ABSTRACT
Since their introduction in the early 1980s, porcelain laminate veneers have become a popular treatment in the cosmetic dentist’s armamentarium. Porcelain laminate veneers can be used to alter the color of the anterior dentition, to close multiple diastemas caused by tooth size/jaw size disharmonies and correct misshapen teeth to a more ideal form. Porcelain laminate veneers can be used to alter the shape and color of “lateralized canines” to correct aesthetic deficiencies. A sound understanding of smile design principles as they relate to proper proportion and balance between teeth and other facial elements1, and the form, color, texture, size and relationship between the hard and soft tissue dental elements is essential to solving aesthetic challenges. Numerous cases are presented showing aesthetic deficiencies which remained following orthodontic treatment, which were successfully solved utilizing a multidisciplinary approach, and porcelain laminate veneers. These cases can be very rewarding to both the clinician’s artistic nature and the patient’s emotional health can be positively affected as well.
Since their introduction in the early 1980s, porcelain laminate veneers have become a popular treatment in the cosmetic dentist’s armamentarium. Today dentists are faced with ever increasing demands to provide their patients with highly esthetic, durable tooth colored restorations, while maintaining a conservative approach to tooth reduction. Porcelain laminate veneers satisfy these requirements.
Porcelain veneers have undergone many changes in their preparation designs and clinical applications since they were first introduced. Originally developed to mask tooth discolorations with no tooth preparation required, veneers are now indicated for color corrections, diastema closures, altering lengths and shapes of existing teeth to correct malformed or misshapen teeth (Figs. 1-4), and restoring anterior guidance and cuspid rise in conservative occlusal rehabilitations.
They have gone through an evolution from no tooth preparation to preparations for bonded porcelain restorations which blur the lines/definitions between veneers and 3/4 crowns .
Aesthetic dentistry requires that the dentist understand the form, texture, and color of natural teeth, and how teeth relate to other facial elements and then translate this information into the fabrication of the final restorations. “Dento-Facial esthetics” has been used to describe the inter-relationship between the face, lips, gingival and teeth in obtaining an overall esthetic result.1-6
Evaluation of a patient’s occlusion, taking into consideration the health, condition and inter-relationship of it’s various components i.e. the teeth and periodontium, Temporomandibular joints, neuromusculature, allows the dentist to best select the most appropriate materials to provide conservative, durable restorations.7-11 Porcelain veneers are not indicated for bruxers and clenchers due to their decreased longevity in these situations.9
As dental adhesive technologies have advanced, bond strengths between enamel and porcelain now equal or exceed bond strengths between enamel and dentin.12
Porcelain laminate veneers provide an exciting challenge to our artistic and technical abilities and call upon our knowledge of smile design principles of proportion, symmetry, harmony and tooth morphology. Smile rejuvenation using veneers can positively impact a patient’s self-esteem and emotional health through improved appearance.13
Although the occlusion is often ideal in diastema cases, the size of the teeth are too small for the jaw. Orthodontists can only rearrange the spaces. Communication with the restoring dentist will allow the orthodontist to align the teeth to their pre-planned positions, paying careful attention to correcting and/or leveling gingival heights and zeniths, correcting canting issues and axial inclinations, and correcting both facial and inter arch midline concerns.15-17
In cases involving small distemas, direct composite bonding should be the first technique considered. Direct bonding in such situations can often be accomplished with little or no tooth reduction, and can provide a durable, esthetic cost effective alternative (Figs. 5-6).
The prosthetic pre-planning should be in place before the orthodontic phase is begun. Diagnostic wax-ups and measurements can be obtained by working closely with qualified dental technicians.18-21 The apparent height to width ratios can be managed to some degree by the dental technician changing/ controlling reflective and deflective surfaces.14 It is also possible to increase the length of a tooth to a limited degree by extending the tooth gingivally when combined with a crown lengthening procedure, and incisally until it interferes with the patient’s envelope of function.7
In the early 1990s, ‘instant orthodontics’ using porcelain veneers was promoted as a technique to correct some types of crowding, without resorting to conventional orthodontics. The case shown (Figs. 7-12) demonstrates how veneers underwent changes in design preparation, from no tooth preparation to preparations for bonded porcelain restorations which blur the lines/definitions between veneers and 3/4 crowns. These types of restorations have become much less popular, due to the aggressive tooth reductions required to bring teeth into the correct alignment, with the resultant increased risk of endodontic therapy.
