Another Option: Collaborative Effort to Mimic Aesthetics

By Rhys Spoor, DDS, FAGD, Accredited Member of the American Academy of Cosmetic Dentistry

This case is an example of excellent collaboration between the restorative dentist, the oral surgeon, and the ceramist to give a patient a truly natural-appearing, functional prosthesis in a less-than-ideal environment. The patient was referred by his dentist due to a continual slow degradation of an anterior bridge that spanned from #5-#11. There had been several failed abutments over the years with two apicoectomies (Figures 1, 2, 3 and 4).

A CBCT revealed significant bone loss in the edentulous segments to the point that several areas did not show on the scan. The #7 abutment had an endodontic lesion and the bridge exhibited significant mobility. The existing bridge was positioned facial of the maxillary bony ridge to accommodate the occlusion and provide lip support.

After a diagnostic wax-up was completed, the bridge was removed and a directly made, stainless steel wire-reinforced provisional bridge was made from #5 to #12 (Figures 5, 6 and 7). Since it was a long span, it was decided to remove the pre-existing crown from #12 to double abut that end of the span. The preparations were impressed at that point and after placement of the provisional, an alginate impression was taken. That model was sent to the dental laboratory for digital scanning and combined with the preparation impression to create a milled polymethyl methacrylate (PMMA) provisional which was much more durable for the extended length of the treatment.

Tooth #7 was extracted, grafted and soft tissue augmentation was performed along the entire ridge with Alloderm and a temporary mini-implant placed in #8. The implant had to be placed slightly more facial than ideal because of the angle of the bone. The PMMA provisional was adjusted to fit (Figures 8 and 9).

Bone augmentation followed and implant placement in the areas of #6, #8 and #10 (Figure 10). The area was allowed to heal for one month and the PMMA provisional was modified by adding to the gingival volume (Figures 11 and 12).

The final impression was taken using polyvinyl siloxane (Kerr Take One) with an open tray and the impression copings stabilized with a composite core paste (Figure 13). The copings were placed in the impression and analogs were again stabilized with core paste (Figure 14). Shades were determined, including gingival shading (Figure 15).

The final prosthesis was a milled zirconia framework with titanium inserts coated with a gingival-colored composite (Bredent) (Figure 16). To get the best gingival color match, the final application of the composite was done intra-orally (Figure 17). Emax (Ivoclar) crowns where at first cemented temporarily, then finally with Panavia resin cement (Figure 18). The final result was a very close mimic of the natural dentition and gingival tissue (Figure 19).

The author thanks and appreciates the artistic skills of Dr. William Hooe, oral surgeon, Shoreline, WA and Mr. Daniel Sorenson, ceramist, Pleasant Valley, Utah.

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