Clinical dentistry by Michael C. DiTolla, DDS, FAGD
- IntroductionHere is a sneak peek of what our R&D department has been working on and what we believe can be done with BruxZir Solid Zirconia. While BruxZir started as a material for posterior indications, we have slowly begun to use it for select anterior cases. This is the first time I've used BruxZir as a full-arch solution on a patient that required a maxillary bridge, replacing all the teeth on just six abutments.Figure #1The male patient presented with a large bridge that had fractured. All of the anterior teeth were missing. You can see it's a yellow high noble gold substructure bridge. It's a really big bridge; in fact, it's a horseshoe (full-arch) bridge.
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Figure #2If you were ever going to make a case for using a base metal as a substructure, you would want to do it on a case like this. That's because it's going to have the highest strength as a framework, it's going to bend the least and the porcelain is going to stay on. -
Figure #3The right way to treat a case like this is to place implants where there are missing teeth, and then to do some smaller bridges. The patient, however, had the bridge for 10-12 years, so he wasn't interested in implants. -
Figure #4I hadn't been doing many bridges recently. Since BruxZir Solid Zirconia has been released, I have been looking forward to the day I'd find a patient who could use a long span full-arch horseshoe-type bridge. Also, I realize that a long-span bridge is probably not the best way to restore this clinical situation. -
Figure #5I cut through the high noble metal using the Razor bur from Axis Dental, which easily cuts through metal. -
Figure #6You can just see it deflect and bend as I turn it back and forth, which makes the bridge very easy to remove. -
Figure #7As I remove the bridge, you can see we've got some questionable teeth and posts that lack buildup. -
Figure #8I see the post, but there's no buildup around it. The post just kind of disappears into the canal and provides no height. I'm going in with a small Gates Glidden Drill to find the canal next to the post. I want to create some space because I'd like to replace the post with a proper-sized post deeper into the canal, and also attach a buildup. -
Figure #9I couldn't get in there with the Gates Glidden Drill. So, I'm going in to verify where the canal is using a hand file. -
Figure #10I attempt to gauge how long is the canal and where is the post. I'm not actually doing endo here. The endo is still good in the apical third. I'm just trying to figure out where I can go with the post. -
Figure #11Once I determine where the canal and hole are located, I go in with the Gates Glidden to develop it. -
Figure #12Next, I remove the little post. -
Figure #13It's a short, little threaded post. -
Figure #14I go in and reshape the canal, with a focus on achieving more depth towards the apical. I remove a little more gutta percha so we can place a 3M™ ESPE™ fiber post. -
Figure #15There you can see the post space is prepared. You can see the threads on the buccal wall of the tooth where the threaded post has been. -
Figure #16The fiber post has been placed with 3M ESPE RelyX™ Unicem. -
Figure #17You can add a little more material to the top of that. -
Figure #18And then cure it. -
Figure #19Then add a little more material on top of that and cure it. -
Figure #20These are quick cures of 2-4 seconds each. -
Figure #21Once we have completely cured the post, we go in to do a rough prep. -
Figure #22We want this to look like a tooth at this point. Get a long cylinder and do some occlusal reduction. -
Figure #23This is a difficult way to prep teeth. It's a lot easier to prep a virgin tooth and do the Reverse Preparation Technique. -
Figure #24We've gained a lot in buildup there; we have absolutely gained a lot. -
Figure #25Now we're cleaning some tissue off of the abutment, right in front of that anterior to the cuspid. This is the NV MicroLaser™ from Discus Dental, my new diode laser that I use on more cases than might be expected. -
Figure #26As you would expect in a case such as this, where we need to expose more clinical crown, I touch-up tissue all the time – especially in anterior cases. Many times, I'm trying to match tooth #8 & #9, which have different clinical crown lengths because of the position of the gingiva. I use the NV MicroLaser to expose more tooth but still maintain a proper biological width of 3 mm. We're going to need more tooth structure if the patient wants to go the non-implant route. -
Figure #27We're going to be putting a lot of stress on these teeth. When you take six teeth and put a whole arch on top of yhem in terms of a bridge, that a lot of stress to handle. Six teeth are doing the work of twelve teeth. -
Figure #28In order to have clinical success, it's going to need to grab onto a significant clinical crown. They also need very good bony support. Oddly enough, as battered and broken-down as these teeth look, they do have good support. -
Figure #29We are now removing a short stubby post on the other side. You are seeing a split screen because you've already seen how we do this and then clean it out. -
Figure #30There are six teeth left, which we will try to restore in this case. -
Figure #31These are the relined BioTemps. The first appointment was all about controlling tissue, ridding of old posts and starting new buildups. I had no intention of taking a final impression at the initial appointment. -
