Meeting an anterior esthetic challenge

First, we take the shade before the teeth become dehydrated. I use the VITA Easyshade Compact (Vident; Brea, Calif.), which displays the shade in both VITA Classical and VITA 3D-Master shades. After taking the shade, I hold the selected 2M1 3D-Master shade tab to the tooth, along with the 1M1 3D-Master shade tab for contrast.

Next, we photograph the shade tabs in the mouth. This is probably the most important part of communicating shade to the technician.

I use an Ultradent syringe to place PFG gel (Steven’s Pharmacy; Costa Mesa, Calif.) into the sulcus of teeth #8 and #9. Next, I use a STA Single Tooth Anesthesia System device (Milestone Scientific; Livingston, N.J.) to anesthetize teeth #8 and #9.

The Razor Carbide bur (Axis Dental; Coppell, Texas) easily cuts through porcelain and metal substructures, and when used in combination with my KaVo ELECTROtorque handpiece (KaVo Dental; Charlotte, N.C.), it is simple to cut through the existing PFM. I torque the crown with a Christensen Crown Remover (Hu-Friedy; Chicago). After using a periodontal probe to sound to bone to ensure I have enough biologic width to safely remove some tissue (Fig. 2), I use my NV MicroLaser (Discus Dental) to remove 1.5 mm of tissue.

With the margins exposed, I use an 856-025 bur (Axis Dental) and KaVo ELECTROtorque handpiece to drop the margins to the new gingival level. My assistant then relines BioTemps Provisionals (Glidewell Laboratories) on teeth #8 and #9 with Luxatemp provisional material (DMG America; Englewood, N.J.).

Using a thin, perforated diamond disc (Axis Dental), we open the gingival embrasures to avoid blunting the interproximal papilla, and we make sure the gingival margins aren’t overextended and the emergence profile is flat.

We use TempBond Clear (Kerr Corp.; Orange, Calif.) to cement the BioTemps, and we use loupes to inspect around the temporaries and gingival embrasures for excess cement.

Second appointment

After two weeks, we remove the temps and clean the preps with a KaVo SONICflex scaler. After trimming the gingival margin with the diode laser, I place an Ultrapak cord #00 (Ultradent; South Jordan, Utah), cutting the cord intraorally on the lingual to avoid any overlap. To make the margin visually obvious, I place a second cord (Ultrapak cord #2E) before refining the preparation.

As I pack the top #2E cord on tooth #8, you can see how the top cord on tooth #9 exposes the margin (Fig. 3). Now we can begin finishing the preps using a fine grit 856-025 bur.

Two moistened ROEKO Comprecap Anatomic compression caps (Coltène/Whaledent; Cuyahoga Falls, Ohio) are placed on the preps, and the patient is asked to bite with medium pressure for eight to 10 minutes.

The Comprecaps are then removed and the top cords pulled. We syringe medium body impression material around the preparations for the impression and then take a bite registration. The temporaries are then replaced.

Third appointment

After two weeks, the temporary crowns are off, the BruxZir crowns are approved, and we place a layer of desensitizer on the teeth (G5 All-Purpose Desensitizer [Clinician’s Choice; New Milford, Conn.]).

I use a Warm Air Tooth Dryer (A-dec; Newberg, Ore.) after applying both coats of the G5, while my assistant places Z-PRIME Plus (Bisco; Schaumburg, Ill.) inside the crowns. We then load the crowns with a resin-modified glass ionomer cement (RelyX Luting Plus Automix [3M/ESPE]) and seat them, using a pinewood stick (Almore International; Portland) to ensure they are fully seated and the same length.

In this “after” picture (Fig. 4), the amazing thing is there isn’t any porcelain on these BruxZir crowns; they are solid zirconia. This is why they are stronger than all other restorative materials, except cast gold.

Also, the facial anatomy on the crowns makes them look like real teeth. Because that anatomy is built into the CAD/CAM database, Glidewell Laboratories can deliver it every time — provided the clinician gives the lab enough reduction.

While I’m not suggesting you suddenly switch all of your anterior restorations to BruxZir crowns, you may want to consider using it for patients with parafunctional habits or old PFMs, where an esthetic improvement is essentially guaranteed.

Note: This article appeared in Dental Tribune U.S. Edition, Vol. 7, No. 2, February 2012.