A Simplified All-Ceramic System for Complex Cases

Dental professionals constantly strive to choose the best materials and techniques possible in order to deliver successful, aesthetic, and predictable restorative outcomes that will be most beneficial to their patients. Historically, this endeavor has been challenging when the case is complex and requires a combination of different types of restorations, such as in full-mouth reconstructions.
This article presents a full-mouth reconstruction case in which all-ceramic veneers, crowns, and implant-supported crowns were the restorations of choice. The fabrication techniques and clinical protocol that were followed in order to realize a successful restorative outcome are described.

CASE REPORT
Diagnosis and Treatment Planning

Figure 1. Preoperative photo of the patient’s natural smile. Note discoloration of the teeth and worn appearance.	Figure 2. Full-facial view of the patient’s natural smile.
Figure 3. Occlusal view of the mandibular arch, highlighting the extent of her missing dentition and pre-existing amalgam restorations.	Figure 4. Palatal view of the patient’s maxillary arch, showing her missing dentition.

Figure 5. Retracted view in closed-mouth position, demonstrating the extent of her uneven occlusal plane.

A female patient presented with discolored and worn teeth. In addition, irregular, worn, and failing composite and amalgam restorations were present. She was missing teeth Nos. 4, 13, 21, 28, and 30, and she exhibited an uneven occlusal plane that was associated with her missing teeth and super-eruption (Figures 1 to 5).
A thorough clinical and periodontal examination was performed, and radiographs were taken. Additionally, a cone beam computed tomography scan was obtained.
To properly treatment plan the case, a full-mouth diagnostic wax-up was created at the dental laboratory (Figure 6), with instructions to open the vertical dimension of occlusion (VDO) by approximately 1.5 mm.¹ This was accomplished by mounting the case (preoperative maxillary and mandibular models) with a face-bow on a Denar articulator in centric relation (CR). Additionally, preoperative photographs (ie, full-face and profile) along with a stick bite to confirm the horizontal plane were sent into the laboratory for review by the dental technicians. The diagnostic wax-up was used to help the patient visualize the projected outcome of her full-mouth reconstruction.² In particular, it demonstrated the proposed length and width of the anticipated restorations.
The treatment plan would involve replacing the missing teeth Nos. 4, 13, 21, and 28 with 4.3 mm implants; and tooth No. 30 with a 5.0 mm implant (NobelActive [Nobel Biocare]), as well as prefabricated abutments (Snappy Abutments [Nobel Biocare]). Then, full-coverage all-ceramic crown restorations (IPS e.max [Ivoclar Vivadent]) would be placed for teeth Nos. 6 to 11, Nos. 3 to 14, and Nos. 19 to 31. All-ceramic veneers would be placed for teeth Nos. 22 to 27 (IPS e.max).
The patient accepted the treatment plan, and the diagnostic wax-up was returned to the laboratory for final adjustments. A matrix for use in creating the temporary restorations would also be fabricated.
It was collectively decided that the restorative material of choice for this case would be an all-ceramic material suitable for combination cases, since it would best match the patient’s shade across all the preparation types and implant abutments. Several years ago, a single all-ceramic system with multiple components (IPS e.max) suitable for anterior and posterior stress-bearing and implant-supported restorations was introduced. These all-ceramic materials demonstrate the outstanding physical and aesthetic properties demanded by both dentists and dental laboratory technicians, enabling the versatile and simple production of restorations that blend harmoniously with each other and the surrounding dentition.

Clinical Protocol

Figure 6. Maxillary and mandibular diagnostic wax-ups were fabricated at the dental laboratory.

A surgical guide was created in the dental laboratory from the diagnostic wax-up and used for implant placement. The 5 implants and abutments were placed as planned and described above and, after 4 months of healing, the patient returned to our office. The maxillary arch was anesthetized and all of the existing amalgam restorations and decay were removed, and the teeth were prepared for full-coverage all-ceramic crowns.
Provisionals were fabricated using Protemp Plus (3M ESPE) temporary material (shade A1) based on a detailed putty matrix created from the diagnostic wax-up. The soft tissue provided stops for accurate seating of the putty matrix. The provisionals were segmented: teeth Nos. 3 to 5, Nos. 6 to 11, and Nos. 12 to 14. They demonstrated good fit and were retentive without adhesive. The mandibular arch was provisionalized in a similar manner.
With the provisionals in place, the occlusion was refined, and anterior and canine guidance in lateral excursives confirmed. Final impressions (Aquasil Ultra/B4 Pre-Impression Surface Optimizer [DENTSPLY Caulk]) were taken of the prepared teeth , and the patient was given one week to evaluate her comfort with the occlusion, aesthetics, and the new VDO as reflected in the temporaries.³

Final Impressions and Bite Registrations

Figure 7. Retracted view of the provisional restorations. Note the harmonious occlusal plane, and more pleasing smile line.	Figure 8. Close-up natural smile of the provisional restorations (Protemp Plus [3M ESPE]). Note the more relaxed appearance.

Figure 9. Full facial view of the patient in her provisional restorations.

