The presence of cosmetic dentistry in the public eye has never been greater. Dramatic examples of the life changing effects of improving a smile can be seen during prime time television, in magazines and newspapers. The public is becoming more and more aware that beautiful smiles are not just for the rich and famous, but can be for anyone. It is self evident that a great smile makes a person look younger, feel better, be sexier, be healthier, improves the quality of life and reduces barriers in communication.1
This article chronicles a case using conservative indirect porcelain veneers combined with bleaching and recontouring to give a beautiful and very natural looking result. This younger woman not only received a fantastic result that she loves but also future options to still use further restorative dentistry later in her life have been left open. We all know that everything we do in dentistry has a lifespan and at some point most if not all of the restorations we place will need to be replaced. The materials and techniques have thankfully come a long way, but they are still not perfect. People are continuing to live to be older and the more conservative the dentistry we do to achieve an acceptable result the better it is for the patient and the practice. Treatment plans should be developed for your patients as if they were close family members and dear friends.
This young woman sought what she described as her perfect smile. Her desire was to be as conservative as possible without compromising the final esthetic result. She preferred no orthodontics and was willing to wear a post treatment bruxing guard. An accident earlier in her life had chipped the mesioincisal of 1-1 and partially avulsed and discolored 2-2 (Fig. 1). She had direct composite restorations placed that had by now discolored and felt rough (Fig. 2). She was displeased with the over all yellow tone that had become more prominent to all of her teeth and noticed the open gingival embrasure between 1-1 and 2-1 (Fig. 3). She commented about the difference in the long axis angulation of the central incisors. Additionally, the lower anteriors had become quite irregular from chipping during protrusive bruxing (Fig. 4).
To help her visualize her final result, we did a direct intraoral composite mock-up of the four incisors developing symmetry and increasing the edge length (Fig. 3a). We sent her home with before and after photographs, printed side by side, that she and her husband could look over (face shots at similar angles and similar lighting are most effective).
After a signed informed consent, the treatment started with radiographs, periodontal evaluation, models and a light enhanced in-office bleaching session (Zoom, Discus Dental). Utilizing the information gained from the mock-up combined with specifics from facial and intraoral photographs a wax-up was done to create a matrix (Siltech, Ivoclar) for provisional restoration fabrication at the preparation appointment.
At the preparation appointment the lower anterior teeth were first recontoured to remove the chipped edges and decrease the overbite that spread the protrusive forces on the maxillary teeth to all four incisors. To aid in the recontouring, a line approximating the final form was placed with a fine tipped black marking pen (Figs. 5 & 6).
An incisal edge matrix was fabricated from the wax-up and used as a gauge to minimize and guide reduction (Fig. 7). Depths cuts were placed with a 0.5mm wheel diamond (Pollard Diamonds) and the surfaces were reduced in three distinct planes, incisal, middle and gingival thirds (Figs. 8 & 9) until the depth cuts were removed. This technique keeps reduction minimized but also allows for adequate room of the restorative material. Inadequate room for the restorative material will not only fall short of the desired esthetic goal, but can also create areas of over-contouring that can negatively affect the health of the periodontium. Post preparation form was compared to the incisal matrix and refined where necessary (Fig. 10).
Because a reduction guide was used significant surface enamel was maintained thereby increasing adhesive bond strength2 (Fig. 11). A diode laser (Odyssey, Ivoclar) created subtle changes in gingival contours that were critical to achieving esthetic symmetry.3 The most pleasing esthetic results are a combination of developing bilateral symmetry of the teeth and the gingiva, which is often overlooked. If the gingival symmetry is not attainable with just gingivectomy, osseous surgery should be considered. Developing a healthy and esthetic mucogingival complex usually takes some time, but is well worth the effort in the final result.
