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May 6, 2009 | DentalProductsReport.com Exclusive
Chairside Confidential

Take it to the next level

Quality continuing education can help you achieve successful clinical outcomes.

by Dr. Marilyn Gaylor, visiting faculty member at the Scottsdale Center for Dentistry’s Spear Institute for Advanced Dental Education.

Thanks to the knowledge we now have about bone and soft tissue response to tooth loss, we can accomplish implant crown restorations with outcomes that are determined before the tooth is extracted. Beautiful results achieved by many dentists have been published in dental literature.

An education appreciated

My mother has an eighth grade education and she lived during the Great Depression. Her father made her quit school and pick cotton to help support her family. She told me she stood in the cotton fields and cried as she watched other kids walk down the dirt road to their high school. Her dream was to earn an education, and I have had the opportunity to live my mother’s dream. I am thankful there are teachers in this world who want others to be more than they are, and they have devoted their lives to making others better.

But what if you consider yourself the average dentist? What if you have average knowledge and a small practice? In my own experience, I received some disappointing results from attempted implant crown restorations. Yes, they were good, but I wanted something better. Every time I had a case I felt would be successful, something happened that left me disappointed.

I felt somewhat out of control, and I wanted to feel from the beginning that I knew what the results would be. I didn’t want to disappoint myself, or more importantly, my patients. Could this procedure be done, and could I feel good about what I had done at the end of the day?

That’s where CE comes in

First, I found a teacher who treated me with respect. He made me feel good about what I knew all along, and after every class I felt I had accomplished something. I was thrilled with the experience and felt I was given more than I expected. He taught me in a way that simplified matters.

All students need a teacher who believes in them. I found that because of the respect I was given, I had more confidence in my decisions. Someone once said thoughts are things. I have found that where we are today is because of where we were yesterday. I am today because of what I thought in the past. Through these continuing education classes, I knew I could be at a higher level; it was possible.

My continuing education gave me the insight to put the factors together that determined the outcome of this successful restoration of an implant-retained single central incisor crown.

The key factors

Factor No. 1: Photography and treatment planning. Photographs were analyzed to visualize the final outcome, and the case was started.

Refer to slideshow for figures

Smile evaluation. From this view, tooth position and incisal edge position were evaluated (Figs. 1 and 2).
Tooth position. Where should this tooth be in relation to where it is now?
Incisal edge position. Does the incisal edge of the tooth follow the curve of the lower lip? If not, where does it need to be? Is it in the right position, or does it need to be placed more gingival or more coronal (Figs. 1 and 2)? How do we get an end result with the tooth in the desired position? In this example, the pre-op photo shows the smile with tooth No. 8 being 1 mm, coronally placed to tooth No. 9. The tooth has supraerupted. Tooth No. 9 is in the correct position, and ideal placement of the crown on tooth No. 8 would be to closely mimic the position of tooth No. 9. The tooth needs to be 1 mm apical to where it is now.
Soft tissue evaluation. At this point, the gingival tissue should be evaluated. For this evaluation, you will need a retracted frontal view of the teeth (Fig. 3). Free gingival margins and papillary heights should be evaluated. Where are they now, and where do we want them to be in the final result? In this example, the free gingival margin is coronal to the adjacent central, and the ideal position would closely mimic tooth No. 9. The final tissue level is determined by the bone levels on the adjacent teeth. Bone levels are determined through radiographs and will also determine interproximal bone height. Periodontal probing is used to verify facial and lingual bone levels.

Factor No. 2: The surgical phase

Click here for a list of upcoming courses at the Scottsdale Center for Dentistry.

If the soft tissue and bone are preserved during and after the extraction, the average amount of bone loss will be 1 mm around an implant. (Dr. Frank Spear, The Restorative Connection for Ovate Pontics or Implants, 2006)

In this case we have a bone level 4 mm from the desired height of the free gingival margin and the papilla. Approximately 1 mm will be lost after extraction if the tissue is supported. After 1 mm is lost during extraction, tissue level will follow and be ideal once healing has occurred.

The surgeon should have the knowledge and ability to perform atraumatic tooth extraction. The bone must be supported during extraction if papilla heights are to be maintained. This can be done with atraumatic tooth extraction where the soft tissue and bone are preserved. This extraction is carefully performed and usually involves additional treatment time compared with normal extraction. While the duration for a normal extraction can be 3 to 10 minutes, an atraumatic extraction can take an hour or more. After atraumatic extraction, the tissue levels are close to where they were before extraction (Fig. 4).

Factor No. 3: The laboratory technician

The laboratory technician holds the key to the treatment’s final outcome. In the case of this single central, the restoration will require more time on the part of the laboratory technician. In my own experience, the ability of the laboratory technician to create a restoration in the anterior maxilla with a natural appearance requires expert skill and ability. Final gingival levels and form are created by the restoration and not the surgeon (Dr. Frank Spear, The Restorative Connection for Ovate Pontics or Implants, 2006). A NobelActive Implant was placed and an index was made at the time of surgery.

The index, impression coping and a prefabricated zirconia NobelProcera esthetic abutment were given to the laboratory technician, and final impressions were made five days later. ZR Adhesive Paste, a special adhesive, was applied to the zirconia abutment to bond the porcelain to the zirconia coping. The restoration was screw retained, allowing the soft tissue to be pushed into optimal position (Fig. 5). With the ceramist’s skill and proper ceramic selection, it was possible to create an implant crown to match a single central incisor.

Working together
This case was started with a visualization of the final outcome through photographs, radiographs and a comprehensive clinical examination. Once the treatment plan was complete, key team members—including the restorative dentist, the periodontist and the laboratory technician—began to create the definitive crown restoration. It was the collaboration of these three individuals, as well as the confidence and knowledge gained from continuous education, that made this case a success.