Maxillary anterior crowns provide an exciting challenge to our artistic and technical abilities and call upon our knowledgeof smile design principles of proportion, symmetry, harmony and tooth morphology. Smile rejuvenation can positively impact a patient’s selfesteem and emotional health through improved appearance. 9
Excellent soft tissue health and correct tooth contours and emergence profiles are just as important as the actual colour of the new restoration/adjacent teeth. 10,11 This article will describe a case where Procera™ ceramic crowns were utilized to replace two long standing PBM’s which demonstrated poor aesthetics and chronic biologic width violation, and corrected tooth size/jaw size discrepancies. Long term provisionalization and a ‘closed flap’ crown lengthening were employed to reestablish soft tissue health, verify stability at the soft tissue/teeth preparation marginal interface and idealize esthetics and phonetics. A source of chronic inflammation was corrected, and helped eliminate a potential factor in the development of many inflammatory mediated diseases. 12,13
CASE REPORT
The patient is a 31-year-old who, along with his family, has been a long-time patient in the author’s practice. He works in the financial sector, and as such, has frequent dealings with the public. His previous dental care has been limited to routine prophylaxis and minor restorative care. He is in good general health, and is not taking any medications. He is quite self conscious about his appearance and smile. Recently, he decided to cosmetically enhance the appearance of his central incisors, which in his words were “yellow, bulky, and my gums are always bleeding and sore around the crowns” (Figs. 1-7). Teeth #11 and 21 have pre-existing PBM’s, approximately 13 years old. The crowns are bulky and over contoured in the gingival third. The crowns were placed following trauma to #11 (with pulpal involvement) and #21. Tooth #11 was endodontically treated, and a carbon fibre post placed in the canal (Synca).
In January 2002, the patient presented with a fistula in the #11 area, and was referred to an Endodontist for evaluation. Endodontic surgery was performed to correct a vertical root fracture in the apical region, and sealed with Super EBA filling material. Some scarring is noted in the surrounding gingival tissues, as a result of the apical surgery flap and suturing procedures. The gingiva adjacent to the crowns is hyperaemic and chronically in-f lamed. Bleed ing on minimal probing is evident.
Despite compliance with our hygienist’s personalized soft tissue program involving three month scaling, oral hygiene instruction, Sonicare™ electric tooth brush and take home chlorhexidine rinses (Peridex Col gate Palmolive), the chronic inflammation
and bleeding around the crowns has persisted, while elsewhere his generalized gingivitis has improved. His periodontal condition overall is good, with no pockets greater than 3mm in the anterior segments or 4mm in the posterior segments. The patient’s Biotype is thinner and somewhat friable. An endodontic re-evaluation in 2006 found #11 asymptomatic with evidence of healing in the periapical area, and #21 tested vital. Re current caries is noted around the margins of #11 and #21. Evalu ation of the TMJ’s demonstrates normal ranges of opening/closing, with no movement deviations or joint sounds . The joints are symptom free under bi-manual load testing. 14 After numerous consultations with the patient, the decision was made to replace his maxillary central incisor PBM crowns with all ceramic crowns.
PRE-OPERATIVE AND LABORATORY STEPS
Preoperative study models were taken (two sets), along with centric relation records and a face-bow transfer. Protrusive and right and left lateral check bites were obtained to program the articulator with the correct condylar settings. These casts were poured up and mounted in CR14 on a Denar Combi-semi-adjustable articulator.
A trial tooth preparation/mock-up/ wax-up performed on the preop casts indicated that the centrals could be fabricated to appear esthetic. Using pre-op stone casts, prepped model duplicate casts and a diagnostic wax-up, it was explained to the patient that endodontic treatment could be required after correcting #21’s labial position, and ideally should be prophylactically done. The patient opted instead to delay endodontic treatment to the future, if indicated, and understood the risks of damage to the new crown following endodontic access. The patient would be provisionalized in temporaries until soft tissue health and stability, possible endodontic concerns, and esthetics were verified, and any adjustments made to the provisionals would be communicated to the laboratory, prior to the final restorations being fabricated. The patient played an active role in selecting his new smile through the pre-op use of various commercial smile guides, and before/after cases of the author’s work and a diagnostic wax-up on stone casts, and input during the preparation and provisionalization phases of treatment.