The art side of esthetics is most apparent when determining the relationship of the long axis of the face with the smile and creating facial harmony.4 The long axis of the face is an average of all of the facial features. Often, it will be perpendicular to the interpupillary line but not always, so using the interpupillary line as a point of reference may not always work well. Almost everyone has asymmetries to the face and sometimes one eye can be significantly higher or lower than the other. It becomes very apparent when the smile is not in harmony with the long axis of the face. After the impression for the restorations (Take One, Kerr) the esthetic plane of the smile was recorded with a stick bite that was later mounted on the model and used as a reference. This relationship was also photographed and sent to the laboratory (Fig. 12).
Provisionalization was attained using a Siltech matrix made from the diagnostic wax-up and Luxatemp temporary crown and bridge material (Zenith) modified with color modifiers (Kolor Plus, Kerr).5 The provisional stage is the time to determine the acceptance by the patient of shape, shade and function including phonetics. Making the provisionals close to the projected final result greatly increases the probability of a successful result because the refinements can be made during this stage.
In esthetics success only happens when the patient is happy with the result (Figs. 13 &13a). That success is ultimately an emotional decision and has little to do with how tight the contact is or how well a margin is adapted. This emotional aspect of esthetic dentistry leads to the greatest joys and challenges for the practitioner. Artists do well, technicians have trouble.
The final shade selection was determined using color corrected light (Fig. 14). An easy and portable way to get color corrected light is the Demetron Shade light (Kerr). This shade verification was done several days after the provisionals were placed to give an opportunity for the tooth structure to rehydrate, which can change shade perception dramatically. In this type of light the subtleties of shading, translucencies, opacities and surface textures can be clearly seen and evaluated.
Exceptional laboratory communication is an essential step to exceptional esthetic and functional results. This type of dentistry demands the most detail and precision and is based on solid foundations of form following function. Attractive teeth that function well stay attractive and unattractive teeth often have significant compromised function. Using focused and well-exposed photographs is the basis to convey the information to the ceramist who typically is in a remote location from the patient and usually never has the opportunity to see the patient. The saying ‘a picture is worth a thousand words’ is true and can be much more effective than long written descriptions.
After the restorations were returned from the laboratory they were checked on the models for form, fit and quality. The provisionals were removed and the prepared teeth cleaned for try in of the final restorations. Each restoration was seated individually and in a dry field to verify the proper fit. Always do this before fitting all of the restorations en masse to get the most precise fit (Fig. 15). The shade was evaluated with water underneath the restoration and is close
to the same effect as the more translucent luting cements.
The luting cement has two major requirements, to adhere the restoration to the underlying tooth structure and to blend the shade of the root surface to the gingival aspect of the restoration. This blending allows for an invisible margin that can and is usually supragingival. Many recent luting cements exhibit excellent flow characteristics with mean film thicknesses between 8-21 microns6 allowing for very fine margins. This particular case was seated with medium shade Calibra resin luting cement (Caulk Dentsply).
Starting with the central incisors, firm apically directed pressure was applied, expressing luting cement from underneath each restoration through the margins before being tacked to place (Fig. 16). Excess cement was removed with brushes, an explorer and dental tape (Fig. 17). When cleaning the cement interproximally, the tape was always pulled lingually to prevent dislodging the restorations prior to final cure. The restorations were then cured for 40 seconds from the buccal and the lingual surfaces with a diode curing light (L. E. Demetron, Kerr). Gross excess cement was removed with a spoon excavator, sickle scaler and an Enhance finishing cup (Caulk Dentsply).
The margins were then finished with a fine diamond (Pollard) and abrasive cups (Dialite, Brasseler) (Figs. 18 & 19). The surface porcelain was finally polished with a diamond paste (Diashine, V.H. Technologies) on a Robson wheel (Fig. 20). For this final step, run the handpiece in reverse to direct the splatter into the suction tip.
