Service With a Smile

As dentists, we provide services that can transform smiles and lives. We have the ability to solve problems and challenges for our patients that give them the basic ability to smile again, function normally and, best of all, feel good about themselves, both inside and out.

CASE REPORT
Diagnosis and Treatment Planning

Recently, SueAnne presented for a consultation, motivated by what was glaring at her in the mirror (Figures 1 and 2). At 54 years of age, having lived with veneers that had been placed in stages during the last 20 years, her first stated concern was about the obvious recession that had been slowly taking place. SueAnne then discussed her next issue with great intensity and frustration, using descriptive words like yellow, bulky, and huge. She could see that there was nothing proportional or cosmetic about her existing restorations. She said, on the verge of tears, “I take pride in my appearance and have spent a lot of money on my smile over the years, but my teeth are making me look like I don’t care at all!”

Figure 1. Pre-op photo, anterior retracted view. Figure 2. Pre-op photo, upper arch occlusal view.
Figure 3. Preparations, left side. Figure 4. Final bite registration (Blu-Mousse [Parkell]).
Figure 5. The completed preparations.

Due to her previous dental experiences, SueAnne also expressed her fear of “pain” and “countless hours” in the dental chair. Also, she was certain this would “take months” to accomplish and wanted a timeline so she could adjust her travel schedule.

Equipped with a full set of digital x-rays, perio­dontal probings, and digital intraoral photos, I was able to “show and tell” SueAnne that she was periodontally healthy and had a stable bite with the exception of some anterior interference. In reviewing the photos with her, confirmation was given that both the color and proportion of her smile could be greatly improved. And, because of the new all-ceramics that we have available today, the bulkiness issue could be addressed as well. During our conversation, SueAnne responded positively to words like longer, leaner, broader, cleaner, and fuller. I could tell that we were on the right track.

SueAnne was informed that we could have everything completed in 2 appointments, within a 2-week time frame. Within those 2 weeks, she would be wearing her prototype smile, which would permit her to evaluate how her new smile could look. If she wanted to change or adjust anything during this phase, she would have the ability to do so. I assured her that this process would be totally painless, and that we would set aside 2 hours for the first appointment and one hour for the second appointment. I reassured her that during these 2 weeks, and immediately after the first appointment, she would be able to eat and drink as she pleased without any restriction. SueAnne calmly asked, “When can we start?”

Figure 6. With the patient in an upright sitting position, a facial plane relator device (Symmetry Facial Plane Relator [CLINICIAN’S CHOICE Dental Products]) was used so the lab team would be able properly mount the case in the correct horizontal and vertical planes for the patient. Figure 7. Symmetry device, lateral view.
Figure 8. Shade selection was done. Figure 9. The completed bis-acryl (Integrity [Dentsply Sirona]) provisionals.

Figure 10. Upper provisionals, occlusal view.

Figure 11. After try-in was completed, the internal aspects of the restorations were deep cleaned using a phosphoric acid gel and then washed off with water.

After reviewing the informed consent and answering any final questions, a preliminary vinyl polysiloxane (VPS) impression (Silginat [Kettenbach LP]) was taken of the upper and lower arches and sent out with detailed instructions (including smile design) to the dental laboratory team for a diagnostic wax-up, provisional stent fabrication (of the wax-up), a bite stent, and a prep reduction guide.

Clinical Protocol
Upon receipt of the wax-up, preparation of teeth Nos. 4 to 13 was initiated (Figure 3). The previously placed porcelain veneers on teeth Nos. 9 to 13 were removed (1847KR016C [DENTSPLY Midwest] and the preparations were minimally revised. A diode laser (Picasso Lite [AMD LASERS]) was then used to establish a more pleasing soft-tissue architecture. After tooth preparation and the minimal soft-tissue revisions were completed, an initial VPS bite registration (Blu-Mousse [Parkell]) was taken in centric occlusion. Next, the previously placed porcelain veneers on teeth Nos. 4 to 8 were removed and minimally prepared. Again, the diode laser was used to establish a more pleasing soft-tissue architecture. The previous bite was then reinserted and finalized to include the preparations on the right (Figures 4 and 5). After all of the preparations and soft-tissue architecture were evaluated, the bite was evaluated for adequate prep reduction in preparation for the temporaries and eventual restorations. Taper, marginal integrity, and prep design were also taken into account.

Figure 12. Arranging final restorations in order prior to the resin bonding procedure. Figure 13. The lithium disilicate restorations (IPS e.max [Ivoclar
Vivadent]), occlusal view.
Figure 14. The final all-ceramic restorations, retracted anterior view.

