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Maximizing Anterior Design for Predictable Results in a Six-unit Anterior Makeover by Luke S. Kahng, CDT Case courtesy of Joseph L. Caruso, DDS, MS

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In a six-unit anterior case it is always essential to have excellent communication between the patient, the dentist and the lab. In order to get the most predictable design possible, it is best to have the patient's pre-op and post-op photos e-mailed to the laboratory so that the technician can work with the dentist and get the results he is expecting. It is important to have this communication tool, especially for tissue design, size of teeth and length of incisal edge position, but also for color selection. Most dentists work with a shade tab that contains two tones, which makes it hard to communicate exactly what the patient is looking for. And unless the patient is an artist, he will probably not recognize exactly what he wants in his restorations.

As background regarding our case study patient, the mandibular anterior teeth had a lot of stain interproximally. The patient and the clinician discussed what to do to accomplish natural looking aesthetics in the final restoration. From the lab's perspective, the technician requested pre-op photos in a rest, retracted and smile view. He also asked for a side view and emergence profile. He noted that between the canines and premolar, the issue of concern was color and the patient wanted better overall aesthetics.

He decided on an A2 base color with mamelon and translucency application in order to create bright, high value. Gingival enamel color was not discussed at that point but it was decided that the first step would be to cosmetically correct the maxillary teeth and work on the mandibular anterior dentition in the future. The lab procedures were discussed and the process for delivering predictable results was explained. Also of significance to the patient and clinician was the final analysis of color and shape for the teeth.

Case Study

The clinician sent the case for evaluation and the technician offered his viewpoint based on what he saw in the photos (Fig.1). Treatment indicated was on the upper anterior teeth. There was discoloration and stain on 7, 8, 9 and 10 with white calcification on the mandibular dentition. The temporaries would be created using A1 and particulars about color would be discussed in the future.

Regarding shape and contour, in the impression it was obvious that numbers 8 and 9 were shorter than 10. The incisal area length was to be increased 2-3mm and the zigzag gap between 8 and 9 was noted as well. Buccal, mesial and distal angulation would be created to be more outward in appearance and a deep champfer prep all around was recommended. Because of the patient's occlusion, zirconia restorations were also recommended in order to eliminate fractures.

The prepared teeth clearly show excellent margin design (Fig. 2). The lab created a wax-up and a stent (Fig. 3) which was sent to the doctor for a try-in guide in order to create proper reduction thickness for the provisionals. Using GC America Composite Self- Curing flow material (Fig. 4) the acrylic material was mixed, poured up and tried in to create a comfortable set of temporaries for the patient.


After placing the material-filled stent in the patient's mouth, the clinician waited for two minutes (Fig. 5), took the stent out, and the patient was left with A1 temporaries. The mid-line and horizontal line was checked from canine to canine, as well as the color and aesthetics. All factors were communicated between the patient and clinician. Next, the lab processed a wax-up for the maxillary anterior in order to conform to the patient's wishes (Fig. 6).

The milled zirconia coping (Fig. 7) is an example of what the appearance is before the pre-shading stage. After sintering and grinding the coping, the fit is checked on the cast model (Fig. 8). Internal staining was applied to the incisal area and then fired at 800 degrees Celsius. An application of dentin GC ZR porcelain in B1 was applied at the beginning of the porcelain layering process (Fig. 9). After multi-layering the six porcelain powders, surface texture was created to properly construct the teeth size (Fig. 10). A glaze material added to the tooth surface for internal color allows for color differentiation (Fig. 11).

After polishing, the surface texture was more clearly defined (Fig. 12). Immediately after insertion (Fig. 13) and cementation, note the incisal edge and the closed gap between the two centrals. In appearance, the color was white but not terribly bright, with color differentiation between the teeth and a high value. The incisal third holds a translucent effect with noticeable mamelon, as well. After cementation, the patient presents with a resting, natural view (Fig. 14).

Conclusion

The patient, a 27-year-old male, was concerned about the size and shape of his teeth, as well as his occlusion issues. However, to invest in all 28 of his teeth was more than he could afford at that time so he needed to take care of the process in segments. In order to get the best aesthetics for six anterior units, there must be excellent communication between the patient, dentist and lab. The better the communication is, the happier the patient is with the service he is given and the aesthetics of his restoration. Tissue design, teeth size, incisal edge - all of these expectations were discussed and met, as well as color selection and occlusion issues. Each problem was solved by working to understand the patient's concern from the beginning.



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