A Combination Case: Satisfying Function and Aesthetics

Ross W. Nash, DDS


Diagnosis and Treatment Plan

A young man getting ready to enter college presented for a consultation on the restoration of his smile (Figure 1). He was wearing a partial denture replacing a missing maxillary right central incisor. In preparation for an implant to replace the missing tooth, Dr. Paul Gibbs (a periodontist in Davidson, NC) had placed a bone graft in this area. In the retracted frontal view (Figure 2), one can see that the patient’s overall dental health was good. The tissue in the mandibular anterior area was inflamed due to plaque accumulation there. However, clinical and radiographic examination revealed no active caries or periodontal bone loss and all teeth had good bone support with Class I occlusion. The left maxillary incisor had a composite restoration on the inciso-facial area. There was incisal wear on the maxillary right canine opposing a similar wear facet on the disto-incisal edge of the mandibular right canine. The maxillary central and lateral incisors were smaller than normal proportions, and the lateral incisors showed significant incisal wear. The preoperative maxillary incisal view can be seen in Figure 3.

Figure 1. Pre-op smile. Figure 2. Pre-op retracted frontal view.
Figure 3. Pre-op incisal view.

Dr. Gibbs reviewed the patient’s history with me, which included 2 traumatic incidents when the patient was younger. The first incident resulted in the need for endodontic treatment on tooth No. 8 (Figure 4), and the second in a horizontal fracture to the same tooth (Figure 5). The patient was 13 years of age at the time of the extraction of tooth No. 8, so Dr. Gibbs elected to hold further treatment until he was about 20 years old to allow for growth completion, at which time a bone graft was placed (Figure 6).

In consultation with Dr. Gibbs, we felt that 5 porcelain veneers and an implant-supported crown could provide the patient with a smile that would exhibit the proper proportions and color. Porcelain veneers were also planned for the premolars to “finish” the smile.

The implant in the No. 8 position was placed by Dr. Gibbs and allowed to integrate.

Figure 4. Endodontic treatment had been done previously on tooth No. 8. Figure 5. Fractured tooth No. 8 (right central incisor).
Figure 6. Bond augmentation after extraction of tooth No. 8.

Clinical Protocol
At the preoperative appointment, full-arch preliminary impressions were taken using a vinyl polysiloxane (VPS) alginate substitute (Status Blue [DMG America]). A face-bow record (Denar [Whip Mix]) was taken as well as a centric relation occlusal registration (Luxabite [DMG America]) and preoperative photographs.

In the laboratory, stone models were made from the preliminary impressions and mounted on a Denar articulator using the occlusal bite registration. A wax-up for the final result was accomplished and VPS stints were fabricated for use in making the provisional restorations.

Dr. Gibbs placed a Straumann implant with a custom healing cap to shape the tissue. In Figure 7, the transfer post can be seen in place, and the surrounding teeth were prepared for lithium disilicate veneers. The intraenamel veneer preparations provided for 0.5 to 0.8 mm of restoration thickness, definitive chamfer margins at the height of the tissue, elbow preparations for proximal wrap, and preparation of the incisal edge to provide for a minimum of 1.0 mm overlap of the incisal edges and butt margins with rounded corners.

A diode soft-tissue laser (Picasso [AMD LASERS]) was used to refine the gingival tissue.

Figure 7. Implant impression post in place. Figure 8. Facial view of the completed restorations on working model.
Figure 9. Incisal view of the completed restorations on the working model. Figure 10. Implant abutment and crown on mirrored surface.
Figure 11. Intaglio surfaces of the finished restorations. Figure 12. Radiograph of the implant abutment in place.
Figure 13. Incisal view of the final restorations. Figure 14. Close-up facial view of the final restorations in place.
Figure 15. Retracted facial view of the final restorations. Figure 16. The patient’s new smile.

A final VPS impression (Aquasil Ultra [DENTSPLY Caulk]) was taken. The wash material was injected around the margins, and heavy-body tray material was placed in the impression tray before seating it over the teeth. The impression abutment was removed and a bite registration was taken (Luxabite). Provisional restorations were fabricated using a bis-acryl provisional material (Luxatemp [DMG America]) by injecting it into the putty matrix made over the wax-up and placing it directly over the prepared teeth. The provisional material was allowed to set and the stint was removed. Margins were refined using a small carbide finishing bur, and the temporary restorations were left in place.

