Advanced Materials for Lifelike Smiles

Case Report

A woman in her mid-40s presented to the practice with the chief complaint of pain radiating from tooth No. 9. The dentist who had previously restored the patient's anterior maxillary teeth Nos. 7 through 10 had placed porcelain veneers on teeth Nos. 7, 8, and 10 and a zirconia crown on No. 9. Tooth No. 9 had undergone a root canal with post and core and crown lengthening procedures. When asked if she liked the appearance of her existing restorations and the esthetics of her smile, she indicated that she did not, although she could not pinpoint aspects of her smile that bothered her.

A series of pre-operative photographs was taken of her existing restorations (Figure 1). The laterals in relation to the centrals were too wide and all restorations were bulky, resulting in an unnatural appearance. The four incisors had very similar mesio-distal width, which made the restorations unattractive. A CBCT scan was taken at the initial appointment and revealed tooth No. 9 had a buccal fracture, likely caused by the oversized post and core. Tooth No. 9 would need to be extracted.

The treatment plan, presented and accepted by the patient, was to convert the veneers on teeth Nos. 7, 8, and 10 to crowns, extract tooth No. 9, and place a screw-retained implant crown at the site after implant osseointegration. The clinician consulted a periodontist for tooth extraction, bone grafting, and implant placement.

A laboratory-processed fixed partial denture temporary for teeth Nos. 7 through 10 was fabricated using PMMA (Harvest Dental). The existing restorations were removed and the provisional restorations were inserted prior to implant surgery.

On the day of surgery, the periodontist removed tooth No. 9, placed a tapered bone-level implant (SLA 4.1 x 12mm, Strauman), and added bone graft material (Puros Cortico-Cancellous Particulates Allograft, Zimmer Biomet) around the implant. The temporary was modified on the day of surgery and inserted.

Upon osseointegration and with the patient's approval of the tooth color, shape, and esthetics of the temporary restorations, the laboratory technician came to the practice for a custom shade appointment (Figure 2). The clinician took an impression of the temporaries and a final impression of the prepared teeth Nos. 7, 8, and 10, as well as a fixture-level impression of the implant on a full-arch tray with VPS impression material (Panasil, Kettenbach Dental). The patient was instructed to return for a try-in assessment of the definitive restorations prior to final insertion.

At the try-in appointment, the patient was very enthusiastic about the esthetic results but asked if the surface anatomy of the restorations could be toned down. The modifications were made in the laboratory and the restorations were inserted utilizing a resin-modified glass ionomer cement. The implant restoration was inserted following the company-recommended torque values and sealed with a direct composite.

Laboratory Procedure

The pre-operative photographs, along with the impression of the temporaries, were sent to the laboratory. The clinician conferred with the technician about his concerns regarding the width and spacing of the laterals and centrals due to the patient's desire to not have veneers on the two canines, and shared the patient's desire for a more natural-looking smile.

The technician recommended milling the restorations from zirconia (IPS e.max ZirCAD Prime, Ivoclar Vivadent) to ensure reduction of the thickness of the restorations and to provide the strength and esthetics the case required. The material was also chosen because of its workflow efficiency. The unique dentin-to-incisal gradient technology of the milling block offers a seamless progression of shade, translucency, and composition—resulting in natural-looking restorations that can be characterized using simplified, time-saving techniques.

The technician poured the model and scanned it for digital design of the final restorations (Figure 3 and Figure 4). The milled restorations (Figure 5) were designed with built-in surface characterizations executed by the mill (PrograMill PM7, Ivoclar Vivadent). Prior to sintering, the technician used an infiltration technique to obtain OM2 shade by infiltrating IPS e.max ZirCAD Prime BL2 shade with the IPS e.max ZirCAD LT B1 Liquid. This technique saved 1 hour of time in comparison to the traditional staining and firing technique. With the application of tooth shade OM2 coloring liquid to the unsintered restorations, the final esthetic appearance was achieved during the sintering phase (Figure 6 and Figure 7). The final restorations were seated on the model (Figure 8 and Figure 9) to check the fit.

The restorations were delivered to the practice and seated by the clinician (Figure 10 and Figure 11). A recall appointment was scheduled to assess the health of the gingiva, which had healed nicely around the new restorations (Figure 12 through Figure 16).

The patient was highly satisfied with the esthetic result of her new smile.

About the Author

Yuki Momma, RDT, is the Owner of Ceramic Artisan Dental Lab in Weston, Massachusetts. Mario Gatti, DMD, CAGS, FACP, is a Prosthodontist with Weston Dental Specialists Group in Weston, Massachusetts.

Disclaimer: The statements and opinions contained in the preceding material are not of the editors, publisher, or the Editorial Board of Inside Dental Technology.

Manufacturer Information:

Ivoclar Vivadent
ivoclarvivadent.com
800-533-6825