Veneer vs. Crown. cosmetic townie clinical. JANUARY 2012» dentaltown.com

Transcription

1 Veneer vs. Crown Initially the debate is veneer versus crown, but a more conservative option might be the best choice.» Dentaltown.com > Message Boards > Cosmetic Dentistry > Veneer vs. Crown post: 1/41 I am a new grad and had a discussion with my principle dentist, who has been out working for 20 years, concerning treatment for RCT incisors that are discolored, and bleaching will not give aesthetic results. My opinion is that if the access is small/average size and there are no other restorations or only the incisal one-third of tooth is restored then a veneer would be the treatment of choice. He told me no, you always want to do crowns as it will give the tooth strength. I am quite confident I read it here on Dentaltown though that crowning a tooth will leave the tooth weaker than a veneer. To me, at least, it only makes sense if you remove tooth at apical third of the crown for crown prep and since you now have less tooth it s weaker. Patient: 24-year-old female Ortho done in her teens About eight years ago there was trauma to the teeth and her maxillary incisors went necrotic. She had the RCT done at that time (not at our office). The RCT on the teeth is good. Conservative access. No pathology and good obturation. The teeth went dark at that time and she has hated it since. I don t think internal bleaching will do anything. As you can see from the pictures, the two centrals in the apical half are very dark gray. She is ready to improve this as it bothers her immensely. My plan is to veneer the two maxillary central incisors. I have never done veneers and would just like a few pointers for the big things to watch out for in this case. My first concern is will a veneer be able to cover up that darkness? I have gone through John Nosti threads on Shrink Wrap temp technique and Sherwin s Just Another Veneer Case. Any other threads to help me out? Any big things to watch out for? I am not going to change the shape/contour of the teeth much, just possibly shorten the incisal edge by 0.5mm to 1mm. Fig. 1 Fig. 2 Figs. 1 & 2: Big smile continued on page 40 38

2 continued from page 38 Fig. 3 Fig. 4 Fig. 5 Like what you re reading? Check out these other veneer cases on Dentaltown.com. Small Teeth. Wide Veneers. How Can I Improve This Smile? Search: Wide Veneers Veneers or Crowns? Search: Veneers or Crowns? Fig. 6 Fig. 7 Fig. 8 Fig. 6: Protrusive Fig. 7: Right excursive Fig. 8: Left excursive member since: post: 2/41 Nice case, and one that will likely get multiple opinions on what is best. However, here s my two cents, for whatever that s worth. Crowns do not make teeth like this stronger, you are correct. Especially once you prep the palatal aspect of the tooth. I would always choose the most conservative prep that will get you the desired end result. However, that s going to be the difficult part with this case, getting the end result (the correct shade). I would, in fact, start with trying to do internal bleaching with these teeth. While it can be somewhat unpredictable in terms of your end result, you will at least get some lightening. And the more you get, the better. Because ideally you want to use a porcelain that has at least some degree of translucency to it, in order to get the most natural looking result. However, if you have a dark stump shade underneath, then you end up having to be more aggressive with your prep, as well as having the lab use a more opaque ceramic. You might end up having a perfect result, in which case you re done. More than likely, you ll get some lightening, but it won t be perfect. I d then take some pictures, send them to your lab and ask what they re going to need from you to get the shade right how much facial reduction, etc.? Just make sure to seal the root/gutta percha (GP) properly prior to doing the non-vital bleaching you don t want to end up with a possible external resorption. Plus, if you get any rebound of color, which is probable over time, with a veneer you can still access the chamber to bleach again. Sherwin has shown some great cases of non-vital bleaching (just search around for them) and both he and John have mad knowledge/skills, so you re definitely paying attention to some good docs here. Brett post: 3/41 Agree totally with what Brett said. I would do internal bleach first and be done with it. If not satisfied, still better than veneer. Your other doc in the office is wrong about the crown strengthening the tooth. continued on page 42 40

3 continued from page 40 member since: post: 4/41 Ditto. The only time a crown can be considered to improve the strength of the tooth or support is in posterior teeth with large restorations. You are talking different forces. Removing the cingulum of anterior teeth reduces its shear strength. Common misconception. I would do internal bleaching as was suggested. Ultradent makes a good endo walking bleach and there are others who would recommend other products. It works! Once you do several visits of bleaching, I would then evaluate and go from there. This case gets veneers if there are Class IV resins, not small access openings. post: 5/41 I have three responses to do internal bleaching first and see what I get from three dentists whose posts are always informative. I have looked into Ultradent s internal bleaching. I was looking at Sherwin s thread on internal bleaching from two years ago and he notes that he cleaned out the GP a few millimeters and then sealed it off with Ultradent s PermaFlo Purple flowable. Do you recommend that or glass ionomer (GI)? I have Vitrabond Clicker, but I think I would have a tough time knowing if my seal of the GP was thick enough or tight enough. So is purple flowable OK or is GI a must? post: 6/41 I think GI or flow is just fine. Some say GI is better cause you can t bond to dentin very well down there, others have had no problem with flowable. Just make sure you seal it adequately on top of the GP and on the walls if you are on root surface, as well as you are apical enough to get bleach down to where it s darker along the cervical of those teeth. I would also tell the patient it s a safe, conservative way treat the darkness and if all goes well they won t even need veneers and save money. Patients like that, but you have to tell them of the very slim chance of resorption. If it happens it really sucks, so at least inform them. member since: post: 8/41 Most anything will work to seal the GP. I ve seen composite, GI, resin-modified glass ionomer (RMGI), zinc phosphate really they ll all get the job done. Composite can be tricky, because it really needs to be bonded, but you don t want bonding agent all over the internal aspect of the chamber either, as it won t allow the bleach to do what it needs. Personally, I like either Fuji IX or zinc phosphate. I like them because you can mix them a little on the thicker side, and once they start to set, you can actually pack them a bit, almost shaping them in the process. You want to make sure that you have sealed the GP and tubules that would extend out to the PDL. I ve heard Magne describe it as a bobsled tunnel shape of material. Let it set completely, and then you should be good to go. Also make sure that you have a good seal of the tooth once you ve placed the bleaching agent. Otherwise, if the seal lets go, it won t allow the bleach to do what you want it to do. Good luck! Brett member since: post: 9/41 I would just throw out a few more things. Your first consideration is if the patient wants to whiten all of her teeth. She needs to make up her mind before you proceed. If she chooses to whiten all of her teeth, this should be done before internal bleaching. When you whiten an entire arch, you have very little control over which teeth you whiten. For example, if you needed to whiten all teeth except the centrals, it would be diffi- continued on page 44 42

