A New Smile for a New Life

In September 2000, Haley, an 11-year-old female, was brought to our office by her grandmother who had concerns about her oral health and emotional well-being. The patient stated that her friends made fun of her ugly smile, and her embarrassment was causing her to become shy and withdrawn (Figures 1 and 2). I had seen the patient’s mother 20 years earlier with the same clinical condition, and made the diagnosis of amelogenesis imperfecta. The mother had lost all of her teeth by the age of 20, and the grandmother did not want the same outcome for her granddaughter.
Amelogenesis imperfecta is a rare, inherited disorder characterized by a brown discoloration of the teeth resulting from a defect in tooth mineralization or calcification. The lack of this mineralization causes unusually soft enamel that wears and decays rapidly.

Figure 1. Preoperative full-face view.

Figure 2. Preoperative retracted view.

TREATMENT PLANNING

We knew because of the patient’s young age that we would have to evolve a treatment plan to span over several years until she matured. Initially our treatment concerns were to remove all of the carious lesions, open the occlusion, and provide her with intermediate crowns on the maxillary anterior teeth to sustain her for 5 or 6 years until the permanent phase of her treatment could begin.
Since there was little to no enamel present on her existing teeth, we decided that the interim crowns would be of Cristobal (DENTSPLY Ceramco) and that the permanent restorations would probably be full-coverage porcelain-to-metal crowns. We eventually selected Captek crowns for her permanent restorations because of the minimal tooth reduction required and their aesthetic excellence. Captek crowns are unique because the gold matrix is made of 97.5% gold with 2.5% platinum and palladium for strength.
The ultra-thin gold coping allows for a thinner layer of opaquing agent, which in turn leaves more room for the aesthetic properties of the porcelain to shine through.
Captek crowns have all of the strength of the porcelain-fused-to-gold crown but with the beauty of an all-porcelain restoration.
Photographs, study model impressions, and occlusal records were taken to document this beginning phase of what would be the most complex restorative case in which I had ever been involved.

PHASE 1—TREATMENT

Figure 3. Preparations for Cristobal crowns.

Figure 4. Cristobal crown Nos. 5 to 12, retracted view.

Figure 5. Full-face view of Cristobal crowns; patient at 11 years old.

Figure 6. Boley Gauge measurement of lower anterior tooth before preparation.

Figure 7. Full-arch view of preparation Nos. 18 to 31.

Figure 8. Provisionals of Nos. 18 to 31.

Figure 9. Captek crowns cemented for Nos. 18 to 31.