The occlusion was adjusted to the pre-existing centric occlusal position with the patient in an upright orientation, then checked and adjusted for para-functional movements. Impressions were taken for a night-time bruxing guard that was delivered several weeks later. If a wear pattern existed before an esthetic change is made and no significant occlusal shift was made, the same functional environment still exists and the body will try to create the same form. Since form always follows function, to gain maximal longevity protect the teeth with a guard.
At the delivery of the night guard we always take post treatment radiographs to verify proper fit and removal of excess luting cement.
Rechecking the occlusion and adjusting as necessary is wise. Pay particular attention to comments about teeth colliding during chewing, especially harder foods. Now is a good time to get final photos that can be used for documentation and future marketing (Figs. 21-26).
This is also a great time to enjoy the positive emotions that go with an exquisite result. Patients are typically thrilled with the unexpected changes that have occurred and are happy to share them with your team and you. If you want more patients like them, here is your opportunity to ask. It should be no surprise, happy satisfied patients usually refer the next happy satisfied patient. Welcome to the art of conservative esthetics.
Significant materials and sources:
– Zoom in-office 1 hour bleaching, Discus Dental (www.zoomnow. com)
– Siltech condensation silicone impression material, Ivoclar (www.ivoclarvivadent.com)
– Diamond rotary instruments, Pollard Diamonds (www.dentaltechniques.com)
– Odyssey diode laser, Ivoclar (www.ivoclarvivadent.com)
– Take One polyvinyl impression material, Kerr (www.kerrdental.com)
– Luxatemp temporary crown and bridge material, Zenith (www. zenithdmg.com)
– Kolor Plus color tints, Kerr (www. kerrdental.com)
– Demetron shade light, Kerr (www.kerrdental. com)
– Calibra resin luting cement, Caulk Dentsply (www.caulk.com)
– L.E. Demetron diode curing light, Kerr (www.kerrdental. com)
– Enhance composite polishing cups, Caulk Dentsply (www.caulk. com)
– Dialite polishing cups, Brasseler (www.brasseler usa.com)
– Diashine diamond polishing paste (www.vhtechnol ogies.com)
Acknowledgements
The exquisite ceramic artistry for this case was created by Mr. John Tecca, owner of Esthetic Oral Arts in Livingston, Montana (www.estheticoral arts.com). The restorative material used in this case was dSign porcelain by Ivoclar.
Dr. Spoor is in active private practice in esthetic and restorative dentistry in Seattle, WA. He is a 1983 graduate of the University of Washington, an Accredited Member of the American Academy of Cosmetic Dentistry, and a fellow of the Academy of General Dentistry and the Pierre Fauchard Society. He authors articles in esthetics, occlusion and photography that are published internationally and is director of Artistry in Dentistry Continuums, hands-on continuing dental education courses in Seattle (www.rhysspoor.com).
Oral Health welcomes this original article.
REFERENCES
1.Astrom, J., Thorell, L.H., d’Elia, G. Attitudes towards and observations of nonverbal communication in a psychotherapeutic greeting situation: III An interview study of outpatients. Psychol Rep 1993 Aug; 73(1):51-68
2.Mota, C.S., Demarco, F.F., Camacho, G.B., Powers, J.M. Tensile bond strength of four resin luting agents bonded to bovine enamel and dentin. J Prosthet Dent. 2003 Jun; 89(6):558-64
3.Studer S., Zellweger, U., Scharer P. The esthetic guidelines of the Mucogingival complex for fixed Prosthodontics. Pract Periodontics Aesthet Dent. 1996 May; 8(4):333-41;quiz 342.
4.Okuda, W.H. Creating facial harmony with cosmetic dentistry. Curr Opin Dent. 1997; 4: 69-75 Review.
5.Spoor, R. Predictictable Provisionalization: Achieving psychological satisfaction, form, and function. Pract Proced Aesthet Dent 2004 Jul;16(6):433-40.
6.Kramer, N., Lohbauer, U., Frankenberger, R. Adhesive luting of indirect restorations. Am J Dent 2000 Nov, 13 (Spec No): 60D-76D. Review.
