OcclusalGold™

OcclusalGold copings are a rich yellow color, ensuring that you will have no dark metal margins on your restorations. The rich color of the coping mimics the color of a natural, vital tooth, which is why OcclusalGold restorations are often mistaken for all-ceramic restorations. In this case, we treat the patient with Captek, but the esthetic results are quite similar to what can be achieved with OcclusalGold restorations. Case featuring Captek crowns treatment plan: Crown on teeth #5, #7-10; build-up tooth #5, #10; BioTemps provisional restorations.

We really try to avoid doing six units, from cuspid to cuspid. This is because the cuspids end up looking way too prominent by the time the final restorations are placed. The cuspids tend to disappear into the dark bucal corridor, and it doesn't look good when the patient smiles.

We are going to prep four maxillary anterior teeth, teeth #7-10, on the patient. Typically, we try to either stay within the cuspids and do the four anterior teeth, as we are going to do in this case, or go all the way back to the first or second bicuspids.

During my interview with the patient, she indicated that she likes the shade, shape and size of tooth #9. So we're going to use this as our reference tooth, if you will. And what we're going to do to use it as a reference tooth is prep teeth #7, #8 and #10, and then take an impression with those three teeth already prepped and tooth #9 untouched.

Shade selection on this case is relatively straightforward because we are preparing teeth #7-10. Our patient has already told us that she likes the shade of tooth #9, and it's got a relatively high value. I'm looking at it next to a B1 shade guide here, and they appear to be relatively close. So we will use B1 as our final base shade.

Before we begin tooth preparation, we address the gingival situation. This is a tissue trimmer from Axis Dental. This is a ceramic tip that fits into a high-speed handpiece.

We're going to use this in our high-speed handpiece and take it around to just trim some gingiva around tooth #8. We're going to try and match the gingival height and the gingival zenith of tooth #9. You'll notice we use this handpiece without water. That's because water actually impedes the coagulation in the capillaries and can lead to a little more bleeding in the area. So, this tip does work better and should be used without the water spray.

As with the other preparations in this case, we will begin by preparing the cervical margin.

We have now completed the depth cut in the gingival third of the teeth with the round bur that we've been using. You'll notice the saucer or smile shape reduction depth cuts right along the gum line. We're staying clear of the gingival tissues here; we don't want to touch it until we have placed our first retraction cord, which we'll do a little bit later.

You'll notice we haven't placed any depth cuts on our reference tooth. That's because we want to leave this tooth unprepared and untouched so we can pass along an alginate to the laboratory technician that will help to match the size and shape of that tooth.

The next depth cut will be performed in the incisal third of the tooth with a 330 bur. This is a standard 330 bur. The head, the cutting portion of the 330 bur, is exactly 2 mm long, and we would like to have 2 mm of incisal reduction here.

So we'll begin the next phase of preparation by placing our 2 mm incisal edge depth cuts.

So this is an 856-016C bur; this bur is 1.6 mm thick at the top of the shank and at the tip is 1.2 mm thick. We can use each of those dimensions on the different planes.

We'd like to have at least 1 mm of reduction in the gingival third; 1.5 mm of reduction in the middle third; and 2 mm of reduction on the incisal edge. Once accomplished, we smooth those together so those three planes form a nice, smooth contour to our preparation.

At this point, we're going to take a thin bur – I prefer a 169 L Bur – to break contacts between our teeth so we can place our first cord. Then, we're simply going to connect the depth cuts we've already made to ensure adequate reduction.

You'll note we haven't placed any significant depth cuts on the lingual surface of the teeth, and that's because the opposing teeth usually give us a very good indicator of whether or not we have enough reduction on the lingual. We don't have that luxury on the facial surfaces or the incisal surfaces of the teeth, which is why the depth cuts come in handy.

We're going to begin placing our first cord. This is an Ultrapak #00 cord from Ultradent. It's a very small, knitted cord, so it's hollow. This is non-medicated and there's no medicaments on it, so we can place this cord in and leave it in for a long period of time without having to worry about any adverse affects on the gingiva.

This allows us, when we go in and work in the area of our gingival depth cut, to place our gingival margin 0.5 mm into the sulcus without having to worry about damaging the gingiva because of the retraction. We'll go ahead and place this around all of the teeth at this point.