This article will describe examples where porcelain veneers were utilized to correct tooth size/jaw size discrepancies and axial inclination issues which persisted following orthodontic treatments, as well as a case where porcelain veneers were used to ‘lateralize’ canines. Prior to commencing orthodontic treatments, these esthetic deficiencies were anticipated by radiographic and pre-operative study cast evaluations, consultation with the orthodontist and periodontist and the future prosthetic phase accordingly planned for.
CASE REPORTS
Case #1 (Figs. 13-16)
The patient is a 24-year-old lawyer, and as such, has frequent dealings with the public. She moved to Canada from the Middle-East 10 years ago, and her previous dental care was limited to routine prophylaxis and minor restorative care. She reports having had some form of appliance therapy in her youth, in an attempt to close multiple diastemas. She reports that some other members of her family also have spaces between their teeth, but not to as great an extent. She was quite self conscious about her appearance and smile.
An orthodontic evaluation revealed that the congenital malformation of certain teeth, and the tooth size/jaw size disharmony could not be solved with conventional orthodontics alone. The orthodontist was able to realign some of the dental segments, as determined from a diagnostic wax-up and mounted study models, for the anticipated veneers, and prepared the mandibular arch for future implants or fixed bridges in the edentulous spaces. She was only interested in the maxillary anterior teeth at the present time, and as she did not display any mandibular teeth during smile display or function, we elected to work on the maxillary arch only.
Six feldspathic porcelain veneers were fabricated for teeth #13 – #23 and direct composite bonding was done on teeth # 14 and #24 to close the diastemas, reshape the malformed teeth and build out the buccal corridor to enhance her smile. The tooth preparations were temporized as described in the Operative Steps section of the article during the veneer fabrication period.
The patient played an active role in selecting her new smile through the use of various smile guides and chairside direct composite mock-up. The patient was thrilled with her new smile, and reported increased confidence in her social situations. Recently, she became engaged.
Case #2 (Figs. 17-22)
The patient is an 18-year-old university student, who has been a long time patient i
n the author’s practice. She presented with diastemas between her maxillary centrals and lateral incisors. Recently she became interested in changing her smile. She was referred to an orthodontist for evaluation and treatment as required.
Radiographs and mounted study models were taken, prior to commencing orthodontic treatment, and it was determined that the tooth size/jaw size disharmony could not be solved with conventional orthodontics alone, and that teeth #13 and #23 had mesially tipped roots (mesially tipped crowns) which could not be uprighted without causing occlusal or long term stability issues.
Due to the patient’s age, the teeth were very conservatively prepared for feldspathic porcelain veneers (approximately 0.3mm). This was done to preserve as much enamel as possible, and to minimize pulpal irritation, and to allow the lab technician to achieve the correct emergence profile to maintain gingival health.
As the preparations were very minimal, no temporization was performed. The laboratory was instructed to create a ‘contact-lens’ effect25 at the cervical area so that the veneers would blend invisibly in the gingival area when bonded. The patient played an active role in selecting her new smile through the use of various smile guides and chairside direct composite mock-up. The patient was thrilled with her new smile, which has resulted in referrals from family members.
Case #3 (Figs. 23-37)
The patient is a 37-year-old registered nurse and PhD. Doctoral candidate. She was referred to me by an orthodontist for a cosmetic evaluation. She moved here from the Middle East when she was a teenager. She had prior orthodontic care to treat congenitally missing maxillary lateral incisors, before coming to Canada. As a result, the maxillary canines occupy the lateral incisor sites.
The central incisors were worn incisally, and radiographs indicated that the roots diverged distally. The canines were larger, more opaque and yellow than laterals and incorrectly shaped to occupy the lateral sites. In addition, there was gingival recession on the #24, and a pronounced root prominence.
