes, and I have always used loupes in my practice, using them for at least 90% of my dentistry. The visualisation offered through using dental loupes is essential when undertaking such treatment as it delivers unparalleled access to the smaller details of the oral cavity.
During the treatment I didn’t create a temporary crown as the issues was not in the aesthetic zone and the patient was not concerned about its appearance.
However, if I were completing this case again I would perform a GBR to improve the aesthetic outcome and better fill the buccal concavity.