Figure #32One of the hardest things to change in the way you approach dentistry is resisting the urge to take the final impression on a day you've made significant changes to the periodontal tissues. I have realized, however, that it is too difficult to get a good impression when you are doing all the prepping. Instead, place the BioTemps and let them heal a little bit. -
Figure #33The BioTemps have been on the patient for two weeks, and he had a chance to evaluate their size, shape and vertical dimension. Today, on the second appointment, we are ready to take our master impression. For the most accurate impression, I use the Two-Cord Impression Technique, where the bottom (#00 cord) goes in first and a 2E cord goes on top of it. -
Figure #34Of course, you will always see me use custom trays because I like the fit and the material savings. -
Figure #35For a case like this, a full-arch case for a roundhouse bridge, you are crazy not to use a custom tray. The impression is in place and the preps look good. -
Figure #36Again, this is going to be a full-contour BruxZir Solid Zirconia bridge. -
Figure #37The entire restoration is going to be solid zirconia, so it will be nice and strong. The last thing to do at this appointment is get the bite registration. -
Figure #38I've sectioned the BioTemps into three pieces. The patient bites down on the two posterior segments; with him biting together, we are able to maintain that vertical dimension for the laboratory. -
Figure #39The key to an accurate bite registration is to give the laboratory the correct vertical dimension. The two posterior BioTemps segments stay in place while we express the material onto the anterior preps. -
Figure #40The patient bites together while we wait 60 seconds at his proper vertical dimension. -
Figure #41Next, we remove the BioTemps and, with the anterior bite registration that's already set in place to get the proper vertical dimension, we squirt on the posterior preparations. The patient then bites into the anterior bite registration. Now we have a full-arch bite registration. -
Figure #42The only way to do this is to segment the temporaries so you can maintain the proper vertical dimension. This is for the cases where we're not going to open the bite or close the bite. -
Figure #43We do that when we maintain vertical dimension. -
Figure #44Our temporaries were relined. This is overkill; you don't have to do this. It's the second set of BioTemps that we're putting in. -
Figure #45The reason for a second set is, the longer we have somebody in temporaries the more likely we are to switch them out. -
Figure #46We then cement the BioTemps into place. -
Figure #47My assistant has been sternly talked to about making sure there is no temporary cement left in place. There are many ways to ensure this, with her favorite way being to floss underneath the bridge with knotted floss. She will clean out all the temporary cement and then pull the floss out. -
Figure #48Leaving temporary cement in is a big problem. We've seen cases that look good in the temporary and then we go to try-in the final work, and the problem is we've had some recession. -
Figure #49Here we are trying in the bridge. -
Figure #50There is literally no porcelain on the bridge. It is 100 percent zirconia with no porcelain. Amazing. Does it look as good as a bridge does with porcelain on it? No, and that's not something we have necessarily ever said about BruxZir, or even tried to achieve for that matter. -
Figure #51We know that BruxZir does not look as esthetic as a PFM bridge, a PFM crown or an all-ceramic crown. But the advantage is that there is no porcelain to chip off. By having the zirconia this thick, we have a super strong framework. -
Figure #52After having tried it into place, we did a couple of adjustments and it now fits. -
Figure #53We put the bridge in using conventional cement (RelyX Luting Plus). It's a resin-reinforced glass ionomer that I have a lot of confidence in, having cut off a lot of restorations just like this. -
Figure #54Unfortunately, the patient doesn't have any lower molars. Usually, we use cotton, but here I want to use something a little stronger. We have pinewood sticks in place of cotton, and ask the patient to close down as far as he can. -
Figure #55Again, the BruxZir Solid Zirconia bridge doesn't look as good as all-ceramic or PFM restorations. But for an all-zirconia bridge that has literally no porcelain on it, it looks pretty great. It can't rival the best esthetics, but maybe one day it will. -
Figure #56The reason why dentists are flocking to BruxZir is its strength. We've said from the beginning BruxZir is "more brawn than beauty." We dentists have been looking for something that is strong yet esthetically acceptable. -
Figure #57BruxZir is not going to rival IPS Empress®, but when we talk to dentists the concern is not, "Boy, we need better looking restorations." -
Figure #58Dentists prefer stronger tooth-colored restorations. In fact, I used to ask dentists: "If we came out with a cast gold that was shade A2, how many of you would use it?" and literally every hand in the room would go up. -
Figure #59Dentists love cast gold for how durable it is. It doesn't break! The fact that it's ugly and unaesthetic is why so many patients are adamant against its use. -
Figure #60This is not a cast gold in shade A2, but it's close. It's a step in the right direction. This is a monolithic restoration that is pure zirconia. -
Figure #61Look at that, it's pretty decent. You can tell it's not a BioTemps. Is it the greatest looking full-arch bridge you've ever seen? Probably not. Was the patient happy with it? Yes, definitely. In fact, there were questions about doing the lower as well, to match the upper.