The patient was unhappy with her smile, but stressed the importance of wanting minimal, conservative dentistry performed. A diagnostic wax-up indicated that the best cosmetic result would be obtained if 6-8 anterior teeth were treated with veneers. The patient opted to have four veneers placed on teeth #13, #11, #21, #23, and understood that teeth #14, and #24 would remain slightly smaller than ideal. They could be enlarged with veneers at a later time if the patient desires. The orthodontist aligned the roots of #11 and #21, and corrected gingival levels and zeniths to a more ideal form, and the patient placed in orthodontic retention.15-17
The patient was referred to the University of Toronto Graduate Periodontal Department, and a free connective tissue graft was performed to cover the exposed root surface on #24. The buccal prominence on #24 was evaluated, and felt to be of no pathologic concern. A ten week healing period followed, to allow for soft tissue healing and maturation. During this time period, the patient completed home tooth whitening to lighten the adjacent and opposing teeth. Teeth #13, 11, 21, 23 were prepared for feldspathic porcelain veneers. Preparation was more aggressive on the #13 and #23 in order to allow for both color and shape corrections (0.7mm.-1.0mm).
The patient wore her home whitening trays, during the interim fabrication period, to cover her prepared teeth, and as the contacts had not been broken during the preparation, there was little risk of tooth movements. The patient played an active role in selecting her new smile through the use of various smile guides, magazine photos and a chairside direct composite mock-up. The patient was very pleased with the esthetic results obtained.
While the “lateralized” canines are still larger than the lateral incisors they replace, a harmonious result was achieved, and the premolars can be “cuspidized” in the future if the patient desires.
Case #4 (Figs. 38-55)
The patient is a 26-year-old teacher who has been in the practice for over ten years. She regularly presented for routine prophylaxis and minor restorative care. Recently, she became interested in changing her smile. She presented with multiple diastemas, peg-shaped laterals, and a prominent “gummy”smile. Her lip mobility was within normal limits. Consultations were arranged with both an orthodontist and periodontist, and diagnostic mounted study models and radiographs obtained.
Orthodontically, it was determined that the tooth size/jaw size discrepancy could not be completely treated with conventional orthodontics alone. The periodontist advised that a combination of maxillary vertical excess and passive altered eruption were responsible for the “gummy” smile, and could be treated with either an ostectomy or gingivectomy, or a combination of the two procedures, to lengthen the clinical crowns and improve the proportions for enhanced esthetics.
Fixed orthodontic treatment was performed, and the maxillary arch was completed a few months before treatment in the mandibular arch was completed. New study models were taken, and the laboratory fabricated a clear acrylic surgical template for the periodontist to use during the surgical stage. The desired gingival levels and zeniths could now be communicated to the periodontist. Probing and bone sounding allowed the periodontist to determine which procedures to employ.
The crown lengthening was completed and soft tissue healing and maturation allowed to progress for three months. The mandibular arch was debanded, and a fixed lingual arch wire was bonded in place. Teeth # 14-24 were prepared minimally for feldspathic porcelain veneers, and the prepared teeth were temporized as described in the previous operative section, during the lab fabrication phase Two weeks later, the case was delivered and bonded into place.
The patient played an active role in selecting her new smile through the use of various smile guides, magazine photos, and a chairside direct composite mock-up. The patient loves her new look. She reports greater confidence in social situations, and has undergone a complete hair, and wardrobe makeover. These cases were very gratifying to both the patients and dentist as well.
OPERATIVE AND LABORATORY STEPS
Following local anesthesia, the teeth to be veneered were prepared using a selection of Brasseler diamonds. Initially two or three depth cuts of 0.3mm were prepared on the labial surface using a depth limiting bur, taking care to orient the depth cuts in the incisal, body and cervical planes of the tooth.
A tapered chamfer diamond was used to join the depth cuts and reduce the labial surface approximately 0.5mm, taking care to follow the incisal, body and cervical planes of the tooth for an even, uniform reduction. The incisal edges were reduced 1.0mm – 1.5mm to allow for the ceramist to create the correct incisal effects, and the definite incisal finish line provided a definite seat for cementation.
