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The mantra goes "pink esthetics before white esthetics" and I thoroughly agree. What our scalpel-wielding friends can achieve for our patients is truly remarkable. Here's an anterior restorative case with combination clinical/esthetic crown lengthening that simply would not have been possible without perio surgery:
I can see the issue because of your excellent photography but I submit that it is not noticeable to the naked eye at conversational distance and nobody cares about this but you. However, if you can sell it to the patient, God Bless You. The people I see would laugh me out of the operatory.
What Parameters are you using?
I think Mike said that the key to the movements was the midline point of the incisors for movement and setting the arch into the articulator.
This happens in all of our practices. A long time patient schedules an appointment yesterday for a "chipped tooth" I walk in to the op and see the case below. As you can see cerec handled the case as we would all expect. I spent time discussing the options with the patient to include:
1) extraction, implant, abutment and crown
2) extraction, Chairside FPD
3) endo, post/core, crown
As I presented the options, I even stated that option number three is becoming outdated in its philosophy and that dentistry as a profession is moving away from the less predictable long term prognosis of the endo/post/ core. I also stated that I did not like option two because of the uncertain condition of #9. The patient chose option #3. I know him very well and as I stated, he has been a patient of mine for twenty years. So I asked him why he chose that option. His answer, "I am 80 yrs old, I have had 17 surgeries in the last 9 years, and I just don't want another one if I can avoid it." Can't argue with that at all. So the question is, what would you guys have done? With all of the technology we have at our fingertips, are we forgetting traditional dentistry?
It's not too often these days where I completely inherit and implant case. When I do, it's generally just a posterior implant that the patient has not restored yet for some reason. This one was a bit different. Was an implant placed on #8 and a crown on #9... ouch ;)
The patient suffered a trauma at work a year and a half ago. He had to have endo on #7 and #9 and tooth #8 was extracted. I asked if the implant was placed immediately and he said no... the implant was placed by the periodontist after 6 months of healing. He moved into my area 2 months ago and found his way to the oral surgeon I work closely with on referral. He then was referred to me to restore the implant and tooth. For the last year or so, he has been wearing a provisional acrylic cantilever bridge that was not even temporarily cemented, but held into place with denture adhesive. Here is how he presented to my office (he took his own temp off):
So, before I could even think about the restorative challenges on this case, I needed to take a 3D to evaluate where the implant was placed. Good news and good start because the Periodontist had excellent implant placement (Straumann BL 3.3)
Now I had to start thinking about the restorative challenges that we were facing. I could identify two right off the bat:
- The midline papilla was mostly lost and blunted. He did have a little on the lingual that I could play with, but I knew right away that I was going to have a long midline. It would have been nice if an immediate provisional was placed to hold the papilla right off the bat.
- The space was very asymmetric. That is, if I wanted the midline to be correct, the spaces were going to be far enough off that I would likely have to leave an open contact with tooth #10 to get proper proportions.
To verify my findings, I did a little planning before scanning the patient. Here are pictures of where I envisioned the midline, the asymmetric space, and where I planned the teeth to be:
So the next appointment we went ahead and scanned the patient for the restoration.
Designed the final restorations. I split #8 into a zirconia abutment and veneering structure. Both Crowns were e.max CAD V3 Impulse (had some left over before the introduction of MT)
Here was seat day yesterday:
The patient and I were both pretty happy with the final result... especially with how we started. After the first of the year we are going to reshape #10 and bond with composite and also restore #7 with a veneer to even out the color and shapes.
Now... 2 mistakes that I made on this case
- I made it very difficult from a color prospective milling an F.5 zirconia abutment (very white). I should have milled an F2 shade zirconia because it would have been profoundly easier to match the two teeth from a color prospective. The crowns were thin on the facial and #8 was clearly whiter than #9 due to the substrate underneath. I had to play around with resin cements (-3 value on #8 and +3 value on #9 were the final) to make this work. It was a pain in the neck.
