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Inside Dental Technology
September 2015
Volume 6, Issue 9
Peer-Reviewed

Accident Case: Diagnosis and Prep Design Following the Treatment Plan Wax-Up

Utilizing a specialized digital concept to create natural color

Luke S. Kahng, CDT

Technicians often face difficult cases and have to imagine themselves in the patient’s mindset to help understand the patient’s experiences and expectations. This case study will focus on a female in her mid-20s who had been in a car accident. Her case was, therefore, rehabilitative. By the time she came to see the author, she had received oral surgery in order to have 3 implants placed.

In this process, she had consulted with multiple dental professionals and had decided on a treatment plan and detailed guide for her final restorations. She was looking for predictability but also high esthetics.

When she visited the author’s laboratory for her appointment, she was wearing a plastic flipper, which was easy to fit into her mouth and remove. But due to problems caused by the missing dentition, the adjacent teeth had shifted and created subtle occlusion contact. The mandibular teeth erupted, hence the need for placement of 3 implants, as noted above.

During the custom shade appointment, the author recorded that the patient’s midline had been offset and would need correction during the rehabilitation. Her flipper was strictly temporary, which she knew. The patient was eager to begin the rehabilitation of her smile.

Through the outlined treatment plan, preparation design, wax-up contour, and tooth shaping, the author was able to utilize the specialized digital concept to create natural color from an excellent foundation and create high esthetics for the patient.

Case Study

Figure 1 shows how the preoperative model had been poured up and mounted with the opposing. In this mounted alignment, the arches lined up. Next, with a pencil, the author drew black lines on the model to break the interproximal contact (Figure 2) from the canine to the central in order to “open up” the central teeth. Figure 3 provides an occlusal view for facial reduction and the incisal 1.5-mm reduction. Figure 4 shows a black line that the author had drawn to mark the tissue contour that he and the dentist discussed preparing. The clinician later performed a gingivectomy to help create that rounder appearance in the shaping of the gingiva line.

The author then moved forward with his preparation design for the canines. After completing the model preparation, he photographed the frontal and side views. The rough wax design was completed on the model for teeth Nos. 6 and 8 and then for tooth No. 7 as well (Figure 5).

The author then placed a titanium base onto the model for the implants (Figure 6) and created dummy copings from his in-house milling machine. The implant cement-retained dummy copings were placed on the model (Figure 7). The author then completed the wax-up (Figure 8). He later recommended a screw-retained bridge because, in his opinion, the laboratory would not be able to duplicate the patient’s tissues with cement-retained restorations. He believed the gingival line area would need high contour for tissue and shape, and the dentist agreed.

The processing and milling of the restorations was handled in the laboratory with Ceramill Motion 2 milling machines (Amann Girrbach, amanngirrbach.com). The pre-shaded appearance is shown in Figure 9. After sintering, the margins and design were modified (Figure 10). In the author’s opinion, this stage is critical because the frame design must not be compromised. Next, the facial contour for the screw-retained bridge is shown on the model (Figure 11).

An interior color No. 44 was applied (Figure 12) before an A1 base dentin (Figure 13), and then was cut back. After firing at 810° C, the copings were then ready for their second buildup. On the model, the author performed a facial contour check for teeth Nos. 6 through 11 (Figure 14). Various shades of porcelain were used during his multilayering technique, illustrated in Figure 15 during his second buildup consisting of dentin, enamel, and pink porcelain for gingival enamel. After firing, the restorations were again placed on the model (Figure 16) before being baked a third time. In Figure 17, the restorations are in the bisque bake stage, and Figure 18 shows a mirrored image of the screw-retained, layered porcelain implant bridge.

Preoperatively, the patient was wearing the aforementioned plastic removable flipper, and the dentist took an impression for the laboratory (Figure 19). Figure 20 is an image of his preparation design for teeth Nos. 6 through 8 and implants for site Nos. 9 through 11. A shade check was noted for the lower anterior teeth (Figure 21) before the pink tissue color was selected using the author-fabricated ceramic shade tabs (Figure 22). For a final preparation color check, the author again used his ceramic shade tabs.

