Upper centrals.100% CAD/CAM . Reversed Restorative Rehabilitation-RRR . 4-Year follow up

139 Rating(s).

Posted on By Anton Andrews In Implants

55y.old male had a broken #8, failed apicoectomy #9 with fistulas on both.
Russian AAA (Andrews Advanced Augmentation) was applied.
During a single surgery
1. #8,9 teeth were extracted,
2. Two Legacy 2 (ImplantDirect, USA) 4.7x11.5mm implants with 4.5 mm platform were placed without any guide.
3. Bone Augmentation with Dynablast (Keystone, USA) ,SonicweldRX (KLS-Martin)was done. Incisal foramen was also grafted.
4. The site was sutured WITHOUT primary closure using PRF as a membrane.
When 5 months later, Implants were uncovered, intraoral scan was done with TRIOS(3Shape) and 3mm-tall healing abutments were placed .
The case was designed by author with Dental System (3Shape) for 2 splinted (due to bruxism ) 100% digital CAD/CAM FCZ , screw-retained crowns.
Andrews RRR (Reversed Restorative Rehabilitation) method was utilized to design the ideal emergence profile.
No CBCT, no impressions, no models, no dental techs.

fistulas around both apices and scarring from previous apicoectomy

#9 Missing Buccal Plate;5 months later - with 3mm healing abutments placed
before uncovery ; final restorations delivered

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Nice surgery but the crowns are ugly by cosmetic standards of today.
As Carl Misch said 10 years ago, " People don't buy implants, they buy teeth (that don't look like crowns.)


I agree, crowns could be better. But patient accepted them, bottom line. Before restoring, I offered more expensive option to him but he denied.
Compared to what we started with its a huge improvement.
Also please take a look at his other teeth. We live in the real world, not "ideal" one. For the sake of your aesthetic demand, consider these crowns as "temps" with the life-time warranty.
Should it be desired and paid for, "million-dollar" crowns could be built on my implants.
Talking about "Dentistry Today", these crowns are way better that "Today's" standards.
After all its posted in "implants" category, not in "anterior aesthetics"


Not to be disrespectful, but I think that you need to spend more time looking at the work of Team Atlanta whose standards are EXCEPTIONAL.

This isn't about the money but exceptional clinical outcomes. In 1994, if you mentioned 'cosmetics' to Carl Misch in an implant course, he literally would threaten to throw you out of the course. By 2002, he realized that implant surgery that led to exceptional esthetic implant outcomes was the standard of excellence.

None of us has a right to determine excellence. We have the good fortune to have clinicians like Team Atlanta who have been so kind as to set those standards which you can either accept and follow or not.


I would like you to come back to the surface of the Earth!
For the sake of exceptionalism I could offer to refere this patient to your practice or " Team of Atlanta" dentist where his crowns will be redone at no charge , since he doesn't want to pay extra for " exceptional" dentistry. If there is no such deal, then let's just stop this pointless discussion. We are in the US , not in USSR!


it is quite a good case.
When any present a personal case I believe wants to show either a nice work or a particular problem or solution that wants to share.
This is a nice case, but Gerald observation appears OMP quite shareable: prostethic could be better.
The Atlanta team is, as he said, a goal for anyone of us and learnig to do better is a world issue: I totally agree.
Main problem on your crown, OMP, is that you haven't left enough space in between, so that papilla remains too high: a possible solution is to open that space and give enogh time to papilla to downgrow: it shouldn't be either expensive or impossible.
Thanks for sharing.


Thank you for the comment. I am slightly surprised to hear from such Xpert like you that the papilla is too short between the centrals.
You see, the problem with papilla between the implant crowns had been discussed in literature enough to realize that it should be not higher than 3 mm from the crest of the bone to avoid so called " black triangle" .
Besides that there is an article (http://www.dentalxp.com/content/1909/f6e5b2b6-bec5-473b-9b4e-c1c2d967438f.pdf) which Charles had mentioned to me earlier, confirming that the bone will be partially resorbed on the buccal of upper anterior implants. That confirms my own observation.
My Andrews RRR technique reflects the knowledge. So I left exactly 3 mm for the papilla space there and it will be no open embrasures for the time to come.
Also the case was inserted only three weeks after uncovery. So the soft tissue had not settled yet on that picture.
Finally this patient has low smile line, thus the functionality and maintenance free design prevails over "exceptional " aesthetic concerns.


I think the point that Gerald was making is even in low budget cases it is certainly possible to spend an additional 5-10 minutes just in carving the temps chairside to make them look better. Even surface stains could have blended the shade better and now with the new very quick polishing wheels Brasseler came out with it takes less than 60 seconds to get a very nice shine.


Ronald ,
These crowns are full contour zirconia, not acrylic.
Ex: opening incisal embrasure between 8 and 9 is really needed I 100% agree , but it can lead to fracture and should had been done during the green stage. Unfortunately the milling center tech ignored my instructions and sintered the case as is. Patient was in a rush to leave the city and I couldn't risk it.
Also if you look at lateral incisors, there are new mesial class 4 composite restorations had been placed as a courtesy to the patient and it took longer than 10-15 minutes, believe me.


One of my (as well as Team Atlanta) mentors Morton Amsterdam often said "I have yet to complete a case for which I couldn't have improved upon or done something differently".
In my personal experience (25+years), this remains to be true.
IMO there is more than one "exceptional" solution for this case. A "movie star" solution or "natural appearance" solution. It appears you have chosen the later.
I feel you have fallen one papilla short of achieving your goal. Do you feel you could have done something better or differently?
In addition to others suggestions, I question whether splinting of these crowns was necessary even for a bruxer.
BTW I feel your implant placement is indeed exceptional. Screw retention under these circumstances is very impressive. Thank you for sharing. Regards. Chuick


Dr. Anton,
I like the implants, as everybody. The problem of the central papilla would have been solved by using a temporary splinted crowns where you could have seen the "asphyxia" of the central papilla. I can see that you have tissue enough for the central papilla but as you said the rush was the problem, as usually happens there and everywhere.
I happened to me also, that a nice case , well prepared and documented had at the end little time to finish it, or the patient is tired of coming and wants the final restoration no matter the aesthetics.
I also like to splint cases like this.
Thanks for sharing


Anton. I found this article to be of interest:




Thank you Chuck


I can’t believe it had been over 4 years since I had started posting my cases here!

4-Year follow up
4-Year follow up


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