Catalog Number:

Running Time: 33 min

Language: English


Anterior Immediate Implant Placement and Function – The Digital Workflow

Release Date: October 08, 2017


[MUSIC PLAYING] [DING] Hi. My name is Dr. Jonathan Ng. I’m really excited to be here with all of you today and share with you a little bit about this topic that we titled Anterior Immediate Implant Placement and Immediate Function. And what I want to do is talk about the digital workflow and how this is all coming together now. So I’ll tell you a little bit about myself. I’m from Vancouver, Vancouver, British Columbia, Canada. This is a view from my office and I invite you to all come and take a look, enjoy the scenery. And if you do come by, give me a shout on all of the social media. We have Instagram, Facebook, Twitter, and of course, my website. So I hope to be in touch, because that’s where we transfer information to each other and keep the information fresh and new. So for today, we’re going to talk a little bit about a couple of things. I want to talk about digital technology. There’s a lot of new things that are coming down the pipeline, so I’m going to show you what I’ve been doing as well as intraoral scanning, which is a huge passion of mine. I’m also going to talk about immediate placement and function through the planning of all these things through digital technology, and of course, what is termed the shorter time-to-teeth. So we’re going to start with this quote that says, “Whosoever desires constant success must change his conduct with the times.” Now, I think that this is a very appropriate comment because of the fact that even back in the 1400s, they knew that as times are changing, we need to keep up with the times by changing the way we do things. And definitely, things are changing. So I introduce you to a number of patients in my office. These are routinely patients that come as referrals to my office because of the fact that they have a broken tooth. Patients break teeth here in Vancouver oftentimes from playing hockey, maybe falling off their bike. Or sometimes, most commonly when someone has a tooth that broke off because they were eating food, they most commonly say, I had bread or salad. Now, they’re always wondering why that happens. But there’s fractures under there, and teeth can just kind of break off. Now, with this type of situation, patients aren’t looking for long-term taking a long time to get things done, but they want to get something done immediately. And if we can, I’m going to talk to you how we can do that now. So as you can see, most of these teeth are fractured below the gumline, most of them even below the bone line. So as long as the bone is stable, we can still use what is there to fabricate something immediately for our patients. Now, patients often ask for what are the options that exist? Now, I’m sure most of our patients aren’t looking to wear a set of dentures, a flipper partial denture’s not exactly what they want, nor do we want to be cutting into healthy teeth to make a bridge for a lot of these anterior treatment cases. So for that reason, I introduce you to Greg. He’s 49 years old, comes to my office with a previously fractured tooth. As you can see, that anterior central incisor was broken off about 20 years ago during a hockey accident. During that time, he told me that that tooth landed up underneath the timekeeper’s bench. Not exactly the cleanest place, but they put that right back in. Now, what happened was over time, there was a period of time where his root canal were doing well, as you can see external resorption of the tooth. And that tooth broke off. His general dentist put it back together, sent him over, and asked me to do something about it. So fast forward, I’ll save you a ton of time, and this is what we ended up doing. Take it out and put in an immediate implant. That implant was also temporized immediately. But let’s rewind and take a look through that process and take you through that journey. So, of course, there is tooth, took it out. And once we remove the tooth, I’m immediately placing an implant that then has a temporary cylinder which we then go ahead and build up a temporary tooth. Now, the purpose of that tooth there’s going to be holding the tissue. But as you can see, we have to relieve the occlusion, making it slightly shorter than the other teeth. So as you can see from start to finish, we essentially give him a tooth immediately. The same day he walks in, we take a tooth out and we’re putting something right back in. Now, Joseph Kan gave a very great quote that says, ” favorable implant success rates, peri-implant tissue responses, and aesthetic outcomes can be achieved with immediately placed and provisionalized maxillary anterior implants.” I believe this statement is very true because we are preserving what is already there, so patients have the function and the aesthetics. So as many of you have heard about, there is a term called the workflow. Basically, what that is is from point A to point B. And in this case, we have a tooth that’s broken– a fractured tooth– and we have to take that tooth out. Now, we can’t just take that tooth out aggressively, because we’re trying to preserve all the bone and soft tissue. So atraumatically, I extract that tooth. And with the use of a surgical guide, I’m placing an implant exactly where we planted it, and in this case, digitally. And then we provide