Doing the least to the underlying natural tooth structure and the proper choice of material to get the desired result best attains the goal of longevity in restorative dentistry.1-5 Time has shown over and over again, that the most conservative preparations last the longest and usually serve patients best. Properly aligned teeth can be treated in the most conservative manner. Cosmetic dentistry by definition is about appearance and most often is a balance between the aesthetics and the functional demands placed on the resulting dentition and restorations. Because most “cosmetic cases” involve multiple teeth the cost to the patient in terms of invasiveness, finances and emotions are usually high so they rightly expect the results to last. This case illustrates the concept of being conservative and the creative use of several techniques that combined together gave exceptional aesthetic results.
The patient was an adult female who was seeking to improve the appearance of her smile (Figs. 1, 2). She had done orthodontics in her teens with bicuspid extractions and experienced significant relapse. This is an often observed occurrence and points to the fact that orthodontics can be finished in an unstable position, if the forces affecting the teeth are not balanced, they will move.6-9 The maxillary left cuspid was in cross-bite and she had an anterior open bite. Post-orthodontically, a mandibular fixed wire retainer had been placed from cuspid to cuspid. She had some isolated areas of recession and the maxillary left central incisor was darker in coloration than the other teeth. Additionally, she had only occlusal restorations in her molars, all other teeth were in excellent condition and un-restored (Fig. 3). She had no TMD symptoms and had acceptable function from her standpoint.
At this point it is important to establish a clear picture with the patient of the goals of treatment. After exploring the patient’s desires and expectations we discussed several treatment options including just bleaching her teeth, full orthodontic alignment, and maxillary composite or porcelain veneers. We settled on a combination of bleaching, straight wire orthodontics, osseous crown lengthening, gingival grafting, and porcelain veneers on the maxillary second bicuspid through second bicuspid, depending on how well the teeth aligned after the orthodontics. A post treatment maxillary nightguard would be used to protect the restorations during night time bruxing and also to act as a retainer for the post orthodontic position. This plan was decided upon because of the relatively short duration of the orthodontics, the desire to change the shape of the laterals and using the increase in width of the final veneers to act as a retentive design to keep the arch from collapsing back to the pre-orthodontic form. It has been my experience that many patients object to orthodontics as an adult, especially cases of retreatment. Often the objection is about either their appearance during treatment and or the amount of time involved. If we can give the patient choices that can positively affect either of those parameters, I have found those objections can be eliminated. At the very least, properly aligned teeth can be treated much more conservatively than poorly aligned teeth.
With the restorative only approach, because of the narrow arch form in the bicuspid region, 10 restorations would have been required to provide a full appearance to the smile. To create a symmetric and pleasing arch form the lateral incisors and the cuspids would have to be heavily prepared that would have lead to greater chances of sensitivity during and after the procedure and an undesirable weakness to the remaining tooth structure and final restorations. Keep in mind how you would treat yourself or a loved family member and treatment planning a case such as this becomes straight forward.
There was a good possibility that the number of veneers would be reduced to as few as four on the maxillary incisors by combining orthodontics into the treatment plan. It turned out we modified the plan to include the cuspids because the transition of the axial buccal-lingual inclination at that area looked better more vertical and we were able to develop a solid cuspid disclusion during parafunction. The risks and benefits were discussed and appropriate informed consent obtained prior to starting treatment.
Orthodontic brackets were placed (Fig. 4) and transitioned through a series of increasingly heavier wires over a 4-month period of time (Fig. 5). Wires were changed approximately at three-week intervals. Compliance with this approach has been excellent because of the short duration of time required for the orthodontics and using a restorative finish to these cases. One could certainly use an alternative orthodontic approach like Invisalign, but the time to move the teeth would be significantly longer and in my experience patients are willing to accept the fixed approach. Additionally, the laboratory costs with straight wire is significantly less making the cost to the patient less.
The advantages of using a restorative finish in addition to the orthodontics, were that the shapes and shades of the dentition could be significantly controlled. Because much of the movements of straight wire orthodontics expanded arch dimension, placing restorations also served the function of long-term retention, by interproximally blocking the path of potential arch form collapse. This technique is appropriate for cases where the vertical dimension of occlusion is stable and expected to remain the same from start to finish.
