I have a very good friend, also an excellent dentist, who hasn’t changed the way he performs crown and bridge dentistry in the past 10 years, despite the enormous advances the industry has brought forth. You know who you are! I would estimate that he represents a large segment of our profession and will therefore address this article to both you and him. You also know who you are!
You are likely the conscientious practitioner accepting the noxious odor of powder-liquid methyl-methacrylate acrylic temporization resins who has also yet to venture beyond polyether impression materials despite their noxious “flavor.” You may even be the conscientious practitioner who is still content to do crown buildups in amalgam and who has shunned the latest one-step bonding agent. Nor do you give the slightest thought to any crown and bridge material beyond conventional porcelain-to-precious or semiprecious alloy.
You’re just plain set in your ways. You’ve settled on materials and methods that have worked for you over the years, tried and true. Why change?
For starters, consider convenience, efficiency, and patient comfort. Consider the benefits of working in an operatory that doesn’t smell like a chemistry lab, and think how wonderful it might be for your patient not to say… “ugghhh… that was gross!” upon removal of your carefully taken impression. Think about how your messy “mixables” could now be “racked up” in a series of neatly arranged auto-mix guns, looking and working ever so streamlined. If this all sounds foreign to you, then maybe it’s time for an update!
This article will take a brief foray into the crown and bridge dentistry of 2004, using a patient case to demonstrate the materials and techniques I used and why I used them.
THE ILLUSTRATIVE CASE
Figures 1 and 2 demonstrate a prototypical baby boomer quadrant (teeth Nos. 2 to 5) deserving of newer and better dentistry. An endodontically treated/built-up tooth No. 2, a disintegrating alloy on tooth No. 3, an unsightly PFM crown on tooth No. 4, and an oversized resin on tooth No. 5 call out for help. Other than the abrasion/recession noted on tooth No. 3, the periodontium is serviceable, requiring only a thorough cleanup. My recommendation of 4 single units of Captek crowns and appropriate buildups on teeth No. 2 to No. 5 was accepted by the patient.
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| Figure 1. A deserving quadrant ready for restoration. | Figure 2. Occlusal view of quadrant, Nos. 2 and 3 endodontically treated. |
Material Selection
Captek has been around for some time, but I had ignored it because I too was set in my ways. After repeatedly hearing and reading about Captek from many a respected educator, I decided to investigate on my own. I did more reading, attended a Captek symposium, and began questioning laboratories regarding their experiences over the past 5 to 10 years with regard to remakes and customer satisfaction.
This gold-hued crown and bridge alloy possesses strength equivalent to or greater than many of our black/gray alloys, needing only 0.3 mm of thickness for such optimal strength (thus minimizing reduction of tooth structure). It is nonoxidizing when fired, has been convincingly shown to repel plaque, and achieves high bond strengths to porcelain.1-3 A variety of margins can be used, including all metal, porcelain covered, or porcelain butt joints, for single units or bridges (Figure 3).
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| Figure 3. Cross-section of a Captek Crown. The gold coping imparts a lifelike hue. | Figure 4. The composite metal structure imparts its proven strength. |
Captek is a “composite metal,” or otherwise can be referred to as an “internally reinforced gold.” It is this nature of the material that enables it to combine the benefits of gold with the benefits of platinum and palladium in the same system. The hard particles of platinum and palladium are arranged like a skeleton or a metal sponge. The gold is drawn in and through that sponge during the fabrication process. The result is a thin gold coping that is internally reinforced with a skeleton of hard, rigid, thermally stable particles. It is designed to support porcelain under significant loads and yet have some degree of shock-absorbing or vibration resistance (Figure 4). (Note: you must engage a laboratory that is Captek certified.)
The Preimpression
When beginning to restore a quadrant, I begin with a tripletray (Accubite) putty impression using Affinis Putty Fast (Coltène/Whaledent). This impression accomplishes several things. The patient is coached on proper closure with a tray in place (a rehearsal for the final), I’m able to evaluate occlusal relationships via inspection of the impression, and finally, a matrix for temporization is provided. This same impression is kept in the patient’s pan in the event of damage to the temps while waiting for the replacements (Figure 5). Affinis Putty Fast will set in just under 3 minutes. The real time savings, however, will occur when it comes time to fabricate the temporary splint.
