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The clinical case shown here required a smile adjustment - shape, length and colour. Multiple consultations can change the opportunity and therefore, patient expectations. This article shows the treat-ment plan and the clinical and technical steps used to achieve a good aesthetic integration.
The 23-year-old female patient presented with maxillary anterior teeth restored with resin com-posite some 3 years previously due to extreme tooth substance loss. The maxillary left central incisor had suffered breakage of the resin composite sev-eral times in recent months and had been restored to a shortened length in an attempt to prevent continual fracture of the restoration.
Case presentation: Restoring the maxillary smile line
ceramic | TECHNIQUES
Clinician: Dr Anders Blomberg BDSc, MDS, FICD, FADI
Specialist Prosthodontist, Townsville
www.nqp.com.au
Ceramist: Massimiliano Zuppardi MDT
Ceramist, Sydney www.maxzuppardi.com.au
38 eLABORATE March/April 2017
Diagnosis
On examination, it was apparent that the mandibular anterior teeth and all posterior teeth displayed severe loss of sub-
stance (Figure 3). The mandibular left first molar had been root filled and had been severely reduced to avoid fracture. There was a significant loss of occlusal vertical dimension (OVD). There were no reported symptoms or signs of TMJ deterioration or TMD (Figures 4-5). The teeth were extremely sensitive to cold and sweet stimulation. Oral hygiene was excellent. There were no caries or periodontal disease. A diagnosis of acid induced tooth erosion was made although the exact cause was not established. There was no elicited history of dietary abuse or eating disorders.
Treatment plan
The treatment plan agreed upon was to:• Re-establish a new OVD using resin composite to build up
the mandibular anterior and all posterior teeth to their cor-rect anatomy. The existing tooth anatomy was used as a guide with some license taken to allow for a correct restorative and occlusal outcome (Restorative material thickness and provision of an anterior disclusive pattern from MIP).
• Restore maxillary anterior teeth with feldspathic lay-ered lithium disilicate full coverage crowns utilising resin bonding to tooth structure and the etched lithium disilicate fitting surface.
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Figure 1. Initial situation. Figure 2. Initial situation.
Figure 3. Examination.
Figure 4. Maxillary occlusal view. Figure 5. Mandibular occlusal view.
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Figures 6-7. Upper and lower wax-ups.
Figure 8. Final teeth preparations.
Clinical preparation
Although the maxillary anterior teeth could also have been restored using resin composite, it was agreed that ceramic
crowns would provide better aesthetics and resistance to fracture and staining for the long term.
Maxillary and mandibular casts were articulated using an occlusal record made at the approximate OVD thought to be required for restoration. A semi-adjustable mode for the articulator (Denar Corp.) was deemed adequate.
Maxillary and mandibular anterior teeth were waxed to an ideal form and silicone keys constructed to transfer this prede-termined anatomy to the clinical situation. For the mandibular teeth, a lingual key was constructed allowing control of incisal edge positions of the resin composite restorations. For the maxillary anterior teeth, a full coverage silicone key was con-structed to guide manufacture of resin provisional crowns (Structure Premium, VOCO).
Posterior restorations were constructed from resin composite (Vitalessence, Ultradent Products) on the articulated maxillary and mandibular casts in conjunction with the anterior tooth diag-nostic wax-up (Figures 6 -7). These resin composite restorations were separated from the casts and sandblasted on the fitting sur-face (50 micron Al2O3) before being cemented to the acid etched and primed tooth surfaces using Optibond FL and Nexus III dual cure resin composite cement (Kerr) and light accelerated curing. Some minor occlusal equilibration was required, however this was minimal.
There was some compromise to the maxillary tooth prepara-tion due to the existing resin composite restorations and previous tooth substance loss.
However, the silicone keys aided in control of crown thickness and aesthetic parameters whilst minimizing unnecessary tooth reduction (Figure 8).
Some fine-tuning of the aesthetic characteristics (length, shape and angulations) were able to be completed in the provisional form with additions to the provisional crowns able to be made with resin composite (Figure 9).
Figure 9. Temporary crowns.
Figure 14. Shade die selection in polarised mode. Figure 15. Prepared teeth.
Figure 12. Shade selection in polarised mode option 1. Figure 13. Shade selection in polarised mode option 2.
Figure 10. Shade selection option 1. Figure 11. Shade selection option 2.
The shade
The aesthetic parameters were then conveyed to the dental laboratory. In this case for the shade selection two options for
the value and hue were considered and chosen with the assistance of a polarised filter for the finals restoration. The same core shade tab was used in order to have an indication of the influence of the abutments (Figures 10-15).
In some cases it is possible to have a very intensely discoloured teeth, therefore, it is essential that the ceramic ingot selected will block out the darkn effect from showing through.
The impression was poured up several times with Fuji Rock 4 Class Stone (GC) (Figures 16-17). The first cast was to keep and check the final marginal fit (Figure 18) and the second for the
wax up (Figure 19). The wax up was constructed to give enough support to the ceramic build up as well as to minimise the contraction during the firings. The more homogeneous the coping, the more even ceramic post firing (Figures 20-21).
