This athletic young boy had an accident on a soccer field about a week earlier and shattered the incisal edges of his central incisors. Other than some cold sensitivity, the teeth were asymptomatic.

The fractured pieces were lost and there was no pulpal exposures. There were some fracture lines passing through the remaining tooth structure with transillumination, but the remaining teeth were sound and radiographically displayed no root fractures.

We discussed the need for improvement of oral hygiene and anesthetized with 1.8 ml of 2% Lidocaine 1:100000 epinephrine. The surfaces were micro-abraded with 50 micron alumina oxide, etched with 37% phosphoric acid for 15 seconds, de-sensitized with Gluma (Bayer) and bonded with layer of Optibond Solo Plus (Kerr). After light curing for 20 seconds per tooth, the dentinal form was rebuilt with Venus AO2 (Hereaus) leaving the incisal edge irregular and light cured for 20 seconds. A second layer of Venus A1 was added and built slightly short of the final length and full facial contour. Composite tints were then used (Kerr Kolor Plus , white, lavendar and ochre) with a fine sable brush to create internal characters before a final layer of Durafill A1 (Heraeus).

The teeth were shaped with a fine tapered diamond bur and polished with an Enhance polishing cup (Caulk Densply), a blue and pink polishing cup (Cosmodent) and finally finished with a rotary brush (Kerr) in a slow speed.

The Durafill is most translucent and allowed the dentinal build-up and the composite tints to show through giving a life-like appearance. Placing a slightly irregular incisal edge mimiced the adjacent dentiton.

As the teeth rehydrated, the color match was very good and the surface texture and luster was very similar to the natural dentition.

The finished restorations recreated the natural form of the missing tooth structure and blended invisibly.

This patient presented wanting a brighter smile that didn’t have the spaces between her teeth.

Asymmetries in the gingival contours complicated the multiple spaces. The shade of this patient’s teeth was also a factor, but shape will always trump shade. The treatment plan included bleaching and 8 maxillary and 4 mandibular indirect porcelain restorations.

A silicone putty matrix (Siltech by Ivoclar) was made from the diagnostic wax-up.

A diode laser was used to raise the gingival contour on the right central incisor and cut the facial frenum. The rule of thumb I use as to whether or not to perform a frenectomy is, if pulling the lip away with my fingers I can see movement of the papillae, then do the frenectomy.

Using a silicone matrix putty as a guide to form the minimal facial reduction. Cut dry so you can clearly see the margin, this will not create excessive heat if you use light pressure and a sharp bur.

To prepare conservatively, one needs a steady hand, good stable instrumentation, loops with great lighting and an attitude that dentistry is not sold by the pound. Less is best.

Conservative preparations predominately in enamel. To develop proper draw to place the final indirect restorations, keep close attention to the interproximal transition from the facial surface to the lingual margin. The lingual margin must be far enough lingually and gingivally to allow for placement by the ceramist of the porcelain to create a natural and cleanable contour.

Planning for the option of a future graft, stop the preparation at the tooth’s original CEJ or the level of the adjacent teeth.

Even though the teeth are wide, tapering the line angles toward the gingival (most apparent on the mesial of the right lateral incisor), reflects light to give the tooth a narrower appearance. Incisal translucencies also break-up the mass of a wide surface along with significant surface texturing.

Symmetry was created by developing gingival harmony and allowing the facial and buccal surfaces to flow from tooth to tooth. The maxillary gingival embrasures where closed successfully without creating a shape that was too square. As the tissue matures around the restorations, the papillae with form an even more intimate adaptation to the teeth. The gingival embrasures on the mandibular arch were not completely closed because it would have made the teeth too wide in the gingival areas. The margin along the mandibular right central incisor will be grafted with a soft tissue graft. The margin of the veneer stops at the tooth’s original CEJ so this procedure can be accomplished.

It is always interesting to see how much more sophisticated an individual looks when the spacing between multiple teeth are closed. The final result is proportional to the overall face and within the dental arch. The teeth tend to have a squarer form when closing gingival embrasures or diastemata and tapering the line angles of the individual teeth toward the gingival areas keeps the appearance most natural.

This patient wanted to have a fuller and brighter smile and display less gingiva when she laughed.

The maxillary teeth were all lingually inclined and there was an adequate band of attached gingiva.

The gingival marginal tissue has been lased with a diode laser (Navigator by Ivoclar) and the enamel acid etched for composite placement. The laser is ideal for this application because of the precise control of the cutting element and a bloodless incision. This allows for immediate composite placement.

A highly polishable microfill composite (Heraus Durafill) was placed in the gingival areas of the lengthened teeth to act as a healing matrix for the tissue, reduce root sensitivity and provide nice aesthetics. After the composite was cured a full thickness flap was dissected over all four incisors but the papillae were not cut. The tissue was carefully stretched to gain access to the osseous margin which was reduced and contoured. With the tissue reflected the gingival margins of the composites were finished and polished.

Immediately post surgery with 3 interrupted Vicryl 6-0 sutures in place to retighten the tissue. The sutures were removed 7 days later and the area allowed to heal three months before the final preparation appointment.

