Aip Opp 2019-winter

Presented by Drs. Alexander, Brewer, and Kuracina

Winter 2019

Advanced Prosthodontics

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New Findings & Best Practices for Cosmetic & Restorative Dentistry

INSIDE THIS ISSUE

Do You Have a Patient With 
 Severely Worn Dentition? Before

CASE SUMMARY: Do You Have a Patient With This Situation? (see photos on right) Details for this Maxillary Restoration using All-Ceramic Crowns… Challenges and Treatment Sequence

After

pages 2-3

Final Result page 3

PRACTICE TIPS FROM THE PROSTHODONTISTS: 4 Tips for Conserving Tooth Structure When Using All-Ceramic Restorations... page 4 © Sams Media Group, LLC

Here’s the story of a patient who was referred from another dental professional... If you have a patient with several missing, broken or severely worn teeth—
 they may be a candidate for oral rehabilitation with the assistance of an advanced Prosthodontist. Read more on the next page…

Do you want another opinion on a complex case? Or to meet and share ideas? There are many ways we can help each other by working together on complex cases and by sharing knowledge and experience. With your reputation for quality dental care, and our experience with restorative treatments, we can work together on advanced cases and both benefit! 
 If you’d like to meet to discuss a difficult procedure, or talk on the phone about how we can help each other, please call or email our office with specific days and times when you are available to talk or meet. Orchard Park Prosthodontics ! The Complex Case Specialists™ ! (716) 662-7229 ! [email protected]

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FROM THE PROSTHO FILES

CASE SUMMARY: Restoration of Eroded Dentition Using Minimally Invasive All-Ceramic Crowns “Kim” was a 30-year-old woman referred to our office to address her maxillary anterior teeth. She was a former bulimic, and the palatal enamel had eroded from the palatal surfaces of these teeth. Not only were the teeth sensitive, but the incisal edges had become more translucent and were chipping, and she was concerned this would continue to worsen 
 (Figures 1 and 2). Her general dentist had noticed that the teeth were in occlusion due to compensatory eruption and was not sure how to manage the situation. The challenges:
 • Repair of the thinned incisal edges with direct composite had not been predictable.

Figure 1

• The palatal surfaces were eroded into dentin, so occlusal reduction for crowns ran the risk of endodontic sequelae. • Her posterior teeth were largely unrestored. Some had minimal erosion of cusp tips, easily managed with resin restorations. Gaining restorative space by opening OVD seemed like an aggressive treatment for a young patient with minimally compromised posterior teeth. The solution: Create restorative space using a Dahl appliance1, a fixed appliance designed to induce localized axial tooth movement, then fabricate minimally invasive all-ceramic crowns for the maxillary anterior teeth. • A diagnostic wax-up was completed that demonstrated the planned palatal contours of teeth 7-10. The occlusal contacts were designed to be on horizontal surfaces. This model was sent with an intraoral scan of the patient’s dentition to the lab to mill a splinted PMMA palatal overlay for teeth #7-10 (Figure 3). The palatal dentin was roughened with a bur prior to the scan.

Figure 2

Figure 3

• The splint was bonded to etched enamel using flowable resin and SR Connect (Ivoclar). Even contact was established on #7-10, leaving all other teeth out of occlusion. • Kim visited our office for monthly check-in appointments over several months. She indicated she was comfortable functioning with the appliance. At each visit, an intraocclusal record was made, and discernable reduction of separation of the posterior teeth was observed.

Figure 4

• By nine months, “Kim” had regained contacts on all of her molars. Treatment was delayed six months more because the patient had been pregnant then had her baby. When she was ready to resume 15 months after the start of treatment, she had gained contact on all teeth except her canines (Figures 4 and 5).

Continued on next page...

Figure 5

Do you have a patient in Kim’s situation? Or another complex case? If you have a question about a case and want another opinion, give our office a call. Or, if there’s a case that you want to work together on, please fill out and send in the enclosed referral form. We will take great care of your patient and keep you informed. Dental professionals refer to us as The Complex Case Specialists™ because we perform complex treatments every day. This experience allows us to find the right solution for your patient's unique treatment needs.

