CHIEF COMPLAINT:
The patient disliked the appearance of her front teeth
DIAGNOSIS:
Female patient, 43 years old, non-smoker. Tooth 2.1 with darkened crown and restored, with a radical endodontic treatment. Tooth 1.1 presented a restoration in composite resin, class IV mesial with a significant color change. The upper incisors were slightly retro-inclined and displayed wear of the incisal edges, compatible with para-functional habits. The patient had a thick gingival phenotype and reasonable oral hygiene.
TREATMENT PLAN:
After clinical and imagiological analysis, the patient was proposed a rehabilitation for tooth 2.1 with an intra-radicular post and a total ceramic crown with Zr infrastructure. In relation to tooth 1.1, three hypotheses were considered: Redo the restoration with composite resin, make a veneer in feldspathic ceramic with incisal edge coating, or make a feldspathic ceramic “chip” without preparation of the vestibular surface. The patient, encouraged by me, opted for this last solution. This solution would have the advantage of being very conservative, while simultaneously assuming that it would be almost impossible to avoid a subtle line of interface between the prosthetic part and the dental structure. Weighing the pros and cons of this treatment, we chose to carry it out.
TREATMENT NOTES:
The treatment started with the placement of a metallic intra-radicular post. The root canal abruption was done with Peeso drills, always with imaging control. A post of the appropriate size was then selected. The post cementation was performed with dual composite fluid resin. Two weeks after placement of the intra-radicular post, the prosthetic procedure was started. A pre-impression was made in putty silicone, removed from the tray, and after dental preparation, used as a key for the temporary restoration in composite resin. The dental preparation of tooth 2.1 used a chamfer finish line and an intra-sulcular location. The dental preparation of tooth 1.1 was limited to the removal of the restoration and the standardization of the transition line. Gingival retraction was done using a kaolin paste, this material being compressed into the gingival sulcus with the help of the provisional. The impression used the double mixing technique with putty-soft and light viscosity material. The provisional bridge was cemented with polycarboxylate cement in tooth 2.1. In the laboratory, two different pieces were made: a full ceramic crown with Zr infrastructure, and a feldspathic ceramic "chip".
This work was carried out after collection of information by the ceramist with the patient. The placement of the work in the mouth was made after removal of the temporary bridge and careful removal of the cement remains. The crown was cemented first using resin-reinforced glass ionomer cement and then the “chip” was bonded. The insulation used was relative, and the bonding simply used the adhesive, and no composite resin was used in the laying of the prosthetic part. The finishes were made with particular care, first making use of the abrasive discs, always in the ceramic-tooth direction. Finally, adhesive residues were removed from the cervical and inter-proximal regions, with the aid of a scalpel blade. The occlusal contacts were verified and correct. The final polishing was done one week after the placement of the work. Although a Subtle Line interface on the vestibular surface of tooth 1.1 was noted, the treatment aesthetically satisfied the patient, while respecting my desire to be ultra conservative.