12 STARGET 1 I 10 s t r a u m a n n CADCAM s o l u t i o n s A n dr ea s Gr a f MDT, Dr. Karin Wolleb and D r. R onal d J ung Individual anterior esthetics Pa rt 1 : t h e p o ssib i l ities o f S traum ann CADCA M i n comb i nati o n w it h a c o n v entional technique Initial findings and treatment plan The 30-year old patient had lost tooth 21 in an accident about 15 years previously. Tooth 11 underwent root treatment (Fig. 1). As a result of fear of the dentist, the patient continuously delayed treatment of the two teeth and wore a temporary denture with wire clasps for years. The treatment plan envisaged an implant in position 21 and a crown on 11. Since the incisive papilla was clinically directly in the implantation region, digital volume tomography (DVT) was performed in order to clarify the position of the incisive canal. The width of the bony ridge at position 21 was 5 mm measured in the sagittal plane (Fig. 2). Treatment A mucoperiosteal flap was dissected for the implantation with vertical relief distally at tooth 22. As expected, the incisive canal was clinically only slightly palatal to the ideal implant position. The implant site was prepared with the aid of a splint along the buccal boundary of the canal (Fig. 3) without perforating the canal. A Straumann Bone Level Implant (4.1 mm, length 12 mm) could be placed in correct prosthetic position without dehiscence (Figs. 4, 5). Because of the thin buccal bone layer and the concavity of the ridge, augmentation was performed with a bone substitute and a collagen membrane, fixed with absorbable pins (Fig. 6). At tooth 11 the crown was extended approx. 1 mm buccally. The flap was mobilized and sutured over the wound without tension (Fig. 7). The sutures were removed ten days later; the wound area healed uneventfully. Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6
s t r a u m a n n CADCAM s o l u t i o n s STARGET 1 I 10 After healing it was apparent that the soft tissue over the implant did not yet have the desired convex contour and had a rather uneven structure (Fig. 8). Therefore, 8 weeks after implantation, a split flap was dissected buccally in region 21 and a connective tissue graft from the palate was inserted (Figs. 9, 10); in addition, the mucosa was de-epithelialized with a diamond bur in order to smooth the surface. The connective tissue graft allowed volume to be gained buccally (Fig. 11). Eight weeks after graft insertion a mini rolled flap was formed over the implant and folded in the buccal direction with a conical gingiva former (Fig. 12). At the same time, tooth 11 was prepared for a crown and fitted with a direct MDT Andreas Graf temporary. Two weeks later, the impression for the indirect temporaries was taken. In the Master Dental Technician, Dental Technology laboratory, a screw-retained temporary on the implant and a temporary crown for 11 were Studio, Zurich/Switzerland. made using a temporary abutment. The temporaries were fitted (Fig. 13); conditioning of zahntechnik@graf-andi.ch the soft tissue began one week later with application of composite to the neck region of www.graf-andi.ch the implant temporary. After conditioning three times, the desired emergence profile was achieved (Figs. 14, 15). For the final impression, an impression post was customized with composite so that it corresponded to the emergence profile of the temporary (Fig. 16). Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 13
14 STARGET 1 I 10 Fig. 13 clinical cases Fig. 14 Fig. 15 After taking an impression with polyether a model was made that reproduced the gingival conditions perfectly. The patient, dental technician and dentist had agreed beforehand to carry out all-ceramic reconstruction with the Straumann CADCAM system. The Wax Up Design function of the CADCAM etkon _visual software allows wax patterns to be scanned and zirconium oxide frameworks to be produced that optimally support the veneering porcelain. First, a try-in wax-up was made from resin and tried in the patient; minor esthetic corrections were made (Fig. 17). Using a silicon index of the wax-up, the frameworks for crown 11 and the directly screwed implant crown 21 were Dr. med. dent. Karin Wolleb formed from scannable wax (Fig. 18). The modeled frameworks were placed in the 3D Dental resident at the Department of Fixed and scanner and scanned (Fig. 19). These data were then sent via the Internet to the milling Removable Prosthodontics and Dental Material center. Three days later the frameworks arrived in the laboratory (Figs. 20, 21) and the Sciences, Center for Dental and Oral Medicine, accuracy of fit was checked on the model. After that, the frameworks were veneered University of Zurich. with porcelain (Fig. 22) and the biscuit bake was tried in in the patient s mouth. The crowns karin.wolleb@zzmk.uzh.ch were then completed and fitted (Fig. 23). An opaque white composite cement was used for www.dent.unizh.ch the crown on tooth 11 in order to prevent the dark color of the die from showing through. Fig. 16 Fig. 17 Fig. 18 Fig. 19 Fig. 20 Fig. 21
clinical cases STARGET 1 I 10 Treatment outcome and conclusion On follow-up two months after insertion, the appearance was satisfactory and the two crowns harmonized well with the rest of the dentition (Fig. 24). The soft tissue in region 21 was similar to the rest of the gingiva in color and texture, and the papillae mesial and distal to 21 were almost completely filled up (Fig. 25). In the final radiograph, an optimal course of the marginal bone could be seen (Fig. 26). The patient appeared highly satisfied with the restoration. PD Dr. med. dent. Ronald E. Jung Deputy director of the the Department of Fixed and Removable Prosthodontics and Dental Material Sciences, Center for Dental and Oral Medicine, University of Zurich. ronald. jung@zzmk.uzh.ch www.dent.unizh.ch Fig.22 Fig. 23 Fig. 25 Fig. 26 Fig. 24 15
