Enhancing Dental Aesthetics and Functionality with the Vertical Freedom Concept

A clinical case by our Community member Dr Stefano Conti
Dental Technicians: Franco Pozzi e Ateikos Quintavalla

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

A 25-year-old patient has presented with an unsatisfactory crown on the upper left central incisor accompanied by gingival recession.
The treatment plan involves replacing the upper left central incisor with a zirconia crown and the upper right central incisor with a disilicate No-Prep veneer. Employing the Vertical Freedom (VF) concept, we will perform vertical tooth preparation on the upper left central incisor to manipulate soft tissue and achieve an ideal gingival architecture. Symmetrical zenith will be ensured for both the upper right and upper left central incisors.

aidite style italiano styleitaliano
aidite style italiano styleitaliano
style italiano styleitaliano intraoral situation of central incisors indirect restoration vertical freedom technique zirconia crown ceramic veneers Aidite 3D Pro Zir

Fig.1
Inadequate quality and quantity of keratinized gingiva.
Altered gingival architecture.
Is a connective tissue graft necessary?

style italiano styleitaliano Tooth-lip relation at rest indirect restoration vertical freedom technique zirconia crown ceramic veneers Aidite 3D Pro Zir

Fig.2
Tooth-lip relation at rest.

style italiano styleitaliano Tooth-lip relation during smile indirect restoration vertical freedom technique zirconia crown ceramic veneers Aidite 3D Pro Zir

Fig.3
Tooth-lip relation during smile.

style italiano styleitaliano smile design indirect restoration vertical freedom technique zirconia crown ceramic veneers Aidite 3D Pro Zir

Fig.4
As the initial step, a Smile Design was conducted to assess the dimensions, shapes, and positions of the upper right central incisor and upper left central incisor, as well as to estimate the amount of recession requiring compensation through the Vertical Freedom (VF) approach to achieve symmetrical zenith.

style italiano styleitaliano mock up for central incisors

Fig.5
Based on the smile design, a wax-up was fabricated, followed by a mock-up procedure.

style italiano styleitaliano initial gingival zenith at tooth 21

Fig.6
As observed, the planned position of the crown margin, as determined by the smile design, does not align with the current gingival level. Therefore, a Vertical Freedom (VF) approach is necessary to reposition the soft tissue coronally.

style italiano styleitaliano abutment after removal of old ceramic crown

Fig.7
The old ceramic crown has been removed, and a vertical tooth preparation has been performed for the upper left central incisor.

style italiano styleitaliano retraction cord placed for soft tissue displacement

Fig.8
Now it’s time for temporary crown relining. Following tooth preparation, an impression cord is placed to create space within the sulcus and expose the finishing area of the tooth preparation.

style italiano styleitaliano provisional crown relining

Fig.9
Temporary crown relining is crucial for the implementation of the VF concept. The margin of the temporary crown now serves as the new finishing line.

style italiano styleitaliano finishing of the relined provisional crown

Fig.10
The margin of the temporary crown now acts as the new finishing line, allowing us to manipulate the soft tissue by adjusting the margin of the temporary crown.

style italiano styleitaliano difference in gingival conditioning by management of the emergence profile

Fig.11
An increase in the emergence profile angle significantly reduces the gingival height while notably increasing gingival thickness.

style italiano styleitaliano conditioning gingival thickness with provisional crown

Fig.12
The greater the angle of the prosthetic emergence, the greater the gingival thickness.

style italiano styleitaliano initial position of the provisional margin

Fig.13
On the day of tooth preparation, following relining and finishing, the margin of the temporary crown is positioned at the gingival level.

style italiano styleitaliano aspect of the thickened gingiva after three weeks with provisional restoration

Fig.14
Three weeks later, we can start soft tissue manipulation by modifying the cervical contour of the crown margin.

style italiano styleitaliano reduction and shifiting of the emergence profile Biodynamic soft tissue shaping

Fig.15
Biodynamic soft tissue shaping.
To shift the zenith towards the distal direction of the crown, we should increase the emergence profile in this area by more than 60°, ideally up to 90°. Conversely, mesially, we should reduce the emergence profile by less than 30°. As a result, the gum in the mesial direction will move coronally and thin out, while in the distal direction, it will displace towards the apical direction and thicken.

style italiano styleitaliano provisional crown after margin modification

Fig.16
Temporary crown is in place following cervical contour modification.

style italiano styleitaliano second modification of provisional margin

Fig.17
Temporary crown in place after cervical contour modification.
2 weeks later.

style italiano styleitaliano third contour modification for gingival conditioning

Fig.18
Temporary crown in place after cervical contour modification.
4 weeks later.

style italiano styleitaliano final aspect after conditioning of the gingiva

Fig.19
Indeed, by conducting a vertical preparation and reshaping the margin (cervical contour) of the temporary crown with appropriate timing and design, we can effectively reshape the soft tissue with a minimally invasive approach. With this accomplished, we can now proceed with the final digital impression.

style italiano styleitaliano fabrication of veneer and crown

Fig.20
The upper left central incisor is restored with a layered zirconia single crown, while the upper right central incisor is restored with a no-prep ceramic veneer.

aidite style italiano styleitaliano
aidite style italiano styleitaliano
style italiano styleitaliano before and after restoration of the central incisors

Fig.21
The final picture displays the restored upper left central incisor with a zirconia crown and the upper right central incisor with no-prep ceramic veneers, along with a newly achieved ideal gingival architecture showcasing symmetrical zenith.

Conclusions

Our patients prioritize strong and durable restorations alongside a natural appearance, favoring minimally invasive treatments. Vertical Tooth preparation with a VF approach aligns with these expectations and offers a remarkable alternative to other procedures. Through vertical preparation, we create horizontal space for soft tissue thickening, and by strategically shaping the temporary crown, we can manipulate soft tissue and achieve ideal gingival architecture. The margin of the final crown for the upper left central incisor precisely mirrors that of the temporary crown. The upper left central incisor was restored with a layered zirconia single crown, while the upper right central incisor received no-prep ceramic veneers. In the aesthetic zone, my preference remains layered zirconia, while in the posterior region, monolithic zirconia remains the top choice. Layered zirconia, coupled with a thin layering in the buccal area, enables the creation of three-dimensional color and ensures optimal aesthetic outcomes.

Bibliography

  1. Rekow ED, Silva NR, Coelho PG, Zhang Y, Guess P, Thompson VP. Performance of dental ceramics: challenges for improvements. J Dent Res, 90 (2011), pp. 937-952.
  2. Guess PC, Schultheis S, Bonfante EA, Coelho PG, Ferencz JL, Silva NR. All-ceramic systems: laboratory and clinical performance. Dent Clin North Am. 2011 Apr;55(2):333-52, ix.
  3. Koenig V, Vanheusden AJ, Le Goff SO, Mainjot AK. Clinical risk factors related to failures with zirconia-based restorations: an up to 9-year retrospective study. J Dent, 41 (2013), pp. 1164-1174.
  4. Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A systematic review of the survival and complication rates of all-ceramic and metal-ceramic reconstructions after an observation period of at least 3 years. Part I: Single crowns. Clin Oral Implants Res., 18 (2007), pp. 73-85.

RELATED CASES

styleitaliano style italiano Indirect digital overlay deep subgingival cavity

Indirect digital overlay

From digital workflows to precise hand skills, ensuring long-lasting results is the ultimate goal for a good adhesive restoration.