|Year : 2015 | Volume
| Issue : 1 | Page : 71-74
Replacement of multiunit joined porcelain fused to metal restoration with an esthetic separated all ceramic crowns: Clinical and technical report
Mohammed M Al-Moaleem1, Metaib A Aldhalai2, Fuad A Al-Sanabani1, Khalid A Assiri3, Mohammed Y Tarrosh4
1 Department of Prosthetics, College of Dentistry, Jazan University, Jazan, Saudi Arabia
2 King Khalid Hospital, Najran, Saudi Arabia
3 Armed Force Hospital, Khamis Mushaiet, Saudi Arabia
4 Department of Conservative Dentistry, Jazan University, Jazan, Saudi Arabia
|Date of Web Publication||20-Jan-2015|
Mohammed M Al-Moaleem
Department of Prosthetics, College of Dentistry, Jazan University, P.O. Box 114, Jazan 45142
Improper treatment plan, designing of the restorations and the selection of the restorative materials resulted in patient unsatisfactory. The purpose of this case is to create a hygienic and esthetic restoration for the patient with good social acceptance. Individual all ceramic zirconia crowns were fabricated for a 54-year-old male patient who attended the clinic with a multiunit joined porcelain fused to metal restoration. The esthetic treatment with all ceramic computer-aided design and computer-aided manufacturing crowns resulted in improved facial aesthetics; psychological status and social life of the patient. In addition to that, patient can practice standard oral hygiene in the present of separated crowns.
أدى التخطيط غير السليم للمعالجة وتصميم الترميم واختيار المواد المرقمة إلى عدم رضا المرضى الذين خضعوا لعمليات ترميم الأسنان. هدفت دراسة الحالة إلى ترميم صحي وجمالي لهؤلاء المرضى. وفي دراسة الحالة المعروضة تم عمل التاج ألخزفي الكامل لمريض حضر للعيادة بخزف متعدد الوحدات ومدمج مع معدن.
خلصت الدراسة إلى أن العلاج بالتيجان من الخزف الخالص MAC/DAC أدى إلى تحسن مظهر الوجه وحالة المريض النفسية والاجتماعية.
Keywords: All ceramic, porcelain fused to metal crown, replacement, zirconia
|How to cite this article:|
Al-Moaleem MM, Aldhalai MA, Al-Sanabani FA, Assiri KA, Tarrosh MY. Replacement of multiunit joined porcelain fused to metal restoration with an esthetic separated all ceramic crowns: Clinical and technical report. Saudi J Med Med Sci 2015;3:71-4
|How to cite this URL:|
Al-Moaleem MM, Aldhalai MA, Al-Sanabani FA, Assiri KA, Tarrosh MY. Replacement of multiunit joined porcelain fused to metal restoration with an esthetic separated all ceramic crowns: Clinical and technical report. Saudi J Med Med Sci [serial online] 2015 [cited 2019 Sep 17];3:71-4. Available from: http://www.sjmms.net/text.asp?2015/3/1/71/149692
| Introduction|| |
Full-coverage porcelain fused to metal (PFM) restorations are still viewed as the standard for teeth restorations. They have disadvantages, such as decreased likelihood of retention, associated soft tissue pigmentation and an opaque-to-darkish appearance in the cervical area of the crowned teeth.  Exposed metal crown margin of old PFM restorations might be an esthetic problem. Therefore, all ceramic crown systems are used for replacing the existing restorations and it is the more prudent choice. ,
As a part of the treatment planning, clinicians should be able to choose the appropriate restorative materials to achieve excellent esthetic as well as proper biomechanics and durability. 
