Focus by Ivoclar Vivadent Ltd UK

focus Edition 1 - January 2015

with Chris McConnell www.dental-education.co.uk // www.ivoclarvivadent.co.uk

Control the outcome. The importance of good communication. In recent years, thanks to the advancement in composite luting cements, which impart a much stronger bond interface, we have been able to move away from the limitations of conventional crown designs. This has allowed us to offer our patients greater options for posterior rehabilitation, and in combination with the outstanding properties of lithium disilicate, crowns can provide aesthetic and functional excellence. Because of the increasing aesthetic awareness of our patients when it comes to indirect restoration solutions, the dentist has to evolve from the safety of the â&#x20AC;&#x2DC;porcelain bonded crown, shade A3â&#x20AC;&#x2122; prescription.

With all the variables that we can now control, the clinic-lab interface has never been more important.

Now we have to give more consideration to the desired end outcome which not only means good translation of characteristics and shade, but also an understanding of the properties of the crown material, the luting composite cements, and the need for excellent lab communication.

A 62-year-old patient presented to the clinic with concerns over the progressive deterioration of her dentition in the upper right region (fig 1). Her main concern was the presence of the UR5 (15) gap and the failing restoration on the UR4 (14). Following clinical and radiographic examination, marginal caries was also noted on the UR6 (16).

Presenting the Complaint

With all the variables that we can now control, the clinic-lab interface has never been more important. Fig 1

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Initial presentation. The patient disliked the appearance of the upper right posterior region.

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Treatment provision Due to the patient’s strong desire to preserve as much tooth tissue as possible, and the severe lack of remaining tooth structure in the upper right quadrant (fig 2, 3), the obvious solution was to use indirect adhesive restorations. With using adhesive solutions posteriorly, it is important to avoid any excessive or unfavourable lateral loading. As such, the patient was checked to make sure there was no existing bruxist disorders or posterior interferences on the lateral excursion.

Fig 2

Pre-operative occlusal view.

The defective restorations were removed and caries excavated. Due to the lack of sound substance and the poor coronal seal on the upper right 5 (15) it was elected to re-root treat, crown lengthen and then place a fibrepost/ core. The upper right 6 (16) buccal margin was finished with a bevel to allow for a wrap over of the final restoration so as to fade the finish line. Appropriate impressions and photographs were taken (fig 4, 5) and the preps were temporised.

Clinic-Lab communication and ingot selection

Fig 3 Pre-operative view of the buccal aspect. The UR4 buccal wall is a glass ionomer restoration.

Fig 4 By recording and translating the stump shade it allows the lab to understand the underlying colours and block out where appropriate.

In order to collectively provide the best outcome for patients it is imperative that the clinic and the technical laboratory have good communication. In this case, the information required included photos of a pre-operative shade and a postoperative stump shade (fig 4) both showing the shade tab as a guide. We chose to use the IPS e.max® Press system because of the versatility offered in the ingot selection and the high aesthetic requirements. As the UR6 had half the buccal wall present I wanted it to have a discreet finish line so requested an HT ingot, whilst with the UR4 and 5 needed more block out so asked for an MO ingot. Due to the patient’s age I requested a low glaze, as I wanted it to look less reflective and communicate the characterisations desired. Due to these being adhesive restorations it was important that there was no significant engagement on lateral excursion and this again was relayed to the laboratory. In all, the communication involved the laboratory prescription, photos, lab script, e-mail script and phone call.

Cementation For the cementation process, I used the dual cure Multilink® Automix adhesive system. This is a composite luting cement and was chosen due to its high bond strength to tooth and restoration. The lithium disilicate crowns and inlay were tried in and checked for occlusal interferences, then cleaned using Ivoclean before silane preparing the surfaces with Monobond. The teeth were prepared with the initiator system and the UR6 cemented with the translucent Multilink® Automix option which would allow for more show through of the underlying tissue. I used the yellow Multilink® Automix option for the UR5 and 4 so as to mask any underlying tooth colours. The restorations were light cured and excess removed then polished. (fig 7, 8)

Fig 5 The severe lack of remaining tissue can be seen, which is an ideal indication for the use of adhesive composite luting cements.

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Fig 6 The UR5 was designed as a parallel sided prep since it supported the post system, the other two teeth were conserved with as little tissue removal as possible.

Fig 7 Final restorations placed. Note the chameleon effect of the margin design on the UR6 buccal aspect. This was achieved by using the translucency of the HT ingot. The UR5 unfortunately shows a bit of the root face margin.

Fig 8 By having the cuspal inclinations fairly shallow, prevented unfavourable lateral forces. The result was very pleasing.

Fig 9 6 month recall. Note the gingival settling around the UR5 margin improving the emergence appearance. The UR6 buccal margin is still barely noticeable.

Conclusion

Fig 10 The patient was delighted with the end result. I like this photo as it says a lot about us as clinicians. We see all the other faults, notably the centrals and UL2, but the patient doesnâ&#x20AC;&#x2122;t. She is delighted with the outcome which was achieved by listening to her concerns rather than directing her treatment to what I thought should be done.

The final outcome was very satisfactory and the patient was overjoyed (fig 10). There was a good result with the UR6 finish line and it is hard to see the margin intra-orally. Due to the level of work carried out on the UR5, it unfortunately did have a small buccal showing of the root face. The patient was asked to brush the gum lightly in a coronal direction when cleaning and on 6-month review there has been gingival improvement (fig 9). The results were achieved through a combination of a good understanding of the materials being used and excellent clinic-lab communication. Without these the restorations would not have been as successful. My thanks go to Paul, Mike and the team at CBC Dental Lab in Thornbury for their excellent technical work.

Dr Chris McConnell is a general dentist with a special interest in cosmetic and sedation dentistry. He works in his predominantly private practice in Cornwall, which is situated within 50 metres of one of the UKâ&#x20AC;&#x2122;s premier surfing beaches. He has a broad working dental background having worked in specialist hospital units, bespoke fully private clinics, and corporate NHS practices. In 2007 he purchased his current business and has developed it into a successful, award winning cosmetic and sedation centre. He is a full member of the British Academy of Cosmetic Dentistry. Chris McConnell, St. Piran Dental Practice, Wheal Leisure, Perranporth, Nr Truro, Cornwall, TR6 0EY e. info@stpirandental.co.uk

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