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Restoring a smile
It’s a great time to practice esthetic and cosmetic restorative dentistry. Today, unlike ever before, clinicians and technicians have a variety of indirect restorative material options to quickly, easily, and predictably restore a patient’s smile. There are dozens of CAD/CAM systems and complementary materials on the market today, affording clinicians the opportunity to confidently place simple, cosmetic alternatives that demonstrate exceptional strength, esthetics, color stability, and biocompatibility, even in the posterior region. And, what’s more, in cases where isolation of subgingival margins and the predictability of a dry field are compromised, these restorations can be cemented with a traditional Type I glass ionomer cement (unlike their pressed ceramic counterparts) without compromising the overall strength and retention of the final restorations.1-4 Zirconium is becoming popular as an alternative to metal substructures. The preparation design for this type of restoration is similar to conventional porcelain-fused-to-metal alternatives; however, I have found that the elimination of metal from the substructure makes these restorations even more esthetic. Some of the advantages of zirconium-based restorations include the elimination of dark lines at the margin and natural translucency or fluorescence.
A 47-year-old female presented dissatisfied with the appearance of her existing restorations and smile (Figure 1). She was displeased with the spaces in her dentition caused by congenitally missing laterals, teeth shortened from uneven wear, and large amalgam restorations that were placed more than 15 years ago. She desired a “white Hollywood smile!” Clinical examination revealed multiple amalgam restorations with fracture lines and an unesthetic porcelain crown on tooth No. 14 (Figures 2 and 3). Occlusal wear was evident on the canines and premolars, resulting in much flattened teeth. She had asymmetrical spacing in certain areas because of congenitally missing teeth Nos. 7 and 10. She had no temporomandibular joint symptoms at this time, but the ultimate treatment plan was to include the development of anterior protection of the posterior teeth with canine guidance on her premolars and increase her vertical dimension to a more comfortable state. Probing depths were within normal levels in the anterior region, and the patient’s periodontal health was within acceptable limits. Although the soft tissue symmetry was inadequate on teeth Nos. 6 and 11 (Figure 4), the patient did not desire any forms of grafting or surgery. A comprehensive treatment plan was developed, which consisted of restoring her entire maxillary dentition with all-porcelain restorations from teeth Nos. 2 to 15 and mandibular dentition consisting of teeth Nos. 18, 19, and 30. The patient selected 030 Bleach Shade on the Chromascop (Ivoclar Vivadent). The lower dentition would be whitened using 16% Nite-White bleaching agent (Discus Dental).
Diagnosis/treatment planning A smile-guide reference was used to complete the smile analysis necessary for pre-designing the case.5-8 From an esthetic perspective, the patient’s maxillary anterior teeth lacked vitality and depth, giving her a very hard look. Facially, the teeth were very flat—they had only one plane and were too rectangular. The final crowns would be designed to soften the patient’s look; tapering the teeth toward the necks in a gingival direction would be one way to accomplish this esthetic objective. Because of recurrent decay in multiple defective amalgam restorations and an unattractive crown, the restoration choices were limited to full-crown restorations except for teeth Nos. 8, 9, 13, and 15. An all-porcelain crown system seemed the logical choice to accommodate the patient’s esthetic and functional needs. Also, a bridge was recommended to fill in the space in the anterior region. In this particular case, the clinician felt confident with the esthetics of zirconium, which required nothing more exotic than conventional chamfer preparation and traditional cementation protocol. The porcelain system used in this particular case was the Lava system (3M ESPE). Specifically, the preparation of the teeth required a chamfer finish, with soft rounded internal line angles. Simple facial and lingual reduction was approximately 1 mm, and occlusal reduction was 2 mm. Once the teeth were prepared, a full-arch impression was taken of each arch using a fast-set PVS (Take-One Super Fast, Kerr). (Continued on Page 2)
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