Definite finish lines were placed along the cervical margins, and the interproximal finish lines were carried lingually, between the teeth with diastemas to help mask margins, and minimize future possible marginal staining problems, without breaking contact points or contact areas where they currently existed between adjacent teeth.
Some clinicians advocate breaking contacts to increase esthetics and impression taking ease; however as previously noted, the more conservative the preparations can be made, the greater the number of future retreatment options, and the less likely possible pulpal irritations. An elbow type preparation allows one to maintain the contacts and still carry the preparation interproximally enough to maximize esthetics and minimize future marginal staining issues. Preparations were kept supra-gingival where possible. Once all the teeth had been prepared, a #000 retraction cord was caref
ully placed to expose 0.5mm – 1.0mm apical to the prepared margin, and the margins were evaluated under magnification, and refined as needed.
A Compo-strip (Premier) was used to refine but not eliminate the contact areas between those teeth which were in contact, to allow them to be more accurately recorded in the final impression. Tooth debris was cleansed off the preparations and adjacent gingiva with a diluted solution of hydrogen peroxide and water applied with a cotton pellet, and the preps were washed with water and dried. A polyvinyl siloxane impression was taken and examined under magnification for marginal detail.
Centric relation records and a mounted face-bow registration were taken. Temporary veneers were fabricated using Luxatemp (Zenith Dental) and a clear thin vacuum formed stent that the laboratory had previously fabricated from the diagnostic wax-up.32 Luxatemp was injected into the stent, and the stent seated over the prepared teeth.
No spot etching was done in these cases as the multiple diastemas provided a locking together of the temporaries into a one piece unit. Excess material was removed under magnification, and gingival embrasures were opened to allow for home care and prevent marginal irritation, inflammation or migration apically in the interim period during veneer fabrication. Occlusion was checked in both centric and protrusive excursions. Cases #2 and 3 were not temporized as the preparations were minimal, and any existing contacts were not broken. The patients wore an empty ‘bleaching tray’ in the interim period between preparation and fabrication, when in social situations.
A detailed laboratory script was prepared outlining the desired shape, shade, texture, stump shade of the underlying tooth preparations etc… Feldspathic porcelain veneers were fabricated and acid etched in the laboratory requested.
The porcelain veneers were returned from the dental laboratory ten days later and the patient reappointed. The veneers were examined on the solid model pour for fit and contacts (Figs. 33, 53). The intaglio surface was evaluated to ensure a uniform frosted appearance indicating a proper etch (Fig. 34). Local anesthesia was administered and the temporaries removed by sectioning them off with a straight carbide bur and a crown removing instrument, being careful to not damage the tooth preparations and nick the gingival tissues.
The teeth were cleaned with plain pumice and water in a rubber prophy cup, being careful not to cause gingival bleeding. A Compo-strip was used to clean the interproximal contacts. Cotton rolls were used to isolate the lips and keep the field dry. The veneers were tried in both individually and together to assess marginal fit and contacts. A try-in gel (Prevue, Cosmodent) was used to hold the veneers on the teeth and allow the patient to preview and approve the shape and shade of the laminates (Fig. 36).
The veneers were removed, the try-in gel rinsed off, and the veneers placed in a beaker containing alcohol and water to remove any residual try-in paste or organic debris. After removing the veneers from the beaker, they were dried off. A two part silane (Prolong, Mirage Dental Systems), prepared earlier that same day, was applied to the intaglio surface and allowed to sit for a minute. A thin layer of non-Hema unfilled resin (Mirage Dental Systems) was painted into the intaglio surface, and the veneers were set aside under a light protective container to prevent premature curing prior to cementation.
The ‘Two by Two’ veneer cementation technique described by Hornbrook33 was employed. This was done to eliminate the possibility of contamination occurring during the seating process. The sequence of veneer placement is important.
Most clinicians begin with seating the two central incisors and then working distally in similar pairs. Once the centrals are seated correctly, the lateral and canine are simultaneously seated and cured, followed by the premolars etc… if applicable. This is repeated on the contralateral side.