- Since the implant was slightly lingual I had to create proper emergence on the facial by pushing on the tissue with the abutment. I over did it just a little bit and made the gingival crest slightly apical than where I would have wanted to be perfect. I did have a concavity there and maybe it will bounce back (this was immediate seat), but we will see. If not... no worries. Low lip line
Long story short... fun case , happy patient. Looking forward to finishing up the case next month
I have been doing all my single stage surgeries with custom healing abutments since Enamic became available. It has been a learning process and took some time to incorporate the digital workflow for the implant procedure. It takes us about 30 minute longer but saves more time from final Imaging. For posterior teeth I can make the final crown from the initial impression. For anteriors you have to evaluate to see if you need to re image. I posted this for discussion, I love this workflow. This custom healing abutment and crown had an emergence profile that I felt was too broad. Love to hear how others would shape the gingival portion.
There was a thread last week when Sam kept asking why not Feldspathic Porcelain for a Veneer or an anterior crown. For me personally, a lot of my decisions for block was a matter of very my comfort was, and not being familiar with the properties of other blocks. After going to Level 4 a few years ago, it was the first time I really saw Sam and Mike's affinity for VITA blocks. As we can all attest to, Mike's case make us want to cry sometimes because they are so good and makes me wonder what type of "hack shop" I run :)
Everyday I get better and better with understanding block selection for certain cases, but as I use VITA Mark II or VITA Triluxe more, I really like the esthetic properities of the materials and obviously being able to see color straight out of the mill is a huge benefit too.
Here are a few cases that I have done to showcase the power of the block. Obviously, VITA isn't the strongest material we have so if strength is a major concern for a cause, I would revert back to blocks like Celtra Duo or eMax.
This patient hated the spaces at the gingival 1/3rd of her lower anteriors. She is post ortho and I inherited the case after the ortho was already finished. We discussed the challenges of closing the spaces completely, and I wanted to prep them as conservative as possible but essentially they are crown preps because I had to prep interproximally to the lingual aspect so far to help with the space closure gingivally, and was only able to preserve the lingual cingulum of the lower teeth. Funny how pics show all your flaws, but I swear I rounded all the preps with a 3M finishing disc and they still look to sharp in a lot of areas. Fortunately, the restorations all milled and seated beautifully. This was a case I did same day. I have 1 mill unit and used Biojaw to help with the design of the crowns, and the patient was in the chair for about 4 hours.
Day of Pics:
1 month Post op:
Ironically I didn't stain and glaze the case. I tried the crowns in and polished them slightly but when I tried them in, she was so happy that she didn't want me to do a thing. So I polished them completely and bonded them using a total etch technique with Variolink Esthetic Neutral. The blocks were VITA Triluxe 1M2. I still am pretty amazed that we have materials that can come out of the mill, be polished and bonded and look like this.
Patient needed veneers on #8 and 9. Again I used VITA Triluxe (A1C) and bonded used total etch technique with Variolink Esthetic Neutral. This was one of my first cases with using GC Lustre Paste. I hate the texture. Part of the learning curve of using Lustre Paste. It really is apparent in the photos but the patient loved them so much that she didn't want me to touch them. One of these days I will find an excuse to polish this veneers more :)
Day of pic:
1 week post op: Sorry about the articulating paper mark...ugh
This was a really frustrating case. Patient hated her crown because of the dark grey margins and asked if I could improve it. I tried and failed with emax LT. Ended up sending her home and milled out a few different blocks and the one that looked the best was VITA Mark II A1. I did bond this with a Variolink Esthetic Light. This was stained and glazed with Lustre Paste. The whole reason I chose to even mill the crown in Mark II was because I was reading about a veneer case that Mike had done where he was able to conservatively prep for a veneer and block out a reasonably dark prep. So I thought, what the heck, I'll try it. Not perfect but the patient was pretty happy.
Color of core after PFM removed:
Thanks for the update. Not too lengthy. Very much appreciated.