PUBLISHED IN DUBAI www.dental-tribune.me July-August 2018 | No. 4, Vol. 8 Making a perfect ceramic crown on a titanium abutment in the esthetic zone SUBSCRIBE NOW https://me.dental-tribune.com/e-paper issn 1616-7390 Vol. 8 • Issue 4/2017 CAD/CAM international magazine of digital dentistry 42017 Overcoming a challenging situation step by step By MDT Patrick Rutten, Belgium For reasons of strength, a titanium abutment may be required in the esthetic zone. However, masking the dark metal to achieve a natural-look- ing outcome will present a challenge. A ceramic crown with a zirconia cop- ing should be used to mask the metal abutment. A layering protocol is used to create natural light and color and avoid a greyish-looking gingival tis- sue in the cervical area. In the follow- ing clinical report, MDT Patrick Rut- ten (Tessenderlo, Belgium) presents how to handle such a challenging sit- uation and obtain predictable white and pink esthetics. Clinical situation More than 40 years after a sports in- jury, extensive caries was detected ra- diographically under a post crown on a maxillary right central incisor (Fig. 1 and 2). The tooth was determined to be nonrestorable and was extracted. After a healing period of eight weeks, an implant was placed (Fig. 3) togeth- er with allogenic bone augmentation and soft tissue regeneration with a free connective tissue graft harvested from the palate. A healing abutment was screwed onto the implant and a removable provisional denture pro- vided. For strength reasons, a custom CAD/CAM-fabricated titanium abut- ment was chosen (Fig. 4). “I do not prefer using titanium in the front if possible, but in this case, function is more important than esthetics,” Rut- ten explains. The challenge was now to veneer a zirconia coping with the fine-struc- ture feldspar ceramic VITA VM 9 to reproduce the natural appearance of the adjacent teeth and to support and sculpt the soft tissue for optimal gingival management. “Working with a titanium abutment is very dif- ficult. The gingiva can look greyish. We have to mask the greyish cervical part,” Rutten warns. Precise shade de- termination was the first essential for success. To guarantee a perfect shade match, the VITA Linearguide 3D-MASTER was used (Fig. 5) to cover the whole three-dimensional tooth shade spec- trum and to allow shade determina- tion in three defined steps. In the first step, the shade value was verified, fol- lowed systematically by chroma and hue. The basic shade of the adjacent teeth was measured digitally with the VITA Easyshade V spectrophotom- eter. Independently of one another, the expert and the digital device both determined the tooth shade to be 3M2. For Rutten to achieve a shade match between the natural teeth and the restorations, the correct basic shade is highly important. Layering procedure The zirconia coping was virtually de- signed, milled, sintered, and fitted. An initial wash firing with VITA VM 9 EFFECT LINER was a crucial step in adding a fluorescent layer to the non- fluorescent zirconia coping. The liner also provided reliable bonding to the framework. The firing temperature should be 50 degrees higher than that of normal dentine firing. interview “Dentistry has finally arrived in the digital age” case report Screw-retained implant-supported restoration in the edentulous maxilla cone beam supplement Dynamic navigation for reliable and predictable flapless implant placement VITA VM 9 BASE DENTINE 3M3 with a higher chroma was used in the cervi- cal area to mask this critical area and to mask the lifeless and greyish ap- pearance of the titanium abutment. Yellow EFFECT CHROMA 4 (EC4) was then applied with a deeper orange in the interdental areas with a mixture of EFFECT CHROMA 5 (golden rod) and 6 (sunflower) to enhance the masking effect. For the incisal third area, a higher value was selected with 3M2. To create the ridges, the bluish ÿPage B2 Fig. 1 and 2: Initial situation, clinically and radiographically, before extrac- tion of right maxillary central incisor. Fig. 3: Radiograph after implant placement. Fig. 4: Titanium abutment screwed onto implant. Fig. 5: Determination of basic shade with VITA Linearguide 3D-MASTER. Fig. 6a: MDT Patrick Rutten at work. Fig. 6b: Layering dentine core. Fig. 6c: Creation of mamelons. Fig. 6d: Layering of enamel. Fig. 6e: Characterization with INTERNO. Fig. 6f: Result after first dentine firing.