Written by Martin B. Goldstein, DMD Tuesday, 28 February 2006 19:00
In essence, what follows is a case presentation. The purpose behind its documentation is several-fold. In addition to the case walk-through, I’ll discuss time management of a phobic (but compliant) patient, the use of mock-up-based sectional templates for provisionalization, and the use of Captek not only for single-unit restoration but for moderate- span bridges. This case may be construed as representative of how I start and finish any case that involves major modification of the existing dentition with the exception, in this instance, of time management. It will include both methods and materials used.
Figure 1. Preoperative portrait.
Figure 2. Retracted preoperative dentition.
Polly, a full-fledged member of the baby-boom generation and a mortgage officer for a well-known local bank, presented to me in the winter of 2004 as a new patient seeking advice on improving the appearance of her dentition (Figures 1 and 2). She was no stranger to dentistry, exhibiting previous placement of 3 ceramo-metal bridges (maxillary right and left, and mandibular right). The mandibular left quadrant was missing teeth Nos. 19 and 20. Her maxillary anterior teeth exhibited extensive wear and multiple, large composite restorations. Somehow they had escaped previous crowning or veneering.
She made it quite clear that she was fearful of dentistry and needed to force herself to make dental appointments. After discussing what restoring her dentition might entail, it was decided that shorter, multiple appointments might make the rehab more tolerable for her. The thought of spending a full day in the chair was simply out of the question for Polly. During the initial exam and interview it was made known to us that Polly, as a young adult, was so self-conscious about her smile that she made it a practice of sequestering and destroying family photos that featured her.
Figure 3. Smile-Vision simulation.
At Polly’s initial visit, in addition to obtaining a new full series of radiographs and digital photos of her dentition, a portrait shot was taken that was uploaded to Smile-Vision (smilevision.net) for cosmetic smile simulation. The resulting simulation (Figure 3) was shown to Polly on her second visit, during which a treatment plan was proposed. As was requested during the initial visit, only the full restoration of Polly’s maxilla and the lower anterior were considered. Polly was quoted a fee that was more than she had anticipated. She left the office that day without scheduling an appointment, but said that she would contact us when “market conditions” improved. She took her simulation with her.
Six months passed before Polly phoned the office to begin her treatment. Upon her return for preliminary impressions, her simulation was in tow. We feel it was instrumental in keeping the fires burning.
It was agreed upon that we would restore the entire maxilla, replacing Polly’s existing bridges on the upper arch (teeth Nos. 3 to 6 and 11 to 14), crowning teeth Nos. 2, 7 to 10, and 15, and placing feldspathic porcelain veneers on teeth Nos. 22 to 27. The configuration of Polly’s existing lower right bridge, though not ideal, was deemed acceptable with respect to creating a physiologic occlusal plane against the new upper restoration. Restoring her lower left region was placed on the back burner. Interestingly, once the upper arch was near completion, Polly agreed to place new bridges on the lower arch as well, resulting in a full-mouth rehabilitation. (Yes…it would have been nice to know this in advance.)
Getting the Ball Rolling
|Figure 4. Resin replica mock-up of restoration.|
To begin the process, I obtained a full-arch triple-tray impression of the upper and lower arches using Premier ALFA trays in combination with Coltène/Whaledent’s Monobody silicone impression material. This combinations is fast, well tolerated, and can be sent to the lab for pouring. In this instance, the impressions would be poured separately and mounted on a Panadent articulator, assisted by a maxillary cast mounting jig that is the transfer component for the Kois scoreless face-bow system. I relied upon Smile-Vision to provide a full mock-up of the case (resin replica) that would be the basis for Polly’s provisionals. Due to Polly’s excessive wear, it was decided to open the articulator 2 mm before beginning the preliminary wax-up. The resin replica is based on the initial simulation that Polly had approved (Figure 4).
As is typical with such cases, I ask to “preview” the wax-up online prior to template fabrication. Upon my approval, Smile-Vision converted the mock-up to resin and then stone. This was followed by fabrication of a hard/soft template and reduction template. The package was returned to me in preparation for preparing and temporizing the case.
As noted above, a sectional approach was chosen in an effort to break the visits into more “palatable” sessions. Treatment would begin with removal and temporization of the upper right area on “day one,” followed by the same for the upper left the very next day. This was important due to the planned increase in vertical dimension. It is also worth noting that sectioning of pre-existing bridgework and subsequent tooth preparation was performed under a rubber dam in an effort to “separate” Polly from the unpleasantries associated with prolonged high-speed instrumentation. I’ve found Hygenic’s FlexiDam to be an invaluable ally in this regard.
Figure 5. G-Force egg-shaped diamond with innovative diamond retentive matrix.
The majority of tooth preparation was completed using Garrison’s G-Force diamond instruments. I’ve found them to cut quickly yet smoothly, and they have considerable staying power, attributed to a unique method of embedding the diamond chips into the host matrix (Figure 5).
