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Combining Modern Materials to Create a Beautiful Smile!

Patients in modern day society are demanding more aesthetic dental treatment. This article will briefly describe 3 modalities that can be used for both aesthetic and functional care.

Recently introduced zirconium oxide systems used to replace metal substructures are becoming more and more popular among some dentists and patients. The preparation design for this type of restoration is similar to conventional PFM alternatives, but I have found that the elimination of the metal often makes good aesthetics easier to achieve. Of the numerous zirconium-based crowns and bridges that we have delivered in our office in the last several years, I have had virtually no failures due to fracture or separation of the aesthetic porcelain from the underlying substrate.

When missing teeth are a factor, implant reconstruction has given us yet another option for partial and full reconstruction. As Dr. Paul Homoly has so eloquently put it, “Implants are not replacements for teeth, but rather replacements for no teeth.” Where no teeth exist in full reconstruction cases, I have begun offering implants as an alternative, and many of my patients are choosing them. Zirconium abutments for implants can enhance aesthetics, and I prefer these for anterior reconstruction.

Pressed-ceramic veneers, onlays, and crowns can be used in some cases when a metal or zirconium foundation is not desired. These materials must be bonded to place with adhesive procedures to acquire their ultimate strength. However, they required less tooth preparation than conventional crowns and other conventionally cemented restorations.
The following case illustrates the use of an implant, 3 zirconium crowns, 2 pressed ceramic onlays, and 5 pressed ceramic veeners for aesthetic improvement and functional reconstruction.

An attractive young woman suffered from internal resorption of her maxillary left central incisor. The prognosis was negative, so the tooth was scheduled for extraction and replacement by an implant and crown. The clinical crown was removed, and the adjacent teeth were prepared for crowns. The right central incisor had been endodontically treated years earlier, and the left lateral incisor had a large Class III lesion on the mesial aspect that had been previously restored with composite resin. The patient preferred to have a provisional bridge placed during the implant integration time rather than to use a temporary removable partial denture. A provisional bridge was fabricated and cemented with temporary cement so that the periodontist (Dr. Paul Tolmie, of Charlotte Perio, Charlotte, NC) could remove it while extracting the central incisor and placing the implant.

Figure 1. Implant healing cap (3I) in place. Adjacent teeth prepared for crowns and veneers.

Figure 2. Restorations on the working model.
Figure 3. Three porcelain-fused-to-zirconium crowns (Vericore zirconium core, Whip Mix, and Venus layering porcelain, Heraeus Kulzer) ready for placement. Figure 4. Zirconium abutment (3I ZiReal), screw, and crown.
Figure 5. The zirconium abutment in place. Figure 6. First molar prepared for a pressed-ceramic onlay.
Figure 7. Internal (etched) surfaces of the pressed-ceramic onlays. Figure 8. Two pressed-ceramic onlays (Venus, Heraeus Kulzer), 5 pressed-ceramic veneers (Venus), 2 zirconium-based ceramic crowns and one zirconium-based ceramic crown on a zirconium abutment attached to an implant all shown in place from the lingual view.
Figure 9. Retracted view of the seated restorations.
Figure 10. The patient’s new smile.

After the implant (Biomet 3i) had been placed and osseointegration was established, final preparation for the 2 crowns was performed. The maxillary first premolar, canine, and lateral incisor, as well as the left canine and first premolar, were prepared for veneers. The impression coping for the im­plant was placed, and a radiograph was taken to confirm that it was fully seated before a final impression was taken with a polyvinyl siloxane impression (Aquasil Ultra, DENTSPLY Caulk). The healing cap can be seen in place in Figure 1. Bisacrylic provisional restorations (Luxatemp, DMG America) were fabricated after the final impressions and occlusal registration were taken. All-ceramic crowns and porcelain veneers were fabricated in the dental laboratory. Figure 2 shows the restorations on the working model. After the first molars were prepared for ceramic onlays, the veneers for the right premolar, canine, and lateral incisor; and the left canine and premolar, were bonded to place. The crowns for the natural teeth and the crown for the implant were made with porcelain-fused-to-zirconium (Vericore, Whip Mix). The internal surfaces of the crowns can be seen in Figure 3. The implant abutment (3I), attachment screw, and crown, are shown in Figure 4. The facial view of the abutment in place can be seen in Figure 5. Both of the maxillary first molars were prepared for onlays. One of the prepared teeth can be seen in Figure 6. The internal etched surfaces of the ceramic onlays (Venus, Heraeus Kulzer) are shown in Figure 7.
The occlusal view of all restorations in place is shown in Figure 8, and Figure 9 shows the facial view. The patient was very pleased with her beautiful new smile after receiving an implant and 10 all-ceramic restorations (Figure 10).

By using modern materials, we were able to provide both aesthetic and functional treatment for this patient. This case report demonstrates the combination use of an implant, a zirconium crown, and pressed-ceramic veneers, crowns, and onlays in the same patient to achieve the goals for treatment.

Laboratory work was completed by the Center for Ceramics, Charlotte, NC.


Dr. Nash is president and co-founder of the Nash Institute for Dental Learning in Charlotte, NC. He owns and operates Cos­metic Dentistry of the Carolinas located in Huntersville, NC, where he and his associates provide general, aesthetic, and cosmetic dental care. Dr. Nash is an accredited Fellow in the American Academy of Cosmetic Dentistry and a Diplomate of the American Board of Aesthetic Dentistry. An international presenter on dental aesthetics and oral rehabilitation, he is also a consultant to numerous dental products manufacturers. He can be reached at (704) 364-5272 or This email address is being protected from spambots. You need JavaScript enabled to view it., or visit his Web site at nashinstitute.com.


Disclosure: Dr. Nash reports no conflicts of interest.

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