The key to every cosmetic anterior case is to listen and diagnose well before picking up a handpiece.
Here’s a case in which the patient presented with a 15-year-old bridge (Figures 1 and 2). Her issues were:
- The color of the her teeth
- Black triangles
- A desire to have #11 blend into the anterior landscape
- Create a more natural appearance of #7 (the pontic).
- Create better emergence from the gingival tissues and more natural profiles.
Initial impressions were taken and lab-fabricated diagnostic models were made with Radica provisional and diagnostic resin (Dentsply Prosthetics) along with prep guides for 6,8,8,10 and a veneer preparation on tooth number 11.
Diagnostic photos showed an unnatural appearance of tooth number 7, which had been extracted years earlier and the patient had no desire to have an implant placed.
With such in mind, the practitioner must understand that success of such a case often rests on soft tissue harmony as well as hard tissue preparation. In this case, we removed her crowns, and prior to beginning the temporization phase, we probed her gingival tissues both buccally (Figure 3) and occlusally (Figure 4) to determine how much tissue we could remove to develop a natural appearance. Traditionally, we prefer to leave approximately 2mm of tissue in these areas and by probing (under anesthetic) we were able to determine how much tissue could be removed. Tissue removal is accomplished with the GENTLEray 980 diode laser.
Once turned on, the laser allows the user to select pre-set settings and move forward. In this case, we selected Gingivoplasty off the menu (Figure 5), which then automatically sets the laser settings. As shown, the setting displays a wattage setting in power and the mode and timing of pulsations (Figure 6). Although energy levels and frequency can be altered, routinely these pre-programmed settings are appropriate for the selected procedure.
Once the setting was selected, we utilized a wet cotton roll to add moisture to the area and with an initiated fiber, the pontic tissue was developed by creating a more natural col (Figure 7). Care was taken not to touch the papillae and create room for buccal emergence. Once complete, the area had minimal bleeding and the pontic is prepared outside the mouth by sand blasting the cervical area and applying a bonding agent.
One then adds a flowable to the pontic area and light cures (outside the mouth) to create the ideal pontic. Upon trying in the temporary bridge, the practitioner should observe intimate tissue contact. If such is not present, add more flowable to the temporary outside the mouth, light cure and try in the temporary bridge again until this is achieved. If too much material has been placed onto the pontic, simply use an indicator paste to guide you into easy and predicable removal of the excess composite. Traditional composite polishing should leave a wonderfully smooth surface.
At two weeks we brought the patient back to observe the tissues response and adjust the temporaries if required both as a cosmetic touch up and tissue enhancement if required. Final impressions are generally 3-4 weeks after the initial temporization. As seen during the final impression procedure (Figure 8), a well developed col and buccal emergence of tissue have formed and final delivery of a LAVA Bridge, 2 Lava Crowns and a veneer (Figure 9) become predictable and routine.