GAP Australasian-Dentist-May June 2019

Category AustrAlAsiAn Dentist 29 5. Full-face photograph of a spontaneous smile (Fig. 6). 6. Photograph of the full face at rest. this sequence allows one to view immediately the presence of orthognathic and periodontal issues (Figs. 1 & 2), to evaluate the biotype (Figs. 2 & 3) and to estimate aesthetic challenges, like tooth colour, tooth texture, soft tissue/ lip exposure and position of the incisal edge/lip (Figs. 2 & 4–6). the 3D intraoral scan is extremely helpful for determining orthodontic alignment of the teeth and in our protocol replaces an occlusal and/or 12 o’clock photograph in most cases. “there can be different ways of treating a disease, but there can be only one correct diagnosis.” Dr Morton Amsterdam, 1974. When anamnesis, intraoral examination and preliminary radiographs are sufficient to conclude that the tooth in question cannot be preserved, it needs to be decided what the optimal timing for extraction and a CBCt scan is and how to provide for a temporary tooth replacement. Also, the timing of implant placement is essential and the operator must choose between immediate, early or delayed placement in the fresh extraction socket. Will there be a (potential) need for bone augmentation and/or a soft tissue graft? in short, our policy is the following: in case of acute inflammation that cannot be effectively treated in a way that an infection of the future implant site will be prevented, we will proceed with extraction. A temporary fixed etch and bond or removable prosthesis can be used to guarantee acceptable aesthetic comfort to the patient. in these cases, a CBCt scan will be taken after extraction so that the most detailed image of the socket anatomy can be obtained. since a provisional solution has been provided for, there is no need for very early implant placement. timing is now based on the expected period needed for the infection to be eliminated and the risk of loss of volume by the collapse of tissue. normally, the implant is placed four to six weeks after the extraction. Another reason for delayed implant placement can be the need for healed soft tissue in order to facilitate proper wound closure to protect, for example, bone substitutes and membranes when bone augmentation is necessary. Additionally, if the patient is suffering owing to the tooth that is to be extracted, it can be a reason to proceed quickly with the extraction, thus gaining time for adequate treatment planning and preparing for surgery and eventual immediate temporary crowns. if the anatomy and biological conditions are favourable, one can decide to proceed with implant surgery at an early stage after extraction, such as one week. Only in those cases in which there is no acute inflammation or infection, and sufficient bone and soft tissue quantity and quality are present is it recommendable to place the implant in the fresh extraction socket. Obviously, in such a case, the CBCt scan would be performed before proceeding. Minor bone augmentation and/or connective tissue grafting can be performed contemporaneously. the decision to place an immediate provisional crown on the implant is strongly related to the expected primary stability of the implant, as well as the opportunity to manage the position of biomaterials in such way that undisturbed and uncontaminated healing is guaranteed. After healing, good aesthetics and sufficient protection of the underlying implant and implant–prosthesis con- nection are requisite if we wish to treat our patients in the best possible way and earn their long-term trust. Risk evaluation First aesthetic risk evaluation A very simple tool to start with can be a render of a 2D photograph. We use the macro intraoral shot with the black background behind the teeth (Fig. 3). With Adobe Photoshop, GiMP, Microsoft PowerPoint or Keynote, for example, it is possible, with little time invested and no expense, to cut out the shape of the contralateral tooth that will not be extracted, copy it, flip it horizontally and paste it in the position of the tooth that needs replacement. it will be clear immediately whether this shape, which provides for symmetry, supports the papillae sufficiently or whether there is a lack of volume that needs to be compensated for (Fig. 7). Another trick is to use this image with the flipped contralateral tooth and align it with the original photograph and then draw a horizontal line across both images that coincides with the same gingival reference points. lInICal Fig 9 Fig 7 Fig 8