Resolving Color Variation

Figure 1. Frontal view demonstrating variations in color.

CASE REPORT
Diagnosis and Treatment Planning

The patient presented to our office with a list of complaints about the appearance of his teeth. Developmental and environmental enamel defects and hypocalcification had affected the hue, value, and chroma of the mid-facial regions of his dentition (Figure 1). The overall color variation of his teeth was too dark, and he had asymmetrical gingival zenith variations (Figure 2). The appearance of tooth color is a complex phenomenon, with numerous factors such as lighting conditions, translucency, opacity, light scattering, gloss, and the human eye and brain influencing the overall perception of tooth color.1 His low smile-line and lip-line were in balance; however, this patient desired a more normalized and aesthetic smile.

Using Dr. Paschal Magne’s aesthetic fundamental objective criteria and aesthetic checklist, it was determined that the zenith of gingival contours and balance of gingival levels for teeth Nos. 8 and 9 were too apical, while the zeniths for teeth Nos. 4 and 13 were not positioned apically enough.2,3 Generalized enamel color variation at the mid-facial one third was optically and aesthetically distracting, with an old PFM crown on tooth No. 8 demonstrating the greatest variation in color. The full-facial view and the retracted anterior view (Figures 1 and 2c) show an arch curvature and incisal edge position that harmonizes with the lower lip-line. Some old dental work can be seen, along with the discolored and unnaturally opaque PFM on tooth No. 8.

Our treatment plan was to start with the preparation of 10 maxillary teeth, with 2 full porcelain crowns (Nos. 5 and 8) and 8 veneers (Nos. 4, 6, 7, and Nos. 9 to 13), concluding with the preparation of 10 mandibular veneers (Nos. 20 to 29). The patient was not concerned with his gingival zenith asymmetry due to his low smile-line and did not wish to correct this aesthetic issue.

Clinical Protocol
During the preparation of the maxillary teeth, folded 2-x-2 gauze was placed in the vestibule to prevent the enamel and porcelain slurry from denuding the facial gingiva during tooth preparation. A depth-cut technique was used with a goal of 0.8-mm facial reduction, utilizing a 0.5-mm depth cut diamond (No. 900-7136 [Henry Schein]). (Although not shown here, we usually mark the depth of the initial cut with a permanent marker, as this is the most accurate method to ensure a specific reduction.) The old PFM crown on tooth No. 8 was removed and tooth structure reduced to the 0.5-mm depth cut with a round-ended diamond (No. 112-5161 [Henry Schein]). The discolored dentin on tooth No. 8 was excavated and replaced with a hybrid composite resin (Renamel [Cosmedent]) to conceal the discolored dentin.4 A 0.3-mm depth cut diamond (No. 900-7135 [Henry Schein]) was then used to achieve a total reduction of 0.8 mm, using the round-ended diamond to reduce the last 0.3 mm of tooth structure. Since our target reduction was 1.5 mm and the round-ended diamond has a diameter of 0.75 mm at the tip, our protocol was to sink this diamond to twice its tip diameter to ensure a 1.5-mm reduction. To finalize the preparations, all of the external line angles were removed and then the preps were polished using a diamond (No. 8878K-31 [Brasseler USA]) (Figure 3). O-Bite (DMG America) bite registration material was used to capture the vertical dimension of occlusion (VDO) in addition to a centric relation (CR) bite. The molars were in contact at the maximum closed position as the O-Bite captured this position of maximal closure in the CR position (Figure 4). The temporization phase began with spot etching (Etch-Rite 38% phosphoric acid gel [Pulpdent]) the dentin of teeth Nos. 6, 8, 9, and 11 for 20 seconds and the teeth were washed thoroughly and air-dried. Next, 2 coats of a desensitizer (Dentin Desensitizer [Pulpdent]) were applied. Then, an adhesive (OptiBond FL [Kerr]) was applied and air-thinned (according to the manufacturer’s instructions) to evaporate out the solvent. Figures 5 to 7 show utilization of Dr. Bob Nixon’s temporization technique (Cosmedent). This rubber-like Rapid Simplified Veneer Provisionals (RSVP) material from Cosmedent has been adapted to the master wax-up to capture all aesthetic and functional lingual and incisal contours. The gingival one third of the facial aspect of the RSVP material has been removed and RSVP low viscosity incisal composite resin (Cosmedent) was placed into the matrix. The low viscosity incisal composite resin was then light-cured (Rembrandt Sapphire Plasma Arc curing light [DenMat]), leaving the operator to hand place and contour the RSVP high viscosity cervical composite resin to the facial margins with accuracy. The initial amount of RSVP low viscosity incisal composite resin was placed to construct the exact location of the incisal edge and lingual aspect of these teeth. The aesthetic contours and functional nature of the temporary were evident. Another advantage with this system is its ease of adding color, characterization, and a glazed finish. A Kolor + Plus (Kerr) kit was utilized to add ochre and white spots, along with LuxaGlaze (DMG America) (Figure 7).

