Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2016-11-22, 11:57:56 | version 1.38.0
had to be harmonised before the permanent restorations were placed. Surgical treatment The patient was given a local anaesthetic and then an implant was placed in the region of tooth #14. Tooth #13 was extracted. The gingival contours of tooth #13 needed to be improved significantly. Therefore, targeted soft-tissue conditioning meas- ures were initiated. For the next few months, the patient had to wear the temporary restorations, which had previously been fabri- cated. The area around the im- plant was able to heal properly during this period. In addition, the patient was able to accustom herself to the new functional and aesthetic situation. The shape and shade of the prepared abutment teeth had to be adapted. The two lateral incisors and the maxillary canines were non-vital and discoloured. When stained areas of prepared teeth have to be concealed and tooth shades are suitably adjusted, it is important to visualise the com- pleted crown for each of the in- dividual teeth (Fig. 7). Changing the perspective from full view (maxillofacial) to detailed view (soft tissue) simplifies the visualisation process and tooth preparation. Impressions and provisional restorations The peri-implant soft-tissue contour around tooth #14 was op- timally shaped by the provisional restoration. As a result, an impres- sion could be taken of the emer- gence profile (Figs. 8a & b). The impressions of the prepared teeth in the upper and lower jaw were taken with the double-cord tech- nique, and the master casts were produced in the laboratory. The long-term temporary was fabri- cated in three segments. The first segment comprised teeth #23–12; the second segment, the restored posterior teeth #13–17; and the third segment, teeth #44–47 (Figs. 5a & b). Once the first segment had been finished, the incisal pin of the artic- ulator was lowered in order to cre- ate a space of approximately 1 mm in the anterior region. This gap was closed with the provisionals of the other two segments. The tempo- rary restoration was now ready for placement in the mouth (Fig. 9). After the provisionals had been placed, their functional and aestheticparameterswerechecked and the patient was released from the practice. During the subse- quent months, she managed very well with the long-term tempo- rary and she was satisfied with the aesthetic aspects. The implants that would replace teeth #35–37 had not yet been placed at this stage. Experience has shown that astep-by-steptreatmentapproach minimises the risk of error. There- fore, the implants were placed eight months later. Owing to the focused ap- proach, the complex initial situa- tion was reduced to a compara- tively straightforward case that could be treated with permanent all-ceramic restorations. The main challenge for the dental labora- tory technician was to conceal the differently coloured abutment teeth effectively. The objective was to cover the non-vital and stained teeth with zirconium di- oxide frameworks. In order to ful- fil all of the functional and aes- thetic requirements, the decision was taken to press ceramic materi- als on to the frameworks and then customise the restorations with layering ceramics. This approach may sound somewhat compli- cated, but it would ultimately help to reinforce the stability and relia- bility of the treatment result. Fabrication of the restorations First, the provisional restora- tion, or rather its functional char- acteristics, had to be copied. The cross-mounting method was used for this purpose. Subsequently, a precision wax-up was fabricated and digitalised. It was correspond- ingly cut back prior to the CAD/ CAM fabrication of the zirconium dioxide frameworks. In the next step, these zirco- nium dioxide copings, which were to conceal the discoloured tooth structure (Fig. 10), were covered with pressed ceramic. The press technique allows the wax-up and its functional details to be repro- duced in ceramic with utmost precision. In preparation for the ceramic press process, the restora- tions were built up in wax on the copings and then pressed with the fluorapatite glass-ceramic IPS e.max ZirPress in Shade A3 (Ivoclar Vivadent). Next, they were cut back as required, ensuring the full contour of the functional parts and the incisal area. Finally, the restorations were layered with IPS e.max Ceram veneering ceramic (Ivoclar Vivadent; Figs. 11 & 12). The teeth were characterised in accordance with the age-related requirements of the patient using Dentin, Incisal, Impulse and Ma- melon materials. The all-ceramic restorations were tried in after the first firing and then completed. After the last try-in, the resto- rations were permanently placed according to the established pro- tocol. The stained tooth structure was optimally concealed. The healthy natural soft tissue suc- cessfully adapted to the ceramic surface. The implants healed com- pletelyandtheradiographshowed a stable situation. The vertical di- mension, incisal edge contour and occlusal plane corresponded to the conditions established during the provisional phase (Figs. 13a–c, 14 & 15). The shape and shade of the ceramic restorations success- fully matched those of the natural mandibular anterior teeth and harmonised with the face of the patient. Conclusion Comprehensive restorative therapy demands a clear and well-organised treatment strat- egy. The route and the goal must be defined right at the beginning in order to establish a sound and straightforward basis for the treatment procedure even in com- plex cases. This approach sim- plifies the treatment for all the parties involved and meets their highest demands. 16 Dental Tribune Asia Pacific Edition | 11/2016 TRENDS & APPLICATIONS Dr Tetsuya Uchiyama is a dentist at the Uchiyama Den- talClinicinTokyo in Japan. He canbecontacted at tetsuya221@ gmail.com. MichiroManaka is a dental tech- nician at Dent Craft Studio M’s Art in Saitama inJapan.Hecan be contacted at mamcr75@ gmail.com. Fig. 10: Framework with zirconium dioxide copings.—Figs. 11 & 12: IPS e.max ZirPress was pressed to the zirconium dioxide copings. Subsequently, the restorations were veneered.—Figs.13a–c: Successful functional and aesthetic integration of the all-ceramic restorations.—Fig. 14: The patient was visibly satisfied with the result.—Fig. 15: Stable situation and excellent aesthetics three years after placement of the restorations. AD 10 11 13b 13a 13c 12 15 14 1011