TREATMENT OUTCOME

Kassiani Stamouli, DDS, Dr med dent

Clinical Associate Professor Department of Prosthodontics, School of Dentistry University of Freiburg, Germany

Sjoerd Smeekens, DDS, Dr med dent

Clinical Associate Professor Department of Prosthodontics, School of Dentistry University of Freiburg, Germany

Correspondence to: Dr Kassiani Stamouli

Sundgauallee 55, 79114 Freiburg, Germany phone: +49 761 270 4838; e-mail: kassiani.stamouli@uniklinik-freiburg.de

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Rehabilitation of a Periodontally Compromised Case Using the Conical Crown System. Part II.

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The aim of this two-part treatment series is on the one hand to emphasize the difficulties a clinician is confronted with when planning complex cases, and on the other hand to reveal the rationale supporting the final treatment plan selection. Among the challenging cases to be considered are periodontal compromised rest dentitions requiring prosthodontic rehabilitation. For these patients the decision-making process deals with the indi-

cations and limitations of both the fields of fixed and removable prosthodontics. The first part of this article deals with the various prosthodontic treatment options, together with the advantages and disadvantages related to each one. This second part of the article presents the final treatment plan, the decision-making process, and the sequence of the treatment steps. (Eur J Esthet Dent 2009;4:164176.)

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Abstract

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Partial Denture Patient comfort Esthetics Compensation of ridge defects Phonetics Invasiveness Fabrication complexity Extensibility/repairability Palatal coverage required Oral hygiene performance Economics Long-term clinical performance

Claspretained + + + -

Attachmentretained + + + + +/+ + +/-

Conical crown-retained + +/+ + + +/+ +/+ +/+/-

Fixed

+ +/+/+ +/+ +

Final decision
The final decision was taken after considering both the patients priorities and scientific objectives. While taking into consideration the wishes of the patient, as well as the benefits and limitations of the various treatment modalities presented, the following decisive parameters were evaluated (Table 1). In the present case, the advantages of a conical crown prosthesis were comparable to the other treatment options. However, the compensation of ridge defects and the extensibility/repairability made it the most favorable type of prosthesis. To overcome the disadvantages (i.e. avoid the subgingival abutment preparation and the visibility of gold margins), it was decided to fabricate full ceramic primary crowns. However, controlled clinical trials and longterm data on the clinical behaviour of zir-

conium dioxide (ZrO2) copings are not numerous, their findings are lacking in evidence, and only case reports on primary crowns made from ZrO2 with the application of the CAD/CAM technology exist.1 In the mandible, due to the reduced esthetic demands, traditional gold primary crowns were planned.

Treatment steps
Preliminary treatment
The hopeless teeth 16, 14, 12, 21, 22, 26, 33, and 46 were extracted, followed by the immediate placement of the provisional prostheses. In collaboration with the dental hygienist, periodontal therapy was performed and re-evaluated after 4 to 6 weeks. The major reduction of probing

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Table 1

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Fig 1

Diagnostic setup on the mounted casts.

Fig 2

Try-in of the diagnostic setup.

Figs 3 and 4

Basal views of the diagnostic setups.

depths allowed the initial prosthodontic treatment plan to be carried out.

tance (phonetic tests used m-sound pronunciation [23 mm interarch space] and s-sound pronunciation [no teeth contact]), existing freeway space of

Diagnostic phase
Prior to tooth preparation, impressions were taken from both the maxilla and the mandible. On the casts obtained, the technician fabricated wax register plates, which were used for bite registration. During the next patient visit the following aspects were controlled.
I I I

2 mm. - the midline. Tooth 11 served as the reference point indicating the length of the incisal edge. The smile line and occlusal plane.

After initial tooth preparation, provisionalization, and bite registration the technician fabricated the diagnostic try-in setup (Figs 1 to 4). This setup offered the opportunity to evaluate and visualize the treatment goal

The vertical dimension was maintained: - facial/lip support, maxillomandibular dis-

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Fig 5

Control with silicon key (made from the setup)

Fig 6 sion.

Definitive space control before taking impres-

of the initial tooth preparation.

Figs 7 and 8

Occlusal view of all teeth before taking impression.

