Uniform aesthetic appearance between zirconium oxide restorations and feldspathic porcelain veneers

CASE REPORT

Diagnosis and Treatment Planning 
Judy presented with a desire to improve the appearance of her smile (see Before images a and b). Because she did not feel that her teeth were attractive, Judy hesitated to smile. Her maxillary central incisor was restored with a PFM crown. A large diastema existed between her maxillary central incisors. Her maxillary lateral incisors were small and malformed. Her missing mandibular lateral incisors had been replaced using a 6-unit fixed bridge, from canine to canine. She wished for more natural-looking restorations and a more symmetrical smile-line with no diastema. 
     Preoperative impressions were taken with a polyvinylsiloxane (PVS) alginate substitute material (StatusBlue [DMG America]), and stone study models were fabricated in the dental laboratory. The ideally designed preparations were cut on the preoperative study models in the laboratory, and then a diagnostic wax-up was created to simulate the desired final result. PVS putty stints were fabricated over the waxed models for use in fabrication of the provisional restorations.

Preparation
At the preparation appointment, the previous PFM restorations were removed and the preparations completed. At least 1.5 mm of axial and incisal reduction was accomplished using a KS2 diamond bur (Brasseler USA). Chamfer margins were prepared at the height of the tissue. Zirconium oxide crowns were planned for the 2 maxillary central incisors. The maxillary lateral incisors and canines were prepared for feldspathic porcelain veneers. Conservative facial depth cuts of 0.5 mm were made with the LVS1 bur (Brasseler USA). The depth cuts were then joined, and the axial preparation was completed with the LVS4 chamfer-ended diamond bur (Brasseler USA). Incisal reduction was performed with the same diamond bur and a “butt” margin was placed over the incisal edges. Next, the 6-unit mandibular PFM bridge was removed and the preparations were refined to allow for 1.5 mm axial and incisal restorative material using the KS2 diamond bur. Chamfer margins were finished at the height of the tissue. 
The finished preparations can be seen from the facial view in Figure 1. Shade M1/0.5 was chosen from the VITA Lumen Bleach Shade Guide (Vident). Digital photographs of the teeth before and after preparation, as well an image of the shade guide in front of the prepared teeth, were sent to the dental laboratory via e-mail for use in fabrication of the restorations.

Impressions and Provisionals 
Final impressions were taken with a PVS impression material (Aquasil Ultra Xtra [DENTSPLY Caulk]) and an occlusal registration was made (Flexitime Bite [Hereaus Kulzer]). A bisacrylic provisional material (Luxatemp Flourescence Shade BL [DMG America]) was injected into the lab-fabricated putty stints and then placed over the prepared teeth. The provisional material was allowed to set and the stints were removed. The margins of the temporary restorations were trimmed with a small carbide-finishing bur (ET3 [Brasseler USA]) and polished with an Enhance Cup (DENTSPLY Caulk).

Dental Laboratory
At the dental laboratory, 2 zirconium oxide crowns (Lava [3M ESPE]), 2 3-unit zirconium oxide bridges (Lava), and 4 feldspathic veneers were fabricated according to the patient’s desired aesthetics. The same porcelain (CZR [Noritake Dental Materials]) was used for the veneers and to add the layered porcelain over the zirconia oxide cores (crowns) and framework (bridge). In Figure 2 you can see the 3-unit porcelain-fused-to-zirconia bridges on a mirrored surface. The zirconia oxide crowns and feldspathic veneers for the maxillary teeth are shown on a mirrored surface in Figure 3.

Delivery
The crowns and bridges were cemented with a glass ionomer cement (FujiCEM [GC America]). The veneers were bonded into place using a total-etch technique and a fifth-generation light-cured bonding agent (ALL-BOND 3 [BISCO]). Silane (BISCO) was applied to the internal surfaces of the veneers which had been acid-etched in the dental laboratory to maximize micromechanical retention. A light-cured composite resin-luting agent (Choice 2 [BISCO]) was then placed inside the veneers and they were seated and light-cured. Excess cured luting composite was removed with a small carbide-finishing bur (ET3) and the margins were polished with a finishing cup (Enhance Cup).

Finished Case
The finished case is shown in the retracted view in Figure 4. Figure 5 shows the incisal view of the final preparations for the maxillary (6) anterior teeth. Notice that the original PFM crown preparation is slightly more aggressive than the new zirconium oxide crown preparation. The veneer preparations are in enamel and are more conservative than the adjacent crown preparations. A close-up view of right canine and lateral incisor veneer preparations next to the full zirconium oxide crown preparations is shown in Figure 6. Two feldspathic veneers and the 2 Lava crowns are shown in place in Figure 7. Note the “extreme” artistry exemplified in the uniformity in shade, texture, value, and character.