Figure 2a. Right lateral view showing malformed enamel. Figure 2b. Left lateral view showing variations in gingival zenith.
Figure 2c. Frontal view showing pretreatment condition of dentition.
Figure 3. Frontal view of completed maxillary preparations. Figure 4. Frontal view of O-Bite (DMG America) capturing maximum closure in centric relation position.
Figure 5. Dr. Bob Nixon’s temporization technique (Cosmedent) was utilized. Figure 6. Low viscosity incisal composite resin (RSVP [Cosmedent]) captures incisal edges.
Figure 7. Frontal view of finalized temporaries. Figure 8. Notice how tightly and well the restorations fit all the dies.

The final restorations were fabricated by our lab team using a very strong and aesthetic leucite-reinforced porcelain system (Authentic [Ceramay Dental]). This ceramic system was chosen due to being one of the strongest pressable porcelains available and the advantage of the availability of the material in a Plus/Plus (++) shaded ingot. This was ideal for blocking out any discoloration and variations in shades of teeth. Notice, in Figure 8, how similar they are to the temporaries, and how closely the final restorations fit the dies. A cut-back technique was utilized by the dental laboratory technician to achieve the illusion of translucency and to incorporate a halo effect necessary to create a natural-looking incisal edge (Figure 9).

At the appointment for the delivery of the final restorations, the provisionals were removed. This was done by cutting down the entire facial aspect of the temporary with a round-ended diamond bur, placing a crown splitter into the slot and torqueing, thereby breaking the cement bond and dislodging the provisionals. Via excellent home hygiene, the patient in this case had created a perfect environment for cementation of the restorations. If a patient presents with poor oral hygiene habits, it is best to have him or her rinse (or brush) with a solution of 0.12% chlorhexidine gluconate (Acclean [Henry Schein]) during the time the provisionals are in place. The maxillary restorations were resin bonded into position using a 4th generation bonding adhesive (OptiBond FL) in combination with an aesthetic resin cement (Calibra Esthetic Resin Cement [Dentsply Sirona]).

Proper finishing of restorations is essential for long-term success. Three burs were used to initiate the finishing process: first, a red-striped, 30-grit diamond (Brasseler USA) was used around all margins; followed by a yellow-striped, 15-grit diamond (Brasseler USA); and then a white-striped, 30-bladed finishing bur (Brasseler USA). Next, 3 Shofu Dental polishing points were used, starting with the no-stripe point, then the yellow-striped, and last the white-striped polishing point. The interproximal finishing began utilizing a CeriSaw (DenMat) to first clear out excess cement in the interproximal areas, then a red-striped Gateway Flexi diamond strip (Brasseler USA) was used to smooth each interproximal surface. The last and most significant interproximal polishing was achieved with a series of EPITEX Strips (GC America). After the blue, green, gray, and tan strips were all used in sequence (according to the manufacturer’s directions) completing the polishing, the final step in the delivery sequence, flossing between the teeth, was extremely smooth. Figure 9 shows one-week post insertion. Notice the natural incisal translucency and halo.