All ceramic systems can be used as alternative to PFM system. During the last decade, zirconia - based computer-aided design and computer-aided manufacturing (CAD/CAM) system, which have superior mechanical properties, high flexure strength and fracture resistance were used for anterior and posterior teeth. ,
The esthetic treatment of anterior teeth has always presented a challenge in clinical practice. Restorative material such as zirconia all ceramic crowns have been chosen as alternative to improve oral condition and existing esthetic.  Anterior esthetic rehabilitation with all ceramic crowns improved the self-esteem and self-confidence of the patient and permitted her to return to a satisfactory social life.  Hence, the dentist and ceramist must follow a proper protocol to achieve higher clinical success rate and long-lasting restoration. 
The natural jaws bear a definite relation to each other both at rest and during function. In natural dentition the presence of teeth makes it easy to determine the relationship of jaws to each other.  Replacement of the existing restorations by a new one should be in harmony with the existing occlusal vertical dimension and the inter occlusal relationship. ,
Fiber reinforced composite (FRC) posts had adequate mechanical properties as recent studies suggested that FRC posts contributed to the reinforcement and strengthening of endodontically-treated teeth under the full-coverage crown restorations. 
This article demonstrates the use of CAD/CAM zirconia crowns replacing an existing joined multiunit PFM crowns in the esthetic zone. The goal of this treatment was to create a maintainable healthy periodontal environment, improve facial appearance and restore his teeth back to normal size in harmony with the existing occlusion.
| Case report|| |
A 54-year-old male patient attended to the specialty clinics. The patient requested long-term solution for an esthetic problem resulted after intraoral composite repair of fractured PFM retainer of tooth no. 11. Patient was unhappy with his existing restorations, felt they were too big and bulky and asked for more natural smile appearance. Furthermore, he complained of the color of the metal at the gingival margin and expressed interest in improving his facial appearance. Intraoral examinations showed multiunit joined PFM crowns, extending from tooth no. 13 to tooth no. 23 and from tooth no. 33 to tooth no. 43 [Figure 1]. No pain in temporomandibular joint was detected. Generalized attrition of occlusal surface of all teeth was obvious. Class 1 molar relationship and canine guidance occlusion were observed. Mild gingivitis in the interproximal and embrasure areas with gray pigmentation at the free gingiva of the crowned teeth was obvious. Radiographic examination showed multiunit joined PFM crowns in the anterior teeth of both maxillary and mandibular arch [Figure 2].
After examination of the patient and collecting data, the steps of the treatment plan sequences and the replacement of the joined crowns were discussed with the patient, his agreement was taken.
The treatment was begun by maxillary and mandibular impression with alginate dust-free impression materials. At this visit, scaling and polishing of teeth were done including the crowned teeth. From the poured impression models, diagnostic wax-up was prepared with the help of the dental technician and ceramist [Figure 3]. Then, rubber base indexes were prepared from the diagnostic wax-up models.
The removing of the joined PFM retainers were started with sectioning of the existing crowns from buccal to lingual using coarse diamond burs (Meisinger, Germany) as recommended by Rosenstiel et al., 2006.  The sectioning was done without local anesthesia. All the abutment teeth were nonvital, so root canal treatments were done by an endodontist. After cleaning, shaping and root canal obturation of offending teeth, their roots have received FRC post (Relaxy Fiber Post, 3MESPE, Germany). The cores of all teeth were built with composite resin (Tetric-NCeramic, Ivoclar Vivadent, Lichenestine) to close the access opening of the prepared teeth.
Modifications of the preparations of the endodontically-treated teeth were done. Provisional crowns were constructed (Success SD, Promedica Neumunster, Germany) and cemented with temporary cementation (Temp-BondNT, Italy) [Figure 4].
After 1 month, removals of the provisional restorations were done. All the interproximal areas around the prepared teeth were healthy. Maxillary and mandibular final impressions were taken with addition Silicon (Virtual Ivoclar Vivadent, Lichtenstein) using double mixing techniques. Pouring the maxillary and mandibular final impression were done with CAD/CAM special stone (BEGO/Germany), die preparation, ditching and finish line exposure were done. The master casts were mounted on laser scanner (Cynoprod Canada Inc. Listings, Montreal, Canada) for scanning and capturing the preparation. The scanner is connected to the computer screen by the software program 1.3 EVLOTION (Cynoprod Canada Inc. Listings, Montreal, Canada) for milling the zirconia core. The cores build-up was done with Vita In-Ceram YZ Disc (VitaZahnfabric/Germany).
