Best-in-class materials and CAD/CAM technology work together to provide a long-lasting esthetic solution
Dental technician Michael Roberts (CMR Dental Lab, ID) and
Dr. Adam Unterbrunner (DDS of Chicago, IL) team up to meet a female patient’s demands for a more natural smile. She was dissatisfied with the shape, length and color of her 10-year-old anterior veneers as well as the unnatural appearance of her smile. She wanted a more esthetic and functional solution.
The goal of restorative treatment is to re-establish the natural look, form and functional properties of the patient’s tooth structure. When faced with an extensive reconstruction, the combination of carefully selected modern materials combined with technology and manual skills can achieve outstanding esthetic and long-lasting results.
The initial examination revealed several challenges. The existing veneers on teeth #4 and #6-#13 and implant crown on tooth #5 lay on a flattened plane with no natural curvature to the posterior. Inadequate tooth length of the central incisors lacked golden proportions and exhibited axial inclination issues. In addition, there was insufficient incisal edge display at rest, inadequate buccal corridors and a general lack of symmetry throughout. Marginal leakage around the veneers was also observed.
The treatment plan proposed to the patient was to replace the veneers on teeth #4 and #6-#13 with full-contour crowns and convert the cement-retained crown on #5 to a screw-retained crown in order to achieve the proper emergence profile and gingival margin heights. Her existing central incisors were 9.5mm wide by 11mm in length. To achieve the correct golden proportions, 1.5 mm would need to be added to the central incisors by adding 1mm to the incisal edges and 0.5mm in gingival height via laser gingivectomy. To blend the gingival height throughout the arch, laser gingivectomy was performed where needed, varying from 0.5 to 1.5 mm. The decision to use the same restorative material for all restorations would allow for the morphological changes necessary to achieve the esthetic results the patient desired.
Digital photographs and intraoral scans of the patient smiling were sent to the laboratory to create a virtual diagnostic waxup of the proposed case outcome. The technician aligned the digital photograph of the patient and intraoral scan in smile design software (3Shape, www.3Shape.com) and created a virtual diagnostic proposal of the final case outcome, based on facially generated esthetics. Screen shots of the proposed esthetic solution were shared with the clinician and patient using TeamViewer (www.teamviewer.com) for case acceptance and approval. With approval granted, the laboratory 3D printed a model of the diagnostic digital design proposal and created a silicone matrix to send to the practice for fabrication of temporary restorations and as a guide in the preparation of the teeth.
At the second office visit, the clinician removed the old veneers and cement-retained implant crown. Mild tetracycline staining on all the teeth would necessitate using a highly esthetic restorative material with block-out capabilities to mask the discoloration. The restorative team decided to use IPS e.max ZirCad MT Multi (Ivoclar, www.makeitemax.com) polychromatic layered zirconia for the final restorations due to its high strength and translucency as well the ability to preserve natural tooth structure with conservative preparations.
The teeth were prepared and the gingiva recontoured to provide ideal gingival symmetry. An intraoral scan as well as a traditional impression were taken of the preparations. To fabricate the temporary restorations, the silicone matrix provided by the laboratory was prepared using Protemp Plus B1 bis-acrylic (3M, www.3m.com). A smile check was performed to refine and perfect her smile. Using the tack-and-lock-on technique, the temporary restorations were fabricated in-office and tried-in for patient approval. With patient approval of the temporaries, the provisional crowns were locked on with a spot etch and spot bonded with Scotchbond Universal Adhesive (3M, www.3m.com). Digital photographs and intraoral scans of the seated temporary restorations were sent along with the scans and traditional impression of the tooth preparations to the laboratory for fabrication of the final restorations.
Final Crown Fabrication
The laboratory created a stone model from the impression taken of the tooth preparations, scanned it, and aligned the scan with the intraoral scan of the seated temporaries and full face digital photo of the patient smiling with the temporaries in place. The digital design of the final restorations would exactly mirror the design of the approved temporary restorations.
The final full-contour zirconia restorations and implant crown were milled from IPS e.max ZirCAD Multi BL1 zirconia (Ivoclar Vivadent, www.ivoclarvivadent.com) on the PM7 milling machine (Ivoclar Vivadent, www.ivoclarvivadent.com). Once milled, surface morphology and internal staining were applied in the green state prior to sintering. The fully sintered restorations were customized, using MiYO liquid ceramic (Jensen, www.jensendental.com) to increase the depth, vitality and texture of the final case, glazed and fired.
The final full-contour crowns and screw-retained implant crown were delivered to the practice for seating. The clinician removed the temporary restorations, cleaned the preparations, and used Multilink Automix (Ivoclar Vivadent, www.ivoclarvivadent.com) self-curing adhesive system to permanently seat the final restorations. The patient was thrilled with her new esthetic smile.
Dr. Adam Unterbrunner
Dr. Adam Unterbrunner received his Doctorate of Dental Surgery from the University of Iowa College of Dentistry and currently practices in Chicago, IL. He provides comprehensive dentistry with a focus on Cosmetic Dentistry.His philosophy is to treat patients like family: provide the highest quality care with minimally invasive techniques, a focus on prevention of future dental disease and treating everyone with honesty, respect and compassion.
Dr. Unterbrunner is passionate about learning and implementing new technology in the clinic to improve patient experience and treatment quality. He is currently a Platinum Plus Invisalign Provider and is a member of the American Dental Association, Illinois State Dental Society, Chicago Dental Society, Academy of General Dentistry, American Academy of Cosmetic Dentistry, Pacific Aesthetic Continuum (certified Full Smile Makeover and Full Mouth Rehabilitation). When he isn’t practicing dentistry, Dr. Unterbrunner can be found spending time with his family enjoying music, cooking, golfing and cheering on his favorite local sports teams.
@dr.adam_smile_studio | email@example.com
Dr. Michael Roberts
Michael Roberts studied electronic, laser, and optics at Idaho State University. After graduating in 2006, he applied this knowledge working as a government contractor in Las Vegas, NV. In 2013, Michael pursued his passion for digital technology by joining CMR as Director of Computer Design and Milling.
Since then he has overseen digital diagnostic treatment planning as the main diagnostic designer and is currently focusing on ceramic cases. He is working towards his AACD accreditation and has taught several courses at The Pankey Institute. When not working, Michael enjoys anything to do with the outdoors especially skiing, mountain biking, and kayaking