OPERATIVE AND LABORATORY STEPS
Teeth Preparation, Temporiza tion, Laboratory steps Following local anaesthetic administration, a triple tray polyvinyl impression (Express putty and light body polyvinyl siloxane 3M ESPE) was taken. The method employed here was that the existing PBM’s would be intraorally recontoured to a more ideal form and then another triple tray impression would be taken of the ‘new’ crown shapes, if the porcelain did not fracture off during the process. If the porcelain fractured, then the first triple tray impression could be used for provisional fabrication, and the excess labial bulk reduced in the Bis-Acryl acyrlic. Preparing the pre-existing crowns, under copious water spray, is faster than refining the Bis-Acryl temporary Crown and Bridge materials, which have a tendency to be gouge, chip or be damaged during any extra-oral margin finishing and polishing steps (in this author’s experience). Another approach which could have been employed would have been to fabricate a polyvinyl stent of the diagnostic wax-up. The porcelain did not fracture during the reshaping process, so another triple tray impression was taken of the ‘newly’ modified existing PBM’s. The PBM’s on #11, #21 were then removed by creating a midfacial groove through the porcelain and metal coping, to the cement line, using a S. S. White #1 crown removal bur, under copious water irrigation (Figs. 8-9).
Following PFM removal, the existing crown preparations were re-prepared using carbide and diamond burs in a Kavo electric handpiece, according to preparation guidelines for Procera™ crowns (Fig. 10). Core build -ups, as needed, were completed on the teeth using Scotchbond Multipurpose adhesive (3M ESPE)) and Grandio composite resin (VOCO). The teeth were dried and a thin mixture of Provilink (Ivoclar) was applied to the prepared teeth, about 1mm shy of the margins, with a small nylon bristle brush. Using the polyvinyl triple tray guide previously fabricated (Fig. 11), Acu-Flow Temp orary Crown and Bridge material (Rainbow Specialty + Health products Markham Ontario) was injected into the guide, taking care not to incorporate any air bubbles, and the stent was seated over the prepared teeth, the patient guided into centric occlusion and the material allowed to set for 120 seconds. Once polymerization was complete, the triple tray was removed. The temporary crowns were trimmed of any flash and the margins evaluated, under magnification, while they remained seated on the prepared teeth. As final impressioning was going to be delayed until soft tissue health was obtained, (with possible revision of the final crown margins), the finishing steps could be done with the temporary crowns seated on the teeth. The temporary crowns were splinted together to increase their retention. The interproximal embrasur
es were slightly opened up to allow for oral hygiene procedures. A ‘closed-flap’ technique (Fig. 12) was employed to correct possible biologic width violations thought to be present. Using a 832-14 bur (Brasseler 7301-A Hom Lay Wong Kit) under water spray and a Zekrya gingival protector (Vic Pollard Dia monds Inc.) and a fine periodontal probe with a small ball at the tip, the attachment levels were probed and adjusted to be 1mm from the free gingival margin and interproximally 2-3mm from the free gingival margin, following the more pronounced osseous scallop noted in the anterior regions. 15 The patient was advised that following tissue healing and remodeling, the temporary crowns might need to be remade, and the crown margins revised. The occlusion was checked, and instructions given in oral hygiene, and the patient dismissed. Chlorhex idine rinse (Peridex Colgate Palmolive) was given to the patient, and daily rinsing advised.