Dead soft matrix material or Teflon plumbers tape (Fig. 35), available in any hardware store, was placed and adapted to isolate the pair of teeth being worked on. The tooth pair being worked on was etched with phosphoric acid for 20 seconds, rinsed completely and air dried. The etch pattern was evaluated to determine if any dentin was exposed.
Tubilcid Red was used to rewet the surface as per a wet bonding protocol, and removed with a dry micro-brush. Dentin bonding primer (Scotchbond 3M) was applied to any exposed dentin and light cured, as per directions. The overhead viewing light was turned down to minimize the possibility of premature curing.
A thin coating of unfilled resin was applied to the tooth preparations. The laminates were removed from the light protective container and loaded with the previously determined shade of luting cement (Insure, Cosmodent). The veneers were carefully seated on the teeth in a incisal — facial direction, and held in place with two micro brush handles, one positioned incisally and the other buccally, to prevent the veneer from lifting off the tooth and trapping any air bubbles. Excess resin was removed with a fine brush wetted with unfilled resin.
Correct alignment and complete seating was checked and the veneers were tacked in place using the curing light for five seconds. The alignment was rechecked from all angles and confirmed. The partial cure allows the clinician to verify the position and can allow the veneer to be removed and reseated if there is a problem with the orientation. Using a # 12 Bard Parker blade and magnification, the soft partially cured resin was easily removed from the margins, and interproximal areas, taking care not to cause any bleeding. The margins were examined to ensure no voids or bubbles existed. If one did occur, it could be repaired at this point by adding some luting resin to the deficient area and curing.
It is more important to remove the excess interproximal resin completely, rather than along the cervical or lingual areas, at this point to prevent the other veneers from being unable to seat completely. Overzealous clean-up along the gingival areas at this point could result in bleeding, making further cementation of remaining veneers very difficult to achieve. The above steps were repeated for the lateral and canine pair, and then the contralateral pair. Lastly the premolars were luted into place following the same protocol.
Gylcerin gel was applied to all surfaces to eliminate the air inhibition layer, and final curing was done both facially and lingually for sixty seconds. Interproximal areas were cleared using dental floss, Compo-strips and a Ceri-saw (Denmat) if required. The #12 Bard Parker blade was used together with a Zekrya gingival protector (Vic Pollard Diamonds Inc.), to remove excess resin in the cervical third, and examined under magnification for any overhangs, flash or marginal voids.
Occlusion, which can not be verified prior to cementation, was now evaluated. The lingual surfaces were finished using a fine football shaped porcelain finishing diamond, with copious water spray, and a light intermittent touch, and the occlusion verified in both centric relation and lateral and protrusive excursions. Impressions were taken for the fabrication of a night-guard appliance. Enamelize polishing paste on a Flexi-buff disk (Cosmodent) was used to finalize the polish on the veneers.
Post-operative care instructions were reviewed, and the patient was reappointed in one week for reconfirmation of resin cement clean-up, oral hygiene and occlusal adjustments, if required, and delivery of the nightguard.
DISCUSSION
In the early 1990s, ‘Instant Orthodontics’ using porcelain veneers was promoted as a technique to correct some types of crowding, without resorting to conventional orthodontics. The case shown (Figs. 7-12) demonstrates how veneers underwent changes in design preparation, from no tooth preparation to preparations for bonded porcelain restorations which b
lur the lines/ definitions between veneers and 3/4 crowns. These types of restorations have become much less popular, due to the aggressive tooth reductions required to bring teeth into the correct alignment, with the resultant increased risk of endodontic therapy.
Today, this author would refuse to do such a case (done in 1994), and would refer the patient for orthodontic treatment. In many similar crowding cases, orthodontic treatment alone will solve the patient’s esthetic desires, or only require minor tooth recontouring and bleaching following treatment. Pre-prosthetic orthodontics will also improve the teeth’s alignment within the arch, resulting in more conservative preparations and less enamel reduction, with increased bond strengths, and less potential pulp trauma.
As clinicians, it is our responsibility to treat our patients to the highest standards, and we must educate our patients to what we feel will provide them with the most conservative, durable, and biocompatible restorations or treatments.
