Excellence and Predictability: Not an Accident!

I feel the 2 most important things I can do to ensure future practice growth in my areas of interest, cosmetic and restorative dentistry, is to develop a reputation for delivering excellent results that my patients all love, and to deliver those cases profitably and enjoyably.
I will present a complex clinical case in this article to demonstrate how we achieved these goals. This case illustrates techniques for meeting the patients’ expectations regarding their own smiles, while maintaining clinical excellence. I will show how we worked out the smile design in the transitional restorations, and then used CAD/CAM technology to translate the chosen design into the final restorations. In this case, we combined the Template Technique (as developed by Smile-Vision Laboratories) with the latest in CAD/CAM technology to create a new smile in pressed-porcelain-to-zirconia restorations.

GETTING STARTED

Figure 1. Preoperative full smile.	Figure 2. Preoperative right-lateral view.

Figure 3. Before and after simulation.

When Paul Gorecki, PhD, a prominent member of our local medical community, asked me “What are my options regarding these unsightly teeth?” (Figures 1 and 2), I discussed with Paul what his goals and expectations were regarding his cosmetic dental treatment. Paul told me, “I never liked the mottled and discolored look of my teeth.” I learned he had bonding on his front teeth for as long as he could remember. The bonding was discolored, chipped, worn, and had been repaired and replaced multiple times. He also reported, “Even after they were cleaned and polished, my teeth never looked really clean and white.” He was looking for a long-term solution that would not discolor and wear as quickly as his previous bonding treatment had. Paul wanted his teeth “very white and perfect looking.”
As we talked, I learned that my patient had always disliked the appearance of his teeth. He felt that having a perfect smile would really enhance the way he felt about his appearance. When I asked what the perfect smile would be to him, he indicated he wanted his teeth, “Straight, smooth, and Hollywood white.” We reviewed images of other smiles that I had restored. I learned that he wanted very symmetrical teeth with very little tertiary anatomy.
In an examination of this 57-year-old male patient, I observed that teeth Nos. 6 to 11 had previous resin bonding of various ages. Teeth Nos. 4 to 12 displayed cervical erosion/abfractions. On teeth Nos. 7 to 10, the bonding extended interproximally to the lingual surfaces on both the mesial and distal sides of these teeth. The bonding was worn and discolored. The incial edges of teeth Nos. 6 to 11 were worn. Tooth No. 13 had a preexisting crown with a darker shade than what he had wanted for his final smile.
I offered him a cosmetic simulation as the logical first-step to a more attractive smile (Figure 3). I took a full-face portrait photograph and sent it to Smile-Vision via the Internet for creation of a professional quality simulation. Although I have the tools and skills to create the simulation myself, I felt Smile-Vision could do it better and at less cost by outsourcing the work.
With a digital display of the simulation running on a monitor in the room, and with printed before-and-after images in hand, I met with Paul to discuss the possibilities. I pointed to the simulation and explained it was a reasonable preliminary projection of the results that could be achieved for him. He also took prints home to review with his family members and friends. We discussed a little about the treatment itself, the associated fees, and a time frame before he agreed to get started.

BRINGING THE PLAN TO LIFE
After reviewing the options (which included doing nothing versus potentially using resin bonding, laminates, porcelain-to-gold crowns, and hand-stacked porcelain over zirconia substructures), I selected pressed-porcelain-to-zirconia crowns as the best restoration for this patient. I understood that Paul had strong feelings about what his perfect smile should look like. Once I had his acceptance on the provisional restorations, I wanted to make certain that we could replicate that result in the final restorations. To ensure that the final crowns would replicate the size, shape, and arrangement of the provisional restorations exactly, I would have my laboratory technicians use a CAD/CAM machine to replicate the coronal contours of the temporaries in the final restorations.

Figure 4. Study models.	Figure 5. Study models, right-lateral view.
Figure 6. Full-contour resin wax-up.	Figure 7. Resin wax-up, right-lateral view.
Figure 8. Preparation guide.	Figure 9. Fabricating the provisionals.
Figure 10. Try-in of the provisionals.	Figure 11. Preparations, retracted view.
Figure 12. Preparations, occlusal view.	Figure 13. Provisionals at the delivery appointment.
Figure 14. Final restorations at delivery.	Figure 15. Final smile at one-week post insertion.