Shape control is the key to establishing the effects position.The copings were pressed with LiSi Press and fitted, ready
to begin layering (Figure 22). A thin layer of Fluoro Dentin FD was initially applied (Figures 23-25). It delivers an impressive fluorescence property (Figure 23) In our experience, these new generation materials, need to be operated properly with a wide selection of masses in order to achieve a detailed effect and opti-mise the integration (Figure 24). The semi translucent coping can easily compromise the outcome with value being the most critical. The hardness characteristics allow us to reduce the copings to min-imum thickness of 0.3 - 0.4 mm with confidence (Figures 26-27).
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Figure 20. Wax up coping - labial side.
Figure 25. Fluoro dentine wash. Figure 26. Wash before firing. Figure 27. Wash post firing.
Figure 21. Wax up coping - palatal side.
Figure 18. First cast palatal profile. Figure 19. First cast labial profile.
Figure 16. Impression. Figure 17. First cast.
Figure 22. Pressed copings. Figure 23. Fluoro dentine 93. Figure 24. Masses selection.
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Figure 28. Ceramic effects build up.
Figure 31. Initial situation.
Figure 32. Preparations.
Figure 33. Cemented crowns. Figure 34. Very happy patient!
Figure 30. Shape evaluation.
The porcelain was built up with stratification of the masses to create several variants for a better natural light reflection effect, completing the shape in two firings (Figure 28). Shape compro-mise was required due to large interdental spaces. By reducing the mesial and distal line angles, the broadness of the crowns could be visually reduced (Figure 30).
The difficulty achieving an ideal size, shape and alignment on the two central incisors is shown in Figures 31-32.
The finished lithium disilicate crowns were etched using 9% hydrofluoric acid and cleaned in an ultrasonic bath using alcohol followed by distilled water. The fitting surfaces were then silanated (Bissilane Bisco) and cemented using Futurabond DC (VOCO) and Nexus III dual cure resin composite cement with light acceleration of the curing.
An optimal result was obtained in terms of gradient colour, hue and proportioned shape (Figures 33-34). The patient was very happy and pleased with such a positive result.
Figure 29. First firing.
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About Dr Anders Blomberg
Dr Blomberg completed his undergraduate dental degree in 1978 at the University of Queensland. His specialist Prosthodontic qualification was completed at Adelaide University in 1984. Dr Blomberg commenced private practice restricted to Prostho-dontics in Townsville, Australia in 1984. He has been involved in teaching and lecturing to various groups during the subse-quent years as well as acting as an external examiner for several post-graduate Prosthodontic programs in Australia and New Zealand. He currently holds an adjunct senior lecturer position within the dental school at James Cook University. He has been President of the Academy of Australian and New Zealand Pros-thodontists, the Multidisciplinary Dental Academy and Queens-land Branch of the Australian Dental Association. He is a fellow of the Academy of Dentistry International and International College of Dentists.
References
1. Fradeani M.La riabilitazione estetica in protesi fissa Analisi estetica vol. 1 2004;4:118-133.2. Fradeani M. Analisi vol 1 2004;3:74,76-86,88.3. Pietre CS,Walker MP, Haj-Ali R, Dumas C, Spencer P, Williams K. Moisture effect on polyether and polyvinylsiloxane dimensional accuracy and detail reproduction. Journal prosthodont 2205;14:158-163.4. Ubassy G. Shape and Color: The Key to Successful Ceramic Restorations. Chicago: Quintessence, 1993:197–204.
About Massimiliano Zuppardi
Massimiliano “Max” Zuppardi is a Master Dental Technician/Ceramist from Napoli, Italy where he earned his Dental Tech-nology Degree. Since the 80’s, he’s been working with his father, Maestro Giuseppe Zuppardi, the first Oral Design Member and has also been mentored by master technicians such as Willi Geller, M.H.Poltz, P.Adar, D.Shultz, M Magne and many more. He is the owner of Oral Design Down Under in the Sydney suburb of Mosman. Since 1993, Max has been a member of the Oral Design International group. He is an international speaker, mentor and author of several publications in some of the most influential international dental magazines. His speciality is complex cases and full mouth restorations on implants and natural teeth with a core focus on aesthetics, precision, bite and morphology that he is currently teaching to dentists. For technical questions please email [email protected].
Figure 34. Patient appreciation.
“Max, I would like to thank you for
my smile. When I was 18, a dentist
told me I had the teeth of a 50 year
old - worn and short. I covered my
mouth when smiling or laughing
and hated photos. Being a dental
assistant made this worse as teeth
are a big part of my life and I was
helping give everyone else
perfection but never being able to
have that myself. This was until I
found Dr Blomberg and yourself.
You gave me the smile I have only
been able to dream of and to top it
off, it looks so natural! Just perfect!
Thank you! Your hard work
definitely paid off and I for one
will be forever grateful...”
Sasha Anderson
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