Temps with lasting looks

There are enough children born with congenitally missing laterals to warrant discussion about how to solve the problem of social embarrassment for them even if it’s just a temporary solution.

Later, when the patient is an adult, he or she can decide to move forward with a permanent answer, be it implants or bridgework, whatever resolution best suits him or her.

Our case discussion will revolve around a young woman of 17, who had been wearing a retainer flipper that she didn’t find to be esthetically pleasing. She was ready for a solution, provisional in nature, but still better than the appearance of a retainer bar across her teeth.

For the lab’s part of the process, we had to look at how we could offer the best solution and material choice. The patient was not yet ready for implants but needed a long-term provisional resolution. It was decided that a Maryland bridge would best serve her needs in the short term.

Between the centrals and the canines there was a large amount of opacity and color with a great deal of enamel. The patient had rough texture, subtle white calcification and also subtle translucency. Her open bite provided excellent positioning for the technician, meaning the clinician didn’t have to do any preparation. At times, in a case like this, there might be a little bit of an undercut but with this patient there wasn’t. Therefore no trimming was necessary on the clinician’s behalf.

Case Study

The 17-year-old girl was not happy with the esthetics of her flipper retainer and the bar that crossed the front of her teeth (Fig. A). Congenital missing laterals are an issue for some children and a problem that’s dealt with when they grow older (Fig. B).

01 For this case, I decided to use GC America’s Ceramic Composite Gradia indirect. The application procedure included layering on the composite, curing it and leaving it for two minutes in the machine, then placing another layer over that (Fig. C). Her case model (Fig. D) mirrors her smile image in Fig. A.

02 The cast model lingual view (Fig. D) shows the connection between the Maryland Bridge and the fiber core between the teeth for maximum strength.

03 I created the bridges with slightly more thickness in the joint area for more support. In the lateral view we see I was able to use more color layering with GC Gradia Composite (Fig. E). Next is the lateral view (Fig. F).

04Figs. G and H are the finished restorations for tooth No. 7 and tooth No. 10 respectively. A B2 dentin base body color was applied with TI translucency after viewing the color and deciding on proper contour for internal staining.

05 After the internal staining and curing, the enamel overlay was applied in E3 all the way to the body area.

06 Next, a liquid glaze application was layered subtly, then cured and polished with a diamond polish.

07 In a facial view on the cast model (Fig. I), the full effect of the color and glazing is in view. A mirrored image of the two Maryland Bridges follows (Fig. J) and then a try-in for tooth No. 10 color and fit check (Fig. K) and tooth No. 7 (Fig. L).

08 A discerning eye can see the contour and incisal length is shorter on tooth No. 10 than tooth No. 7 (Figs. M and N). The height of contour, mesial line angle and shape also were checked while the restorations were on the model. In the smile side view we can especially distinguish the texture (Fig. O). With heavy glazing, we would have had an effect that was too bright in color with high value. It wouldn’t have produced a natural appearance. I worked to make sure the surface texture was rough and the line angle the same as the patient’s.

09 The final view is a good smile line for the patient (Fig. P). Her lower lip is irregular, which makes the teeth on her left appear to be higher than those on her right. This is nature’s way and nothing to be concerned about. I was looking for harmony and coordination of color, which I felt was achieved.

Conclusion 

Young people are very self-conscious about their appearance and apprehensive about how they are perceived by the general public. Missing laterals don’t help with their general sense of confidence-in fact, it just adds to the problem.

The best solution depends on the patient’s stage of life and his or her economic situation, as well. In our case, the patient was, in her opinion, too young for implants. She saw that as a future option.

However, it didn’t change the fact that she was unhappy with her current situation. The Maryland Bridges were a perfect long–term temporary solution for her. The future looks bright for this young girl!