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Spring Case: Maxillary Anterior Implant Case

I recently had a great opportunity to perform dental care on an Iraqi veteran who had lost several maxillary anterior teeth due to trauma. The patient was referred by a prosthodontist in our small city in Kentucky. It was an absolute pleasure working with a prosthodontist on this case. The veteran is a young woman who had just returned from Iraq and was missing teeth #9, #10 and #11. She was wearing a temporary flipper for replacement of these teeth.


I have for several years now used Materialise Dental’s SimPlant® Pro software for my implant planning. When introduced to the technology I started using SimPlant® Planner, but upgraded to Pro for the convenience of quickly getting the case going! Since Materialise Dental has developed 3D segmentation, one can easily clean up scatter and separate bone, teeth, barium pontics, etc. within a reasonable time frame and ‘get the case going’. Also, SimPlant® version 12 now has allowed for speed in previewing the SurgiGuide® before ordering. This is great enhancement for the fact if any changes need to be made it is found before guide construction. One can tweak the plan and make any adjustments as you can see where the guide sleeves are positioned in the treatment plan. Just awesome!

Fig.1

 

This is a maxillary anterior case (Fig.1) which is always challenging due to esthetic demands along with function. Due to the trauma, there is a vertical discrepancy from onset with a higher gingiva/ridge display on her left side. One thing great about Materialise Dental USA is that once a month on-site training is offered at the Glen Burnie, MD location. I brought this case to the training session and several doctors helped with ideas of planning one of my first cases with SimPlant®.

Fig.2

 

 

The prosthodontist fabricated an excellent-fitting barium scan prosthesis (Fig.2) which revealed the necessary positions of the pontic teeth. I would like to encourage clinicians using this technology to always have a scan prosthesis with barium teeth set to occlusion before scanning the patient. This may not be possible in certain instances but at least SimPlant® allows for Virtual Teeth planning if no prosthesis is constructed.

Fig.3

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A plan (restorative driven) of immediate load out of function with two implants in positions #9 and #11 (Fig.3,4,5) was considered.

Fig.5

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Fig.7

 

 

 

This would involve the presurgical construction of a provisional bridge #9-#11 (Fig.6,7,8) by the prosthodontist.

Fig.8

I have for many years now preferred ‘guided’ implant placement. I guess you would say I’m just hooked on ‘guided’ implant surgery. SimPlant® has been the backbone in my planning of cases because of the large selection library of implants (recently updated) and diverse placement in 2D with 3D comparison. It is a snap to plan a case dropping the implant in 2D and aligning its location in a 3D cross-sectional view.

The plan was completed placing two NobelReplace RP ‘Groovy’ tapered implants in position of missing teeth #9 and #11. The beautiful 3D model in SimPlant® helped locate adjacent anatomical structures such incisive and infraoribital foramens. The case was ordered using the swift and easy online process and arrived within a 7 to 10 day time frame. The cast model was sent to Glen Burnie for scanning to hasten the process, and Materialise Dental shipped it overnight to the production facility in Belgium. The SurgiGuide® was then quickly fabricated and returned with the model.


With the Nobel Biocare workflow protocol, guide cylinders with implant replicas are positioned in the SurgiGuide® and retrofitted in the model. This gives an accurate index of the future implant positions at the time of surgery. A provisional bridge #9-11 is then constructed for later immediate placement.

Fig.9

Fig.10

 

The ‘guided’ surgery was performed following the step sequence of protocol utilizing the nicely fitted and designed SurgiGuide® (Fig.’s 9-12). The SurgiGuide® was placed in chlorohexadine prior to surgery to allow proper asepsis for use. The implants were connected to mounts and torqued to the planned depth control – another advantage of SimPlant® planning. Healing screws were placed in the implants for transition to the prosthodontist office where the provisional was placed immediately ‘out of function’.

Fig.11

Fig.12

After the 4-6 month healing period and osseous integration successful, crown-lengthening was performed on the right side to correct esthetic symmetry. This case involved the interdisciplinary of dental procedures in order to accomplish the desired esthetic outcome.

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Fig.14

 

 

 

The final construction of fixed prosthesis was placed by the prosthodontist, and the combined effort to reconstruct her esthetic appearance to a beautiful smile was well appreciated by the patient (Fig.13-15).

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#9 implant final X-ray

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#11 implant final X-ray

Go ‘guided’ in implant surgery for minimally invasive, flapless, and accurate implant placement with controlled depth. It is like a stress relief to know you have done your homework and pre-planned the case with SimPlant®. Thanks to Materialise Dental for the development of sophisticated software with SurgiGuide® fabrication to allow implant planning and be able to accurately position implants in ‘guided’ surgery.

Phillip P. VanMeter, DMD

Practice Limited To Periodontics
627 Eastwood Avenue
Bowling Green, KY 42103

Phone: (270) 781-2772
Email: drphilvm@insightbb.com


Joseph C. Steele, DMD, MS

Practice Limited To Prosthodontics
901 Wilkerson Trace Ste. 1
Bowling Green, KY 42103

Phone: (270) 842-0084
Email: drsteele@insightbb.com

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