I am honored when a fellow dental professional asks me to perform treatment for them. It was no different with this clinician, who told me she wanted to update her smile (Figure 1) with all-ceramic restorations.
While the patient’s dental health was excellent, she had some developmental abnormalities on the facial surfaces of her maxillary central incisors and had previous endodontic treatment for the mandibular central incisors. She had a Class I occlusion with proper anterior guidance and posterior disocclusion in excursive movements. Some anterior wear was noted with some chipping of the incisal edges on her maxillary and mandibular central incisors (Figures 2 to 4). Shade selection was done via evaluation of the hydrated teeth prior to preparation, and shade 1M1 (VITA Toothguide 3D-MASTER) was chosen.
Preoperative Steps
Maxillary and mandibular full-arch impressions were taken using an alginate substitute material (Silginat [Kettenbach LP]), and a centric relation (CR) bite registration was done (Futar [Kettenbach LP]). A face-bow transfer record was taken for mounting of the preoperative models onto a semi-adjustable articulator (Denar [Whip Mix]). The impressions, occlusal registration, and face-bow jig were sent to the dental laboratory team for mounting.
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| Figure 1. The patient’s smile before treatment. | Figure 2. Retracted facial view before treatment. |
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| Figure 3. Maxillary incisal view before treatment. | Figure 4. Mandibular incisal view before treatment. |
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| Figure 5. Wax-up of 10 maxillary teeth. | Figure 6. Lab-fabricated putty stint for maxillary provisional restorations. |
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| Figure 7. Mandibular duplicate hard model of wax-up with clear shim in place. | Figure 8. Clear lab-fabricated mandibular prep guide. |
In the lab, a wax-up of the maxillary centrals, laterals, canines, and premolars and the mandibular centrals, laterals, and canines was fabricated. (Figure 5). Putty stints (Panasil lab Putty [Kettenbach LP]) were made for the fabrication of the chairside provisionals (Figure 6). In addition to the putty stints to fabricate provisional restorations, the lab team duplicated the wax models in stone and then made clear vacuum-formed prep guides (Figures 7 and 8).
Preparing the Teeth
The maxillary 6 anterior teeth were prepared for 360° lithium disilicate (IPS e.max [Ivoclar Vivadent]) laminates to allow for porcelain-to-porcelain contact on excursive movements. Approximately 0.5 mm of facial and lingual reduction with 1.0 mm of incisal reduction was accomplished. Chamfer margins were created at the height of the tissue. The maxillary premolars were prepared for all-ceramic veneers with 0.5 mm of facial reduction and 1.0 mm of incisal reduction, and with chamfer margins at the level of the tissue.
In the mandibular arch, the canines and lateral incisors were prepared for lithium disilicate (IPS e.max) veneers. Composite cores (Visalys Core [Kettenbach LP]) were placed in the chambers of the 2 endodontically treated central incisors, and then these teeth were prepared for all-ceramic crowns (IPS e.max) with 1.0 mm of axial and 1.0 mm of incisal reduction, with chamfer margins at the height of the tissue. The completed preparations can be seen from the facial retracted view in Figure 9, the maxillary incisal view in Figure 10, and the mandibular incisal view in Figure 11.
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| Figure 9. Retracted facial view of the prepared teeth. | Figure 10. Maxillary incisal view of the prepared teeth. |
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| Figure 11. Mandibular incisal view of the prepared teeth. | Figure 12. The provisional restorations in place. |
Impressions and Provisionals
Following an occlusal registration (Futar), the final upper and lower impressions were taken (Panasil A-Silicone [Kettenbach LP]). Since all margins were at the height of the tissue and the patient’s soft tissues were healthy with no bleeding, no cord placement was needed. Panasil initial contact X-Light (Kettenbach LP) was used to inject around the margins, and my assistant mixed Panasil Putty and placed it in an impression tray. With this technique, as the tray was placed, the putty heavy body actually forced the light body further into the sulcus, and the resulting impressions were predictably clear and accurate.
