rehabilitation of a periodontally compromised case using the conical crown system part ii
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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
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Rehabilitation of a Periodontally
Compromised Case Using
the Conical Crown System.
Part II.
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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STAMOULI/SMEEKENS
cations and limitations of both the fields of
fixed and removable prosthodontics. The
first part of this article deals with the vari-
ous prosthodontic treatment options, to-
gether with the advantages and disad-
vantages related to each one. This second
part of the article presents the final treat-
ment plan, the decision-making process,
and the sequence of the treatment steps.
(Eur J Esthet Dent 2009;4:164–176.)
Abstract
The aim of this two-part treatment series
is on the one hand to emphasize the dif-
ficulties a clinician is confronted with
when planning complex cases, and on
the other hand to reveal the rationale sup-
porting the final treatment plan selection.
Among the challenging cases to be con-
sidered are periodontal compromised
rest dentitions requiring prosthodontic re-
habilitation. For these patients the deci-
sion-making process deals with the indi-
165THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 2 • SUMMER 2009
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conium dioxide (ZrO2) copings are not nu-
merous, their findings are lacking in evi-
dence, and only case reports on primary
crowns made from ZrO2 with the applica-
tion of the CAD/CAM technology exist.1In
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 den-
tal hygienist, periodontal therapy was per-
formed and re-evaluated after 4 to 6
weeks. The major reduction of probing
Final decision
The final decision was taken after consider-
ing both the patient’s priorities and scientif-
ic objectives. While taking into consideration
the wishes of the patient, as well as the ben-
efits 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 sub-
gingival abutment preparation and the vi-
sibility of gold margins), it was decided to
fabricate full ceramic primary crowns.
However, controlled clinical trials and long-
term data on the clinical behaviour of zir-
Table 1 Advantages and limitations of fixed and removable dental prostheses
Clasp- Attachment- Conical Fixed
Partial Denture retained retained crown-retained
Patient comfort - + + +
Esthetics - + +/- +/-
Compensation of ridge defects + + + -
Phonetics - + + +/-
Invasiveness - +/- + +
Fabrication complexity - + +/- +/-
Extensibility/repairability - - + -
Palatal coverage required - - +/- +
Oral hygiene performance + + + -
Economics + - +/- -
Long-term clinical performance - +/- +/- +
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STAMOULI/SMEEKENS
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167
tance (phonetic tests used m-sound
pronunciation [2–3 mm interarch space]
and s-sound pronunciation [no teeth
contact]), existing freeway space of
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, provisional-
ization, 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
depths allowed the initial prosthodontic
treatment plan to be carried out.
Diagnostic phase
Prior to tooth preparation, impressions
were taken from both the maxilla and the
mandible. On the casts obtained, the tech-
nician fabricated wax register plates, which
were used for bite registration. During the
next patient visit the following aspects were
controlled.
� The vertical dimension was maintained:
- facial/lip support, maxillomandibular dis-
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.
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Fig 5 Control with silicon key (made from the setup)
of the initial tooth preparation.
Fig 6 Definitive space control before taking impres-
sion.
Figs 9 and 10 Try-in of the maxillary and mandibular primary copings.
Figs 7 and 8 Occlusal view of all teeth before taking impression.
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STAMOULI/SMEEKENS
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and the prospective tooth form and out-
come of the removable dental prosthesis.
It served also as an effective communica-
tion 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 de-
finitive 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 substan-
tial amount of tooth substance to be re-
moved. The location of the margins were
kept epigingivally. With respect to long-
term maintenance of periodontal health,
studies have shown that a supragingival lo-
cation of the crown margin is more favor-
able compared with a subgingival loca-
tion.2,3
From an esthetic point of view, this
approach did not have any disadvantages,
because the primary copings were fabri-
cated out of ZrO2 in the maxilla. After the
teeth had been definitively prepared (Figs
7 and 8), impressions were taken with cus-
tomised trays and PermadyneTM
GarantTM
(3MTM
ESPETM
, Seefeld, Germany).
The fabrication of the stone dies fol-
lowed at the dental laboratory. For the max-
illa, the ZrO2 primary copings were fabri-
cated 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 polycrys-
tal [Y-TZP]) in the Zeno®
4030 M1 CAM unit
(Wieland Dental). For the mandible, con-
ventional gold (BioMaingold SG, Heraeus
Figs 11 to 13 Occlusal and facial view of the sec-
ondary frameworks.