4 continued from page 42 cult to do. We have seen many cases where the dentist did internal bleaching first and then whitening of the entire arch ending up with the internally bleached teeth being lighter than the other teeth. As far as what material to use to seal over the gutta percha used to be up for debate, but multiple studies over the past decade indicate the seal should be via glass ionomer or resin-modified glass ionomer. Current standard of care is a minimum of a 3mm plug with gutta percha. Previous to about a decade ago, virtually all studies found a small percentage of cases having had internal bleaching resulting in external root resorption. This was when the plug was typically made of composite, zinc phosphate or IRM. As of about the last decade, several studies have shown that when the plug is properly placed, and is made of GI or RMGI, the incidence of external root resorption is zero. Of course other materials do work, but with all of the other materials there is a recorded incidence of leakage resulting in resorption so according to the literature, it s no longer up for discussion, which means standard of care. On the case shown, the darkest area appears to be in the gingival/cervical areas, so where you place the coronal end of your 3mm or greater plug is important. Remember that the dentinal tubules exit the pulp in a sigmoid shape where they exit the side of the tooth more coronal than where they started. If you d like, you can me (rkurthy@evolvedental.com) and I ll return an attachment showing the histology of the tooth and relate it to the gingival margin and osseous crest, basically showing where you can end your plug. If you handle this case correctly, the chances are that the patient will be thrilled with the result, and you won t need veneers. Remember, the discoloration of these teeth is organic, which means that with proper internal bleaching you can eliminate nearly all of it and as I mentioned, sometimes you can even get the teeth lighter than the adjacent teeth. Rod posts: 11 & 15/41 I am so excited for this case since the day the patient walked into my chair. I will keep things posted here on this thread. I am going to use Ultradent s Opalescence Endo for the walking bleach technique. My question is regarding the darkest areas in the cervical third (as can be seen in the pictures). How far apical should I remove resin and gutta percha? Also, from Rod s reply, he recommends GI instead of flowable composite. I didn t really understand the minimum 3mm plug of gutta percha part. Did you mean 3mm glass ionomer plug? I have the Fuji GI Vitrabond Clicker that I can mix. Does anyone know of a GI that comes out of a syringe to allow me to easily place it and let it flow into place like a flowable resin would? I hate trying to dab my GI into place and then possibly getting it on the walls. I do use 3.2X loupes. Thanks. [Posted: 8/6/2011] This is going to be my plan of attack. I am going to place rubber dam, remove lingual resin and drop the gutta percha down below CEJ by 3mm. Then I am going to place a GI. Directions say to place a putty-like consistency 1-2mm thick of GP to get a good seal. I am hoping someone can give insight as to if Fuji IX is good where I can place it from capsule or if I should mix my Vitrabond and apply that. Then I am going to place the Ultradent Opalescence Endo, then cotton pellet then TERM. The directions recommend a provisional restorative material like Ultradent UltraTemp. Get patient back three to five days later, redo bleach. Then redo bleach again three to five days later. Then when finished I am going to remove bleach, rinse thoroughly then wait eight to 10 days to place final lingual resins. Thoughts? 44

5 Sounds good. One way I like to measure is to measure the incisal edge to the gingiva with your probe on the post: 17/41 outside of the tooth and then do the same with the incisal edge to gutta percha with your probe on the inside of the tooth. This way you have a good idea that you have removed enough GP to go apical to the darker area on the tooth. AUG Talk to any endodontist about internal bleaching and you will find they use sodium member since: post: 20/41 perborate crystals (get it at the drugstore) and mix it with anesthetic or water. To be honest, this works incredibly as a one-month walking bleach. I rarely need to do veneers in cases like this... take the GP out 3mm below the CEJ, then cover it with GI or another material and lay the granular mix into the access, cotton pellet to dab and dry it out. Cover and provisionalize. I usually get them back in one week and the teeth are amazing in how much they go back and often they are as light as or lighter than the adjacent teeth. Do as Rod said, have them bleach everything in the arch and then do the sodium perborate bleach. Here is an excellent article on the topic: Glenn AUG Picture after I did my final lingual resins and final round of internal bleaching using Ultradent s product. post: 33/41 I followed Rod s advice. I waited three weeks before placing the final resins. Before Final SEP » Find it online at: search dentaltown.com «JANUARY