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Anterior Alveolar Ridge Augmentation with Delayed Ovate Pontic Development

Patient presents with unnatural ceramic restorations displayed upon smiling. (1 - 3) Retracted facial view of preoperative condition reveals bilateral vertical recession on the maxillary left and right centrals and cuspids with Class I horizontal defects in the edentulous regions of the pre-existing lateral incisors. (4 - 6) A diagnostic wax-up is prepared to the ideal shape and contour without connective tissue corrections. This allows the patient to visualize and understand the importance of soft and/or hard tissue augmentation. (7)

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Enamel porcelain was applied over the fired dentin. The entire dentin surface was covered with a combination of translucent and opalescent powders designed to simulate shaded enamel. Although the enamel layer is thin, it will regulate the the brightness of the underlying colors as they are projected through it. The value dimension is determined by the artificial enamel layer. (42 - 43) The initial fire of the enamel layer reveals subtle maverick deposits, these deposits are not discernible in the mouth but are important for harmonization in the oral cavity with the adjacent natural teeth. Note the shrinkage of the first enamel layer. Any correc-tions are made before the second fire. The average thickness of natural enamel is slightly less than 1 mm and the enamel porcelain layer is 0.3 mm. The artificial enamel layer was slightly overbuilt to compensate for shrinkage. (44 - 45)

The ceramo-metal bridges were fabricated using a feldspathic porcelain (Initial™, GC America®) and the lateral segmental layering technique. A 360º circumferential ceramic window (Geller technique) was utilized to allow the light to pass through and create a natural aesthetic result. The metal framework was designed to a labial silicone index that allows the development of an ideal ceramic dimension (38) After the framework was vertically reduced and opaqued, a feldspathic ceramic material (Initial™, GC America®) was layered using the lateral segmen-tal layering technique to form the artificial dentin core. The dentin layer buildup was slightly overbuilt interproximally and incisally to compensate for shrinkage. (39 - 40) Once the inter-nal dentin core was developed and fired the incisal edge is cutback. The body buildup was completed with incisal cutbacks to accomodate the maverick colors. Internal effects within the incisal edge were created by applying specific intensive stains. (41)

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Completed 3-unit ceramic bridges. The metal substructure adds physical strength, whereas, the circumferential window of ceramic material enhances the aesthetics. It is important to remember the ceramic window is fragile until bonded. (48 - 49) Prior to adhesive cemen-tation, the internal surface of the silica-based porcelain shoulder was etched for 2 minutes with a hydrofluoric acid, silanated, and air dried. (50 - 51) Laboratory courtesy of Olivier Tric, C.D.T.

The restorations are precisely contoured and finished on a Geller soft tissue model. If prop-erly built up, only a minimal amount of contouring should be required. This consideration is extremely important because excess grinding can remove essential color. (46 - 47)

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Retracted facial views reflect the harmonious integration of biomaterial, soft tissue, and tooth structure. There is a balance in color and function between the maxillary and mandibular teeth and perio-aesthetic harmony. The incisal silhouette of this postoperative smile demon-strates natural aesthetics. (52 - 56)

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