Figure 9. One week after insertion of maxillary restorations.
Figure 10. Frontal view of completed mandibular preparations with polishing of the incisal one third.
Figure 11a. Right lateral view of restorations in place. Figure 11b. Left lateral view of completed restorations.
Figure 11c. Frontal view of all restorations bonded into place.
Before Image. Frontal view of patient before treatment. After Image. Frontal view of completed case. An extremely pleased and happy patient!


In the next phase of treatment, the preparation of the mandibular teeth was done. We wanted a total facial reduction of 0.8 mm and incisal edge reduction of 1.5 mm. We accomplished this with the same sequence of depth cuts and burs as we utilized to prepare the maxillary dentition. All external line angles were rounded and the preps are polished with a NTI CeraGlaze (Kerr) ultrahigh-shine yellow polishing point (Figure 10). All of the mandibular temporaries were fabricated and color matched to the maxillary restorations. The 10 mandibular veneer restorations for teeth Nos. 20 to 29 were created by our lab team in the same manner, with the same pressed leucite-reinforced porcelain (Authentic) as the maxillary restorations. Finally, all the mandibular restorations were bonded into position (as described above using a light-cured resin cement technique for these veneers), achieving the desired tooth color and form (Figure 11). One can immediately see from the patient’s facial expression that he was extremely pleased with the results of a much more harmonious and aesthetic smile (Before and After Images).

CLOSING COMMENTS
Treating aesthetic cases can be quite rewarding for the clinician and fulfilling for the patient. This patient presented with a list of complaints about the appearance of his teeth. The majority of his concerns were with the mid-facial malformation and discoloration of the majority of his teeth. We were able to correct these aesthetic concerns, bringing harmony to his smile.

Acknowledgment
Laboratory fabrication by John Wilson of Wilson Dental Arts (Raleigh, NC).


References

  1. Joiner A. Tooth colour: a review of the literature. J Dent. 2004;32(suppl 1):3-12.
  2. Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Chicago, IL: Quintessence Publishing; 2002.
  3. Patil VA, Desai MH. Assessment of gingival contours for esthetic diagnosis and treatment: a clinical study. Indian J Dent Res. 2013;24:394-395.
  4. Small BW. Clinical tips for porcelain veneer cases with enamel hypocalcification. Gen Dent. 2011;59:414-416.

Dr. Tyler Wynne received his doctor of dental surgery degree (2014) from the University of North Carolina School of Dentistry. He practices general dentistry in Faison, NC, and is adjunct professor at the University of North Carolina School of Dentistry. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

Dr. William Wynne maintains a private practice in Raleigh, NC, focusing on aesthetic and restorative dentistry. He graduated from the University of North Carolina School of Dentistry in 1971 and has achieved the status of Pankey Scholar. He is a Diplomate of the American Society for Dental Aesthetics and a member of the American Society of Dental Practice Administration. He has published numerous articles on aesthetic dentistry, occlusion, and eating disorders. He can be reached at (919) 851-3716.

Disclosure: Drs. Tyler and William Wynne report no disclosures.

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Anterior Tooth Replacement Made Easy: A Conservative and Predictable Direct Technique

Often, patients and referring orthodontists have a preconceived idea that a cosmetic solution to a problem, such as congenitally missing lateral incisors, will be a very complex and clinically involved challenge. Fur­ther­more, it is often thought of as being a very expensive ordeal to solve. In many cases, when clinically indicated and if the appropriate materials and techniques are employed, nothing could be further from the truth! The following article will focus on a real-world clinical example that demonstrates how a conservative and predictable direct restorative technique can be used to successfully treat a case involving congenitally missing lateral incisors.

CASE REPORT
Diagnosis and Treatment Planning

Rachel, a 32-year-old mother of 4 and a third-year law student, had been struggling with congenitally missing lateral incisors since the removal of her braces at age 18 years. Her oral health was excellent. She has no other dentistry in her mouth. Her gingival and bone health were both very good.

