The advent of high-strength ceramics and the ability to bond to dentin and enamel has simplified the task of making a restoration look like a tooth, however, endodontically treated central incisors continue to be one of biggest challenges.
A 45-year-old female patient presented with a dark, endodontically treated maxillary central incisor (No. 8). A slight midline cant and uneven incisal edges combined to create an obvious esthetic challenge. A complete set of records were obtained to properly diagnose the best treatment for this case. Study models, facebow (Stratos, Ivoclar Vivadent), bite registration, digital photographs, and digital radiographs (ScanX, Air Techniques) were shared with the dental lab (CMR Dental Lab, Idaho Falls, ID) to create a diagnostic wax-up for 2 e.max lithium disilicate restorations.
Lingual restorations were removed from teeth No. 7 and No. 8 and replaced with composite resin (Empress Direct, Ivoclar). Tooth No. 8 was prepared for a full-coverage crown, and No. 9 was prepared for a conservative veneer. Provisionals were fabricated using a putty matrix of the wax-up with a bis-acryl (Structur Premimum, VOCO) and a final impression was taken (Imprint II, 3M). The provisionals were spot bonded with flowable composite. Digital photos of the preps with shade tabs to convey underlying colors and photos of provisionals were sent to the lab. The patient returned 1 week later for an evaluation of the provisionals. We agreed that the length and shape were appropriate. An impression of the patient's provisionals was sent to the lab to allow duplication of the incisal edge position.
On the day of delivery, the provisionals were removed, and the e.max restorations were tried in and evaluated. The patient confirmed the esthetics and the preparation to deliver the restorations began. The restorations were cleaned with Ivoclean (Ivoclar Vivadent) and then prepared with Monobond Plus (Ivoclar Vivadent). The teeth were prepared with a total-etch technique using Excite and Variolink resin cement (Ivoclar Vivadent). The Bluephase Style (Ivoclar Vivadent) curing light was used to polymerize the cement.
Matt Roberts, CDT at CMR Dental Lab did a beautiful job with the IPS e.max V2 ingot (Ivoclar Vivadent) using a combination of facial layering and stains. The final result is a great example of "natural esthetics."