the patients with an immediate temporary crown. And that’s going to be exciting news that we’re going to talk about on how we do that. So when and why are we placing implants immediately? And of course, when can we function on them immediately as well? So as you can see, the tissue that remains is pristine. Once we take that tooth out, the gingiva was going to sort of fall in the moment we leave that tooth untouched. And so what we don’t want to be doing is laying a flap, trying to move the tissue, and create scars. We also don’t want that bone to change on us. So it’s been said that the elevation of soft tissue alone is going to elevate osteoclasitc activity, which means we’re going to be increasing bone loss just by laying a flap. So we’re going to keep that flap exactly where it is. Tissue, of course, is going to change every time we take a tooth out, so we want to preserve as much as we can. Now, the use of a temporary crown is not going to just look nice. We’re also going to guide the tissue. As you can see on the provisional, we have a little bit of under contour and what that does is it helps to hold the gums where they’re supposed to be, so our tissue forms nicely and plumb. Now, I introduce you to a patient of mine, Maria. She’s 40 years old. She comes to my office with a very nice and beautiful smile. Retract her smile, you can see later that it’s a very elegant smile that’s showing all the way to the molars. She tells me that a previous accident at my front teeth is causing some resorption. I asked her, how do you feel resorption on your tooth? Her referral was an endodontist who told me that after this tooth was traumatically injured, it’s starting to resorb. So during the retracted smile, you can see that the teeth are beautiful. But as we look closely, there’s a few things that I start to get a little worried about when I look at these teeth. And of course, if you look closely, you have a little bit of discrepancy between the heights of these teeth. So for that reason, I’m starting to worry ankylosis making extraction a little bit more difficult. Now, if you look at the lateral incisor, we see that the papilla are these beautiful knife-edged papilla. Now, that can be very nice but very difficult to maintain. If we remove that tooth and do nothing, that tissue is going to go away very quickly. And to build that back up aesthetically is going to be quite the challenge. She also has thin gingival biotype, which also makes it quite difficult to work on cases like this. But what do we do? So of course, you see from point A to point B, I’m going to walk you through what we did. So what I did was I atraumatically removed that tooth, as you can see, maintaining as much papilla as possible. Now, in Vancouver area, we love eating sashimi. And as you can see, that papilla looks like a nice piece of salmon sashimi just hanging out looking at us. But the longer we wait, that’s going to fall right in. Doesn’t have a lot of support, nothing holding it in place. And so we want to keep that together because if we were to put a flipper partial or leave it the way it is, we’re crushing that tissue, and it’s almost impossible to grow it back exactly where it was. And this is that picture you saw before already. We’re looking at a nice beautiful socket that we want to maintain. So if we take a look at our CBCT scan prior to any of the planning that we had, for those of you who are placing implants, you’ll know that a lateral incisor typically is a narrow platform implant. And most narrow platform implants are all but one drill. You take one drill in, and the next is your implant. As you can see, I like to call this the pre-drilled hole when you take a tooth out. Because once you take a tooth out, you’re trying to drill a hole into something that already exists. Now, as you can see here, we’ve already used what’s called SmartFusion. I’ll talk a little how that works. But we’re using that to take a wax up of the tooth and create a surgical guide. And that surgical guide is going to help me to position that implant exactly where we planned it. And that’s going to go right into the position and not where the root position is. So that implant is then placed, you can see, following exactly the plan that we had on there. This is another view of that. And let’s take a look at the socket before we took the tooth out and the socket after the tooth is in place. So as you can see, the implant is placed closer to the palatal surface so that we have some space between the buccal bone and the implant. So that leaves us room for some bone grafting or some will opt to leave it empty and start to just let it fill in on its own. Now, it doesn’t go so good as to just leave it the way it is. We’ve got to put something to hold that tissue as well as that bone graft in. So here’s a couple of looks at the radiographs. So you see that that single one and only drill that we use in a narrow platform implant. There’s the implant with a holder and my immediate temporary crown in place. So as you can see, it’s like threading the needle perfectly into that position and holding it, the tissue, with a temporary crown. So the moment I placed that in position, I took a picture. This is where we look we’re looking at hours after we’ve been working on things and just putting the provisional. Now, I was a little bit worried because as I mentioned, that sashimi is already moving up. We’ve