With the patient in an upright sitting position, a facial plane relator device (Symmetry Facial Plane Relator [CLINICIAN’S CHOICE Dental Products]) was used so that the lab team would be able properly mount the case in the correct horizontal and vertical planes for the patient. It is critical that one get the vertical component of the Symmetry bite to bisect the face in half and be vertical to the long axis of the face. Front and side view digital photos were then taken of the Symmetry device in place to sharing with the lab team (Figures 6 and 7). Prior to final impressions, the dentin shade was evaluated and noted. A shade of the desired restoration was noted as well. A photograph of all of the selected shades next to the preparations was taken (Figure 8). A shade map of the desired final restoration was also drawn and sent to the lab team.

A final VPS impression was taken only after final evaluation of the margins, tissue, line angle of preparation, and complete field of vision of all of the above. A digital photograph was taken for evaluation as well. The final VPS impression (Aquasil Ultra Xtra [Dentsply Sirona]) was taken using a heavy-body/light-body technique with the patient sitting in an upright position. As the assistant loaded the heavy-body material into an already fitted stock tray, the doctor placed the light body around all of the teeth in the upper arch, covering them completely. It is important to keep the material flowing, maintaining it against the tissues in order to capture less air. Once the tray was filled, the assistant handed the tray to the doctor and then it was inserted into the patient’s mouth, making sure that the lips were worked over the tray. Care was taken when seating the tray so that none of the teeth were touching any part of the tray. A timer was used to follow the setting process to the end, according to the manufacturer’s specifications, and the tray was removed for visual evaluation. Evaluation of the impression under loop magnification should reveal all of the landmarks evaluated in the preparations prior to taking the final impression. It is critical that the clarity of all of the margins, as well as the integrity of the preparation within the final impression, are verified. It is also critical that the clinician identify any voids, bubbles, pulls, or tooth/tray interferences. Any of these issues within the final impression could seriously compromise the final restoration fit and, of course, would require taking another final impression.

Temporization was accomplished with a bis-acryl temporary material (Integrity [Dentsply Sirona]) using the provisional stent that the lab team created from the diagnostic wax-up fabricated prior to doing the tooth preparations. Before placing the material, the teeth were cleaned with a solution containing 2% chlorhexidine (CAVITY CLEANSER 2% Chlorhexidine Digluconate solution [BISCO Dental Products]). Due to the nature and shrinkage of the bis-acryl provisional material around the preparations, a temporary cement is rarely needed. The minimal excess material present after seating the provisionals was removed using hand instruments and then a polishing wheel, disc, and/or cup (Enhance [Dentsply Sirona]). (Note: No high-speed rotary drill instrumentation should be used at this point.) The temporaries were characterized as needed with stain, then a clear unfilled resin glaze (PermaSeal [Ultradent Products]) was painted onto the facial surfaces of the temporaries and light cured (Figures 9 and 10). Finally, instructions were given to our patient along with a Waterpik Cordless Waterflosser (Water Pik). (The author gives all his large cosmetic case patients Waterflossers along with detailed instructions for home care. The author figures this cost into the overall cost of care for the patient.) SueAnne was then given an appointment to return 2 weeks later for the delivery of the final restorations.

When the lithium disilicate (IPS e.max [Ivoclar Vivadent]) final restorations were returned from the lab team, they were inspected for marginal integrity, contact integrity, color, and design prior to try-in. Then, at the seating appointment, the temporaries were removed, and the teeth were cleaned with a solution of hydrogen peroxide and 2% chlorhexidine (CAVITY CLEANSER) and then rinsed. The final restorations were tried in with water only. The parameters noted above were all found to be excellent. The patient was then given a chance to look at the color, shape, and overall look in order to approve the final placement of the restorations.

Once approved, the restorations were removed and cleaned with 37% phosphoric acid gel, then rinsed with water (Figure 11) and thoroughly dried. Next, silane (BIS-SILANE [BISCO Dental Products]) was applied to the internal surfaces of the restorations for 60 seconds then dried with water- and oil-free air. Then the restorations were readied for the resin bonding procedure by placing them in order (Figure 12). Once bonded properly into place using a light-cured resin cement (Calibra Veneer Kit [Dentsply Sirona]), excess cement was removed, and then the bite was checked and adjusted as needed. Digital radiographs were taken to ensure complete seat and to be sure that any excess cement had not been left behind. The final lithium disilicate restorations can be seen in Figures 13 and 14.

CLOSING COMMENTS
SueAnne was ecstatic about her new smile, crying and hugging everyone as she walked out our office door. She continues to refer other patients to our practice and lets us know that, every time she smiles, she is thankful for the care that we provided. With proper training that allows us to expand and perfect our technical skills, the choices in modern dental materials, and excellent communication between the doctor and patient and the doctor and dental laboratory team, our patients’ smiles and lives can be changed forever!

Acknowledgement
The author would like to thank the talented dental laboratory team at Aurem Group (aurumgroup.com) for the excellent technical work shown in this case report.