After the removal of the brackets, osseous crown lengthening was performed on the maxillary right lateral and central incisor and a subepithelial connective tissue graft placed on the facial-gingival of the maxillary left central incisor. Anesthesia was given using 2% Lidocaine with 1:100,000 epinephrine and a pattern was cut from the foil packing of a scalpel blade and fit to the area where the graft was to be placed (Fig. 6) and was later used to design the donor site incision. While the anesthesia was taking effect, the incisal edges of the central incisors were marked with a black marking pen (Fig. 7) and was helpful to visualize how much shaping would be appropriate before actually reducing tooth structure with a bur. After obtaining patient input, the edges were reshaped and polished (Fig. 8). To give the most life like appearance, the facial surface of the last 1mm toward the incisal edge was rolled lingually, like the adjacent un-contoured teeth. This same shape would be followed in the final restorations. A diode laser gingivectomy was performed on 1-1, 1-2 and 2-2 and the proper zenith created (slightly distal of the axial midline on 1-1 and on the axial midline of 1-2 and 2-2). Tissue fragments along the laser incision line were removed with a periodontal curette and a scrub of 3% hydrogen peroxide (Figs. 9, 10, 11, 12). An ophthalmic scalpel (Wilson Ophthalmic Instruments Microsurgical Knives and Blades) then used to prepare an intrasulcular full thickness flap on 2-1, without cutting through the gingival papillae (Fig. 13). The scalpel was used with a windshield wiper type motion and created a flap that extended from the distal of 1-2 to the distal of 2-2 and about 10mm apically from the incision points. This scalpel allowed for a very fine and precise incision but the flap did have to be reflected far enough to allow enough stretch in the gingiva to access the crestal bone for osseous crown lengthening on 1-2, 1-1 and 2-1, to allow access to place the graft on 2-1 and finish with the graft completely covered by the original epithelium. Once reflected, using fine tissue forceps the recipient graft site gingiva was pulled facially and coronally so the scalpel blade could be introduced from the periosteal side of the flap. Several horizontal incisions, just through the periosteum but not through to the surface were made and allowed the surface epithelium to be placed coronal to the original tissue pos
ition. Incising through the buccal frenum between 1-1 and 2-1 also aided in coronally repositioning this flap. The osseous crestal corrections were made with a #4 slow speed round bur and refine with periodontal curettes. A piece of subepitheal connective tissue was harvested from the palate, again using the ophthalmic scalpel tracing the precut pattern previously made (Fig. 14). The incision was three sided and the flap was raised like a door. The connective tissue was sharp dissected out leaving the surface epithelium and closed with 3 6-0 polylactic acid sutures and butyl cyanoacrylate (Periacryl). The osseous architecture was modified using a slow speed round bur (#2) by lightly decorticating the cortical plate to improve blood flow from the endosseous blood vessels, and the graft placed. The papillae in the surgical area were stabilized with interrupted sutures (6-0 polylactic acid) and the graft with the same plus butyl cyanoacrylate (Periacryl).
Eight weeks was allowed for healing (Fig. 15) and at the preparation appointment the decision was made to veneer from cuspid to cuspid because the cuspids were still too lingually inclined. The way used to help visualize the difference was to place a matrix (Siltech by Ivoclar) of the working wax-up filled with a chemically-cured bis-methacryl resin composite (Temphase by Kerr) and allowed the patient to see the approximate final form with just the incisors involved. It was apparent that adding the cuspids gave a better aesthetic result and also functionally gave better cuspid disclusion. The set Temphase was quickly and easily removed with a sickle scaler. The working wax-up was modified to include the cuspids while waiting for local anesthesia to take maximal effect (Figs. 16, 17) and a matrix made for a three dimensional prep guide and for the provisionals. Temphase was placed in the matrix and placed on the unprepared teeth and allowed to set for 212 minutes. The matrix was removed and horizontal reduction cuts were made through the material with a 0.5mm deep diamond reduction wheel (Pollard Diamonds), the Temphase temporary material was then removed (Fig. 18). The only reduction to the natural tooth structure needed was now indicated by the horizontal marks, no another reduction was necessary other than a light gingival finish line (Fig. 19). After obtaining an impression and a bite registration, provisionals were fabricated (Fig. 20). The purpose of the provisionals was primarily to gain emotional acceptance of the function and appearance for the projected final restorations.10
The patient wore the provisionals for three weeks and returned for the cementation of the final restorations. After making strategic vertical cuts through the temporary material with a 330 carbide bur, orthodontic band removal pliers were used horizontally to remove the material from the teeth (Fig. 21). The restorations were approved and seated with a translucent resin cement (Kerr NX3). Because the gingival embrasure between the central incisors was still open, in the spirit of conservativism, a gingival composite was placed post cementation (Fig. 22). This ‘hybrid veneer’ design allowed for much less reduction of tooth structure because if the preparation had been extended into the gingival embrasure area, to get draw for the final veneer, massive reduction would have been required.
The final photographs of this case show excellent soft tissue architecture and health (Figs. 23, 24, 25). There is a natural and attractive shape and flow to the teeth that will remain in a stable position because of the combination of orthodontics, periodontics and conservative cosmetic restorative dentistry. This patient will enjoy the results of this combination of dental procedures longer than using any of the techniques alone (Fig. 26).
Any dentist can do any of these procedures with not only results that would meet any standard of care but exceed them. Increase the palette of options you can offer patients that can give them the best result possible. You can either refer to someone that can do the things you can not or do not want to do or you can make the investment in getting the training to add creativity to your cosmetic cases. OH
Dr. Rhys Spoor is a 1983 graduate of the University of Washington Dental School where he was later an Associate Professor for 10 years. He is a Fellow of the Academy of General Dentistry and the Pierre Fauchard Society; additionally he is an Accredited member of the American Academy of Cosmetic Dentistry. Dr. Spoor lectures and writes in the US and internationally on aesthetics, occlusion, photography, and practice management. He maintains a private practice in Seattle, WA, in aesthetic, implant and restorative dentistry. He may be contacted at Rhys@RhysSpoor.com.
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