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A Comprehensive Interdisciplinary Approach to the Predictable & Functional Esthetic Correction of Malaligned Teeth

April 1, 2006
by Edward Lowe, BSc, DMD, Nelson Rego, CDT, Juan Rego, CDT


Dental professionals are enjoying an era in which educated patients may be our best customers. Mainstream media have publicized the capabilities and benefits of today’s esthetic restorative treatment options for solving a variety of dental problems, and among these solutions is “instant orthodontics.” Unfortunately, despite patients’ heightened awareness of advanced dental techniques, many are ignorant to the fact that the esthetic correction of anterior dental malalignment is often more complex than they might think. It is only after a comprehensive examination of the hard and soft tissues, muscles of mastication, and occlusion that the clinician can recommend the most appropriate corrective procedure(s).1

Ensuring the health and stability of each of these components is paramount to ensuring predictable treatment outcomes. Therefore, and particularly in cases for which the patient is found to be compromised in several aspects, coordinated interdisciplinary evaluation and treatment planning is essential for long-term functional and esthetic success.2 The creation of optimal esthetic results for patients with malaligned teeth should begin with a collaborative approach that ultimately increases benefits and reduces risks across periodontal, biomechanical, functional, and dentofacial parameters.1

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Tooth misalignment includes tooth rotation, crowding, super-eruption, under-eruption, intrusion, diastemas, and tipping.3 It may also result from inappropriate arch form, position, size, or arch to arch relationships.3 Inherently the hard and soft tissues are affected by the malalignment. The problem may be corrected restoratively, orthodontically, or with a combination of both approaches.3,4 Restorative alternatives change tooth morphology and create the illusion of movement without altering the location of the tooth root.3 To actually move a tooth root, orthodontics is necessary.3 Tooth root location impacts smile esthetics because the maximum and minimum tooth width is determined by the root position and the adjacent teeth.3

Clearly, situations arise when patients are adamantly opposed or unwilling to undergo orthodontic treatment to correct tooth malalignment. If a thorough clinical examination reveals that they are candidates for alternative treatments, they may be able to achieve straight teeth with “instant orthodontics” and the placement of porcelain veneers and/or crown restorations.5 Prosthodontic alternatives can create immediate symmetry and harmony between a patient’s vertical and horizontal planes, rather than he or she having to submit to the extended treatment times associated with orthodontics.6 Patients may be candidates for “instant” orthodontics if there is a need for tooth restoration regardless of whether traditional orthodontics is performed (e.g., to correct tooth color defects or structural losses);3 they have an ideal occlusion; the free gingival margin and papilla levels are manageable; they have a pleasing and esthetically acceptable contour; and required tooth preparations won’t encroach upon the teeth structurally or biologically.4

However, esthetic correction of malaligned teeth may involve both restorative and orthodontic approaches when the patient simultaneously seeks to correct tooth color defects, repair structural losses or replace existing restorations and other complicating factors exist. For example, the clinician may be unable to correct the occlusal relationship of the maxillary anterior teeth by restorative means alone, as in the case of patients with inadequate or excessive overbites, overjets, or single-tooth anterior crossbites.4

Further, the esthetics or condition of the gingiva (i.e., free gingival margin; coronally positioned margin/deep sulcus) may best be corrected by moving the teeth-and hence surrounding tissue-into position using orthodontics.4 Of course, such considerations should be reviewed by the periodontist in an interdisciplinary manner.7 If any of the affected dentition have undergone previous root canal therapy–or there is concern regarding pulpal health during restorative procedures-then consultation with an endodontist is equally prudent.

This article demonstrates the manner in which an interdisciplinary team approach was undertaken in the treatment of a woman who presented with obvious and complex tooth malalignment. Although the patient initially was ready and willing to undergo “instant orthodontics,” clinical evaluation revealed that the most predictable treatment outcomes could only be assured through collaborative efforts between the restorative dentist, periodontist, endodontist, orthodontist, and laboratory technician.

This presentation explains the role of each party in accurately and thoroughly diagnosing her condition; understanding her goals, expectations and limitations; and sequentially planning the treatment alternative that would ultimately yield the most benefits with the least amount of risk.1,4

CASE PRESENTATION

A 41-year-old woman presented with specific concerns about the appearance of her teeth. She was unhappy with their crooked appearance, interdental spaces, color, and obvious presence of old restorations (Figs. 1 & 2). She was additionally concerned about the possible premature loss of her teeth. An educated patient, she had conducted research into possible solutions to her problems, and her initial perception was that porcelain veneers were the answer to her intraoral challenges.