got that papilla chasing away already. We’re worried about just the trauma of doing surgery itself could leave that in that position. But let’s see what she looked like at her three-week checkup. So as you can see, after three weeks, the gingiva is starting to come down very nicely following the papilla line of where things are at. So have a look at where she was before. Nice knife-edged papilla, and where she is at six months. So this is after six-months follow-up when it’s time for final restoration. As you can see, the use of the provisional crown and all of this planning, the purpose of that is to keep all the tissue where it is and also keep this patient happy, functional, and obviously aesthetic. Now, some of you may notice that there is an access channel right in the front. How is that aesthetic? Well, of course, the patient was warned that the position of the implant, where it’s going to be is going to lead to the fact that the incisal edge is closer to where that exit point is going to be. Now, we have solutions for that, because prosthetically, we can use what’s called an anglulaed screw channel. So what that means is it literally angulates that screw channel into a better position. And so if you look at the next graphic here, essentially, an implant on the anterior segment oftentimes is going to be in this tilted position where the access is going to be through the incisal edge, or in this case, the buccal surface. Now, for conventional thinking, we would try to place that implant into a palatal position so that we can get screw-retained access. Now, in these days, we can use an angulated screw channel to mitigate those needs. Now, let me take a look at the difference between the angulated screw channel abutment and a conventional abutment. If you look at a conventional abutment, we’re literally cementing onto this small channel a zirconia abutment. But as you can see, the angulated screw channel is using the clamping force of the screw to hold the abutment and the titanium tie base together. So there’s no cement, and it’s all mechanically retained, so it’s very controlled for what we need. So as you can see on an anterior tooth where you have what would be an exit point of the screw channel through the incisal edge can be easily corrected so that the screw doesn’t change, but the access channel to that does. And so now, we can still benefit from using a screw-retained crown without having to worry about where that implant is placed so that we are starting to jeopardize bone and have to graph extensively to get that into the positions we want. So then the next question is, when do we place an implant? What is the timing for us to place? As you’ve seen with Maria, we’re placing at that same time. With our patient Greg at the beginning, it’s right at the same time as well. But there’s consensus statements that have been placed out by Hemmerle and others in 2004, essentially talked about when is and classifies what is immediate placement. So as you take a look at table 1, essentially, there’s four types of timing which replace implants, classifying that between the destruction of hard and soft tissue. So type one is essentially placing an implant immediately at the same time. We take a tooth out and that socket is immediately placed with an implant. Type two is soft tissue healing, but the bone hasn’t healed yet. Anywhere between six to eight weeks is normally desired, just because that allows soft tissue healing. And in type three and four, it’s closer to a fully healed socket, where we’re looking at tissue, and hard tissue, and soft tissue maturation. So there’s some of the consensus statements that deal with socket healing, bone regeneration, and the use of medications in cases. But socket healing, of course, the a consensus is that we’re going to have some changes, so we need to talk about how we’re going to fill that site, whether it was the implant, bone graft, or allowing its own tissue to heal in. Bone regeneration– of course, there’s a term that has been coined called a horizontal defect dimension, HDD. So if you look at this, there’s a space that surrounds the implant. Where and how thick and how wide should that space be? Well, as you can see here, it’s been in the consensus statements that if that space is less than 2 millimeters, we’re going to expect that there’s spontaneous healing of the bone. However, if it’s greater than 2 millimeters, it’s going to be difficult expect the bone to jump that gap. So some of the criteria for that would be that essentially, we need to assess the patient and make sure that we know what’s happening with their medical health. The extraction technique is very important, and of course, evaluation of the site that we just talked about. So what is important is the evaluation of that space between the implant and the bone, but as well, the thickness of that bony wall that exists. So the bony wall has been known that that area that remains, the buccal wall, that needs to be at least greater than one millimeter to expect normal and spontaneous healing. As well, the horizontal defect dimension, as we mentioned, should be at least one to two millimeters to give us that spontaneous healing. So we looked at the literature and we see that essentially, if there’s greater than one millimeter thickness of that wall as well as the gap that we have, as we mentioned there, being greater than one millimeter, the