Captek™ PFMs

In this clinical case study, we are going to treat a patient with an upper partial and replace that with a 12-unit Captek maxillary bridge.

One of the nice things about Captek is the dentin-colored coping underneath. It is intentionally yellow. We try to stay away from this look with the white opaque where you had to opaque a dark, silvery metal coping. Captek produces a desirable-looking coping.

Captek copings look something like the shade of a prep. I know this because stump shade guides are more yellow than a regular VITA shade guide, for example. The Captek coping has been designed to mimic the coloring of a vital tooth. We're going to be taking those crowns off and replacing this patient's flipper with an upper arch of Captek.

We've placed Profound (Steven's Rx) in the patient's mouth. Now, I'll use the STA System (Milestone Scientific) to deliver anesthetic to these teeth.

The STA System has made injections far easier for me. Here I have to go around and anesthetize those two teeth with the bad PFMs. It takes away all the stress of administering anesthesia.

Here I use an Axis Dental Razor Bur to remove this old PFM. These Razor Burs just fly through porcelain and metal. They are a great time saver; you don't have to switch burs from porcelain to metal removal.

We have some bleeding at the gingival margin due to the porcelain pieces flying off, and that's usually a sign of some periodontal issues. I'm not going to worry about that too much because we don't impress on the same appointment that we prep.

That's been one of the hardest things for me to do: It takes a lot of self control not to take the master impressions on the same day you prepare.

The gingivas usually not in great shape. You need to get the temporaries in there first to see how the gingivas going to react. We want to see what the planned smile design is going to look like in the BioTemps.

We want the tissue to be nice and healthy. Once again, we go in with the Razor Bur.

The Razor Bur has no problems cutting through these old PFMs.

Next I use a crown remover to take off this old crown.

Here is the prep underneath the PFM crown.

You can see how the gingival looks, just taking off that crown.

Here we remove the stainless steel or aluminum crown, whatever this undesirable metal is. You can see it bending. I'm using a Christensen Crown Remover, which I use hoping it will get caught in an undercut and pull the crown off.

You know we are not going to have any nice gingiva next to that.

We do not break any contacts because we don't have a tooth next to there. We go in with a 801-021 bur interproximally, which we don't always get the opportunity to do. Most of the time we are just breaking the contacts. And we make a couple depth cuts.

We've placed 2 mm depth cuts on the occlusal surface of the tooth. Here is the 856-025 bur, the big fatty, to remove the enamel from the occlusal surface as quickly as possible.

I use the 379-023 football bur on the occlusal surface. Because of the huge surface area on this football bur, it can be used to make your occlusal reduction go even faster.

That's the great thing about depth cuts: No matter what bur you use to go in and reduce that tooth structure, once you have the depth cuts, it literally doesn't matter.

Just move along there with as much water as you and the patient can tolerate to keep it cool in there. Just get that structure off of there.

Keep in mind that tooth preparation is the opposite of a massage. The patient will pay you more for less time spent in the chair.

We want to get this done quickly for the patient's comfort. We also know that there will be a follow-up appointment where we will touch this up.

The key here is to remove the bulk of the tooth structure, get the BioTemps to fit passively, reline them and get them into place. Open the gingival embrasures on them, and give the patient the Tooth & Gums Tonic to use at home. At this appointment, the goal is to get the bulk of the work out of the way to achieve better margins so the gingiva can become healthy.

We're setting ourselves up for that second appointment.

In case you haven't noticed, the Reverse Preparation Technique is a technique that works for any type of crown. A Captek crown or bridge as you are seeing me do here, or on an all-ceramic, cast gold or PFM crown. It doesn't matter. It's one prep for all situations so that you don't need to own a bunch of different burs.

Prior to trying in the splinted BioTemps, I use a prep guide provided by the BioTemps department. It's a clear suck-down stent that fits over all of the preparations. Because these are made at lab ahead of time, they guessed at the preparations by doing minimal preparations of 1 mm or less.

Anywhere tooth touches the stent, I know that I don't have enough reduction or the preps are too parallel and/or divergent. I can see where the tooth is contacting the suck-down stent.

This tells me that I need to do more reduction on that tooth. Here we reduce on the incisal edge and on the lingual as well, where it was touching that clear stent. It's a great way to know that we have done enough reduction.

Here you can see how the BioTemps splint goes all the way down. I have a passive fit here as I move it side to side.