Dr. Simos maintains private practices in Bolingbrook and Ottawa, Ill. He received his DDS degree at Chicago’s Loyola University, and he is the founder and president of the Allstar Smiles’ Learning Center and client facility (Bolingbrook), where he teaches post-graduate courses to practicing dentists on cosmetic dentistry, occlusion, and comprehensive restorative dentistry. An internationally recognized lecturer and leader in cosmetic and restorative dentistry, he can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it. or by visiting allstarsmiles.com.

Disclosure: Dr. Simos reports no disclosures.

Aesthetic Implications of Restorative Material Choice: Considering Soft-Tissue Factors

When it comes to anterior aesthetics (often referred to as “smile design”), soft-tissue architecture can be just as important as the dental restorations placed within it. This is also often referred to as “pink aesthetics” versus “white aesthetics.”1

This article will describe a case in which a patient presented with discrepancies in her gingival contours and her medical history, as well as limitations due to “stump shade” that had a profound effect on the process and outcome of the restorations involved.

CASE REPORT
Diagnosis and Treatment Planning

The patient was a 46-year-old woman with an unremarkable medical history, except for having been diagnosed by an allergist many years previously as suffering from a hypersensitivity to gold. Her upper central incisors had been endodontically treated due to childhood trauma in which her left central incisor (tooth No. 9) had been partially avulsed with a resulting soft-tissue discrepancy as it related to her right central incisor (tooth No. 8). Both teeth had discolored significantly after that trauma, and the endodontic treatment had been done. Then, several attempts had been made at aesthetic fixes, from direct composites to indirect restorations, including the zirconia-based veneers that were currently still in place. The patient was unhappy with the veneers, stating she considered them to be unnatural looking. In addition, she was also concerned with the condition of their gingival framework.

The clinical examination revealed an otherwise healthy dentition with no notable occlusal problems or periodontal concerns beyond those at the upper central incisors. There was a major difference in gingival heights, with a cyanotic quality to the tissue that created a bluish tinge. Incipient caries was found at the gingival and palatal margins of both veneers, and their appearance was opaque and unaesthetic (Figure 1). “Sounding” at No. 8 showed there would be an insufficient biologic width2 for a mere gingival recontouring solution to the divergence in gingival levels.

Figure 1. The previously placed existing restorations. Note the unhealthy gingival appearance and marginal level discrepancy. Figure 2. The lab-fabricated provisional crowns (BioTemps [BioTemps Dental Laboratory]), 2 weeks after placement.
Figure 3. The first set of definitive zirconia-based crowns. Note the variation in hue as it related to the lateral incisors. Figure 4. The second set of definitive zirconia-based crowns. While the hue was much closer here, the value was too low.
Figure 5. The third set of definitive zirconia crowns. The value was closer, but the hue was still somewhat off, also with insufficient incisal translucency. Figure 6. The fourth set of definitive zirconia-based crowns. Again, the hue and value were a bit closer, but these units appeared quite monochromatic. Also, the
soft-tissue framework looked to have become irritated.

Reflecting these considerations, the treatment plan called first for crown lengthening surgery (at No. 8), with the placement of laboratory fabricated provisional crowns during the healing period to aid in final soft-tissue configuration. The patient was referred to the periodontist and, after the perio­dontal consultation was completed, this phase of the treatment plan was confirmed in a follow-up phone conversation with the specialist.

The next determination would be what type of final restorations would be placed and what material would be used in their fabrication. Because of the aforementioned marginal decay that had been found, and the ability of the corresponding provisionals to influence gingival margin development,3 the placement of crowns was chosen as the treatment of choice for this case. The treatment plan was sequenced on the advice of the periodontist so that the laboratory fabricated provisional crowns (BioTemps [BioTemps Dental Laboratory]) would be placed 2 weeks after the crown lengthening was done, allowing for sufficient periodontal healing before this initial restorative procedure would be undertaken. The provisionals (Figure 2) would then be monitored and adjusted on a biweekly basis for 2 months in order to achieve the desired soft-tissue relationships once the healing was complete.

Several factors limited material selection for the definitive units in this case. The darkness of the underlying teeth necessitated a restoration that would mask them. Since the patient had been diagnosed as allergic to gold, this precluded the use of a PFM option. The marginal integrity of these restorations would be essential to maintaining the achieved soft-tissue results. The patient’s aesthetic expectations (intensified by a sibling rivalry that she had described in great detail) were also critical.

