Prismatik Clinical Zirconia™

This male patient had two old, unesthetic crowns on teeth #7 and #8. Not only were his anteriors in need of new, vital-looking restorations, but there was recurring decay. We placed Prismatik Clinical Zirconia (Prismatik CZ) single-unit crowns on teeth #7-10. The rest of the smile was finished off with Vivaneers™ No-Prep veneers.

The patient presented with two unesthetic existing crowns. He expressed his desire for a natural, healthy-looking smile.

Here are tooth #7 and #8. Notice that the gingival level on tooth #9 is lower than tooth #8. It also appears to be little bit enflamed, probably from an emergence profile issue.

We recontour the gingiva on tooth #9 to better match tooth #8.

This is something that we really struggle with in restorative dentistry: making sure those gingival lines match up!

When the patient finds something funny, they do tend to show that area. So that area will be addressed, even though we don't think it is going to be something you necessarily see in the photographs.

We anesthetize the patient using Profound topical anesthetic. I like this procedure to be as pain free as possible. I have always felt that if we can get through the injection without a lot of problems, we will be okay. So I go ahead and inject a couple carpules of Septocaine on each tooth.

We are using the Razor Carbide bur from Axis Dental. This bur flies through porcelain and gold, which is one of the things I like most about it. In the past I had to use a diamond to go through ceramic material and then use a carbide bur to go through the metal understructure.

Now you cut through both gold and porcelain with one bur, and it does not get dull until you cut through two to three crowns! You can just fly through the metal into the porcelain as well.

I use a Hu-Friedy Crown Remover to remove the old PFM crowns. We are going to take a look at what we've got underneath these crowns.

Things look okay. The margins on the lateral are a little bit subgingival, so we will deal with that.

We are going to began with the Reverse Preparation Technique on tooth #8. We will use a #801-021 bur on the gingival third. This is a margin formation and proper reduction of 1.25 mm.

The 2 mm MADC bur is used to make 2 mm of reduction in the incisal edge. We use the 1.5 mm MADC bur on the axial surface, making some holes there. Those are all depths that we need to make, and now we can just prep away.

I use the #856-025 to prep away as quickly as possible. We have flattened the incisal edge so we get 2 mm incisal reduction, and that appears to be even with the central next to it.

We begin our axial reduction and remove 1.5 mm on the facial surface of the tooth. This blends with the round bur cut we have already made, so this is a really easy way to prep teeth: (A) make sure you have enough reduction (B) It is completely predictable and (C) It ends up being a really great looking prep (the kind of prep that you would see on a typodont but much harder to accomplish on the mouth).

The great thing about the Reverse Preparation Technique is that it is no slower than prepping the teeth the routine way. In fact, I find it faster because I never have to guess whether I have removed enough tooth structure.

We take the suckdown stent from the BioTemps lab model and try it on the preparation. Check to make sure that you don't have any areas where the tooth is contacting the stent. One millimeter of stone model is removed when the BioTemps are removed.

We will need to prep more because our permanent restoration needs more reduction than that.

The BioTemps are splinted together, but the final crowns won't be. As such, we need to make sure that we don't have any path of insertion issues, so we try-in the stent and try-in the BioTemps themselves. They should sit passively and drop right into place, and they do.

I use a piece of dental floss to measure the gingival levels and see if they are even. We know they're not, just by examining the photographs. We know that we are little deficient on tooth #9.

When I try-in the BioTemps, it covers the tissue on tooth #9. One of the great things about BioTemps is that the lab can idealize the gingivals levels for you, so you are not having to guess.

If you don't want to "free hand" it, as I am doing here, you can put the BioTemps back on, poke a couple of holes in the ginviva, or use a skin marker to mark the gingival where it needs to be cut back.

Here I am taking the tissue back. The BioTemps are no longer impinging that tissue.

At this point, I now have two central incisors that should have the same gingival levels. That is a matter of relining the BioTemps, putting them in place and then trimming them correctly.

If you trim them correctly, you pick up the margin and reline material. We happen to be relining with acrylic material. Two weeks later, you should end up with two centrals incisors that have identical levels on the gingivals.

Why do we use acrylics to reline? While I personally don't like it (it releases a lot of heat and it stinks), acrylic is full of monomer. When you have multiple units, you want to make sure that you don't lock the BioTemps bridge into place. Again, this is a splinted four-unit BioTemps bridge. The final restoration is going to be four single units.

You don't need to prep a proper path of insertion here, but if you try to reline this with Bisacryl it will lock right into place.

That is because Bisacryl goes right to a solid set from its liquid state, which is something that we don't want to happen.

Two weeks later. We are removing the temporaries and can see that we've got some nice gingiva there. Things have been good on tooth #9.