As can be seen in Figures 6 to 9, the upper right quadrant was temporized after having removed the pre-existing bridge. In Figure 10, both upper right and upper left provisionals are in place following 2 brief, back-to-back clinical sessions. Provisionals were constructed from 3M ESPE’s Protemp 3 Garant bisacryl material and luted with Zenith/DMG’s TempoCem. Polly was then given 3 weeks to see how the opened vertical dimension would be tolerated.
What turned into 5 weeks of trial wear resulted in an unaffected TMJ. Apparently, her masticatory system was able to tolerate the increased vertical created in the mock-up-based provisional restoration.
Figure 6. Hard/soft template of upper arch with posterior segment sectioned.
Figure 7. Bis-acryl-loaded template in place for upper right quadrant provisional.
Figure 8. Bis-acryl provisional after initial withdrawal allowed to set in matrix.
Figure 9. Trimmed and glazed upper right provisional.
Figure 10. Upper posteriors temporized.
Figure 11. Electrosurge tissue-plasty with Parkell Sensimatic 600SE.
Figure 12. Anterior (Nos. 7 to 10) provisionals setting under sectioned soft template.
Figure 13. Patient leaves with full arch temporized.
At Polly’s third visit, teeth Nos. 7 to 10 were prepped and temporized in a relatively brief visit. Preparation was preceded by an electrosurge tissue modification in an effort to achieve a more balanced gingival architecture. Parkell’s Sensimatic 600SE was used to accomplish this. She was scheduled to return in 2 weeks for final impression of the upper arch (Figures 11 to 13).
IMPRESSING THE UPPER ARCH
Figure 14. Coltène/Whaledent Magic FoamCord retraction matrix.
Figure 15. Polyvinyl maxillary impression taken in rigid custom tray.
Impression of the upper arch involved the capture of tissue detail surrounding 10 abutment teeth. In an effort to streamline the process, Coltène/Whaledent’s Magic FoamCord (MFC) was employed for tissue retraction. Doing so involved a preliminary impression with Coltène/Whaledent’s AFFINIS Fast Putty Soft. This matrix/impression became the delivery system for the Magic FoamCord used to ply the tissue away from the tooth prior to the impression. In this instance, the MFC was applied to the matrix for retraction. This could just as easily have been accomplished by injecting the MFC directly into the sulci and placing the matrix atop it. The MFC expands upon setting, physically displacing tissue away from the abutment’s finish line. Figures 14 and 15 demonstrate the MFC tissue retractor and resultant Coltène/
Figure 16. LuxaBite used to record occlusion in sectional fashion with left side provisional holding a stable vertical.
Whaledent Monobody impression taken in a rigid, labfabricated custom tray. Bite registration was obtained in a sectional manner by joining segments of Zenith/DMG’s LuxaBite together. This was accomplished by leaving one side of the provisional in place when taking the first bite record, as is noted in Figure 16. In this instance, the left side of the provisional maintained the desired bite relationship. Once the right side was captured, the left side provisional was removed, and more LuxaBite was added to the registration.
CHOOSING A RESTORATIVE MATERIAL
Figure 17. Captek maxillary casting/framework.
Figure 18. Captek units following porcelain coverage.
My choice for restoring Polly’s maxilla was Precious Chemical’s Captek. Because I wanted the strength and predictability of a PFM system, this high gold/palladium composite material brought many benefits to the table. Appealing to my practical side was the ability to mix and match finish lines. From feathers to full-ceramic shoulders to all-gold margins, they all work with Captek. And, because Captek possesses a pleasing golden hue (think dentin), I could anticipate natural-looking tooth shades without having to over-prepare the teeth. The inherently thin (but strong) coping minimizes the need for aggressive tooth preparation, while its warm color reduces the technician’s dependence on opaque to block out the metal substructure. Captek’s reputation for repelling plaque seemed a natural for a higher-risk patient such as Polly.1-3 Finally, as Captek has evolved, Precious Chemicals has developed highly effective methods for making Captek not only a single-unit material but one equally suited to spanning edentulous spaces, as is depicted in Figures 17 and 18.
TIME ECONOMY (CATCHING A TAILWIND)
Returned to da Vinci Laboratory were the following:
• rigid custom-tray-based final impression
• rigid bite registration
• poured counter model
• mock-up resin replica
• Kois maxillary mounting jig
• simulation photo from Smile-Vision
• photos of preps and desired shade of case.
Porcelain butt margins were requested for teeth Nos. 6 to 11, with margins placed just subgingivally. Porcelain covered margins were requested for posterior restorations, with exposed Captek alloy margins on the lingual surfaces of all the restorations.