August Bruguera MDT and Dr. Javier G. Fabrega INDIVIDUAL ANTERIOR ESTHETICS PART 2: THE POSSIBILITIES OF STRAUMANN ZrO 2 STOCK ABUTMENTS IN COMBINATION WITH A CONVENTIONAL TECHNIQUE Initial findings and treatment plan The 37-year old male patient presented with a severe erosion syndrome, due to past regurgitation of digestive acids. Tooth 11 had been restored with an old full contour metal-ceramic prosthesis that suffered with repeated loose of retention, deficient fit and unsatisfactory esthetic appearance. Tooth 21 had an extensive palatal wear due to erosion and break down of the extremely thin incisal edge (Fig. 1). The preoperative diagnosis led to the following list of conclusions and challenges: Poor prognosis for tooth 11 due to insufficient root length and ferrule effect in the remaining supragingival tooth structure. Good prognosis for tooth 21. Endodontic treatment with post and core reconstruction was identified, due to tooth sensitivity and to ensure proper tooth preparation contours. Insufficient restorative space (palatal) was detected for both teeth. An orthodontic treatment was proposed but rejected by the patient. A simulation in the study casts showed the amount of odontoplasty of the opposing dentition that would be needed to ensure enough restorative space. This was the alternative accepted by the patient. High aesthetic risk was identified due to a high lip line although the biotype could be considered favorable (thick, not very scalloped). The treatment plan envisaged the extraction of tooth 11 and an immediate placement of a dental implant with provisional restoration. An endodontic therapy with post and core build-up for tooth 21 was planned and the final restoration was defined to be realized with two full contour all-ceramic crowns on a Straumann Anatomic IPS e.max Abutment (position 11) and the prepared tooth (position 21). 1
Fig. 1 Fig. 2 Treatment A traumatic extraction of tooth 11 was performed, followed by an immediate flapless placement of a Straumann Bone Level Implant (Ø 4.1 mm, SLActive 10 mm, Fig. 2). To provide adequate means for an immediate provisional restoration, a Straumann Anatomic IPS e.max Abutment (straight, GH 3.5) was selected, the cement line was prepared to the appropriate level to obtain a slightly sub-mucosal margin. Afterwards, an acrylic resin shell was relined, trimmed and polished to the desired contours, and cemented in place (Figs. 3-5). Fig. 3 Fig. 4 Fig. 5 Fig. 6 2
Uneventful healing followed, with little mucosal recession taking place in the buccal aspect. Tooth 21 was built up and prepared to receive an all-ceramic full contour restoration. Three months after implant placement, a final impression was made, including the use of an open-tray impression post that was customized with composite to mimic the submucosal contours of the abutment and provisional restoration and the prepared tooth 21 (Fig. 6). For the final restoration, a Straumann Anatomic IPS e.max Abutment (15 angled, GH 3.5) was selected and slightly adapted to match the contour of the final anatomy of the clinical crown with the actual tissue level. IPS e.max ceramic was used to create two copings that were then worked up to ideal contours with the appropriate esthetic IPS e.max ceramics ZirPress and Ceram (Figs. 7-9). After the bisque try-in, the restorations were finished and were ready to be delivered. Please note the contours of the abutment-crown complex, with an initially narrow sub mucosal emergence profile that expands to natural crown contours at the CEJ level (Fig. 10). The Straumann Anatomic IPS e.max Abutment was then screwed in place with a 35 Ncm torque, and both all-ceramic crowns were cemented with composite cement. Fig. 7 Fig. 8 Fig. 9 Fig. 10 3
Treatment outcome and conclusion The excellent biologic and esthetic results can be appreciated in the 6-month recall and radiograph (Figs 11 and 12). The patient was highly satisfied with the outcome. Fig. 11 Fig. 12 CONCLUSION These two clinical case reports show different approaches of achieving excellent anterior esthetics by using either a CADCAMbased restoration or the Straumann Anatomic IPS e.max Abutment, depending on the specific conditions. Straumann CADCAM Solution: Maximum flexibility in abutment design Because of the flexible computer-based design, naturally shaped abutments can be produced in a comfortable way. These have an optimal anatomical emergence profile and can also be used in demanding clinical solutions. By outsourcing fabrication to the specialized Straumann Manufacturing Center, considerable time and cost savings can be achieved. Straumann Anatomic IPS e.max Abutment: Realizing a complete ceramic restoration if a CADCAM System is not available. With the use of the Straumann Anatomic IPS e.max Abutment the restorative team can apply an anatomically formed, ZrO 2 stock abutment and make first steps and experiences with highly esthetic, prefabricated anatomic ceramic abutments, which might build the basis for future use of advanced CADCAM ceramic technologies such as the Straumann CADCAM System. The possibility of modifying the Straumann Anatomic IPS e.max Abutments chairside leads to additional treatment flexibility. 4