In a one dimensional approach, it would be possible to treat this patient with restorative dentistry alone at the expense of tooth structure. The “instant orthodontic” approach is always an option if the patient is ready to commit to full mouth rehabilitation and adamantly opposed to traditional orthodontic treatment, if necessary. However, clinical judgment is paramount to long-term successful outcomes. In this particular case, it was determined that comprehensive records should be collected and the factors leading to the current state of breakdown in her dentition and supporting tissues be explored. To do so would require an interdisciplinary team approach to diagnosis and treatment planning.

Initial clinical findings

The patient exhibited excellent oral hygiene control and was in excellent medical health. She was not taking any unusual medications and is a non-smoker. Her gingival tissues presented with moderate to severe recession in the maxillary anterior region accompanied by some facial bone loss. Her teeth were moderately crowded in the maxillary anterior region. Papillary blunting and recession were noted on teeth #1.1 and #1.2, #2.1, and #2.2 and attributed to root proximity and bone loss in these areas. There were some isolated gingival pockets of 4mm, with the majority of the remaining measurements in the 1mm to 3mm range.

Additionally, the patient demonstrated a skeletal and dental Angle Class II Division I malocclusion in the permanent dentition characterized by a 6mm overjet, 70% overbite, deep mandibular curve of Spee, and non-coincidental dental midlines (Figs. 3 & 4). Centric relation was coincident with maximum intercuspation. There was an early opening click of her right temporomandibular (TM) joint, of which she was unaware, and she had a maximum interincisal separation of 38mm. Her functional occlusion on right lateral mandibular movement exhibited premolar group function with a heavy molar nonworking side interference; on left lateral mandibular movement, there was molar guidance with a molar nonworking side interference.

Teeth #2.8, #3.6, #4.6, and #4.8 were missing. Endodontic therapy had been completed on teeth #1.2, #1.6, #3.5, #3.7, and #4.8. Porcelain-fused-to-metal (PFM) crowns were present on teeth #1.2, #1.6, #1.7, #2.6, and #4.4. Three-unit PFM bridges were present between teeth #3.5 and #3.7 and between teeth #4.5 and #4.7 (Fig. 5). Min
or composite and amalgam restorations were present on several of the remaining teeth (Fig. 6).

Pre-restorative treatment plan

A full-mouth series of radiographs were taken, in addition to digital photographs and mounted study models. The interdisciplinary treatment approach consisted of the following sequence of coordinated evaluations/interventions by the interdisciplinary team.

Endodontic Evaluation. An endodontist examined the patient to ensure that the previously endodontically treated teeth were sound. Based on the radiographs, the existing treatment was sound and re-treatment did not appear necessary. The patient was asymptomatic.

Periodontal Evaluation. The patient was referred to a periodontist for a general periodontal evaluation and risk assessment for orthodontic realignment. It was determined that bone loss could be alleviated with some orthodontic intervention; her overzealous hygiene habits–which resulted in areas of weak gingival attachment–could be controlled. It was recommended that orthodontic treatment was preferable to no treatment in order to help prevent future tooth loss. It was acknowledged that there were risk factors to both approaches, with lesser risk being involved with the orthodontic approach. The patient was advised that the overall benefit functionally, biologically, and esthetically would be significant relative to her existing risk factors.1

Orthodontic Evaluation. The patient was then referred to an orthodontist for a general evaluation to determine the feasibility of either orthodontic alignment of the teeth or an orthodontic/orthognathic surgical approach. After discussing surgical and non-surgical approaches with the patient, orthognathic surgery was not recommended.

The treatment plan consisted of aligning the teeth, establishing bilateral canine Class I relationships, uprighting the mandibular bridge abutments, and optimizing her functional occlusion.8 The maxillary central incisors would be extruded with the objective of improving the gingival levels of the maxillary incisors.4 This would need to be done cautiously to minimize the inevitable “black triangle” that would develop with the alignment of the maxillary central incisors. The orthodontic treatment would involve full fixed orthodontic appliances, in addition to the removal of both maxillary first premolars. The bridge pontics would be separated and removed in order to upright the molars.

Orthodontic treatment commenced, and the maxillary first premolars were extracted. The bridges were sectioned and the pontics removed. The patient wore the appliances for a total of 22 months until the active phase of the orthodontic treatment was complete (Fig. 7). Retention in removable maxillary and mandibular appliances was achieved by full-time wear for 6 months prior to initiation of the recording-taking for the initial waxup for the restorative treatment. This phase was necessary to avoid the potential relapse of crowding of the mandibular lower incisors, so this area was carefully monitored.

