A healthy 41-year-old woman presented who was unhappy with the appearance of her front teeth. She was especially self-conscious of the space between her central incisors, as well as the results of previous dental treatments. She also wanted 2 missing lower molars replaced. Although she was aware she needed extensive dental work, she wanted to have it completed as quickly as possible and, preferably, in one appointment.
The patient reported that she had very unpleasant dental experiences in the past, and subsequently avoided dentists. She was very anxious about having any dental work done at all. She requested that sedation be used during treatment because she wanted as much work as possible completed in one appointment.
The patient reported having asthma, which was well controlled with a rescue inhaler. Her health status was ASA type 1, and she was a “recreational” smoker.
Treatment Plan
We started by updating all of her diagnostic records, and she participated in a sedation consultation. A diagnostic wax-up was fabricated for her approval. Using Glidewell Laboratories’ digital Diagnostic Wax- Up helps simplify the process in 3 ways: 1) The patient can see and approve the wax-up prior to the tooth preparation appointment, which helps ensure the result will be predictable and she will be happy with the final result; 2) Glidewell can provide a reduction guide, which makes properly reducing the teeth simple, efficient, and safer; and 3) Glidewell can store a digital copy of the wax-up so that the final restorations are exactly as the patient initially approved. Streamlining case planning with Glidewell Diagnostic Wax-Ups is a key step in simplifying complex cases such as these. Next, the OP300 (KaVo Imaging) was used to obtain a cone beam image and plan the surgery (Figures 1–3). A model and surgical guide were fabricated by Anatomage.
It was explained that the treatment plan would comprise removing all of her previous dentistry and any new decay on teeth Nos. 2–15. Existing restorations would be restored with crowns and veneers fabricated by Glidewell Laboratories using IPS e.max (Ivoclar Vivadent), and implants would be placed where mandibular molars were missing. The treatment plan would take place under oral sedation. A pre-sedation work-up was completed, including cross-referencing the patient’s medications with the sedative drugs.
Treatment Appointment
Following the sedation protocols and training from the Dental Organization for Conscious Sedation, the patient was directed to take 0.25 mg of Triazolam an hour before surgery. When she arrived, a pulse oximeter was attached, and her level of sedation was evaluated. She asked for more sedation, so 0.5 mg Triazolam was given sublingually and allowed to dissolve for 30 minutes. Then, nitrous oxide/oxygen (N2O/O2) was given for 15 minutes, and local anesthetic was administered.
TSI implants (OCO Biomedical) were placed in the Nos. 30 and 31 tooth sites using the surgical guide (Figures 4–8). Old restorations and decay were removed, and all maxillary and mandibular teeth were prepared for restoration following the diagnostic records. Approximately 2 weeks after surgery, cementation of the final restorations was completed with the N2O protocol. The restorations were bonded with OptiBond XTR and NX3 (Kerr Restoratives). The implant cement used was Nexus RMGI (Kerr Restoratives).
The total treatment time was 2 hours. Later, the patient reported little memory of her sedation appointments and she felt as though the appointments went by quickly. She experienced only minor discomfort and needed very little additional pain medication after her surgical appointment. At her follow-up appointments, the patient said she now feels confident about her smile (Figure 9).
