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Dental TribuneAsia Pacific Edition | 1+2/2016 18 TRENDS&APPLICATIONS In the field of prosthetic dentistry, effectivecommunicationbetween the clinician and dental technician is of the utmost importance. Con- sistent close cooperation between the dentist and the dental tech- nician and their concerted action provide the basis for a successful outcome. This article demon- strates the importance of good cooperation in a case that involved soft-tissue remodelling in the anterior region, among other things. A 32-year-old female patient presented to our practice with an unsightly, defective anterior bridge extending from tooth #12 to tooth #21. The bridge had been placedsevenyearspreviouslybut the patient was unsatisfied with her smile and was seeking an aesthetic, more natural-looking alternative. The veneer of the metal–ceramic bridge had a very opaque and yellowish appear- ance. At tooth #21, the metal margin was exposed cervically owing to gingival recession. Alveolar ridge atrophy in the area of the missing right central incisor (pontic) had resultedinaconsiderablevertical reduction.Theshapeandshadeof the teeth needed improvement, and harmony between the white and pink tissues had to be re- stored (Fig.1). Treatment plan and mock-up Smile improvements often in- volvecomplexprocedures;there- fore, it is advisable to simulate the final result by means of a direct composite mock-up. This important step boosts the pa- tient’s trust and confidence. A mock-up provides the patient withaclearideaofwhattheeffect of the planned restoration will be once it has been seated in the mouth. Inouropinion,thisstepcannot be entirely replaced by digital design previews. Furthermore, the mock-up allows the labora- tory technician to obtain a better understanding of the individual clinical situation. Later, it can be used as a template in the fabrication of the laboratory wax-up and/or the provisional restoration. In our case, the mock-up re- vealed that in order to achieve a morebalancedappearance,tooth #22 had to be integrated into the restoration (Fig.2). Even more im- portant, it showed that not only the correct position, shape and colour of the teeth, but also the correct gingival architecture and emergence profiles were key fac- tors in achieving a harmonious smile in this case. Consequently, thepatientwasinformedthatthe soft-tissue volume would have to be increased in the pontic area in order to achieve a satisfactory result. The patient fully agreed to the treatment plan suggested. Overall, the treatment plan in- volved the removal of the exist- ing restoration, the placement of a provisional bridge and soft- tissue grafting in the pontic area (soft-tissue management that would take several months), as well as the insertion of a new ceramic bridge and a laminate veneer on teeth #22 and #13, if needed. Connective tissue graft and immediate provisional bridge Frequently, tooth extraction is considered a possible cause of al- veolar ridge atrophy. In this par- ticular case, there was a consider- able lack of volume due to bone loss in the pontic area. For the purpose of re-establishing the soft-tissue architecture, two sur- gical interventions were planned. Immediately after the first con- nective tissue graft had been per- formed, a laboratory-fabricated provisional bridge was placed. The bridge was constructed on thebasisofthemock-upinforma- tion and reinforced with metal wire. The soft-tissue contouring phase that followed took several months. Initially, the provisional exhibited an inner concave sur- face to provide sufficient space for the soft tissue. It has been sug- gested that a provisional pontic should have a convex final shape. However, having a concave initial shape allows for progressive tis- sue modelling from the palatal to the buccal side, which is helpful especially when several grafts are needed (Figs.3a–6d). Communication of emergence profiles and shapes to the laboratory Once the desired soft-tissue shape had been achieved, one of the great challenges was to trans- mit all of the relevant informa- tion, especially the length of the inter-incisal papillae and the pontic shape, to the laboratory. This is important because when the impression is made, the pres- sure of the impression material may deform the soft tissue. In order to prevent any possible loss of information, the pontic area of the provisional restoration was filled with a silicone-based impression material and then placedoverthepreparedteethon Togethertowardspink–whiteaesthetics Communication is the foundation for natural-looking results By Dr Jorge André Cardoso,Dr Rui Negrão,DrTeresaTaveira & Oleg Blashkiv,Portugal Fig. 1: Initial situation.—Fig. 2: Simulation of the desired result by means of a direct mock-up.—Fig. 3 a & b: Soft-tissue management with the help of the provisional restorationafterthefirstconnectivetissuegraft.—Figs.4a–c: Theresultafterthefirstsoft-tissuegraft.—Fig.5: Secondconnectivetissuegraft.—Figs.6a–d: Afterthesurgical intervention,a metal-reinforced provisional was placed and the shape of the pontic area was progressively shaped from concave to convex during the following months. Fig.7: Try-inofthezirconiabridgeframework.—Figs.8a&b: Transferofthebasalshapeoftheponticfromthemouthtothemodel.—Fig.9: Gingivalcontours,interproximal stains,thepositionofthebuccalridges,etc.werecommunicatedbymeansofslidesharingsoftware.—Fig.10: Thefinalrestorationsonthemodel(bridgeonteeth#12to#21 and veneer on tooth #22).—Figs.11a–c: Cementation of the ceramic restorations.—Figs.12a & b: Lateral view of the inclined final restorations.—Fig.13: Frontal view. 1 2 3a 3b 4a 4b 4c 5 6a 6b 6c 6d 7 8a 8b 9 10 11a 11b 11c 12a 12b 13 DTAP0116_18-19_Cardoso 12.02.16 13:04 Seite 1 12 3a 3b DTAP0116_18-19_Cardoso 12.02.1613:04 Seite 1