Based on these criteria, a decision was made to use a zirconia core restoration. Zirconia-based full-coverage restorations are very good at masking dark substructures, even though they may not offer the ultimate aesthetics of lithium disilicate or even some PFM crowns.4 While according to at least one report in the literature, the marginal integrity of all-ceramic restorations is not quite the equal of their PFM counterparts,5 zirconia-based restorations would appear to have an advantage in that regard.6

Clinical Protocol
A phone consultation with my dental laboratory liaison resulted in the choice of Zir-MAX (Burbank Dental Laboratory) as the material for the definitive crown cores in conjunction with the Elite porcelain layering technique (Arrowhead Dental Laboratory). After the final preparations and impressions (Examix [GC America]), what ensued was the try-in of a series of units that, while functionally accurate, did not meet the aesthetic expectations of either the patient or the clinician (Figures 3 to 5). Each of the 4 sets was used as the provisional thereafter, until each subsequent set came in. Whether it was a matter of hue, value, or incisal translucency, none of these sets were able to accomplish the particular combination of characteristics needed to produce the vital natural-looking result that was expected. Also, the marginal tissue appeared to suffer somewhat in the process (Figure 6).

Figure 7. The definitive Captek (Argen) units upon insertion. Figure 8. The definitive Captek units, 2 weeks after insertion. Note the improved soft tissue.
Figure 9. The relaxed full smile at the same follow-up visit. Figure 10. The definitive Captek units 6 months after insertion exhibited a fully matured gingival framework.
Figure 11. The relaxed smile at 6 months.

At this point, as should have been done earlier, the patient was questioned more closely about how the diagnosis of gold allergy had been made. She reported that, in her teens, she had experienced a contact dermatitis when she wore gold earrings for the first time. The resultant consultation with an allergist, where a skin test was done with a sample of jeweler’s gold, yielded the same outcome upon which a hypersensitivity to gold was identified. Being skeptical of this diagnosis, because jeweler’s gold is defined (thefreedictionary.com) as being 25% percent copper, it was possible that a PFM restorative (such as Captek [Argen], the author’s preference for PFM restorations) could be used here after all. Captek, a composite metal that is not an alloy, contains no base elements of any kind (per a personal conversation with Nick Azzara [June 11, 2013] then serving as the president of the Captek division of the Argen Corporation). A Captek swatch was sent to our office by next-day service and supplied to the patient’s current allergist, and the skin test with that swatch revealed no hypersensitivity whatsoever. Armed with this fact, Captek crowns were then prescribed for the case as that material has been shown to promote gingival health7,8 and to exhibit a level of aesthetics that is comparable to any all-ceramic9 (both sub- and supragingivally).10 Furthermore, this material has been shown to be demonstrably superior to zirconia-based restorations as it relates to the appearance of aesthetic vitality.11

Upon seating the first set of Captek definitives, a material with which this author has had much shade matching success,12 both the patient and clinician were happy with the aesthetics created. The crowns were cemented to place (RelyX Luting [3M]) after a minimal occlusal adjustment on the restoration on tooth No. 8 (Figure 7). Two-week and 6-month follow-ups with this patient found her to be very satisfied with the aesthetics, and the gingival health was found to be excellent (Figures 8 to 11).

CLOSING COMMENTS
This case exposes the many issues that must be explored in cases with challenges in the aesthetic zone. These include how the soft-tissue architecture must be evaluated and treated (if necessary), the importance of the provisionalization phase, and issues around the selection of the definitive restorative material. As was made obvious in this clinical case example, having an accurate medical history is also a must. When all the dynamics of a case like this one are properly accounted for, a result can be realized that addresses the relevant soft- and hard-tissue challenges and, at the same time, gives the patient the “pink” and “white” aesthetic results that are expected within the context of an optimal outcome.

Acknowledgment
The author would like to thank Dr. Nomith Ramdev (Dover, NH) for his expertise in the periodontal surgery done for this patient, and Mr. Josh Gall and his talented team of dental technicians at BioTemps Dental Laboratory (Irvine, Calif). The author would also like to thank Mr. Ray LeGendre and his talented laboratory team at Arrowhead Dental Laboratory (Sandy, Utah) for the definitive ceramics.


