Materials for Anterior Crowns?

[Althingsdentist]

Advertisement - Members don't see this ad

I"m just wondering what folks are learning in dental school regarding restoration of teeth #8/9 (FDI - 11,21)? I've been out for 10 years and now and am a senior in an AEGD 2yr program - some schools teach different things.

Ok, the patient:
I have a 44 yo female patient who has chipped the incisal edges of 8,9 crowns. She has chipped 3 sets of #8,9 crowns - therefore, I would like your thoughts.

Here's the case - Photos and all:

Cheers

Ashley

 

[HupHolland]

Confused by your post..

She chipped her virgin teeth or porcelain from crown?

If they were incisal edge chips, then I'm not sure why you prepared them for full coverage unless the patient wanted an improvement in tooth color/contour.

The reason why the teeth kept chipping was likely due to occlusion and could be corrected more conservatively than full coverage. I bet if you had the patient go into crossover that there was not a smooth transition from canine to central. This can be easily corrected by a combination of shortening the canines + lengthening the centrals using composite resin.

But since we're talking materials and the teeth have already been prepared, I would use lithium disilicate (EMAX).

Hup

 

[Mackchops]

I agree with Hup. We were taught that perfect occlusion trumps material. If occlusion looks good maybe she has a habit or some sort of nocturnal parafunction? Make a protrussive record and maybe consider leveling off those lower incisors.

I've had great luck with e.max (there are four e.max products, pressed or milled. Check out ivoclars website), which can give you the esthetics of empress but with added strength.

 

[DrJeff]

Totally an occlusion situation. Check out the wear facets on the canines! Look at the number of posterior crowns (just a hunch that the majority if not all of them were due to cusp fracture), check out the wear of the incisal edges of the lower anteriors. That patient of yours I'd bet has a serious clenching/grinding habit. Until you get her occlusion stabilized, she's going to eventually prove ove and over that no matter what ceramic material of choice you use that her habits are stronger.

Stabilize the occlusion. Get her in a night guard. Or else her's will be a name that you'll start to dread seeing in your schedule, since it will be associated with breaking of your work 😱

Strength wise, I've been very happy for the last year or so with lithium disilicate (Zirconia) restorations (a bunch of different brand names depending on the maufacturing company and the lab doing the work). The only real limitation I've had with them though is if you're looking for a final result that has a good deal of incisal transluceny. That lithium disilicate coping is quite opaque, and if you've ever had the "pleasure" of trying to either cut one off or cut an endo access prep through one, you know very quickly how hard of a material it is(have LOTS of fresh, coarse diamond urs on hand!!)

 

[HupHolland]

Totally an occlusion situation. Check out the wear facets on the canines! Look at the number of posterior crowns (just a hunch that the majority if not all of them were due to cusp fracture), check out the wear of the incisal edges of the lower anteriors. That patient of yours I'd bet has a serious clenching/grinding habit. Until you get her occlusion stabilized, she's going to eventually prove ove and over that no matter what ceramic material of choice you use that her habits are stronger.

Stabilize the occlusion. Get her in a night guard. Or else her's will be a name that you'll start to dread seeing in your schedule, since it will be associated with breaking of your work 😱

Strength wise, I've been very happy for the last year or so with lithium disilicate (Zirconia) restorations (a bunch of different brand names depending on the maufacturing company and the lab doing the work). The only real limitation I've had with them though is if you're looking for a final result that has a good deal of incisal transluceny. That lithium disilicate coping is quite opaque, and if you've ever had the "pleasure" of trying to either cut one off or cut an endo access prep through one, you know very quickly how hard of a material it is(have LOTS of fresh, coarse diamond urs on hand!!)

Don't want to get too sidetracked, but thought I would point out (since we are talking materials and all) that zirconia and lithium disilicate are not synonymous and have different indications.

The extremely popular lithium disilicate system is e.max. I have seen some really nice anterior cases with very esthetic incisal translucency.

Zirconia, on the other hand, is like you said a very opaque and durable material. The popular posterior system is Bruxzir.

Hup

 

[Mackchops]

E.max does have a zirconia product (e.max zircad instead of the e.max press or e.max cad lithium dislocate products).

One of the great advantages of the e.max system is that you can create different substructures depending on the clinical situation all of which can be veneered with the same glass for optimum esthetics. Compared to doing a PFM bridge 6-x-8 next to 9 & 10 labial veneers for example the e.max system allows the flexibility of strength without compromising the need for esthetics (this is the same company that produces empress).

Now the zirconia product (zircad) can be veneered with either the veneering porcelain or pressed zirconia (zirpress) for added strength. So many options!!!!!! 🙂

 

[HupHolland]

E.max does have a zirconia product (e.max zircad instead of the e.max press or e.max cad lithium dislocate products).

One of the great advantages of the e.max system is that you can create different substructures depending on the clinical situation all of which can be veneered with the same glass for optimum esthetics. Compared to doing a PFM bridge 6-x-8 next to 9 & 10 labial veneers for example the e.max system allows the flexibility of strength without compromising the need for esthetics (this is the same company that produces empress).

Now the zirconia product (zircad) can be veneered with either the veneering porcelain or pressed zirconia (zirpress) for added strength. So many options!!!!!! 🙂

Ooops, sorry Dr Jeff...Never should question you 😳

 

[Althingsdentist]

Sorry for the confusion - She presented a number of years ago w/ large composite restorations and 8,9 were enamel exchanged for some type of porcelain. From that point on, it's been a continual fracturing of the porcelain - that's where I come into the picture.

 

[DrJeff]

Ooops, sorry Dr Jeff...Never should question you 😳

No problem. Please do question!! Also in modern dental materials, if you haven't realized yet, quickly there tends to be a bunch of "copycat" materials hitting the market 😉

 

[DrJeff]

Sorry for the confusion - She presented a number of years ago w/ large composite restorations and 8,9 were enamel exchanged for some type of porcelain. From that point on, it's been a continual fracturing of the porcelain - that's where I come into the picture.

Still doesn't change the underlying cause, her occlussion. What is manifesting as an isolated, annoying/frustrating event (her fracturing of the porcelain , and I'd guess composite in the past, and probably enamel and dentin before that) needs to be addressed, or else this will be a lifelong battle that you (or her future dentists) will be facing.

I'd probably use an analogy while explaining it to the patient something like the following. Picture your tooth like a wall in your house with a crack in it. And a crack that upon investigation you find is caused by some NATURAL settling of the foundation that has caused a crack in the foundation. You can put a fresh patch and coat of paint over that crack in the wall, but unless you fix the foundation, which isn't a small, easy project to do, that crack in the wall will keep coming back over and over because of the problem with the foundation.

You may very well find that after explaining the problem in a different way that it may open up the conversation with the patient about what options exist to fully fix the problem. And upon hearing very often that even though it could be a big project, that doing it over the course of a couple years (if that is a reasonable option, and very often it is) is something that is appealing to that patient, and you've just sold a big case

 

[SeattleRDH]

I'd probably use an analogy while explaining it to the patient something like the following. Picture your tooth like a wall in your house with a crack in it. And a crack that upon investigation you find is caused by some NATURAL settling of the foundation that has caused a crack in the foundation. You can put a fresh patch and coat of paint over that crack in the wall, but unless you fix the foundation, which isn't a small, easy project to do, that crack in the wall will keep coming back over and over because of the problem with the foundation.

👍 I'm going to use this.