Figure 1: The patient was extremely timid and shy. It took quite a lot of coaxing to get even this tepid smile out of her.

Figure 3: The first big challenge was the enormous mesial-distal width of the anterior space, which was almost large enough for two teeth. At one point, there was probably a diastema between teeth #8 & #9 — an indication not easily fixed with a flipper. There was simply no drop-in solution. One wide tooth would make the patient look like a beaver; on the other hand, placing two teeth in the space would require them to be unnaturally narrow. The main challenge of this case was the redistribution of tooth width. We decided to prep the interproximal surfaces relatively aggressively, giving the lab room to add more to the mesial and less to the distal. The net result would be mesial “movement” of the teeth via fixed prosthodontics. Outside of orthodontia, this solution was deemed the best way to fix such a large diastema.

Figure 4: The patient would have benefitted from palatal expansion during her formative years, but as clinicians, we have to deal with what we are given. Several steps were taken to capture an accurate photo for the lab and ensure its clarity. First, we used an Occlusal Contraster (PhotoMed; Van Nuys, Calif.) to remove any unnecessary tissue from the frame. The mirror was warmed in hot water first and then dried with a micro-fiber cloth to prevent fogging. By hovering our suction just outside the frame of the picture and using the air syringe sparingly, we avoided splashing saliva on the mirror and ruining the shot.

Figure 5: The other big challenge of the case was the vertical atrophy of the ridge. Without the benefit of bone grafts, an elongated pontic or an overly long implant crown is created. This could be less of a problem with a removable appliance.

Figure 6: From the three-quarter view, you can really see the patient’s dramatic atrophy and overbite. The case presented inadequate clearance for implants, bridges or even partial dentures because every one of these procedures requires at least some vertical clearance.

Figure 7: My two keys to shade success are using the VITA 3D-Master^® Shade Guide (Vident™; Brea, Calif.) and sending accurate photographs to the lab. A black-and-white image more clearly shows the technician the value of the tooth relative to the reference shade. Even if your shade selection is off, accurate photographs will tell the technician by how much. If you give good visual information to a good lab, you should never fear the single veneer. If we insist on adhering to the outdated “six veneers or more” mentality, we lose out on smaller cases. You might have a patient with five to seven veneers and one or two chipped ones, or you may run into a young patient with peg laterals in an otherwise gorgeous smile. These smaller cases require precise matching that is only attainable through clear communication with the laboratory.

Figure 8: Photographing with an Anterior Contraster (PhotoMed) shows the lab the amount of incisal translucency. Using one is helpful for makeover cases and crucial if you are only doing one or two front teeth. There is nothing worse than a lonely opaque tooth — except for maybe a dead-looking, overly translucent tooth. If you don’t have a contraster, you can use black matboard and throw it away afterward, or have the patient open his or her mouth slightly to remove the lower teeth from the frame. At minimum, the photographs necessary for an anterior case are: a facial portrait with the patient smiling, a frontal shot with the lips retracted, that same retracted frontal with a shade tab in place, and a retracted frontal with a contraster in place (pictured above) for translucency. I also include black-and-white copies of the images with shade tabs in them to show the relative value. Again, if you happen to pick the wrong shade, the benefit of the photos is that the lab technician can see the tooth positioned next to your selected shade tab and work from there.

Figure 10: Next, I fabricated a custom tray from cold-cure acrylic (Super Dent Self-Cure Tray Plastic [Darby Dental Supply; Jericho, N.Y.]) and painted it with V.P.S. Adhesive (Kerr Corp.; Orange, Calif.). When doing eight units, the uniform impression thickness, stiffness and accuracy created with a custom tray are really nice to have. Sometimes I use triple bite trays (Harmony Posterior [HO Dental; Las Vegas, Nev.]) to save time and material, but I reserve them for single-tooth cases.

Figure 13: To capture a bite record along with the patient’s midline and facial planes, I used an anterior triple bite tray (Harmony Anterior [HO Dental]). The tray is designed to take impressions and the bite record at once, but I still prefer separate trays for multi-unit cases.

Figure 14: To create my temporaries, I injected self-cure temporary resin (Protemp™ Plus Temporization Material [3M ESPE]) into a lab-fabricated putty mold of the diagnostic wax-up. The minor voids were patched with CLEARFIL MAJESTY™ Flow composite (Kuraray America; New York, N.Y.).

Figure 15: It is very tough to polish these delicate veneer temps, so instead I painted on OptiGuard^® (Kerr Corp.) to create a deep gloss clear coat. OptiGuard also fixes the dreaded white finish lines in your composites. TempBond^® Clear™ (Kerr Corp.) was used to cement the one-piece temporary. Teeth #11 & #12 broke off, but it was not a big issue as they were minimal veneer preps to begin with.

Figure 18: Obsidian ceramic was ultimately chosen for its better esthetics and stronger veneer bonding. I used Ivoclean (Ivoclar Vivadent) to clean the intaglio surface of the all-ceramic restorations. Applying a generous drop or two directly into each restoration works great. Give it a good scrubbing to clean off the phosphate bonding sites, and your bonding strengths will be dramatically improved.

Figure 19: The new generation of “universal” bonding agents contains a silane group, so you apply them to the intaglio surface of the restoration just as you would a silane primer. Gel Etchant (Kerr Corp.), Scotchbond™ Universal Adhesive (3M ESPE) and RelyX™ Ultimate (3M ESPE) were used to bond the Obsidian bridge. RelyX™ Veneer Cement (3M ESPE) was used to bond the veneers. NOTE: “Universal” bonding agent really means “self-etch priming adhesive with silane.” These materials bond to tooth structure, light-cure resins and etched ceramics. Unless specified by the manufacturer, they are not compatible with dual-cure resin cements or dual-cure core buildup materials.

Figure 24: Finished upper anteriors photographed with contraster in place. Gratuitous incisal translucency looks great in glossy lab brochures, but often you really just need a touch of it. If the lab adds too much translucency, the darkness of the mouth will show through, and the restorations will look gray and lifeless. If time and resources had permitted, crown lengthening of tooth #9 would have been helpful.

Figure 25: View of the post-op maxillary occlusal arch. Eight units were done spanning teeth #5–12, instead of the customary six, in order to fill out the buccal corridor. Very little preparation was done on the canines and premolars.

Figure 26: In order to make room for the bridge connectors, I had the lab open the articulator 2 mm. No adjustments were made when seating the restorations, so everything initially felt very high. Using the bite stop technique borrowed from the orthodontic field, composite was bonded to the functional cusps of the lower posterior teeth (see teeth circled in image). After etching and bonding, I cured the composite as the patient bit down on it. Basically, the patient was reverse equilibrated with occlusal buildups. Compared to a full-arch reconstruction, this is a more conservative way to make small changes in vertical dimension. If the composite breaks off the occlusal surfaces, it is easily replaced. Best-case scenario, the composite wears faster than the ceramics up front and the posteriors gracefully extrude to rebalance the bite. Only time will tell.