Outcome reassessment & restorative treatment planning

Post-orthodontic periodontal findings included pocket depths of 2mm to 4mm, extrusion of the maxillary anterior dentition that resulted in an increased band of facial keratinized gingiva, exposed roots on teeth #1.2 through #2.2 of about 4mm, and mobility grade (1) on teeth #1.2 through #2.2. Radiographic findings included moderate root resorption on teeth #1.2 through #2.2 and poor crown-to-root ratio (i.e., 50%) on teeth #1.1/#2.1. Although the long-term periodontal plan involved the possible extraction of both maxillary central incisors and placement of implant-supported restorations, the patient envisioned and was adamant about a non-extraction outcome. A conservative, esthetic reconstruction was what she wanted.

A restorative treatment plan involving both arches was developed. The 10 anterior maxillary teeth and 8 mandibular anterior teeth would be restored with all-ceramic pressed porcelain veneers and crowns (IPS Empress Esthetic, Ivoclar Vivadent, Amherst, NY). The possibility of implant supported crowns to replace the lower edentulous areas in quadrants 3 and 4 was presented. However, the patient elected to have all-ceramic, zirconium-oxide supported bridges (IPS e.max(tm) ZirCAD/ZirPress, Ivoclar Vivadent) placed after the 18 anterior units were seated. Teeth #1.7 and #2.7 would not be restored because the vertical dimension would not be altered and they were not in the esthetic zone. They would serve as vertical stops when the anterior segment was being restored.

Teeth #1.1 and #2.1 would be double abutted with the pressed all-ceramic material in order to support the compromised crown-to-root ratio.

The plan also included the removal of the gold endodontic posts in teeth #1.2, #1.6, #3.4. and #3.6, if possible, and replacement with tooth-colored glass fiber posts for an enhanced esthetic result.9,10

Diagnostic waxup

One of the patient’s main concerns was the appearance of her teeth following orthodontic treatment (Figs. 8 & 9). Although the roots had aligned, the molars uprighted, and most of the goals achieved, she did not like the large interdental spaces that were left and felt she had “long, straight ugly teeth.” This patient’s expectations were high. She expected to have a natural smile with perfect teeth and a significant color improvement.

The diagnostic waxup provided the clinician, patient, and ceramist with a 3-dimensional esthetic preview of what was possible (Fig. 10). A diagnostic waxup was created from polyvinyl siloxane (PVS) impressions of her existing dentition. She had been in retention for a total of 6 months prior to this appointment, which was completed two weeks prior to the tooth preparation appointment.

Several items were sent to the dental laboratory as prerequisites for an accurate waxup. These included the PVS impressions, a PVS stickbite record with a Benda Brush (Fig. 11), a facebow transfer record with the Kois Dental Facial Analyzer (Panadent) (Fig. 12), PVS bite records in maximum intercuspation, digital photographs of the teeth, eyebrow to chin photographs of both the stickbite and the facial analyzer in position, a lateral head shot indicating the incisal edge position, and a detailed laboratory prescription outlining the details and expectations of the waxup.

The laboratory provided PVS putty matrices of the waxup, as well as Sil-Tech putty (Ivoclar Vivadent) reduction guides. The final dimensions of 8.5mm in width x 11mm in length for the central incisors was the starting point around which the other teeth would be waxed.

Smile analysis

The patient presented post-orthodontically with a smile arrangement that left room for improvement. Gingival health and color were good, but she exhibited many interdental spaces that needed to be closed restoratively. The gingival balance and symmetry were good, with appropriate gingival heights. Gingival contours and zeniths required some adjustments, and these would be accomplished with a soft tissue diode laser (Odyssey 2.4G, Ivoclar Vivadent) to achieve the desired appearance.11

Her maxillary anterior tooth widths and lengths post-orthodontically were:

#1.1: 8mm x 12mm

#1.2: 6.5mm x 12mm

#1.3: 7mm x 11mm

#2.1: 8mm x 12mm

#2.2: 6mm x 10mm

#2.3: 8mm x 11.3mm

We decided upon a final 8.5mm x 11mm central width/length ratio (i.e., 77%). The golden proportion measurement fell within what appears harmonious to the eye.12 The smile lines and lip lines were ideal. The smile followed the lower lip line. The incisal display was a little excessive with the lips at rest, and this would be improved by shortening the anterior teeth from the incisal by about 1mm. The mesial/ axial inclination of the teeth was normal, but the buccal corridor required development by enhancing the gradation effect.