degree of gap fill is quite substantial, so we can expect bone to fill in. However, it’s hard to expect every single bone wall to be that thick, because as you see in the next article that 87% of buccal bony walls are actually less than one millimeter. And so for that reason, we’ve got to be careful about when and where we’re doing this type of treatment. Immediate placement with a non-detectable bony wall on a CBCT is not recommended because if we are doing that, we’re going to find that soft tissue and that bone is going to go away. Mid-facial mucosal defects and recession are expected if we don’t have anything on a CBCT. Some other factors that were recommended, of course, in the use of adjunctive medications– that means perioperative antibiotics, having a patient pre and post antibiotics is recommended. As well as the survival of implant, that was mentioned in there that a difference between type one and even type four healed sites have the same survival rates, or similar. So let’s look at the next case then. So I introduce you to Jessie. He’s 3 years old, comes to my practice, and he says, I got in a fight, got in an altercation and lost my front tooth. I took a look and I said, let’s help you out. Let’s see what we can do. So this is what his front tooth looks like, left central incisor broke completely off. The general dentist who sent him over said, should I take the root out? I said, nope, just don’t touch him. Send him over. Let’s take a look. So as we take a look, as you can see, he’s got a missing tooth and some pretty torn up gingiva. But the question is, is this a case for immediate implant placement and immediate temporization? Can we do what we did for Maria and others that we just saw for this case for Jessie? Let’s take a CBCT scan. So we look at the scan and we look through all the criteria we just mentioned. How thick is the bony wall? Is the tooth still there? Is there fractures that we notice in the bony walls? We evaluate to see, what can we do in these sites, and can we keep doing what we want to do? So we look at the tissue. Of course, we notice that the gingival height is higher on the left than the right central incisor, so we’re looking at a little bit of an issue with maintenance of soft tissue. So what do we do with this? How do we mitigate problems because of the fact that if we go ahead and start to build up immediately and placing immediately, we might run into some problems here with soft tissue? So this might be a case where we do a delayed temporary. We might do a delayed temporary placement, but we also may delay the implant a little bit. We may extract the tooth at a separate time or we may extract and graft at the same time, but definitely delaying the provisional crown, and of course, the final crown. But I introduce you to a technique known as the root submersion technique. This is described as a method in which we’re shortening the root to allow soft tissue to grow over. Now, remember I mentioned type one, type two, type three, and type four. Well, this makes it sort of like a type two, allowing soft tissue to grow over and create more keratinized tissue so that when we go back to remove the root, we have clean socket and beautiful gingival tissue to work with. So that’s exactly what we did. We allowed the tooth to stay submerged, let the soft tissue grow over. And then after about six to eight weeks of soft tissue growth, we go back in, we expose, and we take a look at or in our tooth site. So as the tooth is removed atraumatically, preserving as much bone as possible, the implant is placed. As you can see, we’re preserving and respecting all those spaces such as the horizontal defect I mentioned. And as you can see, the thickness of bone is good. But we’re still needing bone grafting material. Now, remember, we have tissue that’s grown enough for us to pull it back over. And so let’s see what we ended up doing. A double layer technique of membrane, and then closure of the soft tissue. So without any tension, we’re closing the tissue and creating the bulk back to where we should have it. Now, this is without any soft tissue grafting. It’s only using his own soft tissue to create that space. And there is his provisional crown. Now, how do we do the provisional crown and when do we do it? You might ask, do we do it the same day? And the answer is no. We go ahead and let the soft tissue heal. We let that area thicken up a little bit and let the soft tissue mature. There’s a provisional crown. But when it’s time for an impression, we’ve got to copy that tissue. So that’s another lecture which we’ll give at another time. But it is how to capture that soft tissue beautifully that we’ve just created so that we can make our final crown match exactly to where we are? So as you can see here, he goes from a fractured tooth to a submerged root to allow the soft tissue to heal, a provisional crown, and some time of healing with that, and then building him up further yet. So as we can see from day one in which I saw him looking like you see here to about eight months to a year later, we’ve got him looking like this. Now, the soft tissue is not exactly the same height, but I think Jessie’s very happy and he’s very excited to be able to smile nicely. So you may have heard the term before, shorter time-to-teeth. And it’s essentially just that, the shorter time between extraction of a tooth to back to having