Dr. Spoors Blog

Another Provisional Cosmetic Bridge

Spoor — Wed, 19 Dec 2007 07:17:11 +0000

Another Provisional Cosmetic Bridge

Pre-treatemnt photograph of the mandibular area dentiton. 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.

Provisional Cosmetic Bridge

Spoor — Wed, 19 Dec 2007 07:14:23 +0000

Provisional Cosmetic Bridge

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.

Closed Osseous Crown Lengthening and Minimal Veneers

Spoor — Wed, 19 Dec 2007 07:13:44 +0000

Closed Osseous Crown Lengthening Followed by Minimal Indirect Veneer Preps

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.

Welcome

Spoor — Thu, 13 Apr 2006 22:24:29 +0000

Welcome

Hello, I am Rhys Spoor and I offer a hearty welcome to a forum on the artistic side of cosmetic and restorative dentistry. We are in a wonderful time when the only thing that limits our ability to replace or enhance the natural dentition is our imagination.

The intent of this forum is to share innovating and new ideas that can increase your ability to create truly lifelike dentistry that is beautiful and durable. Everything shown, I do in my practice and there are no hidden agendas. There is no financial interest or compensation in any of the products or materials I use. If ever there was, I would tell you. The forum is designed to be heavily imaged based with short descriptive text and meant to be read and understood in minutes.

I encourage comments, questions and interactivity. The whole point is to learn and grow form each other and help our patients enjoy better dental health and beautiful smiles.

Again, a hearty Welcome!