Optimizing Anterior Esthetics: Combining Porcelain snd Periodontal Considerations in Single- Tooth Replacement: A Case Report F: or many years, the only way to permanently replace a single missing tooth with adjacent abut- mene teeth was with a fixed fall- or partial coverage bridge. This treat ment method is generally accepted as the standard of care in dentiscry and exhibits durability, long-term function, and strength. Then came the age of the traditional “Maryland bridge,” a more conservative treat- ment modality to replace a missing tooth when compared to a conven tional porcelain-fused-to-metal or gold bridge. Limitations of the Maryland bridge include less than. optimum esthetics, owing to the tunderlying metal substructure radi- ating through the abutment teeth, and difficulty of bonding to metal. Debonding has frequently occurred at the metal-cesin interface, because of inadequate micromechanical retention of the resin cements ta the oxide on the erched metal framework. Recent improvements in adhesive technology have reduced the incidence of debonding associated with the metal-tooth, interface.! The modified Maryland bridge, or fiber-reiniorced composite resin bridge, was developed asa way to eliminate some of the draw backs of the traditional Maryland bridge. The addition of an ultrahigh molecular weight polyethylene fiber (Ribbond, Seattle, Washington) to the rooth-colored composite matrix feamewock has significantly improved the strength of the bridge against the forces of occlusion. A porcelain veneer is bonded to the seinforced composite framework to achieve the desired esthetics Significant advances in dental implant therapy have provided another avenue for clinicians and patients wherehy a single implant fixture is surgically placed then restored without involving the adja- cent teeth, As long as there is ede- uate pontic space for the dental implant, this treatment modality represents the ideal way to help maintain and preserve the alveolar bone in the extraction site as well 28 to eliminate the need to use the adjacent or abutment teeth for sup port of the replacement roth, id pC Sait Ma por The focus of this article is che use of an ultraconservative, lingually bonded In-Ceram' (Vident, Baldwin Park, California) bridge in the single- tooth replacement of an upper right Jateral incisor. This technique was combined with periodontal consid- erations to create an esthetic ovate ponte site, esulting in an optimal esthetic final result MATERIAL SELECTION In-Ceram was considered the restorative material of choice for several reesons: unprecedented flexural strength (for an all-ceramic system}, optimal marginal fit, three dimensional color and translucency. no metal show-through, excellent esthetics and periodontal tissue biocompatibility, and no thermal sensitivity? A 24-year-old woman presented oon an after-hours emergency basis because of a broken acrilic stayplace replacing her upper right lateral incisor (Figute 1). As a result, the patient was extremely concernedJOURNAL OF ESTHETIC DENTISTE Optimizing Anterior Esthetics: Combining Porvelain and Periodontal Considerations in Single-Tooth Replacement: A Case Report Figure 12. Final smile long-term reliability. In-Ceram’s proven strength made ie che material ei choice.” Third, the natural beauty of the abut teeth was of particalar concern. If these tooth were prepared for full-coverage restorations, would the laboratory be able to duplicate their appearance, to match the contralateral teeth? A more conser. vative and tooth-colored restoration, which was adhered to the lingual surface of the aburment teeth, was necessary to preserve the natural color and estherics of these teeth This way, only the pontic restoration would have 10 be duplicated co the contralateral tooth. Fourth, the gingival contours of the pontic site were of concern, because ifthe pont site was not recontoured prior to the final pontic restoration, a saddle-type pontic would have ta be placed, to give the appearan of a natural emergence profile from the gingiva. A saddle-type pontic design would be less ideal, not onl from 2 hygienic standpoint but also from an esthetic standpoint, as compared to an ovate pontic site and design Fifth, the properties of the adhesive agent to securely bond the partial- coverage restoration to the abutment teeth were analyzed prior to the preparation stage of the restorative procedure. If the restoration was to succeed long-term, the preparation design was critical 10 provide maxi- mum surface area for retention and adhesion by the luting agent. Because all these concerns were oveluated ia advance, the final result demonstrates outstanding esthetics and a mirror-image effect to the patient's upper left lateral Figure 13. Final appearance of a bappy patient,CONCLUSION ‘With the ever increasing demands from patients for natural and true torlife esthetic restorations, i is imperative that today’s clinician be able to offer treatment