In the following case there was a tight time frame—a 40-year-old male in the Merchant Marines on leave. As a teenager, he received orthodontic treatment, and the proper anterior angulation was established. However, the lower jaw was never properly advanced, and the retention was not in place, and there was a relapse. Teeth Nos. 7 through 10 were tipped lingually, and he was grinding and shortened them about 7 mm. If more time were available, orthodontic banding and bringing the teeth to the correct anterior placement would have been the ideal treatment (Figure A).
Previously, a removable functional appliance was constructed, but the patient did not wear it. Five weeks prior to operative reconstruction, the instruction was to wear the appliance continually as much as possible, and we tightened the screws to move the lingually inverted centrals and laterals until we got them in a vertical position (Figure B).
He did this, and once the teeth were brought out to a more vertical position, we took study models and began working with Dr. Michael DiTolla at Glidewell Labs. We came up with the radical plan to splint veneers or three-quarter crowns, which is a more accurate description, and we splinted teeth Nos. 6, 7, and 8 and 9, 10, and 11.
While the reduction is very minimal on the incisal, I wanted to bring the preps interproximally and open that up to get as much strength as I could interproximally and incisally so that when we bond these, we have some strength. From the study models sent to Glidewell, they made a beautiful diagnostic wax-up and sent me back a polyvinyl putty shim of the wax-ups. We were ready to start the preparations (Figure C).
Along with the diagnostic wax-up and with the polyvinyl shim to help with the temporaries, Glidewell made a prep guide. Also, a mock prep model of what they would look like was provided. However, when I looked at the mock preps, they were not exactly what I wanted. There was too much incisal reduction and not enough interproximal reduction. I used it as a guide but modified the preps to what I thought would give us our best strength and most retention. Since the teeth were still just vertical and needed to be brought buccally, I was able to keep most of the buccal enamel. I did very little incisal reduction, but I wrapped it into the shoulder on the lingual interproximally. I opened it up more so all of those interproximal spaces were larger than normal veneers; this is where the veneers are going to be tied or splinted. This gave us a lot more strength, and we were able to do minimal reduction as far as the enamel but end up with a lot of strength (Figure D).
|Figure A. Pre-op.||Figure B. Removable ortho appliance.|
|Figure C. Model of preps.||Figure D. Putty wash shim of diagnostic wax-up.|
|Figure E. Bonasil Light Body.||Figure F. Diagnostic wax-up of shim.|
|Figure G. Try-in splinted three-quarter crowns.||Figure H. Hemaseal & Cide.|
|Figure I. Bonded restorations.|
After our ideal preps were completed, we did etching, then sealing with Hemaseal & Cide disinfectant desensitizer (Advantage Dental Products), which is important on all of my preps. It has been great to eliminate sensitivity and disinfect, and it also is a tremendous bond enhancer. After that, the preps were sealed. Next, we took the polyvinyl impression and used a full-arch tray. A combination of Bonasil putty and wash (DMP Dental USA) was used give us the detail we wanted (Figure E). It records excellent detail and has great tear strength. We took records of protrusive left working and right working and included that with our centric impression and face-bow and sent it all to the laboratory.
Next, we went ahead with our temporaries. I used the polyvinyl shim that was made from the diagnostic wax-up (Figure F). Since the teeth were already sealed, we had to use lubrication. If I didn’t use lubrication, the temps would bond on. I had plenty of interproximal and incisal retention, and I did not want to have to cut them off. Silicone lubricant was used on the lower two thirds of the prep, from the gingival up to 3 mm below the incisal.
I loaded the shim with temporary material and pressed it down to full seating and let them set in place. When I’m done, I typically take a percussion instrument, tap these, and they come right off. Once the silicone shim was removed, I trimmed very little flashing, adjusted the occlusion, and we used the temporaries to guide us on what we wanted for the final restoration.
Already the temporaries were a huge difference from the patient’s pre-op condition. I thought we could use another 1.5 mm incisally, starting with the centrals, and then keep the laterals slightly off the plane and the cuspids being the same length as the centrals. But also I wanted a little more protrusive advancement incisally, so I instructed the lab to do that. I also instructed the lab that I wanted a mamelon undulation, horizontal light reflection grooves, and incisal translucency. I just don’t see with the way that his occlusion is, how I’m going to pick up clearance on the lingual. If I reduce the whole lingual, I’m going to cut those teeth so much that I would be uncomfortable with it. We agreed that we can try this with the splinted veneers, that I would really call three-quarter crowns, I think is going to be exceptional, and these unique preps would give us strength and retention from relapse.
When the case came back, I used the hook slide crown remover to tap at the interproximal, and they came off very easily. The gingival was in good condition—very little hemorrhage—so we were in good shape to go through the bonding process. To clean the preps I used a solution of EDTA and aluminum oxide on a microbrush. I would have liked to use microabrasion, but I was concerned that we would have irritated the gingiva making the bond process more difficult. Next, I tried the splinted veneers, or three-quarter crowns. We tried on the one unit with teeth Nos. 6, 7, and 8, and it went down uneventfully. When I tried the unit with teeth Nos. 9, 10, and 11, we had some parallel and path of insertion issues. This is a big concern with this type of case because these veneers are not the most solid things, especially when they are splinted. So we had to be really careful about bonding. We used a little green chalk spray-on, and I was able to spot the preps where I had interference and get these to seat. So now I had unit 6, 7, and 8 and unit 9, 10, and 11 seating nicely. I removed the splinted veneers. We cleaned our restorations and then placed silane on these e.max (Ivoclar Vivadent) three-quarter crowns (Figures G and H).
To go through the bonding process, I used the solution of EDTA and aluminum oxide and microbrush again to clean, and rinsed that off. We went to our acid etch and after 15 seconds rinsed that as well. Now I used Hemaseal & Cide to disinfect, enhance bond strength, and reduce microleakage just as I would use it on all my restorations. Leave it slightly moist and then go to the 2-step bonding process. I then used luting cement. Since our shading was correct, we went with a clear shade, not a dual-cure catalyst/base. The one component studies show no darkening of the shade as can be produced by the catalyst base method. We had everything in place, flossed in the central at tooth Nos. 6 and 11 to remove some of the excess flashing, and light cured them. Then I was able to remove any other flashing, check for occlusion. We were very happy.
The next day, I had him back to review and recheck the bite. I looked at the case and thought if I just round the distal incisal centrals and take the laterals slightly more off the plane of occlusion, it will be a very subtle difference that yields a much more natural look. As the before and after images show, this is indeed a radical cosmetic makeover, and the patient is thrilled. He has a new level of confidence and can notice the positive reaction of others who look at him (Figure I).
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