The patient was re-appointed the following week, to evaluate soft tissue healing, phonetics and slightly further refine the shape of the temporary crowns for aesthetics. The patient was seen at 2, 4, 8 weeks, for soft tissue evaluation, and good healing and tissue response was noted (Figs. 13-15).The chair side fabricated temporary crowns appeared to be holding up well after two months, with good marginal sealing and adaptation noted. Slight discolouration and loss of surface glaze were noted. Alginate impressions of the provisional crowns were now taken, and models of the provisionals were set aside with the patient’s other records. The patient was unexpectedly transferred to an out of town work assignment for a four month term. We could not appoint him to fabricate lab made heat and pressure treated provisionals before his departure. When he returned four months later, the temporary crowns were still intact and the tissue appeared healthy (Fig. 16), and ready for the restorative phase. The patient was appointed, and following local anaesthetic administration, the temporaries were re moved. The tooth preparations were cleaned using a rubber prophy cup and plain pumice, being careful not to hit the gingiva and cause any bleeding. Retraction cord (OO Ultradent) was carefully placed and a polyvinyl impression taken in a stock metal tray (Figs. 17 & 18), as well as centric relation records. The impression was rinsed and dried and marginal detail evaluated under magnification. The temporary crowns were recemented
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with Provilink (Ivo clar), and excess cement was cleared away. The laboratory was provided with detailed instructions regarding the desired shade, shape, texture etc., and asked to copy the temporary crowns labial shape and lingual contour. 16-18 Procera™ crowns were selected, as the ceramic system of choice.
CASE INSPECTION, CEMENTATION OF PFM’S
The Procera™ crowns were returned from the dental laboratory. The crowns were examined on an uncut solid model for fit and contacts (Fig. 19). Ten days later the patient was reappointed.
Local anaesthesia was administered and the temporaries removed by tapping them off with a crown removing instrument. The teeth were cleaned with plain pumice and water in a rubber prophy cup, being careful not to cause gingival bleeding. Cotton rolls were used to isolate the lips and keep the field dry. The
crowns were tried in both individually and together to assess marginal fit and contacts. The patient previewed and approved the shape and shade of the crowns. The crowns were removed, and phosphoric acid was applied to the intaglio surfaces
www.oralhealthjournal.com for ten seconds to clean the surface of any contaminants. A thin layer of unfilled resin was applied to the inner surfaces, and the crowns placed in a light proof container. Teflon plumber’s tape (a dead soft matrix material available in any hardware store), was placed and adapted to isolate the teeth from the lateral incisors. The teeth were etched with phosphoric acid for twenty seconds, rinsed completely and air dried (Fig. 20).
The etch pattern was evaluated to determine where any dentin was exposed. Tubilcid Red was used to rewet the surface as per a wet bonding protocol, and excess removed with a dry micro-brush. Dentin bonding primer (Scotch bond 3M ESPE) was applied to any exposed dentin and light cured, as per directions. The overhead operatory light was turned down to minimize the possibility of premature curing. A thin coating of unfilled resin was applied to the tooth preparations. The crowns were removed from the light protective container and loaded with the luting cement (Duel Cure Ivoclar). The crowns were carefully seated on the teeth and held in place to prevent the crowns from lifting off the teeth and trapping/ incorporating any air bubbles at the margins. Excess resin was removed with a fine brush wetted with unfilled resin. Correct alignment and complete seating was checked and the crowns were tacked in place using the curing light for five seconds (Fig. 21) to ‘gel’ the luting cement. The alignment was rechecked from all angles and confirmed. The crowns were light cured for forty seconds both buccally and lingually. Gylcerin gel was applied to all surfaces to eliminate the air inhibition layer, and final curing was done both facially and lingually for sixty more seconds. 19
Interproximal areas were cleared using a Ceri-saw (Denmat), fine grit Compo-strips, and dental floss, a #12 Bard Parker blade was used together with a Zekrya gingival protector (Vic Pollard Diamonds Inc.), to remove excess resin in the cervical third, and the crown/tooth interface examined under magnification for any overhangs, flash or marginal voids. Occlusion, which could not be fully verified prior to cementation, was now evaluated, and carefully adjusted as required. The lingual surfaces were finished using a fine football shaped porcelain finishing diamond, with copious water spray, and a light intermittent touch, and the occlusion verified in both centric relation and lateral and protrusive excursions. Impressions were taken for the fabrication of a night-guard appliance. Post-oper ative care instructions were reviewed, and the patient was reappointed in one week for recon firmation of cement cleanup, oral hygiene home care and occlusal adjustments, if required, and delivery of the night guard. Final photos were taken eight weeks post operatively.