Once the patient returned for the final bite registration procedures, impressions and photographs of the approved provisionals were taken (Figures 7 to 9). The decision for the final shade selection was determined with the patient’s input, and shade mapping was performed. Shade OM 3.5 was selected for the body shade, and shade OM 3.75 was selected for the gingival one third, with slightly more chroma selected for the canines.
In order to proceed with all of the restorative treatment in one phase, the following steps were taken.
A bite registration of the full arch was taken in CR, along with a horizontal bite stick to record the horizontal plane. Subsequently, segmented bite registrations were taken. The upper right provisional segment was removed and the registration taken. Then, the upper left segment was removed and, leaving the upper right registration in place, the upper left was registered. Obtaining the bite registrations in this manner provided occlusal stops against the opposing provisionals.
Then, the anterior segment was removed and an anterior registration was taken with the posterior segments in place. A horizontal plane bite stick was used to record the horizontal plane. This enabled the recording of the upper prepared teeth with the lower provisionals.
The lower segments were then removed, but the other segmented bite registrations remained in position in order to maintain the vertical, anterior-posterior relationships. A preparation-to-preparation bite registration of the right segment was taken. Subsequently, the lower left provisional segment was removed, and a preparation-to-preparation bite registration was taken, using the right preparation-to-preparation segment to preserve the relationship.
While leaving both the posterior segment registrations in place and using a horizontal bite stick to confirm the horizontal plane, the anterior preparation-to-preparation registration was taken. To enable the laboratory to visualize this relationship, photographs of the horizontal plane recordings were taken.
The temporaries were replaced, and the case was then submitted to the dental laboratory for fabrication of the patient’s new all-ceramic restorations.

DENTAL LABORATORY FABRICATION

At the laboratory, similar to what would be performed for any restoration, the ceramist poured models from the impressions (Figures 10 and 11), and a full contour wax-up of the pressed ceramic restorations was made. The final pressed wax-ups were designed specifically for layered porcelain buildups in order to achieve the best aesthetic outcome (Figures 12 and 13). The wax-up was then sprued on the ringer former, invested, and burned out. The ingots for each restoration were then pressed. The ceramist then applied the appropriate aesthetic layering porcelains, thus completing the restorations.

Cementation
Approximately 5 weeks after the temporaries had been replaced, the patient returned for seating of the definitive restorations. After the patient was anesthetized, the provisional restorations were carefully removed and the preparations cleansed using Consepsis (Ultradent Products) scrub with and chlorohexidine. The all-ceramic crowns were then tried-in to verify occlusion, fit of the margins, and aesthetics.
The preparations were isolated with an Optragate (Ivoclar Vivadent) dam, and a layer of a single component bonding agent (Clearfil S3 [Kuraray]) was brushed onto the preparations (teeth Nos. 6 to 11 and 22 to 27), gently air-dried, and light-cured. The anterior restorations were then luted into place with resin cements. RelyX ARC (3M ESPE) was chosen for the crowns (teeth Nos. 6 to 11), and RelyX Veneer (3M ESPE) resin (shade TR) for the veneers (teeth Nos. 22 to 27). A self-etching resin cement (RelyX Unicem [3M ESPE]) (shade TR) was used for teeth Nos. 3 to 5 and Nos. 12 to 14. The restorations were then light-cured and polished. Only minor occlusal adjustments were necessary. Finally, a final occlusal guard was fabricated to protect her new dentition from any additional damage from the forces of bruxism.

CONCLUSION

Figure 14. Postoperative occlusal view of the completed maxillary restorations.	Figure 15. Postoperative occlusal view of the completed mandibular restorations.
Figure 16. Retracted postoperative view of the completed full-mouth reconstruction.	Figure 17. Postoperative right-lateral view, natural smile.
Figure 18. Postoperative left-lateral view, natural smile.	Figure 19. Postoperative close-up view, natural smile.

Figure 20. Final full-facial smile of the patient following her full-mouth reconstruction and placement of the all-ceramic (IPS e.max [Ivoclar Vivadent]) restorations.

In the past, dental professionals struggled to find a material capable of combining aesthetics and high strength material that could be used in combination cases, such as full-mouth reconstructions. As demonstrated here, a single all-ceramic system (IPS e.max) provides dentists and laboratory ceramists with the simplicity and versatility to confidently facilitate restorations that are durable and predictable. Most importantly, the restorations created from this system blend seamlessly with each other and the surrounding dentition (Figures 14 to 20).

References

1. McIntyre F. Restoring esthetics and anterior guidance in worn anterior teeth. A conservative multidisciplinary approach. J Am Dent Assoc. 2000;131:1279-1283.
2. Garcia LT, Bohnenkamp DM. The use of diagnostic wax-ups in treatment planning. Compend Contin Educ Dent. 2003;24:210-212, 214.
3. Achieving predictable, beautiful smiles using a dento-facial esthetic diagnosis system. Compend Contin Educ Dent. 2007;28:50-55.

Dr. Haag received his DDS degree from the University of Minnesota in 1992. He is certified in Advanced Cardiac Life Support and received additional training at the University of Minnesota for Oral and IV Conscious Sedation. He is a member of the American Dental Association, the Minnesota Dental Association, the St. Paul District Dental Society, the Minnesota Academy of Cosmetic Dentistry, the American Academy of Cosmetic Dentistry, and the American Academy of Implant Dentistry. He has hospital privileges at multiple hospitals in the Twin Cities area and has attended advanced training for Invisalign orthodontics and dental implants. He has maintained Creekview Dental in Woodbury, Minn, since 1993. He can be reached at info@creekviewdental.com.

Disclosure: Dr. Haag reports no conflicts of interest.

Mr. Stevens has 39 years of prosthetic dental laboratory experience. He holds an Osseointegrated Implant Restorative Fabrication Degree from Northwestern University Dental Academy and is a member of the Minnesota Academy of Cosmetic Dentistry. Mr. Stevens received a Fellowship Award from the International Congress of Oral Implantologists. He can be reached at realimage@integra.net.

Disclosure: Mr. Stevens reports no conflicts of interest.