A 19-year-old patient, who had congenitally missing maxillary lateral incisors (Fig. 1), was referred to Fixed Prosthodontics Department at Faculty of Dentistry-Damascus University (Damascus, Syria). The patient's chief complaint was her unesthetic appearance. Clinical and radiographic examinations were made. The maxillary central incisors and canines were intact with a little malalignment. The overjet and overbite of the anterior teeth were within the normal limits with a Class I Angle classification of the overall dental occlusion. The different treatment options were discussed with the patient. Two IPS e.max press veneer FDPs were selected as the treatment of choice.
Maxillary and mandibular diagnostic casts were made from alginate impressions. Wax-up was made in the anterior region of the maxillary cast. A silicone index of the wax-up was made to ensure appropriate depth of the preparation. The central incisors and canines were prepared according to the general guidelines of a porcelain veneer preparation, considering the path of insertion of each FDP (Fig. 2). The tooth reduction was made by using a tapered round-end diamond bur (#868 314 016, Komet Dental, Gebr. Brasseler, Lemgo, Germany) in order to create a 0.5-mm chamfer finish line. Labial surfaces were prepared to provide 0.5–1 mm thickness of the retainers at the middle and incisal thirds. Incisal reductions were a feather-edge preparation for the canines, and 1–1.5 mm beveled preparation for central incisors. The proximal reduction was extended just into the proximal contact point at the mesial surfaces of the central incisors and the distal surfaces of the canines, whereas the preparation was extended to the proximo-lingual line angles adjacent to the edentulous area to provide an adequate bucco-lingual dimension of the connectors. All internal line angles were rounded, and all surfaces were finished with fine diamond burs (#8868 314 016, #8379 314 023, Komet Dental). A putty wash impression technique was used to make a complete arch impression with a vinyl polysiloxane impression material (Virtual, IvoclarVivadent, Schaan, Liechtenstein). A provisional FDP was fabricated from autopolymerizing resin material (Structure 2 SC, Voco, Cuxhaven, Germany) according to the wax-up and were cemented with a flowable autopolymerizing composite (Tetric N-Flow, IvoclarVivadent) only. The definitive casts were mounted in a semi-adjustable articulator (Stratos 200, IvoclarVivadent). All-ceramic veneer FDPs were fabricated with a lithium disilicate glass ceramic (IPS e.max press, IvoclarVivadent). Full contour FDPs were heat-pressed with a low-translucency ceramic ingot (Low Translucency A1 ingot, IPS e.max press, IvoclarVivadent). Then, the final shade was obtained by application of stains (IPS e.max Ceramic Shades, Essence, IvoclarVivadent). The dimensions of the connectors were at least 5 × 2.5 mm . The pontics' design was modified ridge lap, because it combined esthetics with ease of cleaning. A first try-in was performed to assess complete seating of the prostheses, marginal adaptation of each retainer, tissue contact, form, occlusion, and shade matching. After all modifications were made, a final approval from the patient was obtained.
The prostheses were cemented with transparent light polymerizing resin cement (Variolink N, Base, IvoclarVivadent) in accordance with the manufacturer's instructions. The prostheses were cleaned with alcohol 96%. The intaglio surfaces of the prostheses were acid etched with hydrofluoric acid 5% (IPS Ceramic etching gel, IvoclarVivadent) for 20 sec. Then, all surfaces were thoroughly rinsed with water spray and dried with oil-free air. The etched surfaces were treated with a silane coupling agent (Monobond S, IvoclarVivadent) for 60 sec, and the agent were dispersed with a strong stream of air. The enamel and exposed dentin were etched with 37% phosphoric acid (N-Etch, IvoclarVivadent) for 30 and 15 sec, respectively. A bonding agent (Excite F, IvoclarVivadent) was applied to all bonding surfaces of the prostheses and the abutments, and carefully air thinned. The light polymerizing resin cement was applied directly to the intaglio surfaces of the prostheses, and then the two prostheses were bonded to the abutment teeth simultaneously. The excess resin cement was removed with a microbrush, and each surface was light polymerized for 60 sec. The occlusion was evaluated, and necessary occlusal adjustments were made using fine diamond burs and porcelain polishing kit (Optrafine, IvoclarVivadent). Recall visits were performed three times over 18 months period (Fig. 3). No debonding was observed, and function and esthetics were satisfactory.