DISCUSSION
Aesthetic dentistry requires that the dentist understand the form, texture, and color of natural teeth, and how teeth relate to other facial elements and then translate this information into the fabrication of the final restorations. “Dento-Facial esthetics” has been used to describe the inter-relationship between the face, lips, gingival and teeth in obtaining an overall esthetic result. 20-27
The apparent height to width ratios can be managed to some degree by the dental technician changing/controlling ref lective and deflective surfaces. It is also possible to increase the length of a tooth to a limited degree by extending the tooth gingivally when combined with a crown lengthening procedure, and incisally until it interferes with the patient’s envelope of function. 14 These upper limits within the masticatory envelope of function can and should be worked out in the provisionals, and this information transferred to the lab oratory. 14,28-30
If the teeth are rotated or crowded (as in the case presented), or the roots are misaligned, the match can be more challenging because the ideal contours of the porcelain must, by necessity, be transpositioned into the poorly aligned contours of the malpositioned teeth. Some of our colour matching illusions stem not just from matching a colour, but also from where the colour reflects light. Just by changing the position or contour of a tooth it is sometimes possible to alter the a
ppearance of a colour. Sometimes it is necessary to alter the colour of a tooth to match its position in order to change how that colour is perceived by the eye and then interpreted by the brain. Because of our perceptions, brighter teeth will generally appear to be larger and closer. 31 In addition, the technician’s control of reflective and deflective surfaces during the fabrication process can create illusions (up to a certain degree) of ideal tooth forms that follow the established Golden Proportions of dental-Facial esthetics. 32
Procera™ ceramic crowns consist of a coping made of densely sintered pure aluminum oxide, with veneering porcelain over it. Procera™ (Nobel Biocare, Sweden) crowns are fabricated using CAD/CAM technology. The sintering process creates a dense coping demonstrating excellent marginal fit and flexural and compressive values well above other all-ceramic systems such as Empress (Ivoclar) or In-Ceram. 33 The firing temperature of the aluminum oxide core is well above the firing temperature of the veneering porcelain, and as a result, the accurate fit of the copings is not affected by repeated firings as the overlying veneering ceramic is stacked.
Although the sintered aluminum oxide coping is dense, it still permits some light transmission/ translucency for increased aesthetics (unlike traditional Porcelain Fused to Metal crowns). These optical properties allow the clinician the ability to mask dark dentinal stains, amalgam buildups and metallic post and cores, without the need for subopaquers Cementation can be accomplished with a variety of luting agents such as Zinc Phosphate cement, resin cements, or glass ionomer cements. 3436
Advantages f ‘closed flap’ crown lengthening include the lack of gingival scarring as no flap is elevated, or sutures placed — an important consideration in some cosmetic cases with a lot of gingival display (in the case discussed
here, some scarring was already present from a previous endodontic surgery). Risks of performing a ‘closed flap’ crown lengthening include risk of damage to the root surface and pulp tissue, difficulty in distinguishing between bone and root surface cementum and dentin. As well the lack of direct visualization can prevent the proper anatomical dimensions from being established to maintain tissue position and/or correct biologic width violations. 37 It was explained to the patient that a ‘closed flap’ procedure could require revision, if insufficient bone was removed
and a biologic width violation persisted) or that the interproximal contact points on the crowns might need to be apically repositioned to develop, support and maintain a papilla if too much bone was removed, 3840 which could alter the esthetics of the tooth mold (tending to a more square vs. tapered shape).