Many patients, having seen the rash of ‘Instant Makeover’ shows, expect immediate results. If we explain to the patient that today, most minor adult orthodontic treatment can be accomplished within short time periods of six months to one and a half years, leading to better, and longer lasting esthetic and biological results, they will accept our recommendations. Remember that we can and should refuse to render those treatments which conflict with our values and beliefs, and can refer the patient elsewhere if they insist on treatment.
Minimal or no preparation designs, exemplified by ‘Lumineers’ (Denmat), maintain maximum amounts of enamel structure, and as such, have the highest bond strengths, and least amounts of pulpal irritation. The typical lifespan of a bonded porcelain restoration is 10-15 years, and when removed for replacement with a high speed handpiece, further tooth reduction is inevitable. The more tooth structure maintained, the greater the options for future replacement and care.23-25
A disadvantage of the no preparation design veneer is that it creates an over contoured region in the gingival third, leading to possible chronic gingival and periodontal irritation. This can lead to gingival recession at a later date.
As a growing body of research is showing links between the periodontal health and systemic health of an individual, all steps should be taken to optimize the soft tissue health of our patients, by selecting supra-gingival margin designs, where possible, having correct gingival contours in our temporaries and final restorations, and using biologically compatible materials and bonding agents.
The pressed ceramic veneer design preparation, exemplified by ‘Empress’ (Ivoclar) requires more aggressive tooth preparation than required for typical feldspathic porcelain veneers. This can increase the risk of pulpal trauma, decrease the bond strengths between the veneer and tooth as more dentin is exposed, and decrease the amount of enamel available for future possible retreatments.
As well, the ‘Contact Lens’ effect,18,21,25 whereby the gingival margins of the veneer blend almost invisibly with the tooth, can not as easily be created with pressed ceramics, requiring a very skilled ceramist. The lesser translucence of pressed ceramics can be a benefit when selecting veneers for color masking or correction cases, i.e. masking tetracycline discolorations.
This author prefers using feldspathic porcelain for veneer fabrications. In the hands of a skilled ceramist, preparation designs as little as 0.3mm – 0.6mm can yield highly esthetic results. The minimal preparation allows for the proper emergence profile to be created, optimizing soft tissue health and minimizing future periodontal issues.
Approximately 6-10% of the population is partially edentulous. The incidence of missing lateral incisors is approximately 1-2%. Missing lateral incisors are the most common missing tooth after wisdom teeth and premolars. Post orthodontic treatment cases where an anterior tooth is missing present aesthetic/restorative challenges.26 If the lateral incisors or premolars are found to be congenitally absent, early diagnosis and intervention can allow for appropriate decisions to be made regarding space closure, or maintenance for a future fixed bridge or ideally an implant replacement of the missing tooth.
Sometimes treatment time, cost, and the need to augment or grow/graft bone in the site of a congenitally missing tooth, or realign the adjacent tooth roots to create space for the implant, results in the patient refusing the implant option. Some patients will opt to lateralize canines to decrease current and future restorative costs.
Patients should be advised regarding the sequelae of “lateralizing” canines i.e. compromised facial esthetics due to loss of nasiolabial support, loss of canine guidance with possible commommittent increases in future tooth wear, and poorer dental esthetics as typically the yellower and more bulbous and incisally pointed canine in the lateral incisor site requires cosmetic modification.
It is best to encourage patients to properly position the canines in their correct arch position and utilize an orthodontic retainer with denture teeth or some similar provisional acrylic replacement, until at some future point when definitive restorative treatments can be rendered i.e. an implant or fixed bridge.
The impact of lateral incisors in smile design is often overlooked.27 Lateral incisors, with the exception of the third molars, are the most variable and irregularly shaped teeth in the permanent dentition. No other anterior tooth allows the cosmetic dentist and dental technician the opportunity to customize a smile by either altering the distance of the incisal edge to the occlusal plane, altering the degree of mesial inclination of the clinical crown, altering the shape of the tooth, altering the amount of labial/lingual rotation, and even customizing differences between the right and left laterals (Figs. 1-4).