Fortunately, the decay was minimal. Several small restorations were performed to replace the clinical caries, and we then were ready to proceed with the occlusal challenges and intermediate crown preparations.
Teeth Nos. 5 to 12 were prepared for Cristobal crowns. It was necessary to cosmetically recontour the tissue and the bone to give us adequate tooth length for crown retention (Figure 3). Impressions, a face-bow transfer, and occlusal records were made to enable the lab to fabricate the 8 Cristobal crowns that would act as her interim treatment solution. This would give her a nice, aesthetic smile until the time we could continue with the more permanent phase of her treatment. The patient was very pleased with her new smile (Figures 4 and 5).
When the patient was 13 years of age we were ready to begin the orthodontic phase of treatment. We determined that we would have to open the posterior occlusion by 2.5 mm to allow the orthodontist room to place brackets on the teeth. The orthodontic phase of her treatment took 2.5 years to complete. During this time we had Haley on a regular recall regimen and treated any carious lesions as they occurred.
At the age of 15 and a half years, Haley’s orthodontic appliances were removed and she was referred to a periodontist for 360° osseous crown lengthening on the lower arch. This was necessary to give us adequate tooth structure to fabricate aesthetically pleasing, functional Captek crowns. Photographs were taken as well as study model impressions and facebow records for the laboratory to use to mock up the mandibular teeth.
We initiated treatment on the mandibular arch with the intent of opening her occlusion by 2 mm. The maximum width of the mandibular anterior teeth was 4 mm (Figure 6). Minimal preparation was required, as it was only necessary to remove enough tooth structure to allow for the thickness of the Captek crowns. A coarse diamond bur (No. 1114.8C NeoDiamond [Micro-copy]) was used to make a 0.3-mm to 0.5-mm chamfer margin, 360°, on each of the prepared teeth. The occlusal surfaces were reduced 1 mm with a football-shaped diamond (No. 1900C Neo-Diamond). A fine diamond (No. 1114.10F NeoDiamond) was used to finish the gingival margin. A garnet fine sandpaper disc (E.C. Moore) was used to round any line angles. An Enhance polishing cup (DENTSPLY Caulk) was used to smooth and polish any rough areas of the preparations (Figure 7).
The provisionals were fabricated from a vacuum-formed coping material and Luxatemp, a self-curing, fast- setting, bis-acrylic temporary material (Zenith/DMG), and were cemented with Zone temporary cement (Dux Dental) for tooth comfort. They were maintained for 6 months to allow the tissue to mature and for Haley to become acclimated to her new occlusion (Figure 8). Three months into this provisional phase Haley underwent crown lengthening procedures on the maxillary teeth.
After the 6-month provisional period we were ready to impress for the permanent restorations. The provisionals had held up nicely, and Haley was comfortable with the changes we had made in her occlusion. The provisional crowns were removed, and both retraction cord and Expasyl (Kerr) were utilized for proper margins and to control any bleeding. The final impressions were made with Exafast vinyl polysiloxane tray material (GC America) and Precision light viscosity injection material (Discus Dental). Occlusal records were taken with Mega Bite (Discus Dental). The final impressions, facebow transfer, and occlusal records were sent to the laboratory that would fabricate our Captek crowns for teeth Nos. 18 to 31. Photographs were taken of the working models and of the finished Captek crowns—on and off of the models. The finished case was used as an opposing model for the wax-up of the maxillary arch.
The mandibular Captek crowns were tried in and checked for proper fit. The interproximal contacts and margins were fine. We gently cleansed the prepared teeth with Consepsis scrub (Ultradent Products). We then applied several coats of AcquaSeal (AcquaMed Technologies) to desensitize the teeth. The mandibular Captek crowns were cemented with RelyX Unicem by 3M ESPE (Figure 9).
The remainder of this article describes the completion of the dental makeover of our young female patient with congenital amelogenesis imperfecta. This journey spanned the course of 6 years with assistance from an orthodontist, a periodontist, a dental laboratory, and a dental materials manufacturing company.

PHASE 2—PREPARATION

Figure 10. Maxillary preparation Nos. 2 to 15.

Figure 11. Provisional crown Nos. 2 to 15.

The dental laboratory had used the finished crowns for the lower arch (prior to their cementation) as the opposing model for the mock-up of the maxillary teeth. This wax-up would be our guide to create the new occlusion and incisal guidance for Haley. It was apparent from the wax-up model that we would have to recontour the buccal cusp tips of the lower molar crowns to correct the slight bilateral cross-bite residue of the orthodontic treatment. We were determined to achieve a lingual positioning of the lower molars in relationship to the upper molars. This would have to be addressed when preparing the maxillary crowns as well as the fabrication of our provisionals on that arch.
The heavy chamfer margins (0.2 to 0.3 mm) were achieved with a round-end tapered coarse diamond bur (No. 1114.8C NeoDiamond). The occlusal reduction was made with a coarse football diamond (No. 1900C Neo-Diamond), and the margins were finished and refined with a fine diamond (No. 1114.10 NeoDiamond). Polishing with a garnet sandpaper disc and an Enhance polishing cup rounded all line angles and removed any rough areas on the prepared teeth (Figure 10). Retraction cord and Expasyl were placed to allow for visible margins and to control bleeding. The final impressions were made with Exafast vinyl polysiloxane tray material and Precision light viscosity injection material. Occlusal records were taken with Mega Bite.
The provisionals were fabricated with a clear matrix vacuum-formed over a duplicated model of the wax-up. The laboratory had overcontoured the maxillary molars in its wax-up to allow us to lingualize the lower molar crowns. Luxatemp was injected into the matrix and placed over the prepared teeth. Once the material was set, the provisionals were removed, shaped, and contoured. The margins were carefully checked. Once the occlusion was satisfactory, the provisionals were cemented with Zone (Figure 11).