References

  1. Singh VP, Uppoor AS, Nayak DG, et al. Black triangle dilemma and its management in esthetic dentistry. Dent Res J (Isfahan). 2013;10:296-301.
  2. Nugala B, Kumar BS, Sahitya S, et al. Biologic width and its importance in periodontal and restorative dentistry. J Conserv Dent. 2012;15:12-17.
  3. Bral M. Periodontal considerations for provisional restorations. Dent Clin North Am. 1989;33:457-477.
  4. Aboushelib MN, Dozic A, Liem JK. Influence of framework color and layering technique on the final color of zirconia veneered restorations. Quintessence Int. 2010;41:e84-e89.
  5. Hosseini M, Worsaae N, Schiodt M, et al. A 1-year randomized controlled trial comparing zirconia versus metal-ceramic implant supported single-tooth restorations. Eur J Oral Implantol. 2011;4:347-361.
  6. Poggio CE, Dosoli R, Ercoli C. A retrospective analysis of 102 zirconia single crowns with knife-edge margins. J Prosthet Dent. 2012;107:316-321.
  7. Goodson JM, Shoher I, Imber S, et al. Reduced dental plaque accumulation on composite gold alloy margins. J Periodontal Res. 2001;36:252-259.
  8. Lowe RA. Periodontal compatibility of intracrevicular Captek restorative margins: a case report. Contemporary Esthetics and Restorative Practice. 2004;8:14.
  9. Fillastre A. A practical esthetic solution to challenging clinical situations. Inside Dentistry. 2012;8:84-86.
  10. Nathanson D, Nagai S, Po S, et al. Preliminary evaluation of the effect of crown on gingival color. Presented at: IADR/AADR/CADR 82nd General Session; March 11, 2004; Honolulu, HI. Abstract 1478.
  11. Lowe RA. A comparison of Captek Nano EZ versus porcelain to zirconia all ceramic crowns in the esthetic zone: a case report. Oral Health. April 2012:35-42.
  12. McArdle BF. Shade matching for single indirect restorations using a remote laboratory. Contemporary Esthetics. 2006;10:44-51.

Dr. McArdle graduated from Tufts University School of Dental Medicine in 1985 and has been practicing general dentistry on the New Hampshire seacoast ever since. He has served on the active medical staff in dentistry of Concord Hospital in Concord, NH, and on the board of directors of Priority Dental Health, the New Hampshire Dental Society’s Direct Reimbursement entity. He is a co-founder of the Seacoast Esthetic Dentistry Association (dentalesthetics.org), which is headquartered in Portsmouth, NH. He is the founder of Seacoast Dental Seminars (seacoastdentalseminars.com), also headquartered in Portsmouth. He has authored numerous other articles internationally in major peer-reviewed publications. He can be reached at (603) 430-1010, via email at either This email address is being protected from spambots. You need JavaScript enabled to view it. or This email address is being protected from spambots. You need JavaScript enabled to view it., or mcardledmd.com.

Disclosure: Dr. McArdle reports no disclosures.

Creating the All Important Emergence Profile

Introduction

In high lip-line aesthetic cases, not only is the success of treatment dependent on the skills of the technician but also on the management of the soft tissues by the prosthodontists who should be highly involved in the design of the definitive fixed partial denture (FPD). It is generally accepted that the use of an ovate pontic in short span FPDs, whether conventionally or implant supported, is the most predictable approach to achieving an excellent and natural appearance.

Figure 1. A 3-unit fixed partial denture (FPD) with a poor ridge-lap pontic and uneven gingival heights.

Figure 2. A 3-unit FPD with a poorly designed ridge-lap pontic and open embrasures.

The aesthetic deficiencies shown in the 2 cases (Figures 1 and 2) are clear. Although the standard of the porcelain work is not ideal, in both cases, little or no attention has been paid to the soft-tissues profiles and so success has been further compromised. The ridgelap pontic design gives an unnatural appearance, with the pontic appearing to “sit” on the gingivae rather than emerging from the gingival tissues as natural teeth do in nature. The lack of tissue support from the pontics has further contributed to the appearance of open embrasures and unsightly “black triangles.” Little effort has been made to ensure that the gingival heights of the central incisors are even.

Figure 3. An ovate pontic with poor aesthetics.

Figure 4. Palatal view of the ovate pontic showing poor tissue support for aesthetics.

Figure 5. The 20-year-old ovate pontic still providing a degree of tissue support for the papillae.

The issue of aesthetics is further demonstrated in the contrasting results achieved with the 2 markedly different designed FPDs shown in Figures 3 to 5. Both prostheses were placed around 20 years ago.

In the first case, the lack of support to the gingivae from the design of the pontic is obvious. The ongoing recession of the underlying bone and soft tissues has further exacerbated the clinical appearance with a space above the pontic and a complete absence of papillae.

The second case demonstrates how the ovate pontic form has helped in supporting the tissues and maintaining the emergence profile and papillae despite the on-going recession. The aesthetics are compromised by the dark exposed root of the abutment tooth rather than the minimal failings around the ovate pontic.

Figure 6. The emergence profile refined during the temporization phase of treatment following extraction of the lateral incisor.

Figure 7. View of the definitive FPD on fitting.

If the emergence profile is correctly created and the gingival tissues adequately supported by the pontics, papillae can be formed interproximally and the pontic teeth shaped to appear to be emerging from the gingival tissues, mimicking the appearance of natural teeth (Figures 6 and 7).

Figure 8. Healing abutment after 3-plus months of integration overgrown by gingival tissues.

Figure 9. Emergence profile refined with a provisional screw-retained restoration.

Figure 10. The definitive cemented abutment supported FPD with pink porcelain merging with the natural tissues.

Figure 11. The final aesthetic result.

