|Year : 2014 | Volume
| Issue : 2 | Page : 97-100
Prosthetic considerations for an esthetic rehabilitation: A confluence of art and science
Shobha J Rodrigues, Vidya K Shenoy, Thilak Shetty, Abhinav Sharma, Shruti Yakhmi, Sameen Dalwai
Department of Prosthodontics, Manipal College of Dental Sciences, Mangalore, Karnataka, India
|Date of Web Publication||15-Oct-2014|
Shobha J Rodrigues
Department of Prosthodontics, Manipal College of Dental Sciences, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Developments in adhesive dentistry have provided the dental profession with new restorative materials and technology to restore esthetics and function to the missing anterior dentition. This phenomenon has been both a boon and a bane to the profession. Over the counter products, media-driven treatment plans, as well as dentists eager to please, have formed a triad with little regard for the risk/benefit calculus of dental rehabilitation. Interdisciplinary treatment planning, knowledge of available restorative materials, sequencing treatment modalities, and adequate communication between the disciplines involved are a key to a successful treatment outcome when pursuing restorative rehabilitation.
Clinical Relevance To Interdisciplinary Dentistry
- This clinical report describes the challenges faced in the prosthetic rehabilitation of a partially edentulous patient to achieve a successful restoration in terms of biomechanics, function, and esthetics.
Keywords: Adhesive dentistry, all-ceramic, rehabilitation
|How to cite this article:|
Rodrigues SJ, Shenoy VK, Shetty T, Sharma A, Yakhmi S, Dalwai S. Prosthetic considerations for an esthetic rehabilitation: A confluence of art and science. J Interdiscip Dentistry 2014;4:97-100
|How to cite this URL:|
Rodrigues SJ, Shenoy VK, Shetty T, Sharma A, Yakhmi S, Dalwai S. Prosthetic considerations for an esthetic rehabilitation: A confluence of art and science. J Interdiscip Dentistry [serial online] 2014 [cited 2019 Jun 16];4:97-100. Available from: http://www.jidonline.com/text.asp?2014/4/2/97/142948
| Introduction|| |
Esthetics is a major concern during restoration of anterior partial edentulous areas. Controversy persists regarding the treatment planning criteria for esthetic restorations. Interdisciplinary treatment planning, biocompatibility, marginal adaptation, color matching, patient selection, technique sensitivity, and mode and rate of failure of tooth-colored restorations are all issues that need consideration prior to restoration of an anterior partially edentulous area.
Although metal-ceramic crowns and fixed partial dentures (FPD) have been documented with 94% success rates over 10-year,  concern regarding limitations in biocompatibility and optical qualities has prompted the use of all-ceramic crowns. All-ceramic crowns have been extensively used in prosthodontics in recent years for their superior gingival response and optimal distribution of reflected light, whereas achieving similar marginal accuracies when compared to traditional metal-based restorations. ,,,,
Long-term clinical data on the success of all-ceramic systems for FPD are few. Olsson et al.  completed a 10-year study on anterior and posterior glass-infiltrated alumina FPDs cemented with zinc phosphate cement and reported a cumulative survival rate of 83%. At 3-5 years follow-up studies on glass-infiltrated alumina FPDs have shown a survival of 88w-90%. , These results are less favorable compared with metal-ceramic FPDs with survival rates of 95%,  90%,  and 85%,  at 5, 10, and 15 years, respectively. Although, success has been more promising with 35% partially stabilized zirconia,  the opaque core precludes its use for the anterior sextant.  Yttrium tetragonal zirconia polycrystal-based materials offer the most versatility because of their mechanical,  esthetic,  biocompatible,  and metal-like radiopaque  properties, although only short-term data are available.  Furthermore, an emphasis on careful patient selection and operating technique appears to be essential. The system is not indicated for bruxers, periodontally involved teeth exhibiting increased mobility, and cantilever prostheses. 
