The Five Senses of Adhesive Rehabilitation - Part II
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Increasingly in dentistry it is necessary to use various specialties to try to get the best final aesthetic and functional result. Moreover the adhesive materials and techniques presently allow us to preserve much tooth structure. A young patient came to our office after finishing an orthodontic treatment to improve the dental aesthetics in anterior teeth. In the intra-oral examination we observed some interproximal spaces to close, a severe change in the shape and color of existing teeth and the presence of deciduous teeth. The existence of a primary tooth in place in the canine, took us to the placement of an implant. One might we follow different treatment plans: ceramic restorations or composite resin restorations. However, the treatment planning would always be the same. Compared to a composite resin, the ceramic has the advantage of being biocompatible and stable in surface gloss and color. In this case, because of the high aesthetic demand the patient has chosen to make ceramic veneers. We want to share the importance of good planning between the various dental specialties and try to preserve the dental tissues, hoping to get a proper and natural aesthetic and functional result.
Img. 1 - Extra-oral clinical situation: the patient came asking for aesthetic rehabilitation in the anterior area after having undergone orthodontic treatment.
Img. 2 - Intra-oral clinical situation.
Img. 3 - Detail of the tooth structure in the anterior area. We can observe modification in shape and and color.
Img. 4 - After having taken an impression, and having done a smile analysis, a wax-up was made by the dental technician.
Img. 5 - A silicone index was made onto the wax-up in order to produce a mock-up. The mockup is the best way to communicate our aesthetic treatment plan to the patient, who can visualize an close idea of the final result. For the mock-up, in this case we used a bis-acryl resin (Protemp 4, 3M). Also, the mock-up is the way to predict the space needed for the restorative material during preparation.
Img. 6 - In the cases in which space is available to add restorative material onto untouched enamel we should use a hard grain disc (Sof-Lex red disc or black disc) to remove the aprysmatic surface enamel and round the sharp angles.
Img. 7 - Before the impressions and with the tooth hydrated, we should select the shade we want to our final ceramic restorations. This shade selection should be made with the same shade guide used by the dental ceramist. Using a proper photographic protocol helps in the communication with the laboratory.
Img. 8 - We place the retraction cord #000 and #00 (Ultrapack, Ultradent) and take the final impression to send to the Lab. In this case we have also an impression of an implant to take, so we proceed with all the tooth impression at same time.
Img. 9 - Zirconia abutment try-in. With a acetate pen we draw a line surrounding the gingival margin for the dental technician to know where the actual cervical margin is, and also the excess of zirconia to remove in the incisal area. After that, a feldspathic glass ceramic layer was applied to cover the Zirconia abutment. This procedure will allow us to bond the ceramic veneers to this structure.
Img. 10 - After we send the impressions to the Lab, the dental technician starts layering the glass ceramic veneers with some different opacities (dentin, enamel, effects). The glass ceramic used was Criation.
Img. 11 - Glass ceramic veneers finished.
Img. 12 - Glass ceramic veneers in the stone model.
Img. 13 - Details of texture of the glass ceramic veneers.
Img. 14 - Glass ceramic veneer ready to bond in the feldspathic / zirconia abutment.
Img. 15 - Try in of the glass ceramic veneers. During this step we can check the shade of the resin cement, the fit and the contacts.
Img. 16 - After having placed the implant abutment the adhesive surface preparation was made (9% hydrofluoric acid per 90 seconds, wash, 37% phosphoric acid per 60 seconds, wash, dry, silane application, bonding resin agent application). We use the ScotchBond Multi Propose adhesive. The main purpose of using a glass ceramic veneer on a glass ceramic abutment is to have a better control of the final shade of the resin cement, compared with the other ceramic veneers.
Img. 17 - Application of the silane in the abutment.
Img. 18 - In this clinical procedure we follow the technique of Pascal Magne, published in 2008.
Img. 19 - The same preparation was made on the inner surface of the glass ceramic veneer (9% hydrofluoric acid per 90 seconds, wash, 37% phosphoric acid per 60 seconds, wash, dry, silane application, bonding resin agent application). We use the Variolink Veneer resin cement as a luting agent.
Img. 20 - After bonding, application of glycerin gel on the restorative margins and light-cure for 20 seconds.
Img. 21 - Before we remove the rubber dam the excess near the margins should be removed, and the ceramic margins polished.
Img. 22 - Intra-oral aspect immediately after removal of the rubber dam.
Img. 23 - Intra-oral aspect five days after the ceramic veneers adhesion.
Img. 24 - Intra-oral aspect two months after the ceramic veneers adhesion.
Img. 25 - Intra-oral aspect of the natural opalescence ceramic outcome.
Img. 26 - Intra-oral aspect three years after the ceramic veneers adhesion.
Img. 27 - Four years follow-up after the ceramic veneers adhesion.
Img. 28 - Four years follow-up after the ceramic veneers adhesion.
Img. 29 - Detail of the natural integration between the glass ceramic veneers and the adjacent tissues: gingiva and lips.
Img. 30 - Integration of the new smile in the face of the patient after four years.
Img. 31 - Natural integration of the glass ceramic veneers with the face of the patient after four years.
Performing a proper functional and aesthetic planning, using effective communication between the dentist, the ceramist and the patient, increases the chances of the restorative success and longevity.
I want to thank the whole team who worked with me on this case at the Instituto Superior de Ciências da Saúde Egas Moniz: João Rua, Cátia Moreno, Helder Costa and Pedro Brito.
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