The facial midline was coincidental with the maxillary midline. The mandibular midline was 2mm to the right of the m
axillary midline. The smile was slightly canted, with the right side about 2mm lower than the left.

The maxillary arch form was ovoid, with a canine-papilla-canine line to the outer surface of the maxillary incisor measurement of 10mm. The level of interdental contacts progressed apically from the incisors toward the posterior teeth, and the incisal embrasures increased in size from central to canine. The cervical embrasures would be challenging to improve due to the interdental spaces, and the facial and lingual embrasures could be improved.

Tooth preparation & temporization

At the preparation appointment, the maxillary and mandibular waxups were transferred to the patient’s mouth using a provisional material (Luxatemp, Zenith Dental, Englewood, NJ) that was loaded into the putty matrices created from the waxups. This provided an instant diagnostic prototype for intraoral evaluation.13 Using a reduction matrix based on the approved waxup as a guide, the patient’s teeth were prepared with 1.0mm reduction facially and 2mm occlusally for the pressed ceramic restorations.

The reduction guides were critical to ensuring adequate tooth preparation where necessary, prevention of over-preparation of tooth structure, and respect of the biologic width (Fig. 13).14 The guides were sectioned horizontally to verify reduction in the middle and cervical thirds prior to obtaining final impressions (Figs. 14 & 15).

Preparation shades and final shades were taken for the definitive all-ceramic restorations (Fig. 16). The final preparation length of the central incisors was 9mm in order to accommodate an 11-mm restoration with 1mm of incisal translucency (Figs. 17 & 18). The gold posts were not removed in order to prevent compromising the remaining tooth structure.15

Conventional PVS impressions were taken for this case. Bite records of the upper to lower preparations, upper preparations to lower provisionals, and lower preparations to upper provisionals, as well as an interpupillary stick bite, were taken with a stiff PVS bite registration material at the current vertical dimension of occlusion.

The preparations were cleaned with 2% chlorhexidine, and provisional restorations (Luxatemp, Zenith Dental) were re-fabricated using the putty matrices. The provisionals were trimmed and polished using finishing burs and disks. A temporary dual-curing luting composite (Systemp.link, Ivoclar Vivadent) was used to cement the provisionals, and a light-curable glaze was applied to the surface (Figs. 19 – 20). The impressions and bite records were submitted to the dental laboratory, along with a facebow record, a detailed prescription, and digital intraoral and extraoral photographs.

Laboratory fabrication

The pressed all-ceramic material selected for the 10 maxillary and 8 mandibular restorations (IPS Empress(tm) Esthetic) has, since its introduction, demonstrated an optimization of the original leucite-reinforced, glass ceramic material. It was particularly ideal for this case because the pressed ceramic enabled the flexibility of using a cutback and layering technique so that the patient’s high esthetic expectations could be achieved. Further, because the material is a pressed ceramic, a full-contour waxup of the proposed restorations could first be completed in wax, providing ample opportunities to perfect the contours. The enhanced color, clarity, strength, and leucite crystal distribution contributed to restorations with superior optical properties and improved strength.

Models of the approved temporary restorations were received by the laboratory, used to create a putty incisal edge matrix (Sil-Tech) and, ultimately, to design the waxup of the final restorations to the optimal shape, esthetics and function. Preparation models were tried into the matrix to ensure that adequate, equal reduction had been achieved.

Once the waxup was complete, it was sprued, invested, and burned out in the burn-out oven, after which the selected ingots were pressed into the molds. After pressing, the ceramic was fit to the dies, contacts between the restorations were adjusted, and the overall contours were verified.

For this case, a cutback was performed to reduce the incisal edges of the restorations to enable layering of effects powders. In particular, depth cuts and incisal edge reduction were necessary to create a subtle framework onto which the enamel porcelains could be applied, but care was taken to ensure that the shape of the final tooth form was maintained. Then, different enamel effects were layered onto the restorations and fired.

The incisal portion of the restorations was then recontoured to remain consistent with the gingival segment, and the occlusion and overall length of the restorations were verified using the putty matrix. The restorations were then glazed and seated back on the model to confirm fit, contacts, form and color (Fig. 21). The final pressed ceramic restorations were then returned to the clinician for definitive placement.