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| Figure 5. Affinis Putty Fast preliminary impression used for temps and occlusal relation examination. |
Leveling the Playing Field
Following local infiltration with Septodont’s 4% Articaine, a HYGENIC Flexi-Dam (Coltène/Whaledent) is employed to isolate the quadrant. While under the dam, all older restorative material is removed as is any recurring caries. In this instance, the crown on tooth No. 4 was also removed. The Flexi-Dam accelerates the excavation process by managing soft tissue as well as preventing the patient from inhaling or ingesting alloy debris. Prior to removing the dam, preliminary preps were completed, saving the fine-tuning for after dam was removed. Unlike more traditional latex rubber dams, the Flexi-Dam can be stretched over any obstacle without fear of tearing. Speed of placement is remarkable. If you haven’t already, you must re-explore the use of the rubber dam in everyday restorative procedures.
Revolutionary Buildups
OK…this is where you may really have been missing out. The advent of self-etching bonding agents and the stackable, dual-cure, core build-up materials that ad-here to such bonding agents have streamlined crown and bridge beyond what was imaginable just 10 years ago. As shown in Figure 6, a single application of Parkell’s Brush & Bond self-etching bonding agent is being applied to all preps after they’ve been prepared by a 5-second, cleansing, 33% phosphoric acid application and wash. Brush & Bond is allowed to both etch and seal the preparation surfaces for 20 seconds, blown thin, and then cured. The surfaces are now ready to have an automix core build-up material such as Parkell’s Absolute Dentin or Zenith’s Luxacore, literally “glopped” onto the prepared surface (Figure 7). The build-up material can be manipulated and thinned with a composite instrument prior to curing. The dual-cure mechanism will ensure that the core will set throughout in less than 5 minutes. The light-cured set will allow you to begin your prep refinements within 3 minutes of placement.
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| Figure 6. Parkell Brush and Bond being applied to excavated teeth prior to core buildups. | Figure 7. Application of dual-cure core build-up material such as Luxacore or Absolute Dentin. |
A word of caution: When selecting your materials for bonded cores, check with the manufacturer to ensure that your bonding agent is compatible with self- and dual-cure resins. Due to their high acidity, many self-etch bonding agents are ineffective for bonding anything other than light-cure composites.4-6 In-dependent research confirms Brush & Bond’s ability to bond dual-cure and self-cure resin as well as conventional light-cure composites.5,7,8
Following prep refinement, I made sure that I had achieved adequate occlusal reduction by placing a Belle DeStClaire thickness gauge between the prep and opposing tooth, as is shown in Figure 8. Also, note in Figure 8 how the core material has “filled in the blanks.” I’m compelled to mention that unlike the days of old, buildups placed in this manner do not appear housed within your impression upon removal. They stay put!
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| Figure 8. Use of occlusal clearance gauge to assure one-fifth mm clearance. |
Temporization
Here is true progress. To make my temporary splint, I coated the preps with a separating lubricant such as glycerin and filled the previously taken Affinis Putty Fast impression with an automix bis-acryl resin material such as Coltène/Whaledent’s Cool Temp Natural. I then placed the impression back in the patient’s mouth and had him fully occlude into the impression. In less than 2 minutes, the impression can be removed along with the temporary splint housed within it. Prior to full curing, a No. 15 disposable scalpel can be used to trim excess resin away while the temp is still contained within the impression. As can be seen in Figure 9, this is a good time to do a spot check of the temporary’s thickness, giving clues as to where additional reduction might be necessary before final impression. You can even check your finish lines for continuity, giving you a last chance to obtain a perfect prep. Figure 10 demonstrates a bit of “add-on” repair work in thin areas using Parkell’s EPIC TMPT composite resin (I call this the “duct tape” of all composite resins).