In order to ensure the case would turn out as planned, I elected to follow the Template Technique protocol developed by Smile-Vision carefully. The first step was to fabricate study models. I took alginate impressions (Jeltrate [DENTSPLY Caulk]). The impressions were poured immediately in dental stone, and then after setting, the models (Figures 4 and 5) were packed and sent to Smile-Vision for the creation of a full-size 3-D replica (wax-up) (Figures 6 and 7) that turned the simulation to life.
After approving the wax replica (in an online preview), a hard-resin wax-up was made by Smile-Vision. There, the dental technicians also created a preparation guide (Figure 8) and temporary template (Figure 9) for making temporaries intraorally that followed the plan with great precision (Figure 10).
Tooth preparation (Figures 11 and 12) and impressions proceeded without incident prior to temporary insertion. All tooth reduction was preformed with an electric handpiece (Ti-Max [NSK]). Depth cuts were placed and initial tooth reduction was made (GW-2 carbide bur [SS White]). The final preparations were completed (1118.9C, 1516.8C, and 1900c NEODIAMOND burs [MICROCOPY]). Tooth reduction was gauged during the preparation by placing the preparation guide provided by Smile-Vision over the prepared teeth and measuring the depth of preparations with a periodontal probe placed through small holes in the preparation guide (Figure 8). A 2-cord technique was used to retract the gingival tissues. A No. zero cord (Ultrapack [Ultradent Products]) was placed prior to starting the preparation. Then after preparations were complete, a second No. 1 cord Ultrapack was placed over the first cord for final impressions. Custom trays were prepared ahead of the preparation appointment. They were fabricated from Blue Heavyweight tray material (Great Lakes Orthodontics) using a MINISTAR vacuform machine (Great Lakes Orthodontics). Final impressions were made with a polyvinylsiloxane (PVS) impression material (Reprosil [DENTSPLY Caulk]). Two final impressions were made, and one was poured immediately in dental stone (Pink Snap-Stone [Whip Mix]) to use in the fabrication of the provisional restorations. The best final impression was set aside for the laboratory. A check bite was taken (Blu-Mousse [Parkell]).
Provisional restorations were fabricated using Protemp 3 Garant (3M ESPE). The fabrication started by filling the template and placing it over the perorations in the patient’s mouth (Figure 9). The provisionals were tried in, then brought into my in-office laboratory area, and completed on the stone model. I marked the margins on the model with a red pencil and trimmed the cast at the gingival margin with a large round bur to remove any stone that could impede the temporary from seating on the model. At my in-office laboratory bench, I trimmed the excess acrylic and shaped the embrasure spaces of the temporaries nicely. By keeping the temporary on the stone cast I could polish the provisional restorations with a rag wheel on a lathe while keeping the temporary crowns splinted together. Wet pumice followed by dry whiting compound on a rag wheel brought the surface finish of the provisionals to life. Desensitizer G (Healthdent’l) was applied to all exposed dentin. The fit was checked, and then the provisionals were cemented in with TempBond (Kerr). Minor adjustments were made to the temporaries while they were in the patient’s mouth at the preparation visit. The patient was then scheduled for a follow-up visit.

With the temporaries in place the patient had time to “try out” his new smile. At the scheduled follow-up visit, I made some small adjustments (Figure 13). My patient reported that he was happy! I knew that we were on the right track and now felt completely at ease about his case. At this time, if I needed to adjust the tooth size, shape, or length, I could do this in the provisionals. When I need to significantly alter the temporaries, I take a final impression of them for the dental laboratory technicians to see. In this case, only very small changes were needed, so I simply sent my study model back to the laboratory.
Meanwhile, back at Smile-Vision, they scanned a model of my preparations into a CEREC inLab setup (Sirona Dental Systems), and superimposed the model of my temporaries over the dies. Smile-Vision created virtual copings as well as virtual full-contour restorations over the copings which were exact duplicates of my temporaries. The copings were milled on the CEREC machine, hand-finished, stained, and heat-processed. The full-contour restorations were printed in green wax, joined to the completed copings, sprued, burned out, and pressed in molten glass. Finally, a skilled ceramist added the final touches needed for accurate color, texture, marginal fit, and incisal translucency.

INSERTION OF THE FINAL RESTORATIONS
Inserting the case was strictly a mechanical procedure because of the detailed preplanning and adherence to the steps outlined in the Template Technique. With confidence, I knew the ending would be a good one!
For the delivery appointment no anesthetic was needed. I find this a common occurrence when using Desensitizer G at the preparation appointment. The provisional restorations were easily removed with a hemostat and hand pressure. The preparations were then cleaned (Consepsis Scrub [Ultradent]) and the final crowns were tried-in. The fit and occlusion were checked and verified. I gave the patient time to get up and look at the final crowns in a mirror. The final restorations were luted in place with a self-etching dual-cured composite resin cement (RelyX Unicem [3M ESPE]), 2 at a time. By cementing 2 teeth at a time, the process of mixing cement, seating of crowns, flash-curing of 3 seconds at the buccal and 3 at the lingual, removing excess cement, and final curing actually proceeds quite quickly. In addition, we can take a break between sets of 2 as needed.
The insertion itself took less than 60 minutes. This included greeting and seating the patient, removing the temporaries, cleaning the preparations, trying-in the crowns, checking the fit and occlusion, giving the patient time to get up and review the final restorations, final cementation, and the clean up. Only very minimal adjustments were necessary to the restorations themselves (Figure 14). The advantages of this restorative technique, which includes detailed preplanning, are in the ease of delivery and quick acceptance by the patient.

CONCLUSION
With the aid of CAD/CAM technology, my laboratory replicated all the aesthetic details that were worked out in the dental office in the provisional restorations. Since restorations with a zirconia coping milled on a CEREC in Lab setup were used, the precise fit made delivery easy and the strength of these restorations should provide excellent longevity. How did our patient feel about the results? In his own words, “Elated!” Paul reported, “I have always admired people with great looking teeth. Now, I smile at my own smile because my teeth look so good.” It was a happy ending for all concerned (Figure 15).

Dr. Powell completed his undergraduate education at Beloit College and earned his DDS from the University of Illinois, Chicago. He has practiced family and cosmetic dentistry for the past 19 years at Barrington Dental Care in Barrington, Ill. Dr. Powell’s background in photography and sculpture lends him a special eye for cosmetic dentistry. He can be reached at drtoddpowelloffice@sbcglobal.net.

Disclosure: Dr. Powell reports no conflicts of interest.