Smile design for porcelain veneers

This patient wanted to improve the look of her front teeth.  Her teeth had staining, wear and decay around existing fillings as well as rotations that needed to be corrected.  Orthodontic treatment was an option, however she wanted an immediate result.  Crowns were made from Emax lithium disilicate and layered.

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Cosmetic composite bonding

Composite Veneers can be a cost effective treatment option for patients that are not ready to have a porcelain bonded restoration.  Composite  can be a conservative method of achieving an equally esthetic outcome with minimally evasive treatment and less time.  However, when compared to a laboratory processed  restoration, the added durability and stain resistance of the porcelain over time reflects the additional cost.

In this particular case, the patient just completed her orthodontic treatment and wanted to improve the esthetics of her front four teeth.  Her pegged laterals were narrow and the incisal edges of her front two teeth were chipped and unpleasant.

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“Closing the Gap” -Improving implant esthetics

Here is a basic case that illustrates the effect of simply changing the contact between an implant crown and a tooth.  Whenever we restore a implant restoration, particularly in the esthetic zone, we want to “close the gap” or “black triangles” as much as possible due to the loss of papilla. This is even more pronounced between two adjacent implants.

Depending on the width of the adjacent tooth, we are either adjusting the contact point back if we want to narrow the width of the tooth, or adding to the undercut.  This creates a broader contact point between the two teeth.  In this case the width was the same so we just added composite to the mesial undercut of #8 to create a long contact surface from the original contact point all the way down to the gingiva.  We then placed a new implant provisional on #9 to follow the same mesial contours and eliminating the dreaded black triangle. On this particular case, it helps to manipulate the tissue with a screw retained restoration than can be placed to apply pressure and manipulate the gingival contours. The provisional was screw retained, but because of the implant placement, the final crown will be cement retained to avoid a facial access. Because the tissue is already shaped in the provisional stage, delivery the custom abutment and cement retained final crown will be predicable and easy.

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The screw retained cemented crown

One of the most stressful procedures in dentistry is locating the screw access hole on a cemented crown. Its monday morning, and your new patient comes in with a complaint of a “loose implant crown.”  You take a radiograph and the implant is intact. 7 out of 10 times, the abutment screw is loose and was not torqued to the manufacturer’s recommended specification.  2 things go through my head: Where is this screw access hole? And did this previous dentist hopefully place a packing material to block out the top of the screw?

After doing rescuing so many of these implants, you wonder what can I do to make this easier for the next doctor? Answer: The screw retained cemented crown.  This allows the screw access hole to be easily located in case the crown chips (which is rare with monolithic emax), as well as replaced since the emax is cemented on a gold-hue custom titanium which can be salvaged and reused. This also allows the crown to be cemented outside the mouth to eliminate cement related implant failures and allows the margin to be placed far sub-gingival for esthetic purposes in case of any further recession. Simply a win-win situation. IMG_8639 IMG_8640 IMG_8641 IMG_8643 IMG_8647 IMG_8649