How to provide multi-disciplinary dentistry [VIDEO]

While striving to accommodate dental patients with as many services as possible, general practitioners often find endodontic therapy to be one of the biggest challenges they face.

Generally undesirable to the patient, endo therapy can be thwarted if the tooth’s condition precludes a predictable end result. In such cases, teeth are often extracted, and the patient departs the dental office with instructions to consider the treatment options, oftentimes never returning for definitive dental therapy.

By remaining flexible to patient needs while formulating a treatment plan, however, doctors and patients can work together to change those statistics in favor of predictable, successful dentistry.

The following case began with an endodontic treatment plan, but we quickly determined the tooth was fractured and non-restorable (Fig. 1 - see slideshow above).

After the patient was presented with the dental treatment options, we decided to extract tooth No. 12 and to move forward with dental implant placement followed by restoration with a cement-retained, implant-supported crown.

Two kits from Komet USA figure prominently in this case, facilitating a successful and predictable end result. The first is the custom-designed Everyday Dentistry Crown Down kit (LD0586) created to minimize fractures.

 Developed in conjunction with ceramics engineers and bur specialists, the kit is a “reverse-engineering” endeavor to create the ideal system for crown preparations. The second kit featured in this case-the MaxilloPrep bone-spreading kit (4596)-addresses challenges faced when dealing with insufficient space for implant placement.

The case

Upon examining the quadrant, it was apparent that a considerable amount of dental treatment was indicated. In addition to tooth No. 12, we needed to treat fractured and carious tooth Nos. 13 and 14 (Fig. 2). A full treatment plan was created, first calling for core build-ups and Sirona Dental Systems’ CEREC® full-porcelain crowns (cereconline.com). The treatment plan then prescribed spreading the maxillary ridge in the edentulous space of tooth No. 12, placing a 4.3 mm X 13 mm TriNex dental implant from Keystone Dental Inc. (keystonedental.com), and repairing the facial defect with Puros® bone particles from Zimmer Dental (zimmerdental.com) and autogenous platelet-rich plasma (PRP).

To begin, we used the Komet® 6807.FG.016 cavity-prep diamond to remove the existing amalgam restorative material (Fig. 3). This excavating bur features a long, inverted tapered-cone design combined with coarse-grit cutting, making it ideally suited for the task.

DenMat’s GeriStore® (denmat.com) B1 composite core build-ups were completed on tooth Nos. 13 and 14 (Fig. 4), and the Everyday Dentistry Crown Down Prep Technique was initiated. Note: In this technique, the operator maintains the handpiece in an occlusal-gingival direction, meaning the handpiece is held in a vertical direction and parallel to the long access of the tooth undergoing preparation for a crown or onlay.

In a vertical position, the Komet® 6845KR.FG.025 inlay/onlay coarse, tapered prep bur was run apically to a depth of 2 mm, creating a mesial-distal trough the width of the bur (Fig. 5).

The bur was slightly angled to reduce the buccal and lingual occlusal inclines. This minimal handpiece re-direction created a 2 mm occlusal reduction appropriate for all-ceramic bonded or cemented crowns (Fig. 6).

The gingival margins were prepared with the Komet® 5801.FG.023 coarse, round bur (Fig. 7). Note: A round bur is the most efficient and quickest preparation bur. On a frictionless surface, two differently shaped objects such as a cylinder and a sphere are given momentum. Over a predetermined distance, the sphere traverses the frictionless surface faster than the cylinder because its shape has less inherent resistance to the surface; therefore, when attempting to create a smooth, precise gingival margin, a spherical bur such as the 5801.FG.023 coarse, round bur is the optimal choice. Also please note that burs 5801 and 6807 are not included in kit LD0586.

The Komet® S5856 FG021 coarse, round tapered bur was used to bring the occlusal and gingival reductions together without overheating the tooth during preparation.

The bur was held in a vertical position, parallel to the long access of the tooth. Very little preparation was required in the mid-body area, and interproximal preparation was completed swiftly (Fig. 8).

The Komet® slowspeed 94010C 040 diamond-impregnated, rubber-bullet bur was held in a vertical position for smoothing and rounding axial line angles for all-porcelain, full-coverage bonded or cemented crowns.

The completed preparations on tooth Nos. 13 and 14 were ready for CEREC imaging (Fig. 9). Fig. 10 shows a facial view of the teeth immediately following the same-day preparation and cementation. Likewise, Fig. 11 depicts the occlusal post-cementation view of the CEREC crowns. The buccal defect of endentulous space No. 12, along with its V-shaped facial defect, presented the next challenges in the case.

Bone-spreading technique

STEP 1
Once all restorative dentistry was completed, the patient rinsed with chlorhexidine oral rinse and was prepared for dental implant placement in the edentulous No. 12.

STEP 2
Blood was drawn and placed in a Salvin 1310 Centrifuge. The blood samples were spun for 10 minutes, and the platelet-rich plasma (PRP) was separated and used to enhance the particulate bone material and speed healing for the patient.

STEP 3
The buccal-lingual width of the edentulous space No. 12 was about 3 mm wide. The Komet® 700 XXL highspeed bur created a trough approximately 5 mm in a mesial-distal dimension and approximately 6 mm deep (Fig. 12). Note: The treatment plan prescribed the MaxilloPrep kit to spread the ridge bucco-lingually to accommodate the implant without fracturing the buccal plate.

STEP 4
A flat-ended, 2-mm-in-diameter parallel osteotome was tapped to a depth of 13 mm. The osteotome was allowed to rest within the site for 30 to 60 seconds, removed, and then the sequential MaxilloPrep procedure began (Fig. 13). Note: At this point, osteotomes #1 through #3 were used and allowed to rest in the site for at least 60 seconds, allowing the maxillary ridge to expand. This facilitated implant placement into the site without facial bone fracture. Fig. 14 shows the final osteotomy after the final osteotome has been removed. Note: The ridge began with a buccal-lingual dimension of approximately 3 mm and was expanded to more than 7 mm in buccal-lingual width.

STEP 5
The implant was placed and fully seated (Fig. 15). The implant platform was positioned at the crest of the ridge and approximately 2 mm apical to the adjacent teeth.

STEP 6
Particulate bone and PRP were used to plump up the facial of No. 12.

STEP 7
Grafting was completed and sutured with 3-0 VICRYL sutures.

STEP 8
PeriAcryl® tissue adhesive was used to glue the sutures and incisions into place.

STEP 9
The final radiograph shown in Fig. 16 depicts the implant at No. 12 and the crowns at Nos. 13 and 14.

Closing thought

“Everyday Dentistry” refers to what many GPs manage on a daily basis. Patients require multiple dental services and often prefer to have dental services provided to them in the safe and comfortable surroundings of their general dental practice. With the new technologies and equipment available today, GPs can be both efficient and proficient in providing multi-disciplinary dentistry. Komet USA’s Everyday Dentistry Crown Down Kit and MaxilloPrep bone spreading kit can be implemented into a general dental practice interested in providing these services.

Note: Training for these procedures can be obtained through the Midwest Implant Institute (midwestimplantinstitute.com) where Dr. Bliski is the co-director. He also may be reached at his private practice in Independence, Ohio (bilskidds.com).