LABORATORY INSTRUCTIONS

The final impressions, facebow transfer, and occlusal records were sent to the dental laboratory for the fabrication of the Captek crowns. Every detail of the case was discussed at length with the master ceramist handling the case. A common understanding can be developed through working with the same ceramist over many cases.

DELIVERY

Figure 12. Captek crown Nos. 2 to 31 in centric occlusion, retracted view.

Figure 13. Captek crowns, retracted view.

The finished case was inspected on and off the working models. The provisional crowns were removed, and the Captek crowns were tried in and checked for fit, interproximal contact, and marginal accuracy. Once it was established that the crowns fit properly, we prepared to cement them by thoroughly cleansing the teeth with a disinfectant (Consepsis) and applying generous amounts of a desensitizer (AcquaSeal). The cement chosen was RelyX for its strength and compatibility with the Captek crowns (Figures 12 and 13).
The occlusal adjustments were held to a minimum due to meticulous attention to detail throughout. The occlusal records were thoroughly checked at each phase of treatment. Ideal protrusive movement was achieved, and left and right lateral excursive movements were balanced. Lastly and equally important, centric occlusion was evenly distributed throughout the entire dentition. This provided her with a comfortable and stable occlusion to ensure the stability of her treatment for years to come.

SUMMARY

Figure 14. Smile with new crowns.

Figure 15. Full-face postoperative.

Figure 16. A playful pose from a grateful patient.

In this article we have shown that with meticulous planning, proper preparation, and good communication, state-of-the-art dentistry can be performed (Figure 14). Our attention to detail in every aspect of this case provided us with exceptional results. By using the Captek crowns as an alternative to conventional porcelain-fused-to-metal crowns, we were able to provide this beautiful young woman with both a functional and aesthetically pleasing smile (Figures 1, 15, and 16).


Sources

1. Smile design. In: Gurel G. The Science and Art of Porcelain Laminate Veneers. Chicago, Ill: Quintessence Publishing; 2003:62-109,2.
2. Feigenbaum N, Mopper KW. A Complete Guide to Dental Bonding. New Brunswick, NJ: Johnson & Johnson Dental Products; 1984:22-29,4.
3. Albers HF. Tooth-colored Restoratives. 8th ed. Santa Rosa, Calif: Alto Books; 1996:1-18,1.
4. Hine M, Levy B, Shafer W. A Textbook of Oral Pathology. 2nd ed. Philadelphia, Pa: WB Saunders; 1964:38-40.
5. Griffin JD Jr. How to Build a Great Partnership With the Technician. Vol 10(7) 2006:26-34.


Acknowledgments

The author would like to thank the following people for their assistance in making this entire case a possibility:

Orthodontic services:
Thomas W. Epps, DMD

Periodontal services:
Nelson H. Eddy, DDS

Laboratory services:
Sherer Dental Laboratory, CEO Joe E. Sherer Jr, for fabrication of both the Cristobal and the Captek crowns.

Laboratory materials:
Nick Azzara, president of Captek.

I am especially indebted to the above as all these services were donated at no charge to myself or Haley. With great pleasure our office treated her pro bono.


Dr. Baker is a graduate of the Medical College of Virginia School of Dentistry. He maintains a full-time private practice in Rock Hill, SC. He is a Fellow and board member of the American Society for Dental Aesthetics, a Diplomate of the American Board of Aesthetic Dentistry, a Fellow of the International Academy for Dental/Facial Aesthetics, and a Fellow of the AGD. Dr. Baker has been selected as a CRA evaluator for new dental products and is a clinical instructor at the Nash Institute for Dental Learning. He can be reached at (803) 328-3891, This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or bakersmile.com.

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