A patient's anterior esthetics are enhanced by careful treatment planning, collaboration between the members of the dental team and use of metal-free material options. Here, an aging pinledge bridge is replaced with a zirconia abutment, implant and a Ceramco iC integrated ceramic restoration.
A 29-year-old woman with a normal medical history had lost tooth #8 in a sports accident over 10 years ago. It was restored with a pinledge bridge, which is rare today since it offers limited esthetics. The facial of the natural teeth on either side of the pontic remained as they had been when they erupted.
The patient wasn't satisfied with the anterior esthetics and the function of the teeth also needed to be improved. The dental team decided to replace the pontic area of the bridge with an implant, and enhance the esthetics of teeth #7, 9 and 10 with conservative all-ceramic restorations.
Implant-Based Restoration
X-ray examination revealed an alveolar atrophy in the anterior maxilla. This was addressed using a mixture of autogenous bone harvested from the retromolar region, augmented with a hydroxyapatite-based xenograft material. These were placed using a resorbable membrane, and healing proceeded.
Six months after the hard tissue augmentation procedure, Dr. Walther Neupert placed a Dentsply Friadent Xive implant with a 3.8mm diameter and 13mm length (see Figure 1 below). In order to ensure undisturbed healing, the soft tissue was closed over the placement site with resorbable polyglactin sutures.
After another six months, the implant was re-exposed and a pick-up impression was sent to the laboratory using Dentsply Friadent's D3.8/GH1-3 pick-up set and Zhermack's Colorize thermochromic VPS impression material. A Friadent D3.8-mm triangular EsthetiCap was used to create suitable emergence profiles that would create esthetic papillae for provisional restorations (see Figure 2 below).
Using the esthetic soft tissue contouring provided by the EsthetiCap, a customized Cercon CAD/CAM zirconia abutment was fabricated by Dentsply Compartis. A zirconia abutment was chosen because it offers translucency for the restoration and natural tissue responses. When the esthetic Cercon abutment was placed on #8, the adjacent central (#9) was also prepared (see Figure 3 below). With the soft tissue managed for esthetics and the customized zirconia contour, the team was able to achieve an excellent foundation for smile lifting. 3M ESPE Protemp™ bis-acryl provisional restorations were placed (see Figure 4 below).
Prosthetic Restoration
The team decided to replace the two centrals with full-coverage pressed ceramic restorations, while the laterals would be conservatively restored with veneers. The all-ceramic pressed restoration cores would be individually layered with available modifiers to enhance esthetics. The patient was pleased at the prospect of having her smile line restored with metal-free restorations.
The Ceramco iC system was chosen because it's an integrated system that offers excellent esthetics and shade matching in complex combination cases. Juergen Gebhardt, MDT, created a silicone preparation key to aid in providing optimal reduction (see Figure 5 below). This is an area where a laboratory with esthetic insights can be a valuable partner in the treatment team.
Dr. Brunel-Geuder prepped the teeth facially (see Figure 6 below) and lingually (see Figure 7below) so there was sufficient restorative space, and the model work in the laboratory provided clear guidance with regard to restorative approaches (see Figure 8 below).
Gebhardt used the pressing technique and a double-layered blend of Ceramco iC translucent and chromatic ingots in CO1 and T2 to fabricate the full-coverage crowns and veneer substructures (see Figure 9 below). To create natural esthetics in the veneer restorations, he used individual layering with A1 Dentin, Opal Clear, Enamel Light and Medium (see Figure 10 below).
Next, Gebhardt took the veneers to the glaze and stain firing stage to see how much the natural color of the teeth would influence the result. He then fabricated pressed copings to near full-contour on the centrals. He layered the crowns to full size and, in the last step, the final stain and glaze firing was done in a single stage. The results, using several components of the Ceramco iC system, were esthetically pleasing (see Figures 11 and 12 below).
After try-in, the crowns were cemented. The restorations offered high quality shades and esthetics and the patient was very satisfied with the results (see Figures 13 and 14 below).