The first cord has now been placed. You'll notice we've cut the ends; there's no exposed cord. That's because this cord is going to stay in place throughout the entire impression procedure. We'll place a second cord on top of this one about five minutes before taking the impression. We'll pull that top cord, we'll leave this bottom cord in here, usually until we've actually cemented the temporaries into place, and then we'll take that cord out and remove the temporary cement with it.

So, the first cord is in, it's flush, none of the ends are sticking out. You can already see our gingival depth cut, for example, on this later incisor that was at the level of the gingiva. The gingiva has now been retracted about 0.5 mm by the first retraction cord.

At this point we blend all of our depth cuts together on the facial and incisal, and we're going to drop the margin down to the level of where the gingiva is now. When the retraction cord is out and the tissues have come back, our PFM margin is going to be about halfway into the depth of that sulcus – about 0.5mm—1 mm under the free gingival margin.

The lingual reduction will be accomplished with the football bur, which will give us the concave lingual surface that we are looking for.

Here is the lateral incisor immediately after removal of the old restorations. You can see some areas that appear to still be carious.

So we'll go ahead and use a caries detecting solution – Seek, a green dye – to check for the presence of caries before we place our filler materials.

And one of the good uses of caries indicating solution is, as shown here, there's not nearly as much caries as one might have expected. Especially in that lingual pit, where there's a darker brown color, where there's distal where that restoration used to be. So we'll go and remove that quickly and then move on with our filler material.

Our dental assistant has mixed the Vitrebond material. I'm going to place this with a Dycal applicator. This is a tri-carrier material, so we will need to light cure it here to get it to set. Because of its glass-iron materials it bonded, and there's no need for pre-etching on this step.

We've now placed the Vitrebond filler material and smoothed it off, and you can see all the voids are gone. This will leave us with an ideal preparation shape that will maximize our crown's retention and resistance on the preparation.

Flexible clearance tabs, available through dental dealers, come from Kerr Dental Lab division. They come in different colors and thicknesses. This one happens to be 1 mm thick, the green one happens to be 1.5 mm thick. For the rest, it depends on whether or not you're going to have a metal lingual or a ceramic lingual.

I'm looking for about 1.25 mm of lingual reduction. When I have the patient bite together on the 1 mm tab, it slips right out.

The 1.5 mm tab should be a little snug, and it is. But when she bites together, she comes all the way together on her posterior teeth, even on the 1.5 mm. Usually our lingual reduction will increase just a little as we go in and smooth the final preparation, as well.

Now that we've obtained an alginate impression with the reference tooth in place, we are free to prepare the reference tooth. So, we'll go ahead and repeat the steps we've already accomplished on the other teeth, starting with the incisal edge depth cut.

We're going to use Sof-Lex discs from 3M ESPE to round off any sharp angles that we might have on the preparations. The reason for doing this is that when we go to pour those in the laboratory, little pieces of thin, sharp incisal angles break off rather easily, and we end up with a master model that has a shorter tooth preparation than the patient does in their mouth. As a result, when the final restoration arrives at your office, it will not seat completely because the restoration was made on a model of a prep that was shorter than the real-life prep.

So we're going to use these discs just to round off any sharp corners we might have, round over any sharp edges we might have that we won't be able to reproduce with our die stone.

We are now placing the second cord, the top cord. The first cord has been placed, it's a #00 cord, and now the #2 cord being placed on top of that. Allow the top cord to sit for eight to 10 minutes for maximum retraction.

We re-wet the top cord prior to removing it from the patient's mouth. This helps release the cord from the tissue so, like a Band-Aid that has been in place, it is easier to remove without causing aggrevation (bleeding).

We will re-wet the top cord, remove it, and then start taking our impression.

As my assistant fills the tray with the heavy body material, I begin syringing light body material around the preparation closest to me. We go at least 360 degrees around the tooth, preferably 720 degrees around the tooth, to make sure we do not get any pulls from inclusion of gingival fluid or any other moisture that may be present around the preparations.

After waiting the three-minute set-time, we remove the impression. And, unlike an alginate impression, because this is a PVS impression, we remove the impression slowly, giving material caught in an undercut the chance to rebound.

