hello welcome back to another episode of chair sight live i'm dr. justin chi clinical research
associate and a member of the team of practicing dentists here at gladwell laboratories this
episode highlights the close working relationship and trust between dentists and assistant as dr.
ana-maria Mershon and registered dental assistant will Schmidt follow a treatment plan involving
crown lengthening surgery bio tense Provisionals and a final obsidian presa metal bridge to create
an optimal outcome let's take a look hello and welcome to our new clinical presentation in which
we will Center our attention on crown lengthening surgery followed by temporization with CAD cam
fabricated biotin Provisionals patient presented with a three-unit pfm bridge that had porcelain
broke off the frame to replace the broken prosthesis and to restore proper function
and aesthetics I chose obsidian pres to Mero knotting the plunging opposing cusp I could
not initiate the procedure without reevaluating the intercostal space and address the lack of it
especially over the distal connector to provide more intervals of space crown lengthening and
selective occlusal adjustment of the opposing cusps was planned measurements were recorded
and revealed deep periodontal pocket mesial 231 the measurements were used to facilitate the
accurate removal of the bone in order to provide clinical crown exposure and space for Biological
width to cut through the metal and porcelain I use a circular burr after removal a significant
amount of leakage and a sub gingival caries was present on thirty-one preps were cleaned of debris
than a periodontal probe was used to assess the height of the preparation walls and lack of the
retention form especially on the medial axial wall of number 31 to properly improve the retention and
access the lingual gingival caries I planned for crown lengthening on the molar only with Picasso
laser I outline the predetermined contour of the gingival tissue in order to die the gingiva from
the tooth and bone I made the incision using a 15 blade going circumferentially along the sulcus of
number 31 and a release along the crest using a periosteal elevator I reflected the flap to permit
the visualization of the underlining bone tissue I reduce the bone height circumferentially using
a diamond ground bird with copious integration then preparation finish line was placed apical
lead to increase the axial wall height chromic got 3.0 suture were used to close the flap and allow
the gum to properly attach to the bone the new bone topography will support and reposition the
gum two millimeter incisal to the newly created bone margin leaving more tooth structure above
the gum this will facilitate retention form and allow space for the technician to epicly
reposition the connector after any flap surgery I always like to apply an antioxidant periodontal
gel over the surgical site I will turn it over to will my RDA as he will complete the temporization
process over the surgical site well thank you dr. Meara Sean now that our patient surgical procedure
has finished the focus on the temporization of the site needs to first be carefully planned and then
followed through I need to realign a bio temp provisional that will not lock into the freshly
placed sutures but will also not contaminate the site or trap particulate my go-to dressing
to prevent acrylic integration into the sutures is a bed of teflon tape strips make sure to run
the strip's through a sterilizer and have them handy for when a situation like this presents
itself place the acrylic realign inside the bio temp and wick away any overflowing acrylic
with motions that pull it out and away from the embrasure areas if you've taken the time to dress
the area carefully you should have no problem removing the bio temp after it has cured as dr.
meerschaum stated she likes to start by applying a generous amount of para Sciences Pro Vantage gel
the antioxidant combination of this product has shown in studies to promote cell proliferation
and healing especially in oral cells the bio temp needs to be shaped in a fashion that will train
the gingiva to heal and rest in a position that is ideal for the final restoration to be completed no
pressure but the level of success that this crown lengthening will have in the long run
starts with the skills we utilize right here I am very careful to plan the line angles of this bio
temp as I trim the acrylic flash I always focus on nice thin embrasure areas and margins that
give the gingiva breathing room but I am also taking great consideration to shape the Pontic
in a way that will allow the gingiva to heal and then form an aesthetic interproximal fill laying
down another bed of teflon tape I fill the finish and polish bio temp provisional with my cement of
choice in this case Tim Posen non eugenol and then I insert it onto the preparations once I'm
satisfied that my bio temp has seated into place I remove the teflon tape while the cement is in its
gel State and then begin to remove the bulk excess always wicking it out and away from the sutured
site I will always manage a floss underneath the Pontic and ensure that all cement has cleared the
tight areas between the bio temp and the gingiva any long suture ends that may infer or become
irritating to the patient can be trimmed and tucked away nicely to finalize the day's procedure
one last application of peri Sciences gel is placed surrounding all margins and angles of the
working area and a supply of gel is sent with the patient to be utilized at home during the healing
process specific indications for use are given along with general post procedural instructions so
flash forward four weeks the patient has returned for final preparations I have removed the bio temp
and prepared the site for dr. marathon to take over thanks well following the completion of the
healing phase tissue looked pink and healed nicely at this time patient was recalled to
initiate the final restoration phase this is at the final impression appointment packing
the first cord all the Morgan's were removed and preps were finalized note how I was able
to provide more occlusal clearance for a more aesthetic obsidian press to metal restoration
in the place of the old full metal coverage after crown lengthening the preparation looks
longer above the gum I provided the lab with a full arch impression and byte registration
using capture material I use capture medium and heavy body for the impression and hard capture
impression material for the byte registration at this time patient was ready to receive a new
set of bio temps here is once again my assistant finishing the subsequent temporization steps let's
take a closer look at this bio temp provisional I have requested that this particular bio temp be
fabricated with wire retention built in gladwell labs bio tip Provisionals are designed by cad/cam
technology and can always be reinforced by request for additional support when needed for this stage
of temporization we have also chosen to start over with a brand new bio temp shell to realign
rather than utilizing the existing bio temp that the patient has worn throughout the healing phase
although the current bio temp could absolutely be retrofit to the refine preparations our goal
here is to continue to train the gingiva until the final restoration is seated additionally I
really want to make sure that I grab the nicest margins that I can in order to prevent any relapse
or overgrowth of tissue I never want the costs of a temporary to be the deciding factor in what
is placed to wear at any stage of treatment especially when focused on surgical healing
in situations where the best aesthetic result may call for multiple bio temp Provisionals to
be delivered simply rolling the cost into the patient's overall treatment fee is the surefire
way to avoid worrying about financial overhead instead of promoting the optimal treatment
process possible for your patients benefit the isolation temporary cement and removal stages
remained standard protocol while always making sure to pass a floss under the Pontic area to
ensure that no large remnants are allowed to stick the occlusion is spot-on and the anatomy
gives these bio temps a lifelike appearance at your discretion staining delays can be added
chairside to enhance the aesthetics of a long term temporary flashing forward once more the
removal of the bio temp is a quick process due to the well-prepared path of insertion to aid
in temporary cement removal an ultrasonic scaler and a pumice polish should be a ministered dr.
Mira Shawn then treats the preparations with two consecutive one-minute coats of g5 all-purpose
desensitize er prior to final segmentation she evaluates the margins and occlusion to
determine that no additional adjustments are necessary rely excluding plus resin-modified
glass ionomer cement is used for seating we tack here the cement slightly to enhance polymerization
and then remove any excess to finish dr. Mira Shawn is there anything you would like to add
in conclusion yes we saw how each aspect of the treatment depended on the success of the
prior procedures in order to achieve an optimal result with this case I attempted to highlight
the approach of using bio temp over a surgical site for a successful restoration treatment in
this case we saw a patient coming in with a compromised situation the final result of
the treatment shows an obsidian press to metal bridge that satisfies the biological functional
and aesthetic criteria established preoperatively additionally we can see the final obsidian pressed
metal is not only beautiful it's also providing the strength necessary on the posterior area
without compromising aesthetics thanks for that case dr. Mira Shawn on behalf of everyone here
at the lab thanks for watching chairside live and we'll see you back here next time
you