In reviewing her intraoral photos (Figures 1 and 2) together at her initial consultation, Rachel had many concerns regarding her smile. She felt that her smile looked “run down,” and she complained of food getting stuck under the lateral incisor restorations. Furthermore, she stated that she disliked replacing the lateral incisor restorations every year because they would fall out at the worst times, and the only thing she could count on is that they would look different every time the dentist replaced them. To add to her distress, Rachel had never been happy with the different restorative/aesthetic outcomes. Rachel’s other concern during our initial discovery was that tooth No. 9 looked disproportional to No. 8 due to the poorly executed composite on No. 9. Also, gaps in the lower anterior teeth and the nonharmonious gray, white, and yellow appearance of her teeth were also issues she that she desired to have addressed.

It was determined that Rachel was not a candidate for an implant to replace tooth No. 7 due to space constraints between the central incisor (tooth No. 8) and canine (tooth No. 6) roots. An implant in the area of No. 10 was possible and would be considered in the future; however, Rachel was constrained by time and money at this point in her life.

Given Rachel’s time and financial constraints, and considering her desire to do something more permanent in hopes that her financial situation would change in 3 to 5 years, a conservative mid-range plan was presented to Rachel addressing all of her concerns. An intercoronal fiber-reinforced direct lateral incisor bridge was presented as a dependable solution that, in the author’s experience, could likely last approximately 3 to 5 years, giving Rachel the appearance of a natural-looking and normal-functioning tooth. Teeth whitening and direct composite fillings were also presented to Rachel for consideration in order to address the upper left central (tooth No. 9) and 2 lower incisors (teeth Nos. 24 and 25). Rachel was informed that this work could be accomplished in only 2 appointments, within her budget. One appointment would be used for the one-hour in-office whitening procedure, and the other appointment (estimated to take about 2.5 hours) for the new restorations to be completed. Rachel was surprised that she could get everything done so quickly and within her budget. Mostly, she was excited to begin confidently smiling again.

Clinical Protocol
Prior to the chairside fabrication of Rachel’s new smile, a review of the informed consent, clinical timeline, procedure outline, and any final questions from Rachel were addressed. A preliminary vinyl polysiloxane (VPS) alginate substitute (Algin-X [Dentsply Sirona]) impression was taken of the upper and lower arches along with a bite registration (Blu-Mousse [Parkell]). These would be used to create a wax-up of the new lateral incisors, and also for the fabrication of an incisal/lingual putty (Sil-Tech [Ivoclar Vivadent]) matrix to be used chairside during the restorative process.

Figure 1. Pre-op anterior photo showing a discolored and poorly proportioned smile. Figure 2. Pre-op retracted anterior photo gives appreciation for the poorly shaped laterals and the gaps between the lower anterior incisors.
Figure 3. Creating the pontic space with diode laser (Picasso Lite [AMD LASERS]). Buccal border of pontic space to mimic ideal scalloping of gingiva. Figure 4. A schematic diagram of the construction of the everStick C&B (GC America) fiber made up of an interpenetrating polymer network of polymethyl methacrylate and bisphenol A-glycidyl methacrylate.

Two weeks prior to the restorative work to be done, a one-hour, in-office whitening (Zoom [Phillips Oral Healthcare]) procedure was accomplished; in addition, take-home whitening trays were fabricated. The patient was given a 16% carbamide peroxide whitening gel (Pola Night [SDI North America]) so that a baseline whitening shade could be established.

Once satisfied with the whitening results, the restorative procedure was initiated by removing the existing lateral restorations. Pontic areas were created using a soft-tissue diode laser (Picasso Lite [AMD LASERS]) (Figure 3) in order to create a proper gingival contour and to help make the pontic appear as though it were growing out of the gingiva. Intercoronal fiber (everStick C&B [GC America]) (Figure 4) would be used for the reinforcement of the bridge. The everStick C&B fiber differs from others in its construction. Instead of fiberglass fibers, everStick C&B is made up of thin glass fibers surrounded by a proprietary interpenetrating polymer network. This network gives everStick C&B its unique characteristics. The fiber can be used intercoronally or extracoronally, and it is also repairable if debonded or fractured. In addition, when the fiber is reduced or contoured by a bur, no threads or roughness remain, leaving the fiber material completely smooth and strong.