Figs 9 and 10

Try-in of the maxillary and mandibular primary copings.

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come of the removable dental prosthesis. It served also as an effective communication tool among the patient, clinician, and the dental technician.

Prosthodontic phase
After correcting the try-in setup, silicon keys were made to serve as a guide for the definitive abutment preparation (Figs 5 and 6). This process assured that an optimal amount of tooth substance was removed. This step is of great importance, since the conical crown system requires a substantial amount of tooth substance to be removed. The location of the margins were kept epigingivally. With respect to longterm maintenance of periodontal health, studies have shown that a supragingival location of the crown margin is more favorable compared with a subgingival location.2,3 From an esthetic point of view, this approach did not have any disadvantages, because the primary copings were fabricated out of ZrO2 in the maxilla. After the teeth had been definitively prepared (Figs 7 and 8), impressions were taken with customised trays and PermadyneTM GarantTM (3MTM ESPETM, Seefeld, Germany). The fabrication of the stone dies followed at the dental laboratory. For the maxilla, the ZrO2 primary copings were fabricated with the Zeno Tec (Wieland Dental, Germany) CAD/CAM system. First, the stone dies were scanned in the 3D shape 200 Scanner. The copings (Fig 9) were then milled out of Zeno Zr Discs (partially sintered yttria tetragonal zirconia polycrystal [Y-TZP]) in the Zeno 4030 M1 CAM unit (Wieland Dental). For the mandible, conventional gold (BioMaingold SG, Heraeus
Figs 11 to 13 Occlusal and facial view of the secondary frameworks.

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and the prospective tooth form and out-

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Figs 14 and 15

Gingival and facial view of the fabricated maxillary conical crown denture.

Fig 16

Facial view of both conical crown dentures.

Fig 17 denture.

Occlusal view of the maxillary conical crown

Fig 18

Focused facial view of the maxillary anterior

Fig 19

Occlusal view of the mandibular conical

part of the reconstruction.

crown denture.

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ings were fabricated (Fig 10). The try-in process of all primary copings revealed a good marginal fit. Impressions of the maxilla and mandible with customized trays and ImpregumTM PentaTM (3M ESPE) were taken over the primary copings, for the fabrication of the master models. With a face bow transfer and a bite registration with wax plates, the master models were mounted in the articulator. The desired vertical dimension was transferred exactly by using the provisional restorations. The technician fabricated the secondary frameworks (Figs 11 to 13) for the telescope dentures on the mounted master models. At the maxilla, owing to the favorable abutment distribution, a palatal-connector-free framework was achieved (Figs 14 and 15). After trying in the frameworks of both arches, the primary setup and the corresponding provisional restorations were used as a reference for the final removable dental prostheses. The clinical re-evaluation before cementation revealed that the patient was satisfied with both the function and the esthetics of the restorations (Figs 16 to 21). All remaining teeth showed a probing depth of less than 4 mm, negative bleeding on probing, and a positive reaction to the vitality test. The periodontal status before cementation is presented in Figure 22. The radiographic evaluation before cementation also revealed healthy dental and periodontal relations (Fig 23). Finally, all primary copings were cemented with KetacCem (3M ESPE). After removing the cement rests, the removable dental prostheses were inserted. The patient received instructions for meticulous home care and was integrated into a 4-month recall program.

Fig 20

Patient smiling after the insertion of the coni-

cal crown dentures.

Fig 21

Smile of the patient after rehabilitation

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Kulzer, Hanau, Germany) primary cop-

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PD

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AL

mm

mm

AL PD Furc
Fig 22 loss). Periodontal status before cementation (Furc: furcation involvement, PD: probing depth, AL: attachment

Fig 23

Radiographic evaluation before cementation.

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Fig 24

Orthopantogram after 18 months of function.

Discussion
This article describes the application of the conical crown system for the oral rehabilitation of a patient with advanced periodontal disease. In such a case, rehabilitation with a fixed prosthesis would increase the risk of failure, whereas a removable dental prosthesis can be retrieved and repaired, and is therefore flexible.4,5 However, the lack of stability, the limited esthetics and the low patient comfort make removable prostheses unattractive for patients as well for the clinicians. Therefore, the conical crown system and its variable modifications are considered to be a suitable prosthesis to cover the gap between fixed and removable prostheses.

