A Central Aesthetic Dialemma,

Cerec Crowns

Ankylos Implants.

Custom Zirconium Abutments Dr Paul Moore www.gateclinic.com Gate Dental Clinic Dock Road Galway Ireland Dr Ian Wellings www.barkhilldental.com

263 Highfield Road, Idle, Bradford. England

drpmoore@mac.com 00353 91 547 592 & drianwellings@me.com 0044 1274 659 700

On examination of the periapical x ray the UR1 showed no periodontal ligament space and combined with the history of trauma as an early teenager we diagnosed this as ankylosed. The root had fused to the bone.

The root canal obturation on the UL1 was poor with widening of the periodontal ligament. The remaining root structure was heavily stained and discoloured

drpmoore@mac.com 00353 91 547 592 & drianwellings@me.com 0044 1274 659 700

Initial Consultation On initial examination the patient was concerned about the discrepancy of height of gums and the appearance of the crowns. The crowns had poor transluscency, and shape and the receeeding margins had exposed the dark roots below.

We considered the option of block discetion of the UL1 and repositioning the tooth and bone to level the gingival heights. This was techicaly feasible and we have done this succcesfully before on many occassions. But the proximity of the UR2 apex would make this option risky and could compromise the neighbouring tooth’s vitality.

So we extracted the UR1 UL1 placing an immediate denture same day. Eight weeks later Dr Wellings entered the healed extraction site and with bone graft and membrane built up the socket with the ambition of finding a midway compromise, allowing the UL1 margin to drop a little and to lift the UR1 gingival tissues.

Six months later the surgical site was once again revisited. The bone graft in the UR1 was reduced to level off the implant sites and two 14 mm Akylos B CX implants were placed with wide sulcus formers.

These were left for 4 months to integrate and removing the sulcus formers, impression copings were placed with impregum impression used the fill the soft tissue profile created by the sulcus formers.

The models were poured and the decision was taken not to use the preformed abutments and the laboratory was instructed to make customised zirconium abutments to mimic the cross sectional emergence profile of a natural tooth with 1mm shoulders at gingival level - 0.5 mm.

drpmoore@mac.com 00353 91 547 592 & drianwellings@me.com 0044 1274 659 700

On return from the laboratory the supragrestal - gingival portion of the abutment was refined to facilitate later flossing and Cerec images were taken in surgery.

We had discussed with the patient the ambition of the final crowns and agreed to intially keep a slight class II div II arrangement. We noted the assymetrical shape and incisal height of the lateral incisors. We noted the rotation of the UR2.

We agreed to plan the crowns initially to establish the centre line and later to ammend the lateral incisors with composite.

Having completed the Cerec design we milled the crowns using Litium Dislicate ( E Max , Ivoclar ) porcelain Low Transluscency. The crowns were fitted and incisla contours refined. The final characterisation was applied with the crowns in the mouth to enable direct comparison. Two layers of glaze were applied.

Cementation was then completed using a high value ( opaque white ) cement in the body of the crown to add depth of colour and a transluscent cement around the margins.

Spot curing fixed the cement and excess was removed with a scalpel blade under magnification. drpmoore@mac.com 00353 91 547 592 & drianwellings@me.com 0044 1274 659 700

Gingival and incisal levels harmonised

Long contact point to encourage papillary growth

Mesial composite placed to build up profile

drpmoore@mac.com 00353 91 547 592 & drianwellings@me.com 0044 1274 659 700

drpmoore@mac.com 00353 91 547 592 & drianwellings@me.com 0044 1274 659 700