teeth again. So that’s what we’re hoping to achieve with our patients. Now, for Jessie, it may have been a little longer, but we’re still getting him his tooth as soon as we can. Now, as you can see, that essentially moves us back to what we saw before, fractured tooth, extracting the tooth atraumatically, surgical guide to place an implant, and immediate provisional. Now, this all comes back to proper treatment planning, because I believe if we don’t have proper treatment planning, we’re going to end up with poor results. So with proper treatment planning, we’re going to get better outcomes. So let’s take a look at how we were doing it before so we know where we are going with what we’ve accomplished. In order for us to know where we’re going with the technology, we have to look at where we were before. So let’s take a look at how it was done. So many of us still use a Panorex X-ray in our offices. And some of the problems that we have with this for implant planning is that there’s magnification. A Panorex X-ray can magnify anywhere between 20%, 25%. That’s a big difference between a site that looks like a 10-millimeter implant could fit, where really, there’s only eight millimeters. That’s almost like a lawsuit waiting to happen. So how do we use that type of information? Well, we took a transparency film. We overlay it on top of it, and we try to use that to gauge roughly how long the implant could be. Now, I may look young, but a lot of times, I teach at universities where sometimes people don’t even know what a transparency film is now. But essentially, it’s a clear plastic sheet that overlays on top of it. Now, there’s a lot of problems with that because they’re trying to combine the magnification of a Panorex and using that, so it’s just hard to calculate. We don’t know what we’re really looking at. Of course, a PA film is equally as problematic, because we’re missing anatomy, and we’re looking at two dimensions. Now, in 2012, the American Association of Oral Maxillofacial Radiologists recommended that cross-sectional imaging be used for the assessment of all dental implant sites. And that CBCT is the imaging method of choice for gaining this information. So for that reason, I am scanning every implant case, even if it looks simple. The reason being is because on a two-dimensional image is very different than three dimensions. So the use of the technology is now going to allow us to see much more. We can visualize using the cone beam CT so that we can anticipate any anatomy or things that we may not otherwise know that are there. Now, of course, with that information, we can diagnose much more clearly. Now, as a prosthodontist, I often take diagnostic information in the way of impressions, whether they be physical or digital impressions. But that information gives us soft tissue and hard tissue. So we look at teeth and we look at gums. But a cone beam CT is only giving us information in the hard tissue realm, bone and teeth. So as you can see on the left side, we have a scan of a physical impression, and we have what is in blue is wax up teeth of where the proposed position of these teeth are. But that’s not good enough information if we can’t take it and marry it together with the CBCT. So currently, we can, and we’re using technology to do that so that we can in one platform, we can see where all this information is together, bone, soft tissue, and teeth. And so this case, we’re using SmartFusion by Nobel Biocare So what we can basically see is essentially where these teeth are going to go. As you can see, those teeth were blue. So why is this one looking a little bit like a white color? Now because traditionally, the way we would obtain this information is that we take a polyvinyl siloxane impression, and we would scan it using a lab scanner, such the 2G scanner. We take that information and create a wax up physically on that bottle and scan it yet again, so we have two files. And that scanned file gives us a blue tooth for the wax, and then the pink colored tooth that you see there. Now, the technology is changing. I use digital impressions in my office for pretty much everything. Now, that digital information is going to give us more clarity in the accuracy of color, precision and of course, diagnostic information. Well, we take that information and we import that directly without printing a physical model of the skin. Now that’s when we get that white colored tooth, because we’re designing it directly on the computer. And so then through what’s called smart set-up, we’re developing a tooth to put on there. So we go ahead and we do the same thing. We take our scan. We put it and overlay it on top of our CBCT. We get fused information. That marriage of information is going to allow us to start to diagnose better. And then diagnosis with a wax up is going to show up in those two lateral incisors that you see there. Now, once we have that in place, we can plan the implants. We now know surgically where we’re going to be placing because of the fact that prosthetically, we know where that information is going to go. Now with the click of a button, we fabricate a surgical guide. As you can see in cross-section, we have an idea of what the bony anatomy looks like, as well as what the prosthetic anatomy will look like. And so for that reason, we have a lot more information using those diagnostic tools that we have. Now as you can see, we