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| Figure 9. Preview of temps reveal more occlusal reduction would be wise. Note thin spots. | Figure 10. Use of Parkell Epic to reinforce buccal wall of temporary: dental duct tape. |
Bis-acryl formulations such as Cool Temp Natural or Zenith DMG’s Luxatemp are hybrids between flowable composites and acrylic resins. They are typically auto-mixed and self-curing. They provide an absence of heat on curing, are dimensionally stable compared to powder liquid acrylic formulations, possess flexibility and strength to resist breakage, and are odor free. Each mix is consistent, taking the subjectivity of powder-liquid mixes out of the picture. As there is little shrinkage on curing, occlusal adjustments are often unnecessary. Figure 11 shows the finished temps cemented with Zenith DMG’s Tempo-cem. Due to time constraints, this patient was dismissed and reappointed for final impression.
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| Figure 11. Coltène/Whaledent Cool Temp Natural temporary splint Nos. 2 to 5. |
A New Set of Eyes…
Upon my patient’s return, and before the teeth had time to dehydrate, we took our shade. The age-old challenge of taking an accurate shade has been simplified. Vita Easyshade (Vident), shown being used in Figure 12, has relieved my middle-aged eyes of having to zero in on just the right porcelain shade. I can still help by comparing the Easyshade’s selection to the actual shade guide (Figure 13), but I’ve found it remarkable how accurate the Easyshade turns out to be in the majority of instances. It will guide you in shade selection using either the Vita Classic shade system or the more contemporary Vita 3D-Master, which focuses heavily on value as opposed to hue to arrive at proper shade selection. I’ve found the 3D-Master to be a more reliable way of determining porcelain selection and would encourage you to experience it.
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| Figure 12. Vident’s Easyshade gathers excellent shade information when used with the Vita 3D-Master shade guide. | Figure 13. Confirmation and lab photo of shade that appeared on the EasyShade. |
It’s worth noting that unlike many shade-taking systems on the market requiring a PC as well as a lab that is on board with that particular system, the Easy-shade is self-contained, PC-free (save for a serial port that enables firmware upgrades), and will provide information that can be utilized by any dental laboratory. While it doesn’t provide the information overload characteristic of highly detailed shade maps, it will provide an average tooth shade or divide the tooth into 3 segments (Figure 14). The chance for remakes owing to improper shade selection becomes significantly reduced.
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| Figure 14. The Easyshade will record single tooth shades or 3 shades as shown here. |
Impression
One of the benefits of having reappointed our patient was the tissue having had time to regroup, as can be seen in Figure 15. In this image, you will note a blood-free environment with bicuspid tissue retraction accomplished with L-epinephrine-impregnated Gingi-Pak (Gingi-Pak) cord, and the molar margins exposed via electorsurgery (Sensimatic 600, Parkell). The Sensimatic also helped out with the bicuspids in areas that were still difficult to visualize even after corded tissue retraction. The quadrant was ready for impression.
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| Figure 15. Prepared teeth after cord retraction and margin exposure with Parkell Sensimatic electrosurge unit. |
Here’s your chance to take advantage of a class of impression material that has no taste, no odor, sets in 3 minutes, and is easily removed owing to its “nonsticky” nature. Polyvinylsiloxane products such as the Affinis Heavy and Light Fast shown in Figure 16 will speed your impression-taking and be better tolerated by your patients. One benefit of this will be appreciated the next time you recommend another crown to the same patient. Patients remember their experiences. Needless to say, the more pleasant the past experience, the more readily accepted your latest recommendation will be.
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| Figure 16. Preps recorded with custom tray and Coltène/Whaledent Affinis Heavy and Light Body Fast impression material. | Figure 17. Zenith DMG’s Luxabite for a dead-on bite registration that cannot be distorted. |
I’ll make a plea for use of a custom tray when it comes to taking impressions of quadrants. You’ll use far less impression material, but most importantly, the hydraulic pressure created by the close-fitting tray will drive the impression paste deep into the sulci, providing a beautiful impression. Make a custom tray when planning the case.