Following crown lengthening procedures, a minimum of six to eight weeks must be given for the periodontal complex to heal, remodel and mature. However; for many patients this amount of healing time is insufficient and five to six months is recommended, with some cases taking as long as three years to achieve soft tissue stability. 4143 Kois describes aspects of periodontal architecture which play roles in determining margin placement. There is considerably more osseous scallop in the anterior region, which progressively flattens out as it heads posteriorly. This follows the greater scallop of the cementoenamal junctions of anterior vs. posterior teeth. Biologic variations within the population exist, whereby while most people have an average of 3mm from the osseous crest to the apical portion of the free gingival margin, some have more than 3mm (termed ‘low crest’) and some less than 3mm (termed ‘highcrest’). Which ever category a patient falls into appears to be consistent throughout his/her oral cavity. ‘High-Crest situations pose a much higher risk of violating the biologic width, during crown margin placement, which results in inflamed and cyanotic tissues. ‘Low-Crest’ situations, in contrast, result in gingival recession on the facial, and the dreaded ‘dark triangle’ situation when interproximal papillae are lost. Supra-gingival margin placement is preferred to avoid inadvertent biologic width violations.
In the event that crown margins need to placed subgingivally, it is important for the clinician to first determine whether the situation is ‘normal crest’, ‘low crests’, or ‘high crest’. ‘High crest’ situations typically require osseous apical repositioning, in conjunction with crown margin preparation to convert the situation to a ‘normal crest’ with correct connective tissue and epithelial attachment levels values. ‘Low crest’ situations typically require a gingivectomy (prior to, or simultaneously with the crown preparation) reduce the excess free gingival tissues, and reduce the risk of post-insertion gingival recessions.
Recent literature has been supportive of a link between periodontal disease and a host of systemic diseases such as Coronary Heart Disease, Stroke, Type Two Insulin Dependant diabetes and Arthritis. 44-45 While periodontal disease is multi-factorial (with bacterial, genetic, nutritional and environmental co-factors), it is often a site specific iatrogenic problem, such as that caused by dental work violating the biologic width, or open contacts interproximally. It is proposed that inflammatory mediators can spread systemically, and play a role in triggering inflammatory mediated diseases. The quality of our restorative work can play a role in initiating, or helping prevent oral inflammatory triggers, and as such, the dentist and hygienist can play an important role in disease prevention.
A debate continues within the profession as to which causative agent is primarily to blame when an adverse gingival response is noted around a crown. Most have argued that the culprit is poor marginal adaptation and fit, overcontour in the gingival third preventing correct food deflection and/or gingival stimulation, and sub-gingival margin placements which encroach on the biologic width relationship. Some have argued that negative soft tissue changes are due to the metals used in the crown copings. Crowns with correct contour and emergence profile, combined with minimal well sealed margins and respecting the biologic width relationship, demonstrate the greatest longevity and least soft tissue irritations (either recession, or hyperemeic/hyperplastic changes), regardless of whether the crowns are ceramic or metal based in nature). If metal based crowns are prescribed, one should select the higher noble metal alloy formulations and avoid base metal alloys which have a demonstrated sensitivity in a percentage of the population, as a means of limiting a possible causative agent in adverse gingival responses around crowns. 46-48 The tissue response to a crown is probably multi factored, involving genetic factors such as one’s gingival biotype, bacterial flora, nutritional factors, the materials used in the fabrication process, oral hygiene and host response to various environmental and psychological stresses, crown contour and margin fidelity and margin location as it applies to the biologic width.