Provisional restorations were fabricated using Visalys Temp (Kettenbach LP). The material was injected into the putty stints, placed over the prepared teeth, and then allowed to fully set. Next, the stints were removed, and the excess provisional material was reduced using a small carbide finishing bur. The finished provisional restorations are shown in place in Figure 12.
The final impressions, occlusal registration, and dental laboratory prescription were sent to Frontier Dental Laboratories (El Dorado Hills, Calif). Pre-op images and images of the prepared teeth and provisionals were also included for use by the laboratory team in the fabrication of the final restorations. In this particular case, the provisional restorations matched the diagnostic wax-up and no changes were required, so it was not necessary to send an impression of the (unrevised) provisionals. When changes are made, I take an impression of the revised provisionals and send it to the lab team so they can match the changes in the creation of the restorations (see Inset on page 92).
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Delivery of the Final Restorations
At the delivery appointment, the provisional restorations were removed, and the all-ceramic restorations were tried-in and approved. After try-in, each restoration was thoroughly cleaned and a silane primer (Bis-Silane [BISCO Dental Products]) was applied to the intaglio surfaces and dried with air. Each prepared tooth was etched for 10 seconds with etching gel (Uni-Etch w/BAC [BISCO Dental Products]) and thoroughly rinsed with an air water syringe. The teeth were then lightly air-dried. Cavity Cleanser with 2% chlorhexidine (BISCO Dental Products) was used to re-wet and disinfect the preparations. The excess liquid was suctioned away, and a universal bonding agent (ALL-BOND UNIVERSAL [BISCO Dental Products]) was liberally applied and air-thinned. Next, the bonding agent was light cured for 10 seconds with an LED curing light (S.P.E.C. 3 [COLTENE]). A resin cement (DUO-LINK UNIVERSAL, BISCO Dental Products) was then placed on the intaglio surface of each restoration. The restorations were seated, and the resin cement was allowed to cure to a gel state. At this point, excess cement was removed from the margins using a scaler and dental floss, and the cement was allowed to continue curing. The LED curing light was then used to finalize the cure by exposing each restoration to the light for 20 additional seconds.
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| Figure 17. Retracted facial view of the final result. | Figure 18. Maxillary incisal view of the final result. |
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| Figure 19. Mandibular incisal view of the final result. | Figure 20. The patient’s new smile. |
Final Result
The retracted facial view of the finished case is shown in Figure 17. The incisal view of the maxillary arch can be seen in Figure 18, and the mandibular incisal view is shown in Figure 19. In Figure 20, you can see the patient’s new smile.
Acknowledgment:
Dr. Nash would like to thank the team at Frontier Dental Laboratories in El Dorado Hills, Calif, for the excellent laboratory work.
Dr. Nash maintains a private practice in Huntersville, NC, where he focuses on aesthetic and cosmetic dental treatment. An accredited Fellow in the American Academy of Cosmetic Dentistry and a Diplomate for the American Board of Dental Aesthetics, he lectures internationally on subjects in aesthetic dentistry and has authored chapters in 2 dental textbooks. He is co-founder of the Nash Institute for Dental Learning in Huntersville and is a consultant for numerous dental product manufacturers. He can be reached at (704) 895-7660, via email at rosswnashdds@aol.com, or via the website thenashinstitute.com.
Mr. West is the vice president and general manager of Frontier Dental Laboratory in El Dorado Hills, Calif, where he has been employed for 24 years. He has been fortunate to work with the likes of Dr. David Hornbrook at PAC-live and Dr. Larry Rosenthal at Aesthetic Advantage, learning the art of smile design. In addition, he has lectured and taught at the California Center for Advanced Dental Studies and the Frontier Institute teaching smile design and material applications. He can be reached at (800) 790-3999, via email at bwest@frontierdentallab.com, or via the Instagram handle @brent_frotierdental.
Disclosure: The authors report no disclosures.
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