This also applies to short span implant supported FPDs. In the case shown in Figures 8 to 11, where the accidental loss of a diminutive lateral incisor and deciduous canine not only complicated treatment by the lack of space but also the tissue loss which was such that the use of pink porcelain was required to optimise aesthetics. The harmonious blend of the pink porcelain with the natural tissues was disguised by the creation of an emergence profile with a provisional screw retained composite FPD prior to impressions being taken. It is unlikely that the final aesthetic result could have been achieved without prior planning of the soft tissues.

Three possible techniques for the creation of the emergence profile for ovate pontics are:
• prior to impression taking, during temporization
• at the time of impression taking
• at the time that the definitive FPD is fitted.

It is the author’s opinion that the most predictable and aesthetic outcome is achieved if the emergence profile is defined during the phase of temporization and prior to impression taking. The versatility of modern composites is such that it is far easier and quicker to work with these materials rather than to try to achieve the same outcome working in porcelain during the definitive phase of FPD fabrication.

One commonly advocated technique is to trim the working models to the desired ovate shape and form in the pontic areas. This technique is, however, reliant on the clinical experience of the operator as the same amount of tissue requires to be removed clinically at the trial fit appointment. Even if this can be accurately and successfully carried out, without modification of the fit surface of the provisional FPD, the soft tissues invariably rebound during the healing phase prior to the final fit. Consequently, the same degree of tissue removal would be required at that visit, along with the administration of further local anesthesia.

The other issues encountered with this technique are related to the degree of empirical removal of tissue on the working model—too much and the bridge may not fully seat if sufficient gingival tissue to maintain the biologic width is retained and, if too little, the aesthetic result may not be ideal, necessitating further modifications to the working model and additions of porcelain to the fit surface of the pontics.

It is the author’s experience that the technique of creating the emergence profile prior to impression taking is the most consistently reliable in achieving the desired aesthetic result. The clinical problem encountered with this technique has been related to the impression stage of treatment. The time taken between removal of the provisional restoration and conventional impression taking consistently resulted in a master working model which did not accurately reproduce the created tissue contours seen on removal of the provisional restoration. Consequently, at the try-in stage of the definitive FPD, the pontic shape and form were poor and unsupportive to the desired tissue profile.

Figure 12. The emergence profile created with a provisional screw-retained composite restoration.

Figure 13. The collapsed emergence profile 30 minutes after removal of the provisional restoration.

Figure 14. The developed ovate pontic form on removal of the provisional restoration.

Figure 15. The degree of distortion of the gingival tissues following placement of retraction cord and removal of the final impression.

The cause of these discrepancies seemed to be due to the rapid collapse of the sculpted tissue upon removal of the provisional FPD. The degree of loss of contour as developed in an implant case is shown in Figure 12 as the provisional is removed, and 30 minutes later in Figure 13.

In conventional tooth supported FPDs further tissue distortion is created by the introduction of retraction cord prior to impression taking. The excellent initial created emergence profile is shown almost immediately following removal of the provisional FPD in Figure 14. Some 30 minutes later, the distorted and collapsed nature of the tissues after removal of the retraction cord prior to impression taking are clearly seen in Figure 15. Further alteration takes place in the laboratory following die trimming. A second pour solid model has rarely proved to be of any predictable help.

Background

In general, with patients becoming better informed about advances in cosmetic dentistry, their expectations are getting ever more demanding. As a result, cases such as the one shown, are presenting more frequently. The patient was dissatisfied with the appearance of his metal skeleton removable partial denture and its associated instability. He wished to explore his options of fixed prostheses and ultimately decided on a conventional FPD rather than one supported by implants. His high lip-line and broad smile dictated the need for the creation of an emergence profile and ovate pontic design within the treatment plan.

Figure 16. View of the edentulous ridge prior to the development of an emergence profile.

Figure 17. The provisional restoration used to develop the emergence profile.

Figure 18. The developed emergence profile.

After administration of the local anaesthetic, the abutment teeth were prepared for a fixed-fixed design for the FPD. Prior to temporisation, the edentulous ridge was modified with electrosurgery to create papillae and an emergence profile. A temporary bridge constructed in a bisacryl provisional material (Protemp 4 [3M ESPE]) was fabricated with ovate pontic design to help maintain this profile during the healing phase of the gingival tissues (Figures 16 to 18).

After allowing 12 weeks for initial healing and tissue maturation, the provisional FPD was removed, retraction cord placed in the conventional manner and an impression taken with a polyether impression material (Impregum Penta Soft Quick [3M ESPE]). The resultant silver-plated working model is shown following sectioning and some modifications to the emergence profile (Figures 19 and 20).

Figure 19. A view of the silver plated working model after sectioning.

Figure 20. The occlusal view of the same model.

Figure 21. The emergence profile prior to impression taking.