Durelon is a great, antibacterial cement. It has stuck to the tooth, so we are scrapping it off. We will go in later with a KaVo sonic scaler to remove the rest of the temporary cement. It is difficult. I know there was a period of time when you had to remove all that Durelon with a hand scaler, which is almost impossible. Durelon, even though it is soluble in oral fluids, will stick to teeth pretty darn well. We don't lose a lot of temporary when we use Durelon as a cement.

The first cord is in. We put that into place, the #00 cord.

Now the top cord, the #2E cord, goes into place.

Then we place the Roeko Anatomical Comprecaps into place. And, boy, do I love these! In fact, I filled out a list of products I cannot live without and Comprecaps are always on the list. They just do magical things with tissue.

The Comprecaps stay in place, as the cords do, for eight to 10 minutes. After both are removed, we will go ahead and express our impression material around the preparation and seat the tray.

After three minutes, the impression is removed from the mouth. It has the look we typically see from the Two-Cord Impression Technique. You can see clear margins all the way around and there is material beyond the margins. We know the lab technicians will see where the margins stop and nail the emergence profile.

Next we squirt some bite registration material onto the prepared teeth, have the patient bite down and recement the temporaries.

The older I get, the more I find myself not impressing on the day we prepare. That's because I find it very hard to have predictability in a restorative setting if we are going to take an impression the same day we prep.

Hope that in the next two weeks there are no tissue changes and the models show up when we go to seat the permanent restorations. It is just too much "guess work" for me.

I don't like the unpredictability of our profession. I like things more predictable; I like to know how it is going to work. It does add an extra appointment to everything but the appointments are shorter and the results are far more predictable.

Two weeks later, the patient returns and I wiggle the BioTemps off. We now try-in the Prismatik Clinical Zirconia restorations.

We start with the central incisors. They are, of course, the most critical element in any restored smile. If the centrals match and they look good and the gingivals match, the rest of the smile will succeed. The centrals almost always determine the rest of the smile. The laterals don't have to match when you get right down to it.

We will cement these at that same time. And I always cement tooth #8 and #9 at the same time, regardless of what type of restoration we are talking about. In doesn't matter the restoration; tooth #8 and #9 go on at the same time.

Here I cement the Prismatik CZ crowns with 3M ESPE RelyX Luting Cement Plus, the most popular crown & bridge cement in the world. Because of the strength of these restorations, we can use regular crown & bridge cement. There is no need to bond anything into place or to use anything special.

Prismatik CZ is also very strong. You saw me earlier pushing on these restorations with an orangewood stick. I have no fear of them breaking as I push, as might happen with a pressed ceramic crowns. This is the first all-ceramic restoration where I routinely ask patients to bite down on a wooden stick or cotton rolls during seating in the posterior.

That was always a no-no for posterior all-ceramic crowns. In fact, you weren't supposed to adjust the occlusion or check the occlusion until the cement had set.

This is not true with Prismatik CZ. You can this restoration like you would a PFM, which has been one of the selling points of this all-ceramic restoration. Now, I finally see that we can treat them like PFMs.

Prismatik CZ restorations are, in fact, all-ceramic crowns. Zirconia is ceramic and we have a lot of people talking about this restoration as if it were metal. We now have four crowns on the front. However, the patient wanted to do enhance his whole smile.

Rather than doing prepped veneers, we use Vivaneers No-Prep veneers – which have become our standard course of treatment when patients want to complete their smile. We will do whatever restorations that need to be done in the anterior and then supplement that with no-prep veneers.

No, I know that no-prep veneers are a little controversial. A major concern is the addition of ceramic to the tooth without taking anything away. But it is sufficient to say that I am willing to make some sacrifice of having some little bumpy CEJ at the free gingival margin ... not subgingival.

We're putting veneers on those teeth when we there is no need to do so. The patient doesn't have to be anesthetized, we don't have to worry about pulp depth and recurring decay, we don't have to worry about any of those things. It wasn't until I start offering these no-prep veneers that I realized just how interested patients were in this type of restorations.

We've now perfected the art of placing Vivaneers No-Prep veneers, which have become popular with patients. You can see the final result.

In the after picture, the patient wears Prismatik CZ crowns on teeth #7-10, with Vivaneers No-Prep veneers rounding out his smile. They filled out the buccal corridor. Things look really nice and there is not a big gradation from the anterior to the posterior.

In fact, right before this picture, we had a second bicupsid missing and we placed a Vivaneer No-Prep veneer to fill the gap. You can see a huge improvement from where he was to now. He knew he needed something done because the anteriors were ugly and there was recurring decay. But to be able to enhance the rest of his teeth by placing no-prep veneers is a great service we offer our patients. It is amazing how many no-prep veneers we do today to round out smiles like this.

Even if we do prepped veneers on #7-10, we will add no-prep veneers to cuspid and first and second bicuspids if the patient so desires. The end result is a great looking case. Today, I can honestly tell you I do more Vivaneers No-Prep veneers than prepped veneers. They are easy to do and fun to do, and patients love them.