Once all materials were in da Vinci’s hands and the case mounted, it was decided to go for broke and take the upper arch to a completed state, eliminating the casting try-in phase.
FAIRY-TALE STORY DELIVERY DAY
Three weeks later the case was tried in. Much to Murphy’s amazement (the law was apparently violated), fit, occlusion, and aesthetics were found to be satisfactory to both patient and doctor, with only minor occlusal adjustment needed. After some deliberation, it was decided to proceed with final cementation that same visit. This decision was based on an observation that pontic/tissue contacts were ideal, as well as a hesitation to cement the case provisionally. Doing so, of course, would make removal of the provisionally cemented case a new challenge that was not appealing to me or my patient.
Six single Captek units (Nos. 2, 15, 7 to 10) and two 4-unit Captek bridges were cemented that day using Kerr’s Maxcem self-etching resin cement. Polly was then given home care instructions and reappointed for case continuation. As mentioned, Polly had at this point agreed to replace her lower right bridge and place a new bridge on the lower left to complement the planned porcelain veneers on Nos. 22 to 27. Her next visit would involve preparation, impression, and temporization of Nos. 18 to 21 for the bridge and Nos. 22 to 27 for the planned feldspathic veneers.
AND SO IT WENT
On Polly’s return several weeks later, she reported that her maxillary restoration felt good and that overall she was very pleased. Her one hesitation was a gingival embrasure space between teeth Nos. 8 and 9 that hadn’t completely filled in with tissue, as I had hoped it would. It didn’t prove to be enough of an objection to prompt replacement at this point; and of course, hope springs eternal.
Again, the sectional provisional approach was employed using the mock-up-derived template. In this instance, the 4-unit bridge was first fabricated, and then the template was reused to provisionalize the lower anterior veneer set. A rigid custom tray and polyvinyl im-pression recorded the new preps. The necessary records were taken, including fabrication of an anterior bite record with Coltène/Whaledent’s Jet Bite, followed by cementation of the posterior left bridge with TempoCem and the 1-piece veneer temp with Kerr’s TempBond Clear. This clear resin cement was used so as not to create an opaque look to the lower anterior veneers.
NEARING THE FINISH LINE
Upon Polly’s return, her lower left Captek bridge was luted with TempoCem while her veneers were luted with Cosmedent’s Insure. This wonderful material, available in firm and light viscosities, is a light-cure-only resin luting cement offering unlimited working time. The luxury of time encouraged me to seat all veneers at the same time, spot tack, clean-up most excess, and then proceed to final curing. This approach eliminates the possibility of interproximal contact discrepancies that often accompany a sequential, single-veneer placement approach.
Figure 19. Retracted view of finished case.
Figure 20. Final portrait of finished case.
Consistent with our “keep it brief” approach, Polly was dismissed and reappointed for removal, repreparation, and reimpression for her lower right Captek bridge. Fabrication and delivery of this bridge was uneventful. The completed case can be seen in Figures 19 and 20. Both lower bridges were cemented with Kerr’s Maxcem.
TAKE AWAY MESSAGES...
This case, like all my cases involving the anterior dentition, began with a preoperative portrait from which a case simulation/design was created. In sequential fashion, and upon case simulation approval, a skilled Smile-Vision lab technician created a mock-up based upon what was designed in the smile simulation. Provisionals translated the mock-up to the mouth for evaluation, while the same mock-up offered a guide for the technicians at da Vinci to move forward with the case. A working reduction template based upon the mock-up provided confidence that my tooth preparation would permit the mock-up to translate to the Captek and ceramic restorations. It has been my experience that such an approach increases the likelihood of the patient, lab technician, and doctor being on the same page with respect to case result expectations. To be sure, anxiety on this end is dialed down using this approach. It was also pointed out that the known benefits of Captek translate well to multiple-unit restorations in the hands of a skilled Captek laboratory. In similar fashion, the materials employed during case fabrication were named.
Finally, while it is my preference to prepare a complete arch at a single sitting, in this instance it was helpful to my patient to divide treatment into several shorter sessions. The fact that the soft shell template used for fabricating the temporaries could be divided into sections that could be pieced together at different times made this approach possible.
1. Goodson JM, Shoher I, Imber S, et al. Reduced dental plaque accumulation on composite gold alloy margins. J Periodontal Res. 2001;36:252-259.
2. Knorr S, Combe EC, Wolff LS, et al. The surface free energy of gold alloy systems. Presented at: 32nd Annual Meeting and Exhibition of the AADR; March 12-15, 2003; San Antonio, Texas.
3. Juntavee N, Nathanson D, Giordano R. A research report on Captek. Captek Web site. Available at: www.captek.com/new_captek/library/publish/research%20report.pdf. Accessed December 12, 2005.
Disclosure: The author is a consultant for Captek, Coltène/Whaledent,Smile-Vision, Premier, and Parkell.
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