CONCLUSION
A case was presented utilizing Procera™ porcelain crowns to replace faulty PBM’s and achieve an esthetic solution involving both maxillary central incisors and their surrounding gingival tissues (Figs. 22-31). Long term provisionalization should be employed when concerns exist as to the initial health and stability of the peri-oral soft tissues, and to ensure that occlusion, phonetics and esthetics are verified prior to case completion. Predictable results are obtainable when attention to detail is paid to all phases of the treatment from the records and treatment planning to tooth preparation and temporization, through to case delivery and follow up. Porcelain crowns can allow for highly esthetic solutions such as color correction/ matching and allow us to reshape malformed teet
h, or reshape teeth in incorrect arch positions, to more closely approximate their correct shapes. These types of cases can be very satisfying to our artistic natures and psychologically and functionally benefit our patients.
OH
Dr. Pollak Graduated From The University Of Toronto In 1989. He is Past-President of the Toronto Academy of Cosmetic Dentistry. He maintains a general dental practice in Markham, Ontario, with an interest in cosmetic, restorative and implant dentistry. He is a founding member of the Canadian Academy of Esthetic Dentistry. He is a graduate of the Misch Implant Institute, The Dawson Center for Advanced Studies, and the SUNY postgraduate program in Esthetic Dentistry. He is a Fellow in the International Congress of Oral Implantologists (I. C. O. I.), and is currently working to achieve fellowship in the Academy of General Dentistry.
Oral Health welcomes this original article.
Acknowledgment
The author wishes to thank Demetrious Andreou R. D. T., Rudy Ghoubrial R. D. T., Sorana Cobal cescu and staff at ADL Laboratory for their excellence, attention to detail and artistry in the fabrication of the prosthetics. Your efforts are greatly appreciated. The author wishes to thank Dr. John Nasedkin, Prosthodontist, for his review and helpful comments during preparation of the manuscript.
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34. Oden A., Razzoog M. E. Masking Ability of Procera All Ceram copings of various thickness J Dent Maxillary anterior crowns pro vide an exciting Connection Part 1 : Biologic Variables J Esthet Dent 6(1): 3-9 1994 16. Roberts M., Trinkner T. Communication guidelines for Achieving Aesthetic Success Signature 5(3) 18-21 1998
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ABSTRACT
A sound understanding of smile design principles as they relate to proper proportion and balance between teeth and other facial elements, and the form, color, texture, size and relationship between the hard and soft tissue dental elements is essential to solving aesthetic challenges. 1-6 A case is presented where both maxillary central incisors were successfully restored utilizing all ceramic crowns (Procera™). Long-term provisionalization was employed to re-establish soft tissue health, verify stability at the soft tissue/ tooth preparation marginal interface, and idealize esthetics, phonetics, and occlusion. Emerging research suggests a strong link between a patient’s periodontal health and risk of developing various systemic diseases. 7,8 Adverse tissue response to a crown is multi factored, and involves factors such as one’s gingival biotype, the materials used in the crown’s fabrication, oral hygiene, crown contour and margin fidelity and margin location as it applies to the biologic width. The patient’s physical and emotional health can be positively affected, as well as rewarding the clinician’s artistic nature.
———
The patient’s physical and emotional health can be positively affected, as well as rewarding the clinician’s artistic nature
———
The patient opted instead to delay endodontic treatment to the future, if indicated, and understood the risks of damage to the new crown following endodontic access
———
A ‘closed-flap’ technique was employed to correct possible biologic width violations thought to be present
———
The laboratory was provided with detailed instructions regarding the desired shade, shape, texture etc., and asked to copy the temporary crowns labial shape and lingual contour
———
Teflon plumber’s tape (a dead soft matrix material available in any hardware store),
was placed and adapted to isolate the teeth from the lateral incisors
———
Just by changing the position or contour of a tooth it is sometimes possible to alter the appearance of a colour
———
There is considerably more osseous scallop in the anterior region, which progressively flattens out as it heads posteriorly
———
The quality of our restorative work can play a role in initiating, or helping prevent oral inflammatory triggers, and as such, the dentist and hygienist can play an important role in disease prevention
———
challenge to our artistic and technical abilities and call upon our knowledge of smile design principles of proportion, symmetry, harmony and tooth morphology