After definitive seating of the pressed ceramic restorations, the clinician forwarded to the laboratory the impressions necessary for fabricating the CAD/CAM milled and layered zirconium-oxide supported bridge restorations (IPS e.max ZirCAD/ZirPress). Because these bridge restorations needed to satisfy a combination of functional and esthetic requirements, it was determined that a restorative system should be selected that would meet these criteria and blend seamlessly with the previously placed all-ceramic restorations. Therefore, a recently introduced universal all-ceramic system that combines CAD/CAM and pressable technologies (IPS e.max) was selected. The use of this system eliminated the difficulties typically associated with using different substructure and veneering porcelain materials and combining restorations to create a lifelike smile with consistent vitality.

A model was made from those impressions and optically scanned, after which the images were uploaded into a computer for processing into a digital model. The CAD program was used to establish the coping thickness and other parameters, as well as finalize the coping and pontic designs. Then, appropriate zirconium oxide blocks (IPS e.max ZirCAD) were placed in the milling unit and milled.

After milling, the bridge frameworks were tried onto the working model and then sintered. After sintering, the frameworks were placed onto the die framework to verify fit, and the margins were finished. To enhance the esthetics of the framework and promote a good bond with the press-to-zirconium material, a very fine yet thick translucent powder (IPS e.max ZirLiner) was applied to the framework. The frameworks were then fired according to the manufacturer’s instructions.

Full-contour waxups of the bridge restorations, similar to what would be completed for any pressed restorations, were performed. The waxups were sprued onto ringer formers, invested, burnt out, and pressed with the appropriately colored IPS e.max ZirPress ingots. An added benefit of using this particular press-to-zirconium material is that it helps to maximize the marginal integrity of the copings when a zirconium oxide substructure is needed.

To ensure that the optical properties of the bridge restorations would match those of the pressed ceramic restorations previously placed, they were then layered with the appropriately shaded IPS e.max Ceram powders, after which they were fired according to the manufacturer’s instructions. The fit of the bridges was verified on the model, and they were stained, glazed and fired to impart a natural luster.

Placement

When the restorations were returned from the laboratory, they were inspected for fit and color on the models. The provisional restorations were removed using hemostats, and the preparations were cleaned with 10% hydrogen peroxide. The restorations were tried in the mouth to verify fit, and a try-in paste was used to evaluate the definitive shade.

The preparations were then cleansed with a chlorhexidi
ne scrub and rinsed. Rubber dam isolation was achieved in the maxillary arch, and the 10 maxillary pressed ceramic restorations were conditioned with 35% phosphoric acid for 1 minute. After rinsing and drying, the restorations were coated with silane for 1 minute and dried. A single-component bonding agent (Excite, Ivoclar Vivadent) was applied to the internal aspects of the restorations, and excess solvent was evaporated with a warm air dryer.

The preparations were then etched with 35% phosphoric acid on the enamel and dentin for 15 seconds and 10 seconds, respectively (Fig. 22), and then rinsed. The bonding agent was applied to the preparations, the solvent evaporated, and the preparations then light-cured for 10 seconds.

The selected cement (Variolink II White, Ivoclar Vivadent) was placed into the double abutted central incisor restorations. The restorations were seated onto the preparations (Fig. 23) and spot-tacked into place using a 2mm light-curing tacking tip for 5 seconds per tooth (Fig. 24). For this technique, the tacking tip was held perpendicular to the facial surface in the center of the tooth, and gentle apical pressure was applied with the index finger to ensure stable seating.

The restoration for tooth #1.2 was dry seated while the remaining restorations were seated, tacked, and cleaned up in pairs. These were then flossed through the contacts twice with the same piece of floss and pulled through to the lingual to remove interproximal residual cement.

Tooth #1.2 was seated alone because its ultimate match to the adjacent restorations was dependent upon successfully masking the preexisting gold post. An opaquer and red tint (Kerr Kolor Plus A1) was mixed to achieve a calamine lotion color. This was applied to the gold post in a thin layer (Fig. 25) and light cured. Cement was added to the crown, after which it was seated as previously described.

Glycerin was placed around the margins to ensure that the oxygen inhibition layer was cured. The restorations were then each fully cured for 30 seconds from the buccal and 30 seconds from the lingual aspects using two halogen curing lights that sandwiched the restoration. After marking the facial surface of the restorations with a pencil, a #15 scalpel was used to remove the excess cement flushed out by the graphite. The margins were then polished with a #12 scalpel blade, an extra-fine football diamond, and extra-fine carbide finishing bur to produce a seamless finish.