Smile design not only relates to the shape, size, and interrelationship of the teeth, but also to the soft tissues and lips as they drape and frame the dental elements. Excessive gingival display or a ‘Gummy Smile’ is a condition characterized by excessive exposure of the maxillary gingiva during smiling and or lip repose. This condition is caused primarily by a skeletal deformity in which there is vertical excess of the Maxillary tissue, a soft tissue deformity in which there is a short or hypermobile upper lip, or a combination of the two.28-30
There is no predictable procedure to correct a short or hypermobile upper lip. Patients who fit this category should be advised of this, as part of a comprehensive smile evaluation so that realistic expectations of the final result can be achieved. Another cause of excessive gingival display is insufficient clinical length, caused by incisal attrition, gingival hypertrophy, or passive altered eruption. Following active tooth eruption, passive eruption occurs.
Passive altered eruption is the apical migration of the dentogingival unit adjacent to the cemento-enamel junction (CEJ), which results in the formation of the 2.5 – 3mm. ‘Biologic Width’. In some cases the gingival margin does not migrate to its final position on the cemental surface. This is called Passive Altered Eruption. Approximately 12% of the population has some degree of passive altered eruption. Most cases present as esthetic concerns to be treated for esthetic reasons, as the gingival tissues are usually healthy.
A ‘Gummy Smile’ can be treated surgically, orthodontically, periodontally, or some combination of all three, depending on the underlying etiology, and the amount of crown exposure required to optimize the esthetic outcome.
The type of periodontal surgical procedure selected depends on the amount of tissue to be removed, the amount of attached gingival present, and the underlying osseous levels. If the osseous levels are appropriate, and if there is more than 3mm. of attached g
ingiva from the osseous crest to the gingival crest, and if it is determined that an adequate zone of attached gingival will remain after surgery, then a gingivectomy is indicated.31
If diagnostic bone sounding procedures indicate that the osseous levels are approximating the CEJ, a gingival flap and ostectomy procedure is indicated, so that the revised crestal bone levels will be approximately 2 – 3mm. from the CEJ’s, resulting in a stable, healthy biologic width. The crestal bone architecture should follow the desired soft tissue drape.
The restorative dentist should have a clear surgical stent fabricated by the dental laboratory, based on the desired length to width ratios determined to yield the best esthetic result. This can be determined chairside using a composite resin mock-up, or from a lab created wax-up. This template allows the periodontist to determine whether a gingivectomy or ostectomy will be best indicated for the case, and allows the tissue heights and zeniths to be correctly positioned.
CONCLUSION
Numerous cases were presented showing how porcelain laminate veneers solved esthetic problems which persisted following orthodontic treatment. Reduced stress, predictable results and near elimination of adjustments are easily obtainable when attention to detail is carried from the records and treatment planning to tooth preparation and temporization, through to case delivery and completion.
Porcelain veneers allow for conservative highly esthetic solutions for diastema corrections, color corrections and allow us to reshape malformed teeth, or reshape teeth in incorrect arch positions to more closely approximate their correct shapes. These types of cases can be very satisfying to our artistic natures and psychologically and functionally benefit our patients.
Dr. Pollak is past-president of the Toronto Academy of Cosmetic Dentistry. He maintains a general dental practice in Markham, ON, with an interest in cosmetic, restorative and implant dentistry .He is a founding member of the Canadian Academy of Esthetic Dentistry. He is a graduate of the Misch Implant Institute, The Dawson Center for Advanced Studies, and the SUNY post-graduate program in Esthetic Dentistry. He is a Fellow in the International Congress of Oral Implantologists (I.C.O.I.), and is currently working to achieve fellowship in the Academy of General Dentistry.
Acknowledgment
The author wishes to thank Dr. Sol Laski for completing the orthodontics for cases 2 and 4, and Dr, Iris Kivity-Chandler for completing the orthodontics on case 3. The author wishes to thank Dr. Howard Gelfand for performing the periodontal crown lengthening procedures on case 4. The author wishes to thank Demetrious Andreou, R.D.T.and staff at ADL Laboratory for their excellence, attention to detail and artistry in the fabrication of the prosthetics in case #2 and case #3. The author wishes to thank Dr. John Nasedkin, Prosthodontist, for his review and comments during manuscript preparation
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