A gingival pontic button was created prior to restoration initiation in order to ensure a smooth interface between the pontic and gingiva. This was accomplished by placing a small mound of flowable composite resin (G-ænial Universal Flo [GC America]) on a Palodent Plus Sectional Matrix (Dentsply Sirona) and light-cured for 20 seconds. Next, this cured mound of flowable composite was removed from the sectional matrix and set aside (Figure 5).
Preparations were then made on the lingual surface of the abutment teeth with a round-ended tapered diamond bur (1847KR-016C [DENTSPLY Midwest]). Occlusion on the abutment teeth should be noted when creating these preparations in order to avoid opposing occlusion interfering with the margin of the prepared teeth (Figure 6). The depth of the preparation should also be deep enough to accommodate the fiber when cured in the preparation, usually 1.5 to 2 mm deep, and should extend into the interproximal area so that the fiber will be invisible from the buccal view when the restoration is complete. Then, after preparation of the adjacent abutment teeth, the fiber should be measured, cut, and prepared for placement.

Figure 5. Creation of the gingival pontic button with a flowable composite resin (G-ænial Universal Flo [GC America]) on a Palodent Plus Sectional Matrix (Dentsply Sirona) to ensure a smooth interface between the tissue and pontic. The button was placed on the gingiva during layering of material to create the pontic. Figure 6. Intercoronal preparation: red lines indicate where lingual receptor sites for fiber were to be created. The opposing occlusion was checked for function and any interferences.
Figure 7. To remove everStick C&B from silicone packaging, the adhesive paper layer on side where fiber is closest to the surface is removed. Grasp fiber with tweezers and pull out. Figure 8. Fiber in place and bowed to the buccal.
Figure 9. Reduced lingual excess material on abutments after placement of fiber. Figure 10. Placing flowable composite resin onto the lingual surface of the putty matrix (Sil-Tech [Ivoclar Vivadent]).
Figure 11. This photo shows the matrix almost in place. Once in place, light-cure it from the buccal. Figure 12. Lingual border immediately after the matrix is removed.
Figure 13. Pontic button placed and held in place with cured composite. The button is placed approximately one mm from each abutment tooth. Figure 14. Build-up pontic 1: The photo shows the G-ænial Sculpt shade AO1 (GC America) placed to mimic opaque dentin, then translucent shades were built up around the fiber.
Figure 15. Build-up pontic 2: Pontic was layered with G-ænial Sculpt composite in less translucent enamel body shades. Figure 16. The restoration was then shaped and polished.
Figure 17. The final outcome.

The everStick C&B fiber is encased in a silicone package. Prior to removing the fiber, cut the package to the length needed by measuring the approximate length of the fiber with dental floss. To remove the fiber from the silicone, simply remove the paper covering on the silicone closest to the fiber, hold the fiber with a cotton forceps, then pull out (Figure 7). When ready to place the fiber, fill the preparations with flowable composite. Position the fiber into the preparations and press and hold with an instrument. Do not worry if the fiber is longer than needed, as the ends can be trimmed with a bur (Figure 8). Once satisfied with the positioning of the fiber, light-cure for 20 seconds. While positioning the fiber, make sure the fiber is bowed in toward the buccal in the pontic area; this positioning gives the clinician the ability to properly contour both buccal and lingual aspects of the restoration. Once the everStick C&B fiber is cured, cut back the lingual portion of the preps to the lingual contour of the adjacent tooth (Figure 9).

Next, the incisal/lingual putty matrix is tried in to ensure a proper seat.