We then use Capture Hard Bite, which I like because of how stiff it is, how hard it sets – very quick set time, just about 60 seconds – and we extrude it right onto the preparations, none of the adjacent teeth, just the preps. Instruct the patient to bite down and hold it for approximately one minute.

We are now trying in the BioTemps by themselves. They should have a passive fit and drop right into place.

We reline the BioTemps with a methyl methacrylate material. And we will leave this in the mouth, then check to see when it's going through its doughy stage, pumping it up and down to ensure we don't get locked into any undercuts.

The BioTemps restorations have been trimmed and cemented into place with Temp-Bond Clear. You can see how nice they look; we've actually got some incisal edge translucency. You can see we've got nice shape, nice shade on those – they blend in well.

We've tried to open the embrasures, for example, between tooth #8 and #9, to make sure we don't do any damage to the papilla during the two-week provisional period. We'd certainly rather leave that a little bit open and allow our papilla to be touched by an interproximal brush or the patient rinsing, as opposed to having too much reline material there underneath the BioTemps and embrasure area and actually cause some recession of that papilla, which could lead to a black triangle situation when we try in our permanent restorations.

Second Appointment, Two Weeks Later. Before we remove the BioTemps, let's take a look at the gingival tissue and how it healed around our provisional restorations. It looks very nice! In fact, if you recall, on tooth #8 we actually did a little crown lengthening here with the tissue trimmer. And one of the advantages of BioTemps is the lab is able to make these two teeth, the two central incisors, the exact same length for us, which anticipates our tissue trimming.

Once we've removed the excess gingival, our BioTemp restoration will be just as long on this central as it is on this one. It will help the healing of that soft tissue so that we get a level that's even when you look at tooth #8 and #9.

As I look at all four anterior tooth, I see that we have had an excellent gingival response to the temporaries, which provides a dry, clean field – exactly what we need to be able to cement our permanent restoration.

We're now going to remove the BioTemp restorations; usually it's just a curved hemostat, just like that, and pop them right off.

Just about all the temporary cement has stayed on the BioTemps and not on the preparation, so we'll have very little clean up prior to trying in the permanent restorations.

We're going to clean the preparations with some pumice. This happens to be Preppies pre-mixed pumice from Whip Mix. It's really nice, very smooth and easy to use, good single-use uni-dose packaging. And we put it in a prophy cap and polish our restorations.

We're now ready to try-in our final restorations. The best way to do this is to try-in the units individually to access the marginal fit. Then, try them in collectively and check the contacts.

All the units have been tried in individually, and they all have excellent marginal fit. So now that we've got them in together, we can go ahead and check the contacts.

Usually, we will place a desensitizer on the teeth, and we're going to do that now. This is Hemaseal and Cide from Advantage Dental Products; it's a combination of chlorhexidine and hema. And, actually, it did very well in a recent CLINICIANS REPORT testing. We almost always, at least with our PFM cementations, place a thin layer of this on and then evaporate it with air prior to the cementation of the final restorations.

We place RelyX Unicem into the crowns. We're going to begin seating them individually, starting with the central incisors. I will place them first and apply finger pressure to push the crowns down into place. Then, I also like to use an orange wood stick, just to get a little more pressure and make sure the crown is all the way down. I will also use the orange wood stick on the two central incisors to make sure we have the incisal edges lined up.

With Captek restorations, there's really only one way that they can seat. And with the Unicem, because it also has a light cure component, our operatory light will start to cure it and we'll start to clean it off as it goes into its gel stage.

With the Unicem, you want to clean it up sooner than later; it's a self-etching resin cement and it's as strong as any resin cement that you've used before. It is very difficult to get little pieces of cement out from between the teeth and the embrasures once it is fully set.

After cleaning off the cement, we use Shammy Bright polishing from Axis Dental. It's a felt wheel with a ceramic polish, and we take it along the facial surfaces of the crowns to remove any excess cement and also to put a final glaze onto our Captek restorations.

We achieved a very nice esthetic and functional result. You can see that the contours look nice, surface texture looks nice, nice embrasures everywhere. Nice incisal edge translucency as you look at the teeth with a nice, white halo effect right underneath it. That's exactly what we're looking for.

Contacts were good, inclusions fine and excursions are fine, as well. And you can see, we achieved a really nice result here with some preplanning, that included the use of a reference tooth so that the lab technician understood our desired tooth size, shape and form.