fabricate a surgical guide. So that is extremely important, because a surgical guide is what’s going to allow me to place the implant exactly where we just planned it. So guided surgery, guided surgery has definitely revolutionized the way I practice dentistry because it allows me to do all of these things, such as flapless surgery, being able to visualize the bone so you wouldn’t do that with a flap. Immediate placement, as well as immediate function, as we mentioned, and cases like All-on-4, you can now be placing these through guides and getting the outcomes that we are looking for. And of course, the shorter time-to-teeth, as we’re seeing in all the cases today. Now, I like to go time and time again to this quote, because essentially, it says that, “The objective of implant dentistry is to provide the patient with an aesthetic and functional prosthesis.” Now in bold, I put “and” because sometimes we forget that the two of them are together. We look at function and forget it’s got to look good, or we make it look great, and it doesn’t function well at all. I think that for something to be successful, we need to marry these together and make sure that we’re looking at both of them together. So I introduce you to Alexis. She’s a 30-year-old female that comes my office. And she comes to me saying that I’ve been missing my lateral teeth my whole life, and I hate this for her. Now, I’m sure many of you have heard of or seen patients in your practice that don’t come in saying, I love my flipper denture. It’s one of those things that people just have to wear because there’s no other option. Now, let’s take a look at what she has and see if she has some other options. So again, here’s her smiling. You can see she’s missing lateral teeth. And we’ll take a retracted smiled to see what her teeth look like in her mouth. So as we look at her upper and lower teeth, but focusing mostly on her upper teeth, we see there’s a couple of things we want to do. So we turn to our treatment planning hat we figure out what’s going on. So when we take a look, there’s a few things that we want to look at. Of course, there’s a little bit of a diastema. Shall we do something about that before we place implants? Of course, we do want to get some orthodontic positioning of those teeth and figure out how we’re going to retain everything in position. So what we do is, of course, this case was all done completely digital. So on your right side, we see that essentially, the teeth with their initial presentation, we scan that using a trio scanner. And with the use of the digital information, I fabricate orthodontic retainers and reliners. Actually, sorry. That’s the wrong one. Let me go back. So as this case is done completely digital, what we then end up doing is we take a digital scan of her initial presentation as you see on the top right. We use that to create clear liners and orthodontic appliances to move the teeth into the position that we want. So on the bottom, you see once her teeth are positioned, closing that diastema, we now have the appropriate position of the roots of the teeth. We go ahead and we scan that and use the scan, overlaying that on top of the CBCT. So once we do that, we use the computer program to use smart set-up and place a tooth in both those locations. So once we have those positions, as you’ve already seen, we go ahead and plan implants, because now, we know prosthetically where the function and the aesthetics are going to come together. Once we’ve confirmed our implant locations, we go ahead and we can try to make sure our abutments and other parts are fitted. We go ahead and we make a surgical guide. Now, the surgical guide is excellent in getting us the outcomes that we want surgically. But what about all this prosthetic planning that we’ve done? Those wax ups, all these things, how do we get that to make this patient have exactly what we planned on the time of surgery? So that’s when I bring in the use of immediate provisionals. So in this case, we use things such as smart set-up, temp shells that are going to be coming out, and as well as DTX Stuidio Design to put all this together. So this is what a temp shell looks like. Essentially, it’s a shell of the temporary crown with wings to hold it in place, much like a Maryland bridge. Now, with that, we have to have a temporary cylinder that’s going to hold everything together, and we’ll pick that up in the patient’s mouth. Now, because the positions are placed with the wings, we know that that tooth is in occlusion properly in what we’ve designed it to be. Now, you might wonder, what is this temporary snap abutment? How does it differ? Well, here’s what a conventional abutment looks like, an engaging abutment that rotates– or does not rotate, but has a screw to retain it. But in this case, we’re talking about an abutment that does not require a screw, because it has engaging components in the rotational but also the horizontal method. And so there’s a snapping mechanism and a function to put it in without the use of a screw. Now, this one’s nice, and it comes in various heights or already pre-cut heights as well. But you may ask, well, when we put a provisional over that, how do we get access back into the hole? Well, because there’s no screw and we take it back off, we turn it around and place a holder abutment and essentially drill from the opposing side and get our nice access channel back