The bite was recorded with Zenith DMG’s Luxabite, another bis-acryl formulation that is ideally suited for distortion-free bite registrations (Figure 17).
The Crowning Touch
A quick comment on removing a 4-unit temporary splint. While a full explanation is beyond the scope of this article, I was recently introduced to an air-driven, reverse-mallet crown and bridge removal device, the Anthrogyr, marketed by J. Morita. I’ve found it to be the fastest, most comfortable, most versatile device that I’ve yet to encounter for removing simple and complex, provisionally cemented restorations, both resin and PFM.
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| Figure 18. Captek units featuring a variety of marginal finishes. |
Figure 18 demonstrates the 4 Captek crowns fabricated by Glidewell Laboratories. I elected to use all porcelain butt margins on the bicuspids, a porcelain-covered margin on the first molar, and a gold collar on the second molar. Figures 19 and 20 demonstrate the crowns following cementation. In this instance, GC America’s Fuji Plus capsules were used to lute the crowns in place, but any favorite cement would be applicable. Fuji Plus is a resin-reinforced glass ionomer cement that mixes in your old amalgam triturator, is injected directly into the crown, and sets in 2 minutes to an insoluble, fluoride-releasing, pulp-quieting cementing agent.
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| Figure 19. Occlusal view of cemented units using GC America’s Fuji glass ionomer cement. | Figure 20. Buccal view of completed case. |
IN THE END
By now a few eyebrows have been raised by a few very conscientious practitioners perhaps willing to try some new tricks in the name of patient comfort and doctor convenience. If it all seems too new, then try but one thing at a time. Many of you will be so overjoyed by how far the industry has brought us that you might even consider delaying retirement! Slowly but surely, the drudgery often associated with our past practice limitations is being weeded out by the dental manufacturers competing for our favor. You owe it to yourself to discover the best of what today’s dentistry has to offer. You know who you are.
References
1. Goodson JM, Shoher I, Imber S, et al. Reduced dental plaque accumulation on composite gold alloy margins. J Periodontal Res. 2001;36:252-259.
2. Knorr S, Combe EC, Wolff LS, et al. The surface free energy of gold alloy systems. Paper presented at: The 32nd Annual Meeting and Exhibition of the AADR; March 12-15, 2003; San Antonio, Tex; paper 0629.
3. Juntavee N, Giordano R, Nathanson D. Porcelain shear bond strength to a new ceramo-metal system. J Dent Res. 1995;77(spec. issue): abstract 1181.
4. Miller MB. Dental adhesives. In: Reality. Vol 18. Houston, Tex: Reality Pub Co; 2004:252.
5. Clinical Research Associates. Core build-up and adhesive compatibility. CRA Newsletter. April 2003;27:4.
6. Tay FR, Pashley DH, King NM, et al. Bonding of some self-etch adhesives to unground enamel. Paper presented at: The 32nd Annual Meeting and Exhibition of the AADR; March 12-15, 2003; San Antonio, Tex; paper 0027.
7. Brush&Bond. Reality Now. March 2004; No. 159.
8. Brown PL, Schiltz-Taing M, Sharp LJ, et al. Microtensile strength of adhesives utilizing indirect and direct composites. Paper presented at: IADR/AADR/CADR 82nd General Session; March 10-13, 2004; Honolulu, Hawaii; paper 1526.
Dr. Goldstein, a graduate of the University of Connecticut School of Dental Medicine, practices general dentistry in a group setting in Wolcott, Conn. He enjoys promoting the cosmetic side of his practice and has found it helpful to incorporate high-tech methodology into his daily routine to accomplish this. He serves on the staff of contributing editors at Dentistry Today and contributes regularly to multiple dental periodicals. Dr. Goldstein can be contacted at martyg924@cox.net. He lectures on both digital photography in dentistry and on the use of such high-tech methodology to further the cosmetic and restorative practice. Information on his lecture schedule can be found at drgoldsteinspeaks.com, while information on the Comfort Zone Cosmetics seminar series can be found at smilevision.net.