The screw-retained implant zirconia bridge was tried in for teeth Nos. 9 through 11 and then teeth Nos. 6 and 7 singles, after which tooth No. 8 was added for an immediate smile view (Figure 23). An occlusion view is shown in Figure 24, with healing caps in place and then a left view comparing the size of teeth Nos. 7 and 9 (Figure 25). Immediately after a full try-in, the author photographed the patient from multiple views. The final image of the patient illustrates the harmony and blending of color that the author was able to achieve due to the planning and care taken with the case during each step (Figure 26). A radiograph of the screw-retained bridge is the final image (Figure 27).

Conclusion

By having open and continual communication, the dentist, patient, and technician were able to reach the final goal established for this case. The patient was pleased with her final restorations, telling the author that they looked better than her natural teeth.

The treatment plan, material selection, color, and the size of the teeth had been discussed beforehand, leading to superior results. Everyone involved was happy with the outcome.

About the Author

Luke S. Kahng, CDT
Owner/Founder
LSK121 Oral Prosthetics
Naperville, IL

Fig 1. Preoperative models.

Figure 1

Fig 2. Pencil-line drawing to break interproximal contact.

Figure 2

Fig 2a. Pencil-line drawing to break interproximal contact.

Figure 2a

Fig 2b. Pencil-line drawing to break interproximal contact.

Figure 2b

Fig 3. Occlusal view.

Figure 3

Fig 4. A black line drawn by the author shows the tissue contour.

Figure 4

Fig 4a. Prep design for canine.

Figure 4a

Fig. 4b. Prep design for canine.

Figure 4b

Fig 5. After prep, frontal view.

Figure 5

Fig 5a. After prep, side view.

Figure 5a

Fig 5b. Wax roughly done for teeth Nos. 6 and 8.

Figure 5b

Fig 5c. Finished wax-up.

Figure 5c

Fig 6. Titanium base for implants.

Figure 6

Fig 6a. Dummy copings.

Figure 6a

Fig 7. Copings in place on the model.

Figure 7

Fig 7a. Wax-up.

Figure 7a

Fig 8. Completed wax-up.

Figure 8

Fig 8a. Amann Girrbach Ceramill Motion 2.

Figure 8a

Fig 8b. In-laboratory milling/processing.

Figure 8b

Fig 9. Mirror image of the pre-shaded appearance.

Figure 9

Fig 9a. Sinter stage.

Figure 9a

Fig 10. Modification of margin and design.

Figure 10

Fig 11. Facial contour for the screw-retained bridge.

Figure 11

Fig 12. Inside color application.

Figure 12

Fig 13. A-1 base dentin is applied.

Figure 13

Fig 13a. A-1 base dentin is applied.

Figure 13a

Fig 13b. Cutback.

Figure 13b

Fig 13c. After firing 810° C.

Figure 13c

Fig 14. Facial contour check for teeth Nos. 6 through 11.

Figure 14

Fig 14a. Post-firing, on the model.

Figure 14a

Fig 14b. Porcelain for multilayering.

Figure 14b

Fig 15. Second buildup consisting of dentin, enamel, and pink porcelain for gingival enamel.

Figure 15

Fig 16. After firing, the restorations are placed on the model.

Figure 16

Fig 16a. Third build-up.

Figure 16a

Fig 17. Restorations during the bisque bake stage.

Figure 17

Fig 18. Mirrored image of screw-retained bridge.

Figure 18

Fig 18a. Mirrored image 6 units.

Figure 18a

Fig 18b. Pre-operative/flipper.

Figure 18b

Fig 19. The dentist takes an impression.

Figure 19

Fig 20. Preparation design for teeth Nos. 6 through 8.

Figure 20

Fig 21. Shade check for the lower anterior teeth.

Figure 21

Fig 22. Tissue color check.

Figure 22

Fig 22a. Prep color - final.

Figure 22a

Fig 22b. Try-in screw-retained bridge.

Figure 22b

Fig 22c. Teeth Nos. 6 and 7 try-in.

Figure 22c

Fig 23. Immediate smile view with tooth No. 8 added.

Figure 23

Fig 24. Occlusal view.

Figure 24

Fig 25. Left view.

Figure 25

Fig 26. Final shot.

Figure 26

Fig 26a. Right side view.

Figure 26a

Fig 26b. Left side view.

Figure 26b

Fig 27. Radiograph.

Figure 27

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