Try-in for the milled cores were done in the patient's mouth. Then, shade guide selection using the digital shade guide VITA System 3D-Master (Vita Easyshade (R) Compact, Vita, Germany) was done; the selected shade was (2R1.5-3D master). The maxillary and mandibular master casts with the tried cores were mounted on semi-adjustable articulator (Hanau TM Waterpik (R) Technologies, Fort Collins, Company) using face bow. Porcelain build-up were done with porcelain VITA VM(R)9 (VitaZahnfabric/Germany). The final shape of the porcelain crowns were the same as in the diagnostic wax-up.
At the final step, porcelain try-in of the individual crowns in the patient's mouth were done, interocclusal adjustment, canine guidance, as well as protrusive and lateral movements were checked before glazing. Cementations of the glazed individual crowns were done with resin cement (Relaxy XTM, Unicem AppliCap Resin Cement, 3M ESPE, Germany) [Figure 5]. All the steps of constructions, fabrications and cementation of the all ceramic crowns were following the manufacturer instructions. The case was followed-up for maintenance.
| Discussion|| |
The darkness of color associated with PFM crowns is one of the main reasons that cause the patient to replace them with all ceramic crowns.  The operative removal of an existing PFM restoration from teeth that are to receive new restorations can be traumatic for the patient and stressful for clinician. Often, the restorations must be cut completely through high-speed rotary instruments.  The operator and clinical assistant are exposed to debris, even wearing surgical masks. Protective eyewear for the patient and dental team is recommended to prevent eye injuries from projectile matter, so the patient should be informed that there is a degree of uncertainty about the outcome before proceeding.
The esthetic treatments of anterior teeth have always presented a challenge in dental practice. As dental materials continue to evolve, new all ceramic materials with superior mechanical properties, such as high flexure strength, high fracture toughness and biocompatibility are continuously introduced to the market, such as zirconia-based CAD/CAM systems.  In this circumstance, dentists and patients must choose the best alternative to improve oral condition and existing esthetic. 
The formulation of simple treatment plan that considered separated crowns will help patient to practice oral hygiene at the interproximal area. Furthermore, the evaluation of the integrity of the crowns during maintenance phase can be easy with separated crowns.  The occlusion technique that followed in this case was the confirmative occlusal technique mentioned by Dawson. The replaced existing PFM joined restorations with new all ceramic zirconia restoration coincided with the maximum intercuspal relationship, putting in consideration the type of existing occlusion scheme which was canine-guidance occlusion. 
The FRC posts with composite resin cores build-up were used to establish a good bond with the remaining tooth structure, which enabled homogenous transmission of occlusal forces and thus potentially strengthen the coronal structure.  In addition, the core build-up procedure could be completed in the same visit.
The clinical significance of this case is that, all ceramic restorations resulted in marked improvement of the esthetic appearance and enhances periodontal health, so the patient can practice slandered oral hygiene measurements between the restorations. Furthermore, the size resulted from all ceramic restorations improve the lip position regarding to smile line. Finally, the need of retreatment can be carried out easily.
| Conclusion|| |
Understanding the restorative materials, properties for esthetic replacement of an existing PFM anterior restoration is a must as it results in creative esthetic restorations, increasing self-esteem, confidence of the patient; hence promoting return to a satisfactory social life. Zirconia-based restorations are a promising prosthodontics alternative material to PFM restorations and showed excellent clinical performance. One principle should be kept in mind in the treatment plan for prosthetic restorations, is that the design of the restorations should be as simple as possible for prognosis and the retreatment should be observed if needed during follow-up phases.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]