It’s funny how things come in cycles / clusters. Immediate implant provisionals seem to be my “thing,” lately.
I enjoy the challenge, and each case is a bit different. So, it seems I’m inventing new techniques as I go with each case.
Today’s case is a new patient. She moved down, mid-treatment, from “up north.” Her periodontist up north had placed an implant in site #9. Apparently, #10 had been grafted to prepare for a future implant. In the mean time, she has been wearing an Essix retainer as a temporary.
Her periodontist up north referred her to a periodontist here, who happened to be “my periodontist.” And, then my perio referred her to me. The plan was for my perio, Dr. Gornstein, to uncover implant #9 and place implant #10. Then I would place immediate provisional crowns on both.
I started with an exam and study models. I sent the study model for a wax-up of #’s 9 and 10.
Instead of getting a wax-up back, I got what appears to be a printed model and a putty matrix (I didn’t request the matrix – usually make’em myself, but OK).
The appointments were set, and the patient would come directly to my office from the perio.
As I initially examined the surgical result, I didn’t think I’d need to reduce the temp (PEEK) abutments, but I wasn’t sure. The putty matrix is opaque, so with that, I could only “feel” if there was any interference. But, I wouldn’t be able to see if there was adequate clearance to avoid “show-through” of the abutments in the provisionals.
Then it occurred to me that I could make a quick transparent stent on the lab’s printed model! Hooray! I took the model to my office lab and used my MiniStar pressure former. I decided to use the “Copyplast” material. It’s not completely transparent, but transparent enough. But, it’s flexible, and I would be able to get it off the model and trim it quickly.
Then it occurred to me that I could use this matrix to mark where the screw-access openings were oriented.
Then I drilled a “pilot hole” over each abutment in the matrix, aiming at the screw.
OK… it’s time to git’er done! I loaded the putty matrix with Luxatemp and seated it over the abutments. Before I did that, I blocked out the proximal undercuts with OpalDam (Ultradent). I also filled the screw access holes with Teflon tape.
OK, now I’ve got to find those screws!
I put the Copyplast matrix back on and initiated the prep to uncover the screws.
The access to the screw on #10 ended up more facial than I’d like, but that’s not unusual for upper anterior implants. Not a problem, as you’ll see.
I unscrewed the abutment screws and teased the provisionals out. Then I trimmed the excess and filled in the gaps to create an emergence profile.
I filled the screw access holes with Teflon tape and then sealed the openings with Filtek Supreme composite. I used Ivoclar’s Tetric Color composite stain to get the shade dialed in a bit. I used medium brown and some violet. Then I mixed a bit of violet with Luxaglaze light-cured glaze to dial down the value.
The patient was very happy with the result. All occlusal contacts (centric and excursive) were removed. I also like to remove the proximal contacts – just barely enough to see “daylight” between them. My theory is that the adjacent teeth can move slightly under function, and I don’t want that movement transferred to the implants through the proximal contact.
Next, I’ll go back and see what I can do to try to develop a papilla between 9 and 10.
Edit to add 3/11/20:
I delivered this case today. During the healing phase, I prepped and temped natural tooth #11. Then final impression of all three (9, 10, 11). Final photo is immediately after delivery.
I was quite pleased with the shade match (on the first try!).