Aesthetic dentistry has evolved from applying bonding principles that adhere porcelain and composite to a multidisciplinary approach of treatment for patients to receive beautiful, natural, functioning dentistry. Bonding has opened doors to allow us to conserve more tooth structure and expect longevity out of our restorations, therefore forcing us to treatment plan our cases differently from say 10 or 15 years ago. The limits have been pushed and we now have long-term clinical data on what works and what doesn't. Combined with advancements in research in implant surgery, this leaves many more options open to restoring a patient’s mouth.
Figure 1.
Our patient presented with the chief complaint of spaces between her teeth. She is a 23-year-old model with no significant medical history. At first glance during the consult, this looked to be a straightforward diastema closure case with a single tooth replacement in the lower right (Fig. 1). The patient expressed that time was an issue, she wanted things done in a timely fashion, and that she was unwilling to wear braces.
A full series of digital radiographs were taken along with a set of digital photographs and the patient was examined keeping her concerns in mind. Before starting any case, it is imperative that we do a facial analysis along with a dental analysis. Doing either alone will not give us function and aesthetics.
Figure 2.
First we looked at the facial analysis to visualize three-dimensionally where the teeth were within the framework of the face. We started with a facial “T” which is imaginary horizontal and vertical planes. The horizontal goes through the interpupillary plane, the vertical goes through the facial midline (Fig. 2). From here, we could see if vertical and horizontal elements of the teeth were imparting with the elements of the face.
The next step was facial-lingual positioning . After facial analysis, it was determined that the dental midline was to the patient’s right and the axial inclinations of the laterals and centrals were canted to the patient’s right. Facially, her teeth were retruded and needed to be placed labially for a nicer profile. The last thing noted was a slight lip asymmetry upon social smiling but was corrected when a full smile was present.
Figure 3.
Figure 4.
Figure 5.
Once this was determined, the next step was to diagnose dentally. It was noted that teeth No. 8 and No. 9 were chipping incisally due to the edge-to-edge position of her bite. Nos. 10 through 13 posteriorly were in cross bite. No. 29 was missing with diastemas noted throughout all upper and lower left teeth (Figs. 3, 4, 5 ). Our goal was to establish a functional bite, close the spaces, and create a smile that would enhance facial appearance through color and contour. With these parameters established and our vision clear, preparation could begin.
Preparation/Temporization
Keeping the end result in mind while preparing is critical for preservation of tooth structure. Tooth structure is crucial for strength, longevity and vitality in color of a restoration. Bulk reduction was done first to place the teeth in the correct planes. No.’s 6 and 8-13 were prepared from the lingual to create a ramp and path of insertion for the porcelain to jump the bite and to create a positioning that allows our ceramist to build thin, lifelike incisal edges. If these teeth were not prepared from the lingual, the result would have been either not being able to create overjet, or thick incisal edges that look heavy and fake.
Next we re-created our gingival zeniths with a soft-tissue laser, checking not to invade biologic width.
Figure 6.
Finally, the margins were finished with a chamfer bur (Fig. 6). In order to gain overjet, No. 27 was prepared for a veneer. An implant was placed in the No. 28 site and a Nesbit was fabricated and bonded in the space to allow healing for four months.
To create natural aesthetics, I like to know where I am starting and create from stable landmarks. To temporize, an AlgiNot impression (alginate alternative) of the teeth was taken prior to preparation and the teeth were prepared.
Upon completion, the alginate alternative was filled with a dual-cure bis-acryl temporary material and placed over the teeth. Once this is partially set, the impression was removed and the temporary material was allowed to fully set outside of the mouth, providing a duplicate of the original teeth and showing the amount of tooth structure removed.
Setting parameters (length of centrals, width of smile, positioning of teeth) prior to preparation allows complete aesthetic control. With the provisionals set, they were trimmed and spot bonded with etch, OptiBond FL adhesive (2FL) and cemented with PermaFlo Ultradent Products Inc.) into the mouth, creating shape and contour.
Finally they were shaped and finished. The same thought process while preparing the teeth is applied to creating lifelike provisionals. First we look at the parameters of the face and then dental parameters.
Figure 7.
Figure 8.
Form follows function, and if these are closely examined, the result will be a smile that looks like Mother Nature intended (Figs. 7 and 8).
Second Appointment
The patient was called back the next day to evaluate occlusion, shape, contour, speech and color. Final revisions, photos, and a mold of the provisionals were made along with a detailed lab script.
It is important to have a good relationship with your lab, hopefully with a ceramist you work with exclusively. My ceramist and I discuss, at length, surface texture, line angles, color, translucency, and so on. The best way to communicate this is to take pictures of teeth you like that you come across in your practice and keep a library of them. For each patient, send a sample of translucency, texture, or color.
Insertion
Figure 9.
The key to making restorations look real is using the underlying tooth structure for color and vitality in the porcelain. This starts with preparation design. When creating the veneer, the ceramist takes into consideration the stump shade and warmth of the tooth to blend with the color of the ceramic. The best cement to capture this is one that is viscous, clear and color stable. For insertion, we use a combination of dual- and light-cure clear NX3 Nexus Third Generation cement (Fig. 9).
Insertion is always done under isolation for a clear, dry working field. After the teeth were isolated, each veneer was tried in with water for fit and color. The tissue was treated along with the veneers to make sure bleeding was eliminated.
The standard protocol is etch, OptiBond Solo Plus, then the application of cement. The light-cured veneers were placed first (No.’s 4-9), wiped clean of excess cement, then tack cured for three seconds.
This was followed by the application of dual-cure cement (No.’s 10-13), due to the thickness of porcelain in the mid buccal, which were tack cured, cleared of debris and fully cured for 20 seconds facial/lingual.
The veneers were polished, stripped and finished at the margins.
The patient was recalled the following week to check occlusion and have a cleaning to eliminate any excess cement and minimize postoperative sensitivity.
Conclusion
Figure 10.
Figure 11.
Figure 12.
There is always more than one way to treatment plan a patient. Our philosophy is to create a treatment plan that satisfies our goals and the patient’s comfort. This is a fine balance between understanding the science of dentistry, knowing the products you’re using, and understanding the lifestyle of your patient to create something that will work and last. Bonding agents and cements allow us to do things we couldn’t do 20 years ago. Coupled with implant dentistry, we were able to redesign our patient’s entire smile in a week and have her looking great, as shown in Figs. 10 – 12 - Rt Lateral. The patient was scheduled to return in three months to have the implant restored.
I would like to thank Dr. Larry Rosenthal for his mentoring throughout my career and Jason Kim, CDT for his hard work and mentoring.