Figure 22. A view of the working model following sectioning.

In Figures 21 and 22 it is clearly seen that there is no physical resemblance between the patient’s soft tissues and those on the working model especially after die trimming.

A second hard-tissue model poured from the same impression was of little help. The collapse of the created emergence profile and its reproduction such that, despite some arbitrary model trimming in the soft-tissue area, the temporary restoration, which fits accurately and fully supports the tissues in the mouth, will simply not seat onto the working model (Figures 23 and 24). It follows that any definitive restoration made on these models would be deficient and lacking in the necessary shape to support the gingival tissues in their desired profile.

It was the frustration experienced in this case that lead to the development of the following technique to replicate the created emergence profile in the working models. Figure 25 shows the accuracy of fit of the same temporary restoration as in Figure 24 fitted onto a hard-tissue model made using the technique.

Figure 23. The poor fit of the patient’s provisional restoration on the working model.

Figure 24. The poor fit of the patient’s provisional restoration on the working model.

Figure 25. The excellent fit of the provisional restoration on a hard-tissue model fabricated from the proposed impression technique.

Figure 26. The patient with his removable partial denture (RPD) prior to commencement of treatment.

Figure 27. The appearance of the fitted definitive FPD.

Figure 28. Lateral view of the patient with his RPD.

Figure 29. Lateral view of the completed case.

Figure 30. View of the created emergence profile on removal of the provisional screw-retained restoration.

Figure 31. View of the soft-tissue working model showing accurate and undistorted reproduction of the gingival tissues.

The before and after photos of the case are shown in Figures 26 to 29. The shape of the ovate pontics of the provisional FPD were so accurately reproduced in porcelain that the only adjustments required following the try-in stage were related to occlusal refinement and issues with colour matching.

The developed technique was then further refined and adapted to short span implant-retained FPDs and the degree of accuracy achieved shown in Figures 30 and 31. The technique will be demonstrated in a series of future articles.

Technique

The technique uses a stent that accurately replicates the fit surface of the provisional FPD (Figure 32) that was used to create, maintain and support the emergence profile of the soft tissues. The untrimmed stent is shown in Figure 33.

In this case, the edentulous ridge prior to, and following the creation of, the emergence profile is shown (Figures 34 to 36). It is not within the scope of this article to describe the technique behind the creation of the emergence profile itself, merely its reproduction.

The provisional FPD, which is used to maintain the tissue contours during their maturation, is also used to create the impression stent. Once cleaned, of all temporary cement, the bridge is submerged to around one third of its fit surface in Provil Novo Soft Fast Set impression putty (Heraeus Kulzer). Once the putty has set, the provisional FPD is removed (Figure 37 and 38).

Flowable light-cured composite Venus Flow (Heraeus Kulzer) is then injected into the mould in layers and cured until flush with the level of the putty. Ordinary light-cured composite Venus (Heraeus Kulzer) can then be used to bulk up the stent and create a retention tag to facilitate removal in the definitive impression (Figure 39).

As polymerization shrinkage will have occurred during the curing process, the composite stent will not fit accurately onto the abutment teeth in the mouth without further adaptation. The inside surfaces of the stent abutting the tooth preparations are therefore cored out (Figures 40 and 41) and all excess “flash” trimmed.

The stent is then trial fitted to ensure a passive fit on the abutments and correct tissue displacement in the pontic areas (Figure 42). There is invariably some tissue blanching for one or 2 minutes, indicating that the gingivae are being pushed back into the same position that was supported by the provisional FPD prior to removal.

The impression stent is now ready for final adaptation. A water soluble separating medium (Wink [Pulpdent]) is applied to the abutment teeth. Composite Activator (BISCO Dental Products) followed by Bonding Fluid (BISCO) are applied to the internal surface of the stent as per the manufacturer’s instructions. Composite bonding agent (OneStep Plus [BISCO]) is then applied to the fit surface of the stent and light-cured for 10 seconds. Finally, flowable composite is applied as shown to the abutment teeth (Figure 43), the stent fitted and maintained in place with finger pressure (Figure 44) while the composite is light-cured (Figure 45).

Figure 32. The fit surface of the provisional restoration used to create the emergence profile.

Figure 33. The fit surface of the duplicated provisional restoration prior to conversion to an impression stent.

Figure 34. The edentulous ridge prior to creation of the emergence profile.

Figure 35. The developed emergence profile.

Figure 36. View of the provisional composite restoration used to develop the emergence profile.

Figure 37. The provisional restoration submerged in impression putty.

Figure 38. View of the impression putty on removal of the provisional restoration.

Figure 39. The finalised stent in impression putty prior to removal and trimming—the retention tag is clearly visible.

Figure 40. The fit surface of the duplicated provisional restoration prior to conversion to an impression stent.