In order to establish the lingual border, place flowable composite into the lingual of the putty matrix and position the matrix, then light-cure it from the buccal for 20 seconds (Figures 10 to 12). Position the pontic button on the gingiva leaving approximately 1.0 mm of space between the 2 adjacent abutment teeth (Figure 13). Remove the putty matrix and begin building the buccal portion of the restoration starting from the pontic button to the everStick C&B fiber so that everything is held in place. Using a compactable universal high-density composite (G-ænial Sculpt [GC America]) with a layering technique, start with an opaque dentin shade AO1 against the lingual border to mimic natural dentin (Figure 14). On top of these opaque layers, you can put staining or different enamel (translucent) shades to mimic the natural color of the surrounding teeth. In Rachel’s case, A2 was used on the outer enamel surface. A translucent shade was placed in the incisal portion concurrently with the placement of the enamel shade in this buildup to enhance the slight incisal translucency of the natural teeth.

After buildup of the desired shades of composite, shaping of the restoration was accomplished with a pointed carbide finishing bur (379-109 [DENTSPLY Midwest]), a pointed egg-shaped carbide finishing bur (389514 [DENTSPLY Midwest]), and a pointed cone-diamond bur (1859012C [DENTSPLY Midwest]) and finishing discs (Enhance [Dentsply Sirona]). Because of the unique size and consistency of the microfillers in G-ænial Sculpt composite, the finish and polishability of this material is very easy, and it will maintain its luster with daily brushing. In addition to this, excellent handling and wearability also makes G-ænial Sculpt a perfect composite choice for this particular application.

Once completed, Rachel could not get over how the teeth appeared to be a natural part of her smile (Figures 15 to 17). She said, “No more short teeth that catch food underneath! No more hiding my smile and trying not to laugh. Best of all, I feel great about my smile, and more confident!”

CLOSING COMMENTS
The clinician should realize that direct anterior tooth replacement is far from a perfect solution. Often, aesthetics can be compromised due to the amount of space and also depending upon the patient’s occlusion. However, if executed properly with the materials and techniques, these restorations are a reliable, affordable, conservative, aesthetic mid-range solution for patients who are in a holding pattern due to orthodontic care, other dental treatment related reasons, or budget limitations.


Dr. Simos received his DDS at Chicago’s Loyola University. He is the founder and president of Allstar Smiles and the Allstar Smiles Learning Center. He teaches postgraduate courses to practicing dentists on cosmetic dentistry, occlusion, and comprehensive restorative dentistry through Allstar Smiles’ state-of-the-art learning center and client facility in Bolingbrook, Ill, and throughout the country. He is nationally recognized as a leader in cosmetic and restorative dentistry, promoting awareness, communication, and education within the dental profession, and is an internationally published author on the use of innovative techniques and materials in dentistry. He can be reached at (866) 614-8455 or via email at This email address is being protected from spambots. You need JavaScript enabled to view it..

Disclosure: Dr. Simos reports no disclosures.

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Techniques for Predictable Aesthetic Smile Designs

INTRODUCTION
Predictable aesthetics can mean many different things. One definition of predictable is that it is an accurate predetermination of an outcome. As dentists, we can become better at predicting outcomes by understanding risk management.1 Predictable is not the same thing as perfect. Predictable aesthetics does not always translate to perfect outcomes, but rather an end point that lacks surprises. Outside of dentistry, predictable is not always a good thing. For example, when we go to the movies, predictable is bad. For our aesthetic dentistry to not play out like a suspenseful film (with twists, surprises, and scary moments), there are protocols that can be implemented by the clinician to make dental treatments as predictable as possible. In order to finish a case with the outcome being a happy and satisfied patient, expectations must be very well understood from the beginning. One expectation that a clinician may have is that every patient is going to cry tears of joy when they look at their new teeth for the first time in the mirror (Figure 1). While this is not always the case, we can do a better job of controlling the patients’ expectations during treatments. Careful review of pretreatment images from a patient’s photographic series enables the practitioner and the patient to visualize areas of the smile that could use improvement, giving the patient choices for options that minimize risk factors.