Laboratory Fabrication
In the dental laboratory, 9 lithium disilicate veneers (IPS e.max [Ivoclar Vivadent]) were fabricated as well as a zirconium oxide custom abutment for the implant and a lithium disilicate crown (IPS e.max). The restorations, as delivered from our laboratory team, daVinci Dental Studio (West Hills, Calif), can be seen in Figures 8 to 11.

Delivery Appointment
The provisional restorations were removed and the prepared teeth were cleaned with pumice. The implant abutment was tried in and the retaining screw was lightly tightened by hand. A radiograph was taken to verify the fit (Figure 12). At this point, all restorations were tried in together, checking for fit, contacts, and aesthetics. The patient was allowed to view the restorations in place and approved the appearance. All the restorations were then removed from the teeth and the implant abutment and thoroughly cleaned and dried. Silane Primer (BISCO Dental Products) was applied to the intaglio surfaces and thoroughly dried with oil-free air.

The implant abutment screw was torqued and a small cotton pellet was placed directly over the screw head. A temporary seal was placed over the cotton pellet using a light-cured, single-component temporary resin material (Fermit [Ivoclar Vivadent]). The lithium disilicate crown (IPS e.max) was luted to the implant abutment using dual curing resin cement (DUO-LINK UNIVERSAL [BISCO Dental Products]) with no bonding agent.

The prepared areas of the other teeth were etched with 37% phosphoric acid gel (UNI-ETCH-37 with BAC [BISCO Dental Products]) for 10 seconds, thoroughly rinsed, and then lightly dried. Next, these surfaces were treated with a wetting and antimicrobial agent (CAVITY CLEANSER [BISCO Dental Products]) and left slightly moist. A 5th generation bonding agent (ALL-BOND 3 [BISCO Dental Products]) was liberally applied and air-dried to remove the moisture and carrier, leaving a glossy surface. The bonding agent was light cured for 10 seconds with an LED curing light (SmartLite Focus [DENTSPLY Caulk]). A light-cured luting composite (CHOICE 2 [BISCO Dental Products]) was applied to the internal surfaces of the ceramic veneers and they were placed on the prepared tooth surfaces. Excess luting agent was cleaned away with a brush, and each veneer was “tacked” in place by a short burst from the curing light. Excess luting composite was removed using a (0.12) surgical blade, and floss was worked into the interproximal areas to clear uncured composite. All restorations were then light cured for 20 seconds from both the facial and lingual directions. The occlusion was checked with articulating paper, and slight adjustments were made using fine diamonds (Brasseler USA), a multifluted carbide finishing bur (Brasseler USA), and porcelain polishing points and cups (Brasseler USA).

The final restorations can be seen in place in Figures 13 to 16. In the postoperative retracted frontal view (Figure 15), you can see that the tissue health in the mandibular anterior area is excellent and the tissue is beginning to mature around the new restorations.

This case report has demonstrated the use of a combination of an implant-supported all-ceramic crown and minimal preparation ceramic veneers to restore aesthetics and proper function to a smile damaged by previous traumatic incidents. The treatment also allowed for the development of more ideal proportions than existed with his natural teeth. Communication and coordination on the part of the general dentist, specialist, and laboratory team resulted in an excellent long-term prognosis for this patient.

The author would like to thank Dr. Paul Gibbs for his masterful work in placing the implant. The author would also like to thank daVinci Dental Studio (West Hills, Calif) for the outstanding laboratory work and the restorations provided for this case.

Dr. Nash maintains a private practice in Huntersville, NC, where he focuses on aesthetic and cosmetic dental treatment. He is an Accredited Fellow in the American Academy of Cosmetic Dentistry and is a Diplomate for the American Board of Dental Aesthetics. He lectures internationally on subjects in aesthetic dentistry and has authored chapters in 2 dental textbooks. He is co-founder of the Nash Institute for Dental Learning in Huntersville and is a consultant for numerous dental products manufacturers. He can be reached at (704) 904-3458 or via email at rosswnashdds@aol.com.

Disclosure: Dr. Nash reports no disclosures.