The primary mode of failure is fracture, usually located in the area between the retainer and pontic, emanating from the gingival surface of the connectors under high tensile stress, resulting in catastrophic loss. , An in vitro test evaluating moduli of rupture with a three-point bending test suggests that placing zirconium on the intaglio surface of the pontic and connector area instead of veneering porcelain may increase the load bearing capacity of the FPD up to 10 times.  A minimum connector girth of 9 mm 2 has been recommended for 3-unit FPDs.  Longer span FPDs are experimental and have only been evaluated in vitro.  Marginal fit has been shown to be similar to metal-ceramic restorations.  Furthermore, the coping design and luting system may be critical to maximize long-term success. A coping design allowing for optimal ceramic thicknesses, a thin and uniform cement layer, and reduction of the mismatch in thermal expansion of the laminate and core porcelains may decrease combined stresses for all-ceramic crowns.  The use of feldspathic ceramic reinforced with leucite, lithium di-silicate, aluminum oxide, or zirconium have improved fracture resistance but the clinical success of this class of restorations depends on a precise cementation process and bonding protocol which varies according to the ceramic material. For example, silane efficiency and hydrofluoric acid chemical conditioning is compromised in ceramic systems highly reinforced with alumina and lacking in silica ,,, Cementation of zirconia-based FPDs with either composite resin, glass ionomer, or resin-modified glass ionomer cements has been suggested, although long-term clinical studies are lacking. ,
Longitudinal clinical studies, spanning >10 years, evaluating glass ceramic crowns , and those with a densely sintered alumina core  have shown results similar to metal-ceramic crowns, but have demonstrated higher failure rates in the posterior region, where these restorations are prone to brittle fracture.  Patient selection and technique sensitivity may be more critical with all-ceramic versus metal-ceramic restorations.
This clinical report describes a method for prosthetic rehabilitation of a partially edentulous patient with an all-ceramic resin bonded FPD.
| Case report|| |
A 23-year-old woman was referred to the Department of Prosthodontics, of this institution with a history of poor esthetics of her lower anterior teeth. Medical history was noncontributory. Dental history revealed congenital absence of mandibular lateral incisors. Clinical examination revealed porcelain-fused-to-metal resin bonded FPD [Figure 1] with metal wings imparting a grayish hue to the labio-lingually thin central incisors and a mismatch in color and shape of her restored mandibular lateral incisors. In addition, an anterior open bite with moderate bone loss in mandibular central incisors and disto-angular rotation of the right central incisor was noted. Space available for the lateral incisors was inadequate [Figure 2]. Various modalities of prosthetic reconstruction including implants were discussed with the patient. The poor bone quality and quantity precluded use of implants without grafting. A comprehensive treatment plan with a multidisciplinary approach to correct the open bite and create optimal space for further restorations was explained to and agreed by the patient. It included short-term orthodontics to close the open bite and create space for the permanent restoration and resin bonded FPD in IPS e max (Ivoclar, Vivadent, Schaan, Liechtenstein) [Figure 3] and [Figure 4]. The integration of orthodontics provided the option of improving the clinical situation considerably prior to initiation of invasive procedures. Preliminary impressions with a bite registration, as well as a series of diagnostic photographs to facilitate communication and to integrate the patient's desires, the dentist's vision, and the technician's skill for a successful outcome. Furthermore, the treatment limitations and the approximated time frame were discussed.
Following removal of the metal-ceramic partial dentures, 1 mm lingual reduction was done on the mandibular anterior teeth for resin bonded FPD. In addition, the finish line at the proximal and cervical aspects of the tooth preparation were extended so as to obtain a 180˚ wrap around to enhance resistance form, and a shoulder finish line throughout was prepared for the restorations [Figure 5]. All mandibular anterior tooth preparations were completed so as to obtain an inciso gingival path of insertion with an identifiable supragingival finish line 1 mm from the gingival margin without any sharp line angles. Gingival retraction (Traco; VOCO GmbH, Cuxhaven, Germany) was maintained to accurately record finish lines in the definitive impressions made with polyvinyl siloxane in a two-step single impression technique (Reprosil; Dentsply Caulk, Milford, USA) [Figure 6]. Shades for the definitive restorations were determined prior to and reviewed after tooth preparation and provisional restorations were cemented [Figure 7]. Resin bonded FPD in IPS e max were fabricated for the mandibular incisors. Definitive restorations were evaluated, adjusted for optimal contacts, contours, and esthetics, and luted with a composite luting agent (RelyX ARC; 3M ESPE, St Paul, Minn., USA) following etching and bonding protocol of cementation [Figure 8]. Polymerization of the luting agent was accomplished with a light polymerizing unit (Hilu 350; First Medica, Greensboro, NC) at 350 mW/cm 2 for 40s for each of incisal, mesial, and distal surfaces. Definitive treatment outcomes in terms of function and esthetics satisfied the expectations of both the patient and the interdisciplinary team.
| Summary|| |
This case highlights patient treatment with an interdisciplinary approach using orthodontic intervention as a viable modality to correct occlusal, axial, rotational, and space discrepancies before undertaking fixed prosthetic rehabilitation. This valuable treatment option facilitated tooth preparation, path of insertion, optimum oral hygiene, and a better pontic and abutment design for a more predictable prognosis. The use of lithium di-silicate based ceramics as a viable alternative to metal-ceramic restorations facilitated an esthetic and functional therapy.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]