Because we have multiple teeth that the BioTemps are hooked to, the preps need to be parallel. A lot of times when you have single units but the BioTemps are splinted, it helps get the path of draw correct even if you don't need it for the permanent restoration. Tooth #6 has a little blanching on the gingival and that's fine.

My dental assistant mixes the reline material. Because the BioTemps will be used with multiple teeth, we can't really use a bisacryl.

As nice as it would be to use a bisacryl material in the BioTemps abutments because it does not go into a doughy stage, it would probably lock the BioTemps bridge into place. I know from experience! I've done that before and I'm trying to keep you from doing the same.

The benefits of having a 12-unit BioTemps bridge that looks this good, where everything is already done, are great. You can see my assistant has the patient put the bridge in and bite down. That's usually all that happens at this stage.

At this point, the methyl methacrylate can be cleaned off the facial surface of the BioTemps. Because BioTemps are glazed, you don't want it to sit or it will adhere to the surface. You can grind if off later, but you'll have to repolish it. It's just easier to clean it off while the patient bites down. We're going to trim and cement those temporaries with some TempBond, and then the patient can go on with their day.

This is two weeks later and the patient has been rinsing with Tooth & Gums Tonic.

We've got a pink tooth there on the upper right hand side. That usually only means one thing: the bridge came off. We remove the denture adhesive that the patient cleverly used.

Look how nice the gingiva is. As we pack this #00 cord, we should have little to no bleeding.

The tissue has greatly improved in the time that the patient has worn the BioTemps provisional. The second or top cord of the Two-Cord Impression Technique is the #2E cord. The "E" stands for epinephrine. I've used epinephrine for more than 20 years because two of my mentors, Drs. Gordon Christensen and Bill Strupp, use it. The rule of thumb is not to use it on those who can't tolerate it in the local injection.

With a healthy gingival, there isn't much absorption of the epinephrine. Back in the day when all the margins were subgingival, when there was a lot of tissue cut up and bleeding to be stopped, I can imagine there would have been much more epinephrine absorbed.

Even if you were using this as a single-cord technique, I can see how there is bleeding and inflammation in the base of the pocket. I can see how there would be epinephrine absorbed if this cord was in the base of the socket.

Because we have that non-medicated #00 cord on the molar at the base of the sulcus with the epi cord on top of it, for me it's more important to keep the epinephrine in contact with the margin of the gingival – not down at the base, where I can imagine there would be a lot more absorption.

The #00 cord will stay in place for approximately 45 minutes. A lot of times we will leave the cord in there and do some additional preparation and clean up the margins. On a patient that doesn't have enough room for a #2E cord, there is a #1E cord. I've also seen dentists use Expasyl (Kerr) on top of the #00 cord.

You will see me go around each tooth two or three times as my assistant pulls that top cord out. I go around two or three times to avoid a pull or a drag from a moisture inclusion.

Why a custom tray? Because they always fit and because you actually save some material. There is no reason not to use a custom tray.

Here's a full-arch impression of our six abutments for this Captek bridge case. As I look at it, I can see all the margins represented around the teeth.

Here we are at the seat appointment. As you can see, even after we anesthetize, the BioTemps are still in place.

We remove the BioTemps provisional after the patient has worn them for another two weeks.

Here, we are just cleaning up.

I don't see any denture adhesive in place this time. That's a good sign. A lot of times we use Durelon as an adhesive. Just make sure you have a Sonic Scaler to remove that.

We have placed the Captek bridge. The patient bite down on cotton rolls, instant orthodontics, which I routinely have the patient do on a new bridge for about ten minutes. Sometimes things have shifted.

We have put our RelyX Luting Plus cement from 3M ESPE into the bridge. Again, we ask the patient to bite down on cotton rolls.

Can you imaging going from a flipper to that? What a difference that will make in the patient's life.

As you can see, we haven't done the lower arch yet. There was enough strain on the finances just to do the upper.

There's the Captek bridge and the patient's smile. We have gotten rid of that flipper look and something that was removable.

You can see the opaque PFMs before not really matching the discolored, dark, low value teeth on the flipper. The stainless steel crown is gone. The wires are gone.

You can see here the patient smiles bigger now. He shows more tooth because he is now proud of his smile. With the benefits of Captek, this is a periodontally positive material that actually helps the gingival stay in shape and remain healthy.