November 2012, Volume 8, Issue 11
Published by AEGIS Communications
In the Case of a Clinician
A dentist becomes the patient when he seeks out updated restorations for himself.
Because of his family’s financial limitations, the childhood dental visits of the patient—now a practicing dentist—were always on an emergency basis. With no fluoridated public water supply at that time, those dental visits resulted in significant restorative work on the clinician’s maxillary anterior teeth. The teeth had been well restored with bonded composites, but the incisal edges had begun to fail. In keeping with the standards he maintained for his own patients, he asked a friend and fellow clinician to perform the dental work for him.
Initially, he scheduled an appointment with the laboratory for photographs and custom shading and explained his goals regarding color and shape for his teeth. He sought life-like but age-appropriate shading and balance in his veneer work, the same outcomes he sought in his patient’s restorations.
Preoperatively, the attending dentist listened to the patient’s chief complaints, largely involving his reverse smile line and excessive wear to the anterior dentition (Figure 1). The central teeth had the appearance of being shorter in length than the canines and the posterior teeth seemed longer than the anterior.
Multiple photographs were taken, including shots of the existing dentition, shade tab photos (Figure 2), stump shade records, and digitalized images of the desired final results. Custom shading was handled in the laboratory setting using custom-made porcelain shade tabs. Radiographs showed the presence of Class 3 restorations, which would be given consideration during preparation. Tissue condition indications were: no inflammation present and normal gingival architecture. The clinician ordered a full-contour wax-up based on patient expectations (Figure 3) for the anterior maxillary and mandibular teeth Nos. 6 through 12 and 22 through 27. Correction of the crowding in the mandibular anterior was considered. However, it was decided that those teeth would be adjusted as needed to minimize functional risks. Treatment planning then focused on veneer placement for teeth Nos. 6 through 11 to restore normal proportion and contour.
An acrylic mock-up from a matrix of the diagnostic wax-up was used during tooth preparation (Figure 4). Initial preparations were made with an acrylic mock-up (Figure 5) in place representing the final contour of completed restoration. A 0.5-mm depth-cutting diamond established the initial reduction. After preliminary preparations, modifications were made to include coverage of any Class 3 interproximal restorations. Impressions were taken using a polyvinyl material, and the provisionals were fabricated using a silicone matrix of the wax-up and bisacryl temporary acrylic. The provisional restorations were divided into two 3-unit segments: 6–7–8 and 9–10–11. The initial temporary restorations were slightly longer than the patient desired, so they were shortened to meet his expectations before the final restorations were fabricated.
In the laboratory setting, the models were scanned and Aadva zirconia copings (GC Advanced Technologies, www.gc-at.com) were milled at the GC Milling Center (Figure 6). For better value, the color was modified. The dentin and enamel applications were layered onto the copings (Figure 7). GC Initial™ low-fusing porcelain (GC America Inc., www.gcamerica.com) in various colors was used in fabricating the restorations. After baking, the technician re-contoured the restorations in order to illustrate the preferred shape, using black and red pencil markings to demonstrate which areas to grind and by how much (Figure 8). After baking, glazing liquid was applied in order to check the final color. The technician’s porcelain layering technique was delineated underneath the glazing (Figure 9). A facial texture and color check was performed using a mirrored image of the stone model (Figure 10). The restorations were tried in the patient’s mouth for a fit, shape, color, and contour check. A protrusion view showed the harmony of color and blending of the restorations in the mouth (Figure 11). An angled view from the patient’s right side was checked for proper incisal silhouette (Figure 12). During normal conversation, a relaxed shot of the patient was taken for a fit check (Figure 13); a final full facial view (Figure 14) indicated results that were pleasing to the patient.
The goals and expectations of the patient were met. Added incisal length to correct the reverse smile line and restore the incisal wear was accomplished where necessary to reduce the risk of future decay. The patient, who was pleased with the results, reported that he got compliments on his smile all the time, with patients frequently saying they wanted “their teeth to look like his.”
From the technician’s viewpoint, it is a delicate matter to fabricate the case of a clinician when the clinician is the patient, especially one who has been a long-time client. It was helpful that the dentist had an enormous amount of experience and was very knowledgeable about color and shade matching. Before the case began, the clinician indicated he wanted a natural-looking but slightly brighter color to coordinate with his inherent dentition. With a two-dimensional shade tab, this type of color would have been difficult to master—even using multiple shade tabs in the effort to achieve harmony. Fortunately, custom shade tabs with layered porcelain were available, which made it possible to mimic the adjacent teeth as closely as possible.
As a professional, the technician cared about the results of his work and treated the clinician as he would any patient, producing the best possible work for his case.
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This case was provided courtesy of Franz Weyandt, DMD, a private practitioner in Naperville, Illinois. The author would also like to extend special thanks to Douglas C. Palmer, DDS, a private practitioner in Oswego, Illinois.
About the Authors
Franz Weyandt, DMD, PC
Luke S. Kahng, CDT
LSK121 Dental Laboratory