CHIEF COMPLAINT:
The patient showed particular interest in improving her aesthetic appearance.
DIAGNOSIS:
Female patient, 44 years old, smoker. Presented a three-element metal-ceramic bridge on the first quadrant, with teeth 1.4 and 1.5 as pillars and 1.6 as distal pontic. Endodontic treatment on the abutment teeth needed to be redone. The four upper teeth had extensive resin restorations, tooth 2.1 had endodontic treatment and the rest had apical processes. The second quadrant had a metal-ceramic bridge on the two premolars with endodontic treatment. Tooth 2.6 was missing and 2.7 had endodontic treatment. On the lower jaw, the third quadrant was missing teeth 3.6 and 3.7. Teeth 3.4 and 3.5 were pillars of a metal-ceramic bridge with two elements. These pillars had endodontic treatment with apical pathology. Soft tissues were somewhat inflamed on the anterosuperior sector, and gingival architecture showed the side aisles in need of a clinical crown aesthetic increase. The patient practiced good oral hygiene.
TREATMENT PLAN:
After clinical and imaging analysis, study model casts mounted on semi-adjustable articulator were analyzed, together with the dental technician. Patient was presented with a plan involving endodontic treatment of teeth 1.2, 1.1 and 2.2, and redoing the endodontic treatment of teeth 1.4, 2.1, 2.4, 2.5 and 2.7. For the first quadrant, tooth extraction was proposed for tooth 1.5 and aesthetic crown lengthening for 1.4. Following that, two implants would be placed (1.6 and 1.5) to support a screw metal-ceramic bridge over the implants, cemented on tooth 1.4. For the anterosuperior sector, after placement of fiber posts, a four-element Zr-ceramic bridge was planned. On the second quadrant, after reworking the endodontics, metallic posts would be placed for a three-element Zr-ceramic bridge. On the third quadrant of the lower jaw, teeth 3.4 and 3.5 would be extracted, and three implants would be installed to support a four-element Zr-ceramic bridge. Six years later, the patient wanted to change the morphology and color of the upper canine teeth, for aesthetic reasons. The plan to address this requirement consisted of two feldspathic ceramic veneers, without tooth preparation. Being minimally invasive, this procedure would preserve the palatal surface with its functionality unhindered.
TEAM PLAY ‘DENTIST – DENTAL TECHNICIAN’ NOTES:
After reworking endodontic treatment on tooth 2.1 and performing it on 1.2, 1.1 and 2.2, intra-radicular fiber posts were placed. On the second quadrant, endodontics were reworked and intra-radicular metallic posts were installed. Two provisional acrylic bridges were prepared in the lab, one with four elements (1.2 / 1.1, 2.1, 2.2) and another with three elements (2.4, 2.5, 2.7). After dental preparation of the four incisors and second quadrant bridge removal, provisional bridges were relined in mouth. An aesthetic crown lengthening was also previously done in the second quadrant. On the lower jaw, two implants were placed in the edentulous space. After eight weeks, a four-element screwed provisional bridge was placed, with teeth 3.4 and 3.5 in extension. Tooth 3.5 was extracted and the temporary bridge was placed in mouth, screwed on the implants and supported by the implant placed on the 3.4 location. In the first quadrant, tooth 1.5 was extracted and two implants were placed on locations 1.6 and 1.5. The metal-ceramic bridge was removed and replaced with a provisional two-element bridge (1.4 as dental abutment and 1.5 as pontic). After osseointegration of implants and soft tissue maturation, prints were made, yielding working model casts for the plastic pre-infrastructures to be tested in the mouth. A mismatch was detected in the vestibular area of ​​the upper incisors. The plastic pre-infrastructure was relined with composite resin after gingival retraction with kaolin paste. This was followed by a pick-up impression with wash technique. After this adjustment, infrastructures were prepared and ceramic was placed. The ceramic was proofed in the mouth, achieving clinical approval. Final work was placed on the mouth after aesthetic approval by the patient.
After six years of presence in the mouth, this treatment was completed with the placement of two "No Prep" type feldspathic ceramic veneers on the upper canines. Color selection was supported by individual color guides. After placing a gingival retraction cord, a print was done with wash impression technique. Veneers were prepared on a Geller type model with custom color torques. Veneers were bonded in-mouth with relative isolation.