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Practice Solutions: LSK121 by Luke S. Kahng, CDT

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Header: Building a Beauty
by Luke S. Kahng

Our patient, in her 60s, had undergone a reconstructive dental process 15 years earlier, with unfortunate issues involved with the work from the beginning. The porcelain popped off repeatedly, requiring frequent visits to a new dentist and numerous recementations. She was frustrated and unhappy with the overall case aesthetics and the work that had been completed by a previous dentist. She approached the new doctor about redoing her case and he agreed to undertake the process for her.

Everything went well with the preparations and temporization process, and the patient couldn't be happier with her improved bite, new shade and overall aesthetics. We will discuss the streamlined process and how we arrived at this excellent outcome.

Case study
In a preop view (Fig. 1), we can see the patient's dental work that had been completed before her initial appointment. Teeth 8 and 9 are not symmetrical and are short on the incisal length; 10 is longer than 7, and there is a big variation in color between 6, 7, 8, 9, 10 and 11.

Some of the restorations are veneers and some are crowns. Veneers, as we know, are thin and we are able to see completely through them. The material we use for veneers is either porcelain or lithium disilicate. Crowns, meanwhile, have a certain thickness and a different substructure and were fabricated with either porcelain or lithium disilicate. However, we can now use zirconia with different opacity and more translucency, which translates into a more natural appearance. We can also depend on greater longevity with this material. We can also see that there is a large color differentiation between the bridges included in the dental work—specifically teeth 3-5 and 11-13. The patient is a grinder, which is why there had been problems with cracking and her crowns or veneers popping off. Composite bonding can patch the ceramic work, but it is not the same sort of material. It will stain, leading to a mismatch in color.

ceramill map400 For these reasons and more, material selection can prove to be a very important decision in the long-term. During the 15 years that had elapsed since her original dental work was completed, there were new options the dentist and technician could choose to improve the patient's overall appearance and longevity with her case.

The clinician's prep work and tissue management offered a nice, deep chamfer to work with (Fig. 2). In this view, we can also see the flat occlusion of the premolars and molars, indicating we would need to have a very strong restoration for this bruxing patient. Next is a close-up view of teeth 7-10 after preparation (Fig. 3).

After the lab received the case from the dentist, I worked with the digital design department to scan and design the case with the Amann Girrbach Ceramill Map400 scanner. After milling the copings with the Ceramill Motion 2 milling machine and sintering for eight hours, this was the copings' appearance before color application (Fig. 4).

For comparison purposes, I placed the copings on the model below the upper arch prepped model (Fig. 5).

Next is a lingual view of the zirconia copings on the pinned model, after sintering, for a fit to model check (Fig. 6). Porcelain had not yet been applied, but I worked toward maximum strength for the restorations so they could hold up under the patient's grinding habit. Teeth 4 and 5, 12 and 13 are full-contour zirconia restorations.

Fig. 1 Fig. 2 Fig. 3

Fig. 4 Fig. 5 Fig. 6


After porcelain application, glazing, polishing and baking, the restorations were placed on the model for an occlusion-view check (Fig. 7). An opposite view from Fig. 6, shows the final restorations on the model, with the prepped model below for another comparison view (Fig. 8). The final restorations were placed on the solid model, with porcelain from the GC Initial Zirconia system (Fig. 9).

A mirror image follows of the five single units and two multiple-unit bridge restorations based on color selection between A1 and A2 with translucency (Fig. 10). Looking at the protrusion view with the mandibular model and the restorations in our immediate post-bonding image, we can see the color blending and harmony in the patient's mouth, as well as the contour and shape of the teeth

(Fig 11). In the immediate view after cementation

(Fig. 12), the differences between pre- and post-treatment are obvious. In this last smile view, note the final restorations with the accomplished aesthetics sought by the patient and the dentist. Teeth 8 and 9 are 2 millimeters longer than her original restorations, and narrower, with room for freedom of occlusion. The tone of the restorations is actually two tones lighter than that of her natural dentition (Fig. 13).

Fig. 7 Fig. 8 Fig. 9

Fig. 10 Fig. 11 Fig. 12
Fig. 13


Conclusion
As we can all attest, communication between the dentist and the laboratory is essential. As a lab owner and technician, it's my duty to help lead the dentist with questions to achieve the very best result. A dentist has the right to expect maximum aesthetics from a well-experienced technician and will often ask questions when treatment-planning a large case such as this one. Through either digital design or phone communication, everyone should have the same expectations going into the treatment stage, with great care taken regarding the reconstruction of the patient's dentition. This was definitely the pattern that our case study took, and the results show just how well it paid off.



Luke S. Kahng, CDT, is owner and president of LSK121 Oral Prosthetics in Naperville, Illinois, one of the largest dental laboratories in the country. He invented the Chairside Shade Guide—Volumes 1 and 2, and created the Seasons of Life Selection, a ceramic shade guide system. Kahng has served on several dental journal boards as a contributing member and has published more than 120 articles in national dental publications. He also has written several books, including The Aesthetic Guide Book and Smile Selection Plus CS3 Clinical Cases. He publishes complex, combination and cosmetic rehabilitation cases daily on Facebook and LinkedIn.



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