When doing aesthetic dentistry, consultations utilizing detailed photographs enable the clinician to emphasize areas of the mouth and smile that will improve significantly with certain courses of action. If patients chose not to undergo those actions to make overall aesthetic improvements, then, at a minimum, they can fully understand where any compromises may exist in the final aesthetics of their smile or in the outlook for the success of the restorations. After reviewing a series of photographs and mounted study models (Figure 2), the clinician should make time to meet with the patient to discuss the steps necessary to get the smile looking as ideal as possible. Taking time to determine the ideal placement of the gingival margins on all patients (high, medium, or low smile-line?) will minimize patient concerns over final results.2 Addressing limiting issues before treatment begins is a better way to add predictability to patient approval at the end of treatment. The patient should be given the opportunity to refuse or pursue treatment to idealize the situation prior to beginning any restorative work. Remember that patient expectations change dramatically when the tooth we treat is in the aesthetic zone versus in the posterior. Often, a patient may be satisfied with an occlusal composite filling that does not match the tooth exactly in the posterior. However, they may be completely unsatisfied with a treatment done to an anterior tooth that may be within the standard of care but falls short from an aesthetic standpoint if it fails to follow the proper principles of smile design.

CASE REPORT
Diagnosis and Treatment Planning

A 52-year-old female patient presented with a chief complaint of wanting a nicer smile. This is something she had been thinking about for quite some time. The patient was in good overall health and had a history of regular dental visits. Her consultation revealed that she wanted brighter teeth and a more youthful smile. She stated that some cosmetic dentistry had been done more than 10 years ago to help make her upper central incisors look straight before her wedding. The dentist improved her smile using direct composite veneers.

Figure 1. Patients can have unrealistic expectations; doctors can too, thinking that the patient will cry tears of joy when they see their new smile for the first time. Figure 2. Pre-aesthetic visualization should include well-taken digital photos, study models, and a checklist to review before discussing the case with the patient.

A photographic series was taken of the patient at the first appointment in the photo studio. Then, the images were reviewed with her in the consultation room on a large, wall-mounted, flat-screen television. Evaluating the smile with her, while referencing principles of smile design, enabled the clinician and the patient to review all areas of immediate and potential concern (Figure 3). While the aesthetic issues were addressed in the consultation room using the photo series, other risk factors were identified and evaluated using a clinical exam which consisted of radiographs, clinical charting, and a temporomandibular joint exam.

The first step in treatment planning is determining the aesthetic end point, then the clinical exam will help determine the modality for achieving the desired results. Just like understanding what constitutes health when evaluating a patient for occlusal dysfunction, the dentist must understand what constitutes ideal aesthetics in order to provide suggestions for creating a more ideal smile. Treatment planning should start with the goal of making sure the anterior teeth are located in the correct position of the face. This can be accomplished by using incisal edge positions of the maxillary central incisors or maxillary canines with lip at rest.3

Figure 3. (a) Full-face and (b) smile images are a couple of many views used to discuss different aspects of the patient’s smile.
Figure 4. A lip at rest, or repose, is taken to help determine the ideal maxillary incisal edge position. The author utilizes photography and video to analyze the smile. (a) A picture is a static image in time, but (b) a video is more dynamic and can be paused during playback for careful observation.

Both pictures and videos of the patient are used to analyze principles of smile design to assist in finding the most relevant values (Figure 4).4 In evaluating this patient’s full-face-at-repose image, she was informed that the average amount of incisal display with lip at rest is 3.0 to 4.0 mm for a 30- to 40-year-old woman, but that this parameter is quite variable depending on age, lip length, and gender. It was decided that showing slightly more incisal edge was more ideal and in center of the bell curve.

