Same Day Smile: Crowns #5-12
Kristine Aadland, DMD
Intro
What do you do for those cosmetic cases when someone wants a brighter smile, and bleaching will not accomplish the desired results?
Background
Here is a patient in his 50s. He works in sales and he is self-conscious about his teeth when he meets with clients. His wife had recently gotten veneers done and he also wanted a brighter, fresher look to his teeth. His specific concerns were:
- The overall shade of his teeth.
- Tooth #5 looked dark.
- Teeth #7 and #8 stained and chipped easily due to large IV composites.
- The crown on tooth #9 was too dark and a bit wider than #8.
- The Tetracycline staining at the gingival third of teeth #11 and #12.
Findings
This patient had a deep overbite (See Figure 2) with obvious lingual wear on his upper anteriors due to a restricted envelope of function, meaning he had a really “tight bite.” Teeth #6 and #9 had existing crowns that were different materials, different shades, and had recurrent decay. Teeth #7 and #8 had large, four surface composite fillings that were stained and constantly chipping. Tooth #10 had a large DL composite with recurrent decay and Tooth #11 had tetracycline staining at the gingival third of the tooth with noticeable abrasion. Teeth #5 and #12 have large MOD composite with recurrent decay.
Discussion
When I approach a case like this, I spend time really finding out what the patients desired outcomes are and then decide if I need a wax-up or not. Ideally, this patient would go through orthodontics, and intrude his lower anteriors to create less restriction in his envelope of function. This would have allowed me to buildup his lower anteriors and place his upper anteriors in proper canine guidance while also reducing his overbite. If that had been the plan, I would have used a wax-up based on articulated models.
This patient was not interested in orthodontics. He did like the shape of his teeth, other than how #5 looked hidden by #6. He just wanted his teeth brighter and to not see the tetracycline staining anymore. Because I didn’t need a lot of changes to the midline, incisal length, or even tooth shape, I decided to do this case in BioIndividual but add a BioCopy catalog (See Figure 3) of his existing teeth so that I could ghost the image of his existing teeth over the proposals to know where my incisal edges and midlines were (see Figure 4).
As you can see in the Figures 5 and 6, the tetracycline staining was quite severe on the apical thirds of #5, 6, 11 and 12. Tooth #9 also had significant darkening of tooth structure with a metal post. The other difficult challenge is the facial positioning of the laterals #7 and #10. Material options can be limited with this severe of staining. One way to increase your material options is to use opaquers to create more similar substructures. I personally like Cosmedent Creative Color Opaquers. When blocking out black or grey, if you use the pink opaquers it will turn the prep white as you can see in Figure 7. I used an A1 shade opaquer to mask the gingival third of teeth #5, 6, 11 and 12. The technique is similar to adding flowable composite and the material is very user friendly. It is important to remember that you image after you place the opaquers.
One major time saving function with the new software update is the automatic margin finder. It is much faster for me to verify and edit the margins in a case like this with 8 units than it is to marginate each tooth. I love this feature (Figure 8.)
The technology that we have at our fingertips in office is pretty impressive. This patient travels a lot for work and getting him in for appointments is difficult. He had wanted to fix his teeth for some time, so when I told him that we could do this case in one day, he was very excited and scheduled immediately. From start to finish, these 8 restorations took 6 hours. While I designed and milled the crowns, he sat in our office and enjoyed lunch and worked on his laptop. I love these days because I get to concentrate on only one patient for the day and to see his smile at the end of the day is priceless. The designs are becoming faster and more realistic limiting the amount of post-mill contouring that is needed (see Figure 9). A small amount of characterization with staining and glazing was added at the incisal edges to give the teeth a bit more pop.
Conclusion
The main goal of this case was to have a more consistent and brighter smile. Due to the previous dental work done, this could not be accomplished by simply bleaching or doing composite work. The main challenges were the tetracycline staining and dark substructure of tooth #9 as well as his restricted bite. I chose to do this case in BioIndividual design mode but add the BioCopy folder to use as a guide. I chose BioIndividual to reduce the amount of steps to save time. Features like auto model axis and auto margination greatly reduced the amount of design time. The material used was Ivoclar e.max B1 MT.