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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 Occlusal view of the maxillary conical crown
denture.
Fig 18 Focused facial view of the maxillary anterior
part of the reconstruction.
Fig 19 Occlusal view of the mandibular conical
crown denture.
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Kulzer, Hanau, Germany) primary cop-
ings were fabricated (Fig 10). The try-in
process of all primary copings revealed a
good marginal fit. Impressions of the max-
illa 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 exact-
ly by using the provisional restorations.
The technician fabricated the secondary
frameworks (Figs 11 to 13) for the tele-
scope dentures on the mounted master
models. At the maxilla, owing to the favor-
able abutment distribution, a palatal-con-
nector-free framework was achieved (Figs
14 and 15). After trying in the frameworks of
both arches, the primary setup and the cor-
responding provisional restorations were
used as a reference for the final removable
dental prostheses.
The clinical re-evaluation before ce-
mentation revealed that the patient was
satisfied with both the function and the es-
thetics of the restorations (Figs 16 to 21).
All remaining teeth showed a probing
depth of less than 4 mm, negative bleed-
ing on probing, and a positive reaction to
the vitality test. The periodontal status be-
fore 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 pros-
theses were inserted. The patient received
instructions for meticulous home care and
was integrated into a 4-month recall pro-
gram.
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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Fig 23 Radiographic evaluation before cementation.
Fig 22 Periodontal status before cementation (Furc: furcation involvement, PD: probing depth, AL: attachment
loss).
PD
AL
mm
mm
AL
PD
Furc
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In cases of favorable number, distribution,
and condition of the abutment teeth (as in
the present case) the secondary denture-
framework can be fabricated without sup-
porting big connectors (palatal, lingual
bar).6,7
Moreover, a cementation of the re-
construction 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 ce-
mented on the tooth, remained intact
showing a good marginal fit. Another as-
pect that should not be underestimated is
the feeling of having fixed restorations in
a patient’s mouth. For many patients, this
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Discussion
This article describes the application of the
conical crown system for the oral rehabili-
tation of a patient with advanced periodon-
tal 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 prosthe-
ses 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.
Fig 24 Orthopantogram after 18 months of function.
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Fig 25 Fig 26 Fig 27
Fig 28 Fig 29
Fig 30
Figs 25 to 31 Intraoral views of the patient after 18 months of function.
Fig 31
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is of high priority, offering an improved
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 mate-
rials.8-10
The low fracture strength of the tra-
ditional ceramics limits their wide applica-
tion.8The improved mechanical properties
of the new high-strength ceramics, espe-
cially the ZrO2 ceramics, have expanded
their application for reconstructions under
increased loading1. This allows the appli-
cation 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 shoul-
der 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 inter-
vals the periodontal re-evaluation revealed
healthy hard- and soft-tissue relations. An
orthopantogram (Fig 24) after 18 months
of function revealed healthy dental and pe-
riodontal relations. Figures 25 to 31 show
intraoral views of the patient after 18
months. The patient reported an enhance-
ment in quality of life (Fig 32).
Generally, it is well established that self-
performed plaque control, combined with
regular attendance of maintenance care
following active periodontal treatment, rep-
resents 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 tech-
nical part of the case.
Fig 32 Patient reported of an enhancement in qual-
ity of life.
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10. Sadan A, Blatz MB, Lang B.
Clinical considerations for
densely sintered alumina and
zirconia restorations: Part 2. Int
J Periodontics Restorative Dent
2005;4:343–349.
11. Shillingburg HT Jr, Hobo S,
Fisher DW. Preparation design
and margin distortion in porce-
lain-fused-to-metal restora-
tions. J Prosthet Dent
1973;3:276–284.
12. Goodacre CJ, Van Roekel NB,
Dykema RW, Ullmann RB. The
collarless metal-ceramic
crown. J Prosthet Dent
1977;6:615–622.
13. Chiche G, Radiguet J, Pinault
A, Genini P. Improved esthetics
for the ceramometal crown. Int
J Periodontics Restorative Dent
1986;1:76-87.
14. Axelsson P, Nystrom B, Lindhe
J. The long-term effect of a
plaque control program on
tooth mortality, caries and peri-
odontal disease in adults.
Results after 30 years of main-
tenance. J Clin Periodontol
2004;9:749–757.
5. Wenz HJ, Hertrampf K,
Lehmann KM. Clinical longevi-
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crowns: outcome of the dou-
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J Prosthodont 2001;3:207-213.
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