Following completion of Ira’s preparatory specialty care (lasting approximately 8 months in total), the maxillary dentition was prepared for full-coverage crowns and a fixed partial denture (Figures 6 and 7), taking care to expose the margins for taking the final impression and the anticipated restorations. Having completed periodontal care in advance of restorative treatment, no exudates, blood, or other crevicular fluids that would have compromised the final impression were detected. 

Figure 6. Facial view of the completed preparations for the dentition of the maxillary arch.	Figure 7. Occlusal view of the repaired anterior dentition.
Figure 8. Placement of the preliminary retraction cord.	Figure 9. Insertion of the impression cords (double-cord technique was used).

     Achieving proper hemostasis was critical to capturing a precise impression. A dual-cord technique and laser-troughing ezlase (BIOLASE) were used in order to ensure that the gingival tissues were sufficiently deflected from the preparation margins for accurate registration of these critical areas. The first epinephrine-soaked cords (size No. 0, Gingibraid [Dux]) were placed circumferentially around the prepared teeth (Figure 8). Then, a second continuous cord (size No. 1) was inserted around all the teeth to further facilitate retraction (Figure 9). In areas where the margins were not fully exposed using the dual-cord technique, a soft-tissue diode laser was also applied to improve access of the impression material to all the details of the margins (Figure 10). The second cord would be removed just prior to the injection of the light-body material, leaving the sulcular cord in place throughout the process.

Figure 10. A soft-tissue diode laser (ezlase [BIOLASE]) was used to optimize the position of the gingival tissue for impression making.	Figure 11. Application of a surfactant (B4 Pre-Impression Surface Optimizer [DENTSPLY Caulk]), done prior to the application of the vinyl polysiloxane impression material.
Figure 12. Injection of wash material around prepared dentition.	Figure 13. Flowing the impression material (Aquasil Ultra Xtra Smart Wetting Impression Material [DENTSPLY Caulk]) into the custom resin impression tray.
Figure 14. Seating of the impression tray.	Figure 15. Occlusal view of the resulting impression.
Figure 16. Provisionalized maxillary dentition.	Figure 17. The definitive restorations were polished on the model and forwarded for try-in, cementation, and final finishing/polishing.

     Next, a surfactant (B4 Pre-Impression Surface Optimizer [DENTSPLY Caulk]) was then applied to the prepared teeth. This important new clinical step was done to break the surface contact tension, thus providing a lubricating effect for the light-body impression material (Figure 11) that was subsequently syringed around the prepared dentition (Figure 12). An elastomeric impression material (Aquasil Ultra Xtra Smart Wetting Impression Material [DENTSPLY Caulk]) was selected for the procedure for a variety of reasons. Its extended working time afforded me 45 additional seconds for syringing the material around the preparations, enabling full capture of the margins minus the undesired voids, air bubbles, or draws. I like to use a resin custom tray with an open palate design which makes it easy to retrieve any excess impression material that may escape down a patient’s throat. It’s worth mentioning that the thixotropic (yet flowable) consistency of the Ultra Xtra tray material all but eliminated any concerns of tray run-off. (Figures 13 and 14 demonstrate loading of the custom tray followed by its intraoral seating.) In addition, this impression material would also be easy to remove upon setting, thus eliminating but one more source of stress when impressing multiple teeth in a close-fitting custom tray. Upon removal from the patient’s mouth (Figure 15), the impression was easy to read and was sent to the dental laboratory with all the diagnostic information gathered during preoperative consultation and at the chair. 
     Bisacrylic (Protemp Garrant [3M ESPE]) provisional restorations, fabricated from the template demonstrating the ideal position of the patient’s dentition (determined preoperatively in the Smile-Vision wax-up and mockup), were delivered to the patient at this time (Figure 16). The provisional restorations would enable proper function during laboratory fabrication of the definitive restorations and ensure evaluation of patient function, phonetics, and aesthetics during this 2-month period.
     The impressions of the patient’s maxillary and mandibular arches were used to pour accurate working models and were used to create the restorations required to satisfy the patient’s aesthetic objectives. The impressions were forwarded to the dental technician along with digital photographs (eg, of the preoperative condition, preparations, the seated provisional restorations) and the 3-dimensional Smile-Vision mock-up itself. Single-unit, full-coverage, porcelain-fused-to-metal (PFM) crowns were created for teeth Nos. 3 to 7, as well as teeth Nos. 13 and 14 (Figure 17). A PFM bridge was seated for teeth Nos. 8 to 12 (with pontics at teeth Nos. 9 and 11).

Delivery of the Final Restorations
Teeth Nos. 22 to 27 received orthodontic care (during which tooth No. 23 was also extracted) to align with the anticipated position of the maxillary anterior teeth. Six veneers (including one for a lower premolar tooth) would be delivered for the anterior mandibular arch to restore it to ideal form, position, and aesthetics. These restorations would be seated with the combination of a self-etching, self-priming, light-cured adhesive system and resin cement (BiFix QM [VOCO]). 

Figure 18. Occlusal view of the maxillary dentition following insertion of the definitive restorations.	Figure 19. Final view of the patient (4 weeks postoperatively).
Figure 20. Retracted postoperative view.	Figure 21. Postoperative view of the anterior maxilla demonstrating the predictable results achievable when using the proper collaborative (interdisciplinary) techniques.

     Delivery of the definitive maxillary restorations was conducted at a second appointment in order to provide sufficient time for the healing of the gingival tissues and extraction sockets. The single-unit PFM crowns and bridge were accomplished with self-etching resin cement. Final occlusal adjustments were performed, and then the restorations were polished to a natural luster (Figure 18). 
The patient was recalled approximately 3 weeks postoperatively for follow-up, including taking the final case photos (Figures 19 to 21) and to confirm success of the treatment.

DISCUSSION
The precision of the resulting indirect restorations was directly influenced by the accuracy (defined as the ability to properly relate all the details of the prepared teeth) of the impressions taken in this case. Consequently, it was imperative that I obtain an impression that duplicated the prepared teeth as well as the uncut tooth surfaces beyond the margins. The 2 combined would enable the dental laboratory technicians to ascertain the exact position and configuration of the finish line. The adjacent teeth and gingival tissues were also encompassed and reproduced in the void-free impression, which consequently allowed the casts to be properly articulated and the restorations to be naturally contoured.

CONCLUSION
Multiple factors contribute to the success of any case, including the one presented in the following description:
One was the digital simulation from Smile-Vision, which aided considerably in gaining patient acceptance of the treatment plan. It also allowed for efficient treatment planning (as well as yielding the resin replica, preparation guide, and template for the provisional restorations). 
     The impression material chosen, with its extended working time and accompanying surfactant, made it conducive to multiple treatment sites, enabling me to proceed with confidence through this otherwise technique-sensitive process. Ultimately, we are only as good as our impressions, no matter how many hours are spent preparing the dentition.
     Finally, the collaborative approach—involving our periodontist, orthodontist, endodontist, and dental laboratory technicians—allowed each professional to optimize the health, position, and function of the dentition prior to restorative care. All involved provided valuable contributions to the outcome depicted herein.