options hhased on the mast current technal- ogy available. With numerous cos- metic restorarive systems presently in use, itis even more important that dentists and laboratory techni- cians both have a thorough under- standing of the various systems before they are actually incorporated into a patient’ treatment plan, Careful pre-treatment analysis of the patient's condition is mandatory to achieve the optimal esthetic result. This is especially true when the area of concern isin the anterior segment of the mouth—the most visible to the patient. The preceding article describes the detailed progression of a multifac- eted, highly esthetic, and material- selective case. When all factors influencing the desieed outcome are initially addressed and systematically treated, the end result will be most rewarding, enabling the patient to enjoy life with confidence because of the improved smile FINAL NOTES Most recently, the introduction of the ‘Iargis-Vectris™ system |Ivoclar North America, Amherst, New York} in the dental marketplace has dramatically improved the techno- logical advances in the areas of con seevative, acid-etched, and resin: bonded nonmetallic bridges and further expanded the options for patients when it comes to single tooth or multiple-reeth replacement. Although the use of In-Ceram in the Maryland-type bridge has not been clinically proven successful over the long-tesm, both the and the patient agreed it was the best esthetic restorative option at the time, given the complexity of the patient’ existing dental condition and the limitations of the thor vailable restorative nuaterials. ACKNOWLEDGMENT The author thanks Shawna Trimble For her patience and cooperation in this restorative procedure. REFERENCES 1 Rade GM, Beyond de Marna Onde ANCD yond 1318-22 Sorensen JA, Toros TH, Kaug SK, Avera SP Marginal fctiy of cera crosem tet diferent ramen.) Dat Bos 1990; 379-285 3. Flas. Onatepontis to east intoron tel pupil, Presented at the American fy Coxmetic Demis 12th “nal Siete Sevan Sen Digs, Ci Mav 1-5 1996, “4 Dickerson A canserate altraate 12 rgletnh rplacemens thesar Tse-up, Prac Peiont Sev Dost Garker D. Nh edentulous ig in fsed prosthnionts. Compendia (981: Brot 6 Miller Mw. Aesthetic anterior recous mbined Bent 19055 535-4 7. Hoveard NY, The sist ade chile lenge the vestaration ofa stale contr incisor, AACD (199%; Winter2-32, 5S Clondane RA. Dental ceramic restorative tons, Comper 1988; 17 ti eta we ial Ci a Zaher 16, Ferrers M, Cagtaca MC, Suet G. Alt Fea eed torsion peclienary ‘Shucal evaluation, Prat Pridont Gestber Dent 1806s. 11, Levy I, DanelX. Work ‘Ceram porcelain sytem Bente 1970;48 12, Kern M, Thompson VP. Honding 0 glase methods and tare drabiiry. | Prasthot Don 1995; 72400299. Repri for ¥, Howard, DDS, 18013 WS Mavene Bld. Suite 11, Son Marens, CA 9268 (©1997 Decker Peridi VOLUMES NUMBER 305Optimizing Anterior Estheties; Combining Poreelain and Periodontal Gonsiderations in Single-Tooth Replacement \ Case Report The options included: 1. Single implant fixture and crown to replace her upper right lateral incisoi Composite resin marrix-poly- ct er reinforced Maryland-type bridge from her upper right cuspid to the right central incisor with an overlying porcelain veneer bonded over the matrix pontic area. 3, Am all-ceramic Maryland-type bridge from her upper right cus: pid the right central incisor with che ceramic framework and pontic tooth fabricated together as aone: ce structure, about her appearance and wanted a anent solution to her “temporary” stayplate. The patient stated that she was scheduled to ain-fused to-metal bridge from her upper ri ave a conventional por prepared in 3 days, at a local dental clinic. Because she could not contact pid to her right central incisor the clinic for this after-hours emet gency, her husband had contacted my office. Affer repairing the stay plate (Figure 2), several options for a more conservative and esthetic form of treatment were discuss with the patient based on an evalu= ation of her smile (Figure 3) and the ‘occlusal relationships present in her mouth (Figure 4 vpearance after stayplate repaireFigure 3. Close Farther analysis of the pontic sice revealed a less than ideal gingival form (Figure 5), which if not would result in a pontic swith a “saddle eype" design on the underside of the pontic where it contacts the gingival ridge. The pre- fected gingival pontic design to hac- moniously blend esthetics, optimal access for oral hygiene, and peri- odontal health is the ovate pontic design. An esthetic gingival disharmony was also noted on the facial marginal gingiva of her upper right centeal incisor compared 10 her upper left central incisor. This was due to a concavity in the root surface ar the mesiofacial aspecr, resulting in a slight overgrowth and asymmetry of tissue compared 10 her contralateral tooth. In addition, the patient also presented with of patients existing snail approximately 4 mm of facial recession on