The cementation protocol was similar for the mandibular restorations. Following seating of the mandibular restorations, the occlusion was verified, any necessary adjustments were made, and the restorations were polished with a porcelain polishing kit. Additionally, the teeth that were treatment planned for mandibular bridges were prepared, impressions taken for use in fabricating the bridge restorations, and the teeth provisionalized.

It is important to note that in this case, all of the original anterior restorations (i.e., 10 maxillary and 8 mandibular) required a remake based on esthetics (Fig. 26). The provisional restorations with which the patient was provided were lighter in color than the final restorations provided. Even though the patient had agreed upon the color/shade for the final restorations, the fact that she preferred the color/shade of the provisional restorations demonstrates the need for the clinician to use the provisional restorations as a means for the patient to “test drive” every aspect of the proposed restorations-size, shape, occlusion and esthetic properties-prior to initiating the fabrication of the final all-ceramic restorations.

The zirconium-oxide supported CAD/CAM bridges were seated 2 weeks later using a multi-purpose dual-cure adhesive resin cement (Multilink Automix, Ivoclar Vivadent). Glass ionomer cements, BisGMA luting composites, and modified BisGMA (Panavia 21) cements are recommended because they have been shown in studies to produce the highest median retentive strength values when luting zirconium oxide ceramic crowns.16

The provisional restorations were removed, the preparations cleaned, and the restorations tried in. The internal aspects of the bridge abutment copings were acid etched, rinsed and dried, and then silanated and dried. A zirconium primer was placed on the internal aspects of the abutment copings and gently evaporated. The manufacturer (Ivoclar Vivadent) asserts that this process results in significantly higher bond strengths of approximately 25 to 35 MPa.

The Multilink Primer A and Primer B were mixed in a well for conditioning the preparations. The primer mix was applied to the preparations for 15 seconds to complete the self-etching adhesive conditioning and then air thinned. Using the automix applicator, the base and catalyst of the cement were mixed and injected into the abutment copings and the restorations were seated. The margins were spot-tacked, and the excess cement was cleaned up using a Hollenbeck carver. After flossing, the restorations were allowed to self-cure before final polishing and finishing.

The patient returned a week later for minor occlusal adjustments and verification of the occlusion using the T-Scan (Tekscan).

CONCLUSION

Successful esthetic correction of tooth malalignment requires a comprehensive evaluation of the patient’s complete oral condition (Figs. 27 – 32). In some instances, this necessitates an interdisciplinary approach and collaboration between the restorative dentist and endodontic, periodontic, orthodontic, and laboratory professionals. Additionally, it is important to recognize that changing tooth position may involve orthodontics, restorative options, or both,3 and that either may be predicated upon periodontal and endodontic health.

Patient goals and expectations for treatment-based on a thorough understanding of all possible alternatives-as well as limitations, help provide the basis for the interdisciplinary team’s plan with the objective of achieving long-term predictability from functional, esthetic, and clinical perspectives.1,3,7

The authors would like to thank Dr. Konstantinos Georgas for the initial periodontal assessment and Dr. Michael Wainwright for the orthodontic phase of the treatment plan. Their contribution was paramount in making the case a functional and esthetic success.

Edward Lowe, BSc., DMD, was the clinical director of the Pacific Aesthetic Continuum and is currently faculty at the Pacific Implant Institute in Vancouver, BC. He maintains a full time private practice devoted to comprehensive aesthetic and reconstructive dentistry in Vancouver, BC.

Nelson and Juan Rego, CDTs, own and operate ‘Smile Designs by Rego,’ a progressive dental lab specializing in ceramics in Santa Fe Springs, CA. They also serve as evaluators and speakers for several dental manufacturers including Ivoclar-Vivadent, Vident and Axis Dental.

Oral Health welcomes this original article.

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10.Pegoretti A, Fambri L, Zappini G, Bianchetti M. Finite element analysis of a glass fibre reinforced composite endodontic post. Biomaterials. 2002 Jul;23(13):2667-8.

11.Stabholtz A, Zeltser R, Sela M, et al. The use of lasers in dentistry: principles of operation and clinical applications. Compend Contin Educ Dent. 2003; 24(12):935-48.

12.Mahshid M, Khoshvaghti A, Varshosaz M, Vallaei N. Evaluation of “golden proportion” in individuals with an esthetic smile. J Esthet Restor Dent. 2004;16(3):185-92.

13.Adar P. Lab Talk. Communication: the ultimate in synergy. Inside Dentistry. October 2005;82-83.

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16.Kurbad A. Clinical aspects of all-ceramic CAD/CAM restorations. Int J Dent. 2002 Apr-Jul;5(2-3):183-97.


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