Orchard Park Prosthodontics ! The Complex Case Specialists™ ! (716) 662-7229 ! [email protected]

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FROM THE PROSTHO FILES Continued from previous page — Kim’s treatment included… • The splint was removed, and abundant palatal clearance was observed (Figure 6). 
 
 Teeth #6-11 were prepared for conservative all-ceramic crowns: the labial reduction was largely confined to enamel as in a veneer prep, and the palatal surface required little more than placing a finish line (Figure 7). 
 
 Interim restorations were based on a diagnostic wax-up that restored incisal edge length and anterior guidance on these teeth (Figure 8). • Layered E-max crowns were fabricated based on the interim restorations, and luted with Variolink Esthetic DC.

Figure 7 Figure 6

Figure 8

Figure 9

Phosphoric acid etching confirmed that much of her enamel had been preserved (Figures 9- 12). • Kim was referred back to her general dentist, who then fabricated an occlusal guard to complete her treatment. Restorative procedures were planned 
 and carried out by Dr. Jennifer Kuracina.

Figure 10

——————- Poyser NJ, et al. The Dahl Concept: past, present and future. Br Dent J. 2005 Jun 11;198(11):669-76. 1

Final Result: All-Ceramic Crown Restorations…

Figure 11

We take the care of patients referred to us seriously, 
 including knowing how to educate them so they feel 
 comfortable. It’s our goal to help every patient understand even 
 the most difficult procedures, so they can regain the 
 function and esthetics they desire. Figure 12

Orchard Park Prosthodontics ! The Complex Case Specialists™ ! (716) 662-7229 ! [email protected]

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The Complex Case Specialists

TM

PRACTICE TIPS FROM THE PROSTHODONTISTS 4 Tips for Conserving Tooth Structure 
 When Using All-Ceramic Restorations by Gillian Alexander, DDS, MS, FACP, Board Certified Prosthodontist

Conservation of tooth structure should be one of our ultimate goals as restorative dentists. With continued improvement of all-ceramic restorative materials that have enhanced mechanical properties, and advanced adhesive luting agents, the success of minimally invasive all-ceramic restorations is now well documented. When planning for minimally invasive all-ceramic restorations, preparation design must be carefully planned and executed. Here are four things to keep in mind: 1.

Conservation of enamel is key — increasing enamel thickness markedly increases the load needed to produce terminal catastrophic fracture of veneers1

2.

Enamel is thin in the gingival third of the facial surface of incisors (0.3 - 0.5 mm) — preparation must be conservative in this area2

3.

Thin porcelain should be avoided in areas of high stress (ie: maximum intercuspal contacts)

4.

The difference in palatal margin design (palatal buttjoint margin with 0.5-1.5 mm in incisal reduction [OV preparation design] vs. 0.5-0.7 mm palatal rounded shoulder margin [FV preparation design]) did not have a statistically significant difference on overall survival rate of extended coverage veneers that were adhesively cemented3

——————- Ge C, Green C, Sederstrom D, McLaren E, White S. Effect of porcelain and enamel thickness on porcelain veneer failure loads in vitro. J Prosthet Dent 2014;111:380-387. 1

- Ferrari M, Patroni S, Balleri P. Measurement of enamel thickness in relation to reduction for etched laminate veneers. Int J Periodontics Rest Dent 1992;12:407-13. 2

- Guess P, Selz C, Voulgarakis A, Stampf S, Stappert C. Prospective clinical study of press-ceramic overlap and full veneer restorations: 7-year results. Int J Prosthodont 2014;27:355-358. 3

How can a Prosthodontist assist you and your dental team? A prosthodontist from our practice can assist you and your team in many ways. We specialize in the diagnosis 
 and treatment of complex cases, usually involving several procedures over months, possibly years, of treatment. The next time you see a challenging case, please feel free to call us and we can discuss treatment planning or help you with any part of the treatment. If you refer a patient to our group, we will do an initial consultation and exam to help your patient select his or her best option before beginning treatment. Orchard Park Prosthodontics ! The Complex Case Specialists™ ! (716) 662-7229 ! [email protected]

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