her upper right cuspid, which was asymptomatic to sensi tivity. This area of recession, if left untreated, would severely compro- mise both the esthetics and sue- rounding periodontal health of her upper right cuspid if any type of full-coverage fixed bridge was fab ricated and placed for this restora- tive treatment. After discussing the treatment options with the patient and edu cating her regarding the advantages and disadvantages of each restora- tive procedure (as well as her previ- ovsly planned porcelain-fused-to- metal bridge}, a tecatment plan was desermined. The patient opted for the one-piece all-ceramic Maryland. type bridge in combination with electrosurgical periodontal zecon- touring to achieve an ovate gingivalFxgare S. Reg) abnormal gi pontic site and a resculpting of the facial gingiva on her upper right isor co harmonize with central her upper left central incisor. The patient did not want to have the gingival grafting procedure per- formed on her upper right caspid to optimize the overall esthetic out- come. The appearance of this tooth did noc bother or concern her at the time, hut she would consider the procedure at a later date. The gingi val appearance of her upper right central incisor was also not a con- cern to the patient, Her main con- cern was to permanently replace her lateral incisor as quickly as possible. The patient did not desire periodontal surgery for her upper right cuspid or dental implant surgery. She had experienced numerous endodontic and oral surgeries in an attempt to save her leteral al ridge form Optimizing Anterior Periodontal ( A Case Repart lateral incisor from eventual extrac: ned our” fromall the previous procedures. tion and was simply “bai The patient had expressed a strong desire to lighten her teeth prios to the final restoration. The inital phase of the patient's trearment consisted of the Fabrication of cas- tom bleaching trays from maxillary and mandibular alginate impressions The material selected to lighten or bleach the patient's teeth was LiferLike 10% (LifeeLike Dental Prodacts, Santa Barbara, California) The author has used this material with numerous patients, and the incidence of sensitivity or failure to lighten is less than 0.15%. The Patient was in ited to use the bleaching gel for a maximum of 3 hours per day according to the manufacturer's instructions. The ‘s condition illest heties: Combining Porvelain and ‘ousiderations in Single-‘Tooth Replacement desired level of bleaching or lighten ing was achieved in 2 weeks.” The patient was then scheduled for the periodontal aspect of her treatment PERIODONTAL PHASE OF THERAPY ‘After infileration with local a thestic, electrosurgical resculpting of the facial marginal gingiva on the upper right central incisor was achieved to match che upper left central incisor, Because of the extreme concavity at the mesio= facial aspect of the root structure con the upper right central incisor, she patient was informed thar singi val regrowth might occur and chat more definitive periodontal pr dures may be necessary at a later date to permanently correct the gingival disharmony.Prior to initiation of the ovare pontic site recontouring, the gingival- most height and position of the future pontic was located. Using a lear millimeter ruler, a line was drawn from the highest point of the facial gingiva on her upper left cus- pid to the same point of reference on the upper left central incisor The location of the highest point of the facial gingiva on her upper left lateral incisor was measured to this reference line and noted. The identi- cal line from her upper right cuspid to right central incisor was drawn. and the position of the facial gingiva of her upper left lateral incisor with respect to the line from the upper left central incisor to left cuspid was transferced to the patient's gingival tissue and marked by a periodontal probe punch. Since both the facial gingival height of the upper central incisors as well as the incisal ro ntocnamel junction (CEJ) length on both upper cuspids were the same, this point of reference served as a guide from which to begin the ovate pontic site recon- touring. The ovate pontie site was carefully recontoured with a large round electrosurgical tip, to achieve the ideal site form. Upon completion of the ovate pontic site, the under- side of the pontie on the patient's stayplate was modified wich a fast- setting acrylic to maintain the soft tissue ovate pontic morphology. Oral hygiene instructions were given to the patient and the azea was allowed to heal for 1 week. The final ovate pontic site seen in Figure 6 shows excellent healing and tissue response, with a relapse of the facial gingival form on the upper right central incisor, as expected. PREPARATION APPOINTMENT Initial shade selection, using the Vita Lamin Shade Guile (Vita Zahnfabrik, Bad Sackingen, Germany) was confirmed and color-mapping was performed so that the laboratory could reproduce the desired shade identical to her upper left laceral incisor, Local anesthetic was given for patient comfort and the lingual aspects of the upper right cuspid and central incisor were prepared with two dia- mond burs, No, 6878 and No. 6847, and one carbide bur, No. 1701. (Brasseler, Savannah, Georgia). The minimal thickness of the framework coping for In-Ceram is approximately 0.5 mm and the pontic joints should be as thick as possible.’ Because of the opposing occlusion contact scheme, as well as the thickness of the enamel on both teeth, the preparation depths achieved were 125 mm to 1.50 mm, to provide for maximum strength, ‘The margins were prepared as a shoulder with rounded axial-cervical line angles. All preparation margins were kept suprogingival and the lingual aspect of each tooth was prepared, to maximize the pontic joint strength and thickness. The interproximal facial preparation margins on either side of the pontic space were kepe to just short of the ideal contact area, This would allow the interproximal contact areas of the final restoration to con- act the adjacent abutment teeth at the ideal position, not coo facial or too lingual. The final preparations are shown in Figure 7. Final impressions were taken using a polyether material Impregum, Figure 6, Close-up view of the recontoured ovate pontic site.Optimizing Anterior Esthetic Combining Porcelain and Periodontal Considerations in Single-Tooth Replacement A Case Report Figure 7. Occlus: Espe-America, Norristown, Pennsylyania). A lower alginate impression was taken for the oppos- ing model, and a bite registration was taken (Regisil PB, Dentsply Caulk, Milford, Delaware). No temporizarion was necessary since the entire preparation was kept within the enamel structure, The patient was comiortable and experi enced no postoperative discomfort. LABORATORY FABRICATION The In-Ceram fabrication is a two- stage technique, The firse step uses an extremely fine-grained aluminum oxide powder suspension in a slip. casting procedure to create a core material for crowns and fixed bridges. The powder slip suspension is applied co the plaster dic, which absorbs the moisture immediately, causing an almost dry and densely packed material l the die. This layer can be modeled with 2 scalpel to the required form, During sintering, the die shrinks er to form on 10 of the final bridge prepa and can be removed in one picee from the substructure. Since sintet- ing of the slip-casting aluminum has only been initiated during firing ie., the particles have just began to stick lightly together), shrinkage of the substructure is virtually impos- sible. This allows perfect fit of the substructure onto the master die that remains intact on further firing? The final substructure ifeamework core) is seen in Figure 8. The actual clinical try-in of the substructure is seen in Figure 9. The marginal is then checked. The second step is the infiltration firing step. The outer surfaces of the porous, sintered substructice are coated with a shitty of glass powder and fired at 1100°C. By means of this infiltration firing process, the sintered substructure is infused with molten glass, which results in a fine-grained substructure ‘with an optimal glass matrix, Crack propagation is limited, owing to the densely stacked aluminum particles. The different thermal expansion coefficients of glass and aluminum serve ro increase the strength and limit crack propagation. Thus, this homogenous, bubble-free substruc: ture is responsible for the high sta bility and elevated bond stcength af the restoration compared to other currently used dental ceramics." Any surplus glass particles remain- ing on the substructure after the infiltration firing are removed by grinding or ai-abrasion.” After the coping has been completed and the marginal integrity clinically verified, the porcelain application is initiated. For full-coverage restora- tions, the marginal fit is achieved ducing the first firing and is retained throughout the entire procedure, despite repeated firings."* The retention of the marginal fit is due to the fact that the subsequent porcelain firings are carried out 200°C below the temperarare of che initial fring.” Vita-Dur-u® porcelain was used to recreate the desired esthetics necessary for the final restoration of her upper right atoral incisor bur was not applied to the abutment “wings” since the ideal shape and thickness of the abatment wings was achieved with the framework core material, Upon completion of the porcelain appli cation, the final restoranion was ready for clinical evaluation t» assess overall esthetics, contonrs, eclusion, and symmetey to the contralateral side (Figure 10CEMENTATION PROCEDURE The manufacturer recommends cither a sine phosphate coment o- a glass ionomer cement as a luting agent for In-Ceram crowns and bridges. Panavia® (J. Morita USAKuraray, Tustin, California), a seli-curing resin cement, has be shown to bond well with In- which cannot be easily etc! especially with inlay and partia coverage restorations.’ For the cementation prose: of this partial coverage restoration, Panavia was selected as the cement of choice because ofits exceptional strength and adhesive properties Alter the clinical try-in was com- pleted, the abutment wings of the In-Ceram bridge were rinsed with ried, then etched for 60 seconds with 35% phosphoric acid (Ultraetch, Ultradent Products, South Jo pose of the etchant was to clean the fan, Utah). The main pu: inernal surface of the wings for eventual adhesion to the tooth structure. The wings were then rinsed and air-dried, and the bridge set aside. Rubber dam isolation of the abutment teeth was placed, and the prepa pumiced with a medium-g pumice and water mixture. The h were rinsed, air-dried, then rched for 30 ed tooth surfaces wi seconds with 35% Figiee 8 A, Facial rework. Cyl phosphoric acid, then rinsed again with water for 60 seconds and air-dried. The ma etchant on the prepared tooth sur ee of the faces was to remove any surfac contaminants that might interfere with the adhesion of the Panavia cement to the In-Ceram bridge ‘The Panavia cement was mixed ording to the manufac instructions and applied to the nd internal surface of the wings d teeth surfaces, The was then placed into position and excess cement removed with a rubbertipped instrument (Gum Stimulators .0. Butler, Inc., Chicago, Illinois). Since af the In Coram Fingaligure 9. A, Facial view of the In-Ceram framework at the tryin stage. Note how the pontic extends from the ie. B, Lingual views Panavia will not ser in the presence of oxygen, Oxyguard (included in the Panavia kit) was applied to the restoration macgins for the cement co set completely. After the appro: priate setting time, the Oxyguard and rubber dam were removed. The ‘occlusion, laterotrusive, and pro- trusive movements were checked and adjusted. Final finishing in the traditional manner was completed using fine carbide and diamond fin- ishing burs, then porcelain polish ing cups and points Optimizing Anterior Estheties: Combining Porcelain and Periodontal Considerations in A Case Report The final restoration, shown in Figure 11, demonstrates excellent esthetic harmony as well as uniform balance and symmetry to the contra. lateral side, The perfect emergence profile of the pontie restoration from the gingival ridge is a direct result of the proper use of the ovate pontic and sie design as previously discussed. The patient was extremely pleased with her new smile (Figure 12) and with the ultraconservative nature of her treatment, compared to what she might have had with a inglo-Tooth Replacement rate pomtic conventional porcelain-fused-to- ‘metal bridge. Her facial appearance clearly expressed her happiness with this highly advanced esthetic procedure (Figure 13) Discussion Achieving optimal esthetics in any treatment modality necessitates the clinician's awareness of many aspects. This is even more apparent when the area of concern isin the anterior segment of the mouth. Not only is it importane chac she clinicianhave a diverse knowledge of the dental materials and products cur- rently available, but that he or she be able to properly use them for the particular restorative situation. ‘The restorative case presented here illustrates several areas of concern that were addressed prior to begin ning the actual restorative proce dure, First, che high smile line and the existing facial recession on the upper tight cuspid were evaluated. Clinicians desire that patients com: plete all of the recommended treat iment, tb ensure the most optimal Figure 11 Final close-up right lateral view after cemen gongiva C, Final ling A, Final direct facial view after cementation, demo) cad result, expecially when it involves the anterior teeth and the smile that will follow. Buc this expectation is not always met, particularly when financial consid: ccations, time consteaiats, and patient likes and dislikes become determining and often limiting fac- tors; these fectors can often compro- mise an ideal outcome that is en sioned by the restorative dentist. This is reality, and simply stated, notall patients want what the prac- titioner wants them to have, even if iv is for their best long-term benefit. Because this patient did not want co tim, shouting excellent es! view after cententatton. ating mitrorimage effect undertake « periodontal graft on her upper right cuspid prior to the bridge preparation, a modified, more conservative, and esthetically challenging bridge was necessary £0 achieve the best overall result Second, the strength of the subse- quent bridge is an important con- cera, especially where the opposing dentition occludes and functions: against it. An all-cecamic material that possesses herter strength and durability than conventional porcelain-fused-to-metal restora- sions way necessary to provide the contralateral incisor. B, tes and a harmonious emergence profile from the