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Dr Rao Implant Treatment



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). fig. 1 patient missing ul5A 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). fig. 2 patient before treatment
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). fig. 3 view of upper jaw
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).

fig. 4 initial radiograph showing missing UL5 fig. 5 Radiographic analysis Fig. 6 Study model on articulator fig. 7 full contour wax up fig. 8 Surgical acrylic stent

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:
First Stage:  
Diagnostic work out:
Study model, jaw registration
Full contour diagnostic wax up
Construction of rigid clear acrylic surgical stent

Second Stage:
Endosseous implant placement (one stage)
Placement of Nobel Replace tapered groovy implant (4.3 x 10mm)
Healing Abutment

Third Stage:
Restorative procedure
Open tray pick up impression
Final crown

Fourth Stage:

Surgical Placement
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).

fig. 9 fig. 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).

fig. 11 fig. 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). fig. 13 Implant placedThe healing abutment was placed 4.3 by 5mm (fig. 14), fig. 14 healing abutment in placeand the flap was sutured without any tension with  interrupted  sutures  (Vycryl  4.0)  (fig.15). fig. 15 flap closed with interupted sutures 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). fig. 18. 3 months after surgery

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). fig. 19 final crown shwoing good passive fit on the modelOn 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.

Review appointment
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). fig. 20 front view 4 weeks after treatment

Reflective comment
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.

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