Figure 41. The stent with the surface abutting the tooth preparations cored out

Figure 42. Trial fit of the stent to ensure a passive fit.

Figure 43. Flowable composite being applied to the abutment teeth.

Figure 44. Finger pressure being applied to the stent to ensure it is fully seated and the soft tissues correctly displaced.

Figure 45. The stent being firmly held in place while light curing is carried out.

The stent could be left located in place, but any excess composite that may overlap the margins of the preparation could, at a later stage, interfere with the accurate location of the master dies resulting in an inaccurate soft-tissue working model. It is recommended that the stent be removed and trimmed as necessary. A trial relocation of the stent on the abutment teeth should then be carried out to ensure a positive fit. If there is any hint of instability, it is likely that the stent could be dislodged during impression taking and a resultant distorted working model. If movement is detected then it is advisable to use provisional cement such as Temposil (Coltène/Whaledent) to aid retention as it can be easily peeled out of the stent on removal out of the mouth without leaving any residue, which would be the case if a more conventional cement was used. Alternatively, some further OneStep Plus could be added to the fit surface of the stent and light-cured. To allow future accurate location of the working dies in the stent it is essential that the fit surface is clean and undistorted by temporary cements which usually require removal in an ultrasonic bath—these types of cements should be avoided.

The located stent is now ready for the final impression. It is important to realize that the soft-tissue impression technique shown in this article should be taken prior to the final impression. The degree of distortion created by the retraction cord and on-going tissue collapse cannot be compensated for by the formed impression stent.

Although the retention tag should ensure accurate removal of the impression from the mouth without distortion, it could additionally be painted with tray adhesive recommended by the manufacturer of the chosen impression material. As tissue reproduction is provided by the stent itself a quick-setting material (such as Template [CLINICIAN'S CHOICE]) can be used. The impression is shown after removal and location of the working dies, which were taken from the definitive working master model (Figures 46 and 47).

Figure 46. A view of the stent located in the impression.

Figure 47. The stent with the working dies accurately located ready for pouring.

Gingival retraction cord was then placed around the abutment teeth and after being left in place for the appropriate period of time, removed, and the definitive impression taken in a polyether impression material (Impregum Penta Soft Quick [3M ESPE]). The huge difference between the soft-tissue details in the stent impression compared with the normal working impression is clearly visible (Figures 48 and 49).

It is the author’s preference to silver plate the final impression in cases where the dies will require to be moved from one working model to another. After the dies from the definitive working model are trimmed, they are carefully and accurately transferred to the stent impression and a soft-tissue model poured. The stent impression can also be used to pour a hard model in stone as shown (Figures 50 to 52). The impressive reproduction of the gingival tissues in both the soft and hard tissues is clearly visible.

This definitive FPD was constructed in porcelain fused to precious metal. The metalwork and most of the porcelain work was carried out on the working silver plated model. Refinement of the fit surface of the porcelain pontics was achieved by transfer to both the soft- and hard-tissue models. The degree of accuracy achieved by the duplication technique is shown in Figures 53 and 54.

Only one trial fit of the definitive FPD was needed. At this appointment the fit of the pontics was passive yet supportive to the created emergence profile and further modifications were not required.

Figure 48. View of the distorted tissues in the “working” impression.

Figure 49. View of the accurate reproduction of the soft tissues with the stent.

Figure 50. The created emergence profile.

Figure 51. The accurate reproduction of the soft tissues achieved with the technique.

Figure 52. The hard-tissue working model.

Figure 53. The definitive FPD on the hard-tissue working model.

Figure 54. The FPD one week after final fit.

CLOSING COMMENTS

The author has consistently found it easier to work with composite during the temporisation phase rather than in porcelain at try-in of the definitive FPD. Any extra time spent at this stage is more than made up for later on.

The putty impression of the provisional FPD can be taken at the last check appointment of the emergence profile and the stent made at a convenient time prior to the definitive impression appointment. Needless frustration, both clinically and in the laboratory, is also avoided. This technique produces excellent and consistently reliable.

Acknowledgement

The author would like to thank his technician Mick Kedge for all his support and help in the development of the technique. The author would also like to thank his patients, John McGarrell and Andrew Fraser, for the endless hours in the chair while he worked on refining the technique itself at the chair side.


Dr. Bereznicki graduated from Edinburgh Dental Hospital and School in 1976. He moved to London, UK, and after various House Surgeon appointments at Guy’s Hospital and The Royal Dental Hospital he entered general practice and started his own private practice in Queensgate, London in 1982. Recently, he has joined the Dawood & Tanner Dental Practice in London as a member of the restorative team. Dr. Bereznicki’s area of special interest is aesthetic dentistry and in particular the creation and duplication of the created emergence profile in conventional and implant retained crown and bridgework. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

 

Disclosure: Dr. Bereznicki reports no disclosures.



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