CASE PRESENTATION
A Multidisciplinary Approach to Restore Esthetics and Function
A female patient presented from a referring specialist for implant restoration. She had a neoplasm in the left mandible removed and had lost teeth Nos. 22 and 23 in the process. Tooth No. 10 also was missing at the time of initial consultation. Following a period of orthodontic treatment to correct tooth alignment as much as possible, the orthodontic appliances were removed, and an articulated full-arch diagnostic wax-up was fabricated to serve as a blueprint for the prosthetic component of the case.
The restorative plan was to place an implant in the tooth No. 22 position and restore Nos. 22 and 23 with a 2-unit cantilever bridge. Tooth No. 10 was treatment planned for a single cement-retained implant restoration. Tooth No. 21 would need root canal therapy, a post and core, and crown due to extensive caries.
Due to the extent of the damage from the neoplasm and the bone remaining after healing of the graft, positioning of the implant in the No. 22 position was very difficult. So, the first step in planning the restorative phase was to get a detailed wax-up fabricated. The wax-up was mounted on a semi-adjustable articulator with a facebow transfer and centric relation bite record. It would be critical to design the prosthetics so that no lateral interferences would be present on the implant-borne restorations. Because No. 22 (canine) was now an implant-borne restoration, the canine disclusion on the patient’s left side was designed to be shared by the first bicuspid so that lateral forces would be shared. Anterior coupling in protrusive and lateral excursions also would help distribute forces so that a more favorable atraumatic occlusion would exist.
Initial Phase Treatment
Temporary implant abutments were placed at the time of provisionalization (Inspire, Clinician’s Choice) to support the transitional prosthesis. To help guard against future recession and bone loss, a secondary periodontal surgery was performed to augment the amount of attached gingiva in the operative area.
After the surgery had sufficiently healed, a closed-tray full-arch master implant impression was made of the maxillary and mandibular arches. A facebow transfer was made, and centric relation bite records were obtained. The following appointment would be a try-in appointment to verify fit of the custom abutment components (ATLANTIS, Dentsply Sirona), including design, arch position, and interocclusal distance. Digital photographs were obtained to help the ceramist in the shading and customization of the ceramic restorations so that a seamless blend could be achieved with the patient’s natural teeth. The restorations were then completed by the laboratory and a delivery appointment was made.
Restoration Placement
During the delivery appointment, shade match, restoration contour, and occlusion were reviewed. Any occlusal adjustments were made as warranted, and the restorations were polished. The cementation of the restorations was then accomplished using a bioactive calcium aluminate cement (Ceramir, Doxa Dental), which allowed for a tight, reliable seal. A 2-week postoperative visit was then scheduled to evaluate occlusion and make any necessary refinements. The patient was more than pleased with the results.
Go-To Product Used in this Case
CERAMIR BIOCERAMIC IMPLANT CEMENT
A permanent, radiopaque bioceramic cement, Ceramir has an inherent ability to form a tight seal with ceramics and metals, making it ideal for implant cementation. It is indicated for implant abutments of metal and porcelain-fused-to-metal restorations and high-strength ceramic restorations that are suitable for conventional cementation, such as zirconia, alumina, and lithium disilicate. Each QuikCap capsule holds a mixed volume of at least 0.17 mL of cement and offers an easy, direct application.
Robert A. Lowe, DDS
Dr. Lowe graduated magna cum laude from Loyola University School of Dentistry in 1982 and was a clinical professor in the restorative dentistry program until the school’s closure in 1993. He maintains a private practice in Charlotte, NC, lectures internationally, and publishes articles on esthetic and restorative dentistry. Dr. Lowe is a member of the Catapult Elite Speakers Bureau and has Fellowships in the AGD, ICD, ADI, ACD, IADFE, and ASDA. In 2004, he received the Gordon Christensen Outstanding Lecturers Award, and in 2005, received Diplomat status on the American Board of Esthetic Dentistry.