Diagnostic wax-up of final form. The shiny surface on the model is from a coating of liquid floor wax (Future by Johnson and Johnson) that seals the stone and keeps unset putty from sticking during the stint construction.

Stint made from condensation silicone putty (Siltech by Ivoclar) adapted over the diagnostic wax-up.

Luxatemp (Zenith) placed over the teeth prior to preparation was allowed to set for 2 1/2 minutes before removal of the stint.

A 0.5mm wheel diamond was used to cut depth grooves and stopped cutting when hubbed. Use a single wheel instead of multiple wheels on a single shaft because the tooth has a curve to the surface.

The wheel diamond was used to cut through the temporary matrix and left marks on the tooth structure identifying where less than 0.5mm clearance existed. You could certainly cut multiple horizontal lines for more guidance.

You can just see a few spots (wheel bur marks) where the projected shape of the final restorations would have inadequate reduction. Because all of these teeth are tipped lingually, the only areas that needed reduction were gingival to the marks. The incisal edges were reduced just to give a bit of room for translucency to be built into the restorations and the remaining enamel was scuffed. You can be more conservative in preparation if you reference the final form in three dimensions as you prep.

The completed preparations prior to the impression. To adequately close the gingival embrasure between the central incisors, the contact was broken and the the finish line moved to the lingual. Another choice would have been to fill the embrasure by bulking the gingival of each tooth in composite before prepping and keeping the mesial margins facial of the contact. This design even though more aggressive, gives better longevity to the restorations.

The completed shaped, glazed and polished provisionals at the end of the preparation appointment. The occlusion is verified for proper clearances and function. The nuances of aesthetics, phonetics and function will be reviewed with the patient while the final restorations are being fabricated. In addition to good clinical photos, your ceramist will certainly appreciate a precise impression or model of the provisionals as you have finally shaped them.

This 58 year old male patient who smokes heavily, has moderately advanced periodontal disease under marginal control had been diagnosed with a non-restorable upper left central incisor that had been temporarily repaired and was slated for extraction. The practicality of an implant replacement had been explored and declined.

The periodontal disease had been stabilized for the time being. To limit a negative periodontal reaction, the provisional bridge design was supragingival. The gingival embrasures in the provisional will be closed for a better aesthetic appearance.

The preps were as parallel and as bulky as possible for retention and strength. A model and wax-up had been previously done and a condensation silicone putty stint made prior to the appointment.

The tooth was atraumatically extracted and a stainless steel wire tacked to the preps. Flowable composite (A-3 Revolution by Kerr) was placed over the wire and a pontic form was created then cured. About 1/3 of the way into the extraction site was a piece of cotton to prevent the composite from flowing to far into the site.

The stint was filled with Zenith Luxatemp (A-1), placed over the wire framework and preps that had been coated with mineral oil and allowed to set for 2 1/2 minutes. The set material was gently removed with hemostats and shaped with a rotary tapered fine diamond bur. The final polish was done with Enhance finishing cups (Caulk Densply) and composite tints (Kerr Kolor Plus) applied to create a life-like appearance. The shades used were ochre, lavender and white. The surface was then coated with an unfilled resin (Heliobond by Ivoclar). After light curing the surface was polished with a dry 2×2 piece of cotton gauze for a lustrous finish.

The gingival tissues were recreated using pink composite (Cosmodent) medium and light shades and a little blue tint (Kerr Kolor Plus). Note how the pontic extends slightly into the extraction site for an ovate healing surface.

The provisional bridge was placed with TempBond Clear (Kerr) and the tissue will be allowed to heal for 3 months before construction of a final prosthesis.

Pre-treatment photograph of the mandibular area dentition. All four incisors had been endodontically treated and were failing. The left lateral incisor had a draining fistula.

The site has been prepared for the fabrication of the provisional (see more detail of the technique under the blog archives “Provisional Cosmetic Bridge”). The whitish surface on the gingiva is due to brief application of Superoxyl (37% Hydrogen peroxide) which allows for adequate hemostasis while provisional material sets without staining.

A wire was suspended between the abutment teeth for the provisional bridge. 2mm Connect fiber (Kerr) was wrapped over the top of the abutments and coated with a flowable composite Zenith Luxaflow)The incisors have been reduced to the gingival level to allow for the creation of the proper form of the provisional. The roots of the incisors were removed at the time of implant placement in the areas of the lateral incisors.

At approximately 6 months later, the alveolar ridge collapsed more than expected. The titanium endosseous implants are discernible in the positions of the lateral incisors.

The base of the alveolar ridge is only 0.6mm thick between the areas where the implants were placed. The buccal frenum is noted by pulling the lower lip down and away.

A diode laser (Odyssey by Ivoclar) was used to cut the frenum, reducing the muscle pull on the future graft site for ridge augmentation.

The modified provisional with pink composite (Cosmodent) added on the gingival to simulate gingival tissue. A combination of medium and light pink were used with addition blue and red composite tints (Kerr Kolor Plus).

The modified provisional in place prior to attempting bone ridge augmentation. The laser incision will heal uneventfully and will release some of the muscle pull on the graft site.