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contaminating the surgical site with any
porcelain debris. The lateral roots are
extracted and implants placed, including
any osseous and soft-tissue augmentation.
After the central crowns are removed and
the surgery is complete, the bridge shell is
trial-fitted over the preparations, exercising
caution not to force the acrylic shell into
place, which could lead to chipping or frac-
ture (Fig. 12). Once passive fit is verified, the
intaglio surfaces of the central incisors are
lightly abraded with 50-micron aluminum
oxide, and a bonding agent (OptiBond Solo
Plus) is placed to enhance adhesion of the
bisacryl material that will be used to reline
the CAD-Temp shell. The bonding agent
is cured, and all external surfaces of the
restoration are coated with a thin layer of
water-based lubricant (KY Jelly) to prevent
unnecessary adhesion of the bisacryl to the
polished external surface of the bridge. In
this case, Protemp Plus (3M Espe) in an
A1 shade is injected into the shell and the
bridge is gently seated to place (Fig. 13).
Having the patient gently close into centric
occlusion at this point, while maintaining
the proper incisal plane, will greatly reduce
the need for occlusal adjustments after
trimming and polishing.
After the material-specific intraoral
curing time, the bridge is carefully teased
from the preparations and placed in a Triad
oven for five minutes to assure a densely
cured restoration. Final contouring and
polishing is achieved using appropriate
acrylic burs, discs and polishers. At this
point, thebridge is of adequate strength that
flexible diamond discs can be used to create
the illusion of separation between the teeth
as well as refining point and line angles. I
find that the best overall polish with CAD-
Temp is accomplished using pumice and a
wet ragwheel on a lathe (Figs. 14-15).
The restoration is then returned to the
mouth, tried in and verified for marginal
integrity, contacts and occlusion. It is
also important to verify that the ovate
extension of the pontic does not contact
the implant fixture or bone graft to avoid
pressure necrosis of bone or soft tissue.
Durelon is used to cement the restora-
tion into place and care is taken to metic-
ulously clean up the excess to avoid irri-
tation of the healing gingival and osseous
tissues (Figs. 16-17).
Utilizing the accuracy of the CEREC
design and MCXL milling system,
combined with the strength and esthetics
of the VITA CAD-Temp material, an
esthetic and functional, fixed-interim
prosthesis can be delivered to the patient,
on the day of surgery, withminimal exten-
sion of appointment length.
The precise marginal integrity and
biocompatibility of the material assure
ideal tissue healing and the ovate pontics
are wonderful for beginning the training
and supporting of the soft tissues that
will eventually surround the final implant
crown and abutment.
Proper execution of this technique
can fulfill both esthetic and functional
demands of the implant patient. The
bridge can be removed and re-cemented
as necessary during the healing, tempo-
rization and restoration phases of the
implant treatment, ultimately leading to
satisfied patient and clinician.
For questions or additional information,
Dr. Hamilton can be reached at
eastmtndental@yahoo.com.
Fig. 12: The shell provisional is tried
in the mouth.
Fig. 13: The shell is relined with bisacryl
material.
Fig. 14: After allowing the reline to cure,
the embrasures are trimmed and the
restoration polished.
Fig. 15: Inside view of the shell provisional.
Fig. 16: The view after final cementation
of the provisional.
Fig. 17: Intraoral retracted view of the
shell provisional.