In cases of favorable number, distribution, and condition of the abutment teeth (as in the present case) the secondary dentureframework can be fabricated without supporting big connectors (palatal, lingual bar).6,7 Moreover, a cementation of the reconstruction with a temporary cement is also possible. This modification allows the restoration to be retrieved if needed. In case of de-cementation, there is no risk of secondary caries, as the failure zone is between the primary and the secondary crown. The primary crown, which was cemented on the tooth, remained intact showing a good marginal fit. Another aspect that should not be underestimated is the feeling of having fixed restorations in a patients mouth. For many patients, this

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Fig 25

Fig 26

Fig 27

Fig 28

Fig 29

Fig 30

Fig 31

Figs 25 to 31

Intraoral views of the patient after 18 months of function.

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quality of life and increased self-esteem and confidence. On the other hand, the gold margins, the view of metal in the oral cavity, and the overcontour are major disadvantages. The increasing demand for more esthetic and natural-looking restorations has led to an advanced development of ceramic materials.8-10 The low fracture strength of the traditional ceramics limits their wide application.8 The improved mechanical properties of the new high-strength ceramics, especially the ZrO2 ceramics, have expanded their application for reconstructions under increased loading1. This allows the application of ZrO2 for the fabrication of primary copings for the conical crown system, avoiding the unattractive gold margins and achieving an esthetically and functionally pleasing restoration. However, to avoid the visibility of the anterior maxillary secondary crowns, the core margins were cut back buccally up to 2 mm (vertically) and shoulder composite was applied according to the facial porcelain margin principle of Shillingburg.11-13 From both the esthetic and functional point of view the end result was satisfying. At the 3-, 6-, 12-, and 18-month recall intervals the periodontal re-evaluation revealed healthy hard- and soft-tissue relations. An orthopantogram (Fig 24) after 18 months of function revealed healthy dental and periodontal relations. Figures 25 to 31 show intraoral views of the patient after 18 months. The patient reported an enhancement in quality of life (Fig 32). Generally, it is well established that selfperformed plaque control, combined with regular attendance of maintenance care

Fig 32 ity of life.

Patient reported of an enhancement in qual-

following active periodontal treatment, represents an effective means of controlling gingivitis and periodontitis and limiting tooth mortality over a 30-year period.14

Acknowledgements
The authors would like to thank the dental laboratory Woerner Zahntechnik, Freiburg, Germany for the technical part of the case.

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is of high priority, offering an improved

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1.

Pellecchia R, Kang KH, Hirayama H. Fixed partial denture supported by all-ceramic copings: a clinical report. J Prosthet Dent 2004;3:220223. 2. Reichen-Graden S, Lang NP. Periodontal and pulpal conditions of abutment teeth. Status after four to eight years following the incorporation of fixed reconstructions. Schweiz Monatsschr Zahnmed 1989;12:13811385. 3. Valderhaug J, Ellingsen JE, Jokstad A. Oral hygiene, periodontal conditions and carious lesions in patients treated with dental bridges. A 15-year clinical and radiographic follow-up study. J Clin Periodontol 1993;7:482489. 4. Bergman B, Ericson A, Molin M. Long-term clinical results after treatment with conical crown-retained dentures. Int J Prosthodont 1996;6:533538.

11.

12.

13.

14.

densely sintered alumina and zirconia restorations: Part 2. Int J Periodontics Restorative Dent 2005;4:343349. Shillingburg HT Jr, Hobo S, Fisher DW. Preparation design and margin distortion in porcelain-fused-to-metal restorations. J Prosthet Dent 1973;3:276284. Goodacre CJ, Van Roekel NB, Dykema RW, Ullmann RB. The collarless metal-ceramic crown. J Prosthet Dent 1977;6:615622. Chiche G, Radiguet J, Pinault A, Genini P. Improved esthetics for the ceramometal crown. Int J Periodontics Restorative Dent 1986;1:76-87 . Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol 2004;9:749757 .

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References

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