in there. So there’s no guessing as to where the channel is. So as we look at Alexis, we go back to where she was. This is what she looked like with provisionals. But let’s take you through the journey. How did we get there? So essentially, we’re looking at the use of digital scanning and digital CBCT overlay, as we already talked about, the digital wax up as well. That gets put together, and then we make our temp shells. So these temp shells are designed on Nobel Design, in which we then have our labs involved at this point to help with the taking of that information that we waxed up and create a milled provisional. Now, you can mill this out of composite. In this case, I used polymethyl methacrylate materials for strength. But here’s our surgical guide and here’s our winged provisionals, our temp shells. So I had my lab print a model just to verify, just to make sure that they are seating on there, but it’s not completely necessary to have anything analog at this point. But essentially, we go ahead and do surgery. So these are the implants that I placed. And you may say they look a little palatal. But through our plan, we realized that there was not a lot of buccal bone, given the fact that she was missing these teeth for so long. Now, here’s those temp shells in place sitting over our abutments. We pick those up. When we take it out, we see that there’s a gap or a void between there, which we go ahead and fill in. And I’m using my composite materials, floatable composites to fill that in. Once we have a contour that we like, we go ahead and cut off the wings, Now, we place those in place. And as you can see, some pressure on the soft tissue. Now, much different than the cases we saw earlier today, she did not have teeth here to begin with, unlike the others, where we had a socket after removing the teeth. So we’re relying on the provisional to start to sculpt the tissue for us. Now, after about two or three weeks, on her recall examination, we see that the tissue is already taking great form. So as we can see, Alexis is very happy with the provisional outcome. But let’s take a look close up how that all happened. So of course, here’s her initial presentation. Then she shows up for a scan. We do a digital scan, use orthodontics to move her teeth back into a better position. She probably should have had a cleaning as well, too. You can see the digital information is so good that it captures even the stains and calculus there as well. But we go ahead and we make our surgical guide, have surgery made and completed, and our provisionals in place. Now, she wore these professionals for about six months while things were healing. And as you can see, the length of those teeth the much shorter. It kept them out of occlusion to protect them as much as possible. But in her final restorations, we can see that she now has beautiful gingival tissue. So growing that tissue, sculpting it into the position we wanted was through the use of the provisional crowns and the changing of the provisional crowns through the addition of material to get us to where we look at and see now. So Alexis is a primary example of how we’re using the technology now for this workflow to go from point A to point B. She comes in for a CT scan. We do some digital scanning. We overlay all this information so that we can plan her implants more accurately, and again, using digital techniques to leverage a lot of the technology that we now have. Now, then we use an iPad in this case to run the surgical motor. And what I do is I export my surgical plan, and it’s right on my iPad, so it records it, and I’m again, keeping in the theme of digital. I’m using everything there. Then at the end, once her teeth are healed and ready, we go ahead and use digital planning to fabricate her final restorations. So Alexis is a primary example as to why we’re using the technology for all these benefits. She came in initially saying that I’ve been missing my lateral teeth my whole life. I hate this flipper. And now, she leaves my office saying a completely different tune. Says, I love my new smile. I have much more confidence. And again, she’s 30 years old, getting ready to be married to her fiance. And now, she’s not worried about a flipper or partial coming out at her dinner. So she leaves my office with a beautiful smile. She tells all her friends all about it, and she’s excited to now be able to eat and function normally. So I started off my lecture by saying whosoever desires constant success must change his conduct with the times. So I end with this quote that’s a little more close to home and a little bit more current with our times that says, “It’s time to let go of the familiar stuff from the past and embrace the future.” Now, this doesn’t come from a prestigious dental journal, but comes from a journal that you may know of with high-impact value, GQ Magazine, Mr. Michael Kors. Now, he was talking about clothes. But I think for us, this statement holds true. Technology is changing, and we must embrace this future so that we can be better at what we do. So I invite you to stay in touch. If you’re coming to Vancouver, give me a ring. I definitely want to get in touch with you and show you what I do in my office. And as well, I’m thankful that you have been here with us, and I hope that there was something you learned today. Thank you. [DING]s

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