In reviewing her retracted images, discrepancies in tooth proportions of her maxillary anterior teeth were noted (Figure 5). When the previously done aesthetic treatment had been completed to make the central incisors look straight, the width-to-height proportions (W/H) of the centrals had gotten too narrow. This is common when treating cases with crowding. A more ideal W/H proportion of the central incisor is 80%; and the lateral incisor should be about 60% of the width of the central incisor.5 A graphic drawing can relate the ideal proportions based on the width of the teeth from distal of canine to distal of canine. The technique used in digital smile design enables the clinician to determine proportions of anterior teeth when viewed from the front.6 The equation [y = 3.92x] can recreate a graphic drawing in any scenario to assist in finding proportions of central incisors, lateral incisors and canines, where y = (distance from distal of maxillary canine to distal of maxillary canine) and x = (new width of the central incisor) (Figure 6).

In this patient, the central incisors were about a 70% W/H ratio and the laterals were 90% of the width of the central incisors. This relationship creates a violation of a smile design principle that makes the patient appear to have 4 central incisors.7 Restoring or maintaining central dominance in the smile is paramount to aesthetic success.

Figure 5. When viewed from the front, the lateral incisors should be about 60% the width of the central incisors and the canines should be about 60% the width of the lateral incisors. Figure 6. A graphic drawing can relate the ideal proportions based on the width of the teeth, from distal of one canine to the distal of the other canine.
Figure 7. The necessary space would need to be created by directional preparation of the teeth toward the patient’s left side. The gingival zeniths must also be relocated slightly to the patient’s left.

The patient was also informed about the midline, plane of occlusion, incisal plane, buccal corridor, and color of her teeth. She had asymmetric gingival display that was hidden under the lip at full smile. The gingival margins were discussed with the patient and, together, we determined areas that could be improved by soft- or hard-tissue contouring and grafting. A referral was given to her for a periodontist with whom to consult for soft-tissue grafting of tooth No. 6 to make it more symmetrical with the gingival margin height of tooth No. 11. We also discussed some minor tissue contouring of teeth Nos. 9 and 10. The option for orthodontic treatment was also presented as a way to prerestoratively idealize the positions of the teeth. The patient immediately denied tooth-straightening options and also elected not to have the periodontal surgery.

A laboratory wax-up was ordered to represent a prototype of the final restorations. A wax-up serves as a valuable tool to indicate the preparation type and margin placement needed to complete the case. Additionally, communication with the dental laboratory team was facilitated with well-taken photos and videos; these communication tools allow the clinician to play a significant role in designing the case.

Figure 8. (a) A bis-acryl (Venus Temp 2 [Heraeus Kulzer]) mockup was done using a silicone impression matrix of the diagnostic wax-up (Sil-Tech [Ivoclar Vivadent]). (b) The mockup should be an accurate representation of the final product, before depth cuts are made to start the preparations.
Figure 9. In this case, the first set of provisionals lacked the wow factor. The proportions were more ideal and the color was brighter, but the smile could still be improved for the patient by making the teeth whiter, the shapes more accurate, and correcting the facial morphology and incisal canting. Figure 10. Nanohybrid composite (Venus Pearl Bleach Shade [Heraeus Kulzer]) was used as to directly veneer the anterior teeth in a brighter color, changing the shapes and correcting the cant.
Figure 11. (a) The patient returned for a postoperative appointment and digital photo series in the studio. (b and c) The patient was pleased with her new brighter smile and improved teeth proportions.

In order to correct the proportions of the anterior teeth, it was determined that this could not be treated as a conservative preparation smile design. Re­viewing the laboratory wax-up confirmed that the necessary space would need to be created by directional preparation of the teeth toward the patient’s left side (Figure 7). When complex preparation cases present themselves in our offices, the attention to details during the preparation appointment is even more important.

Clinical Protocol
A silicone impression matrix (Sil-Tech [Ivoclar Vivadent]) of the completed diagnostic wax-up was loaded with a bis-acryl provisional material (Venus Temp 2 [Heraeus Kulzer]) and then seated over the patient’s unprepared teeth; this was done after only removing enough enamel (enameloplasty) to properly seat the matrix over the teeth. The resulting bis-acryl overlay closely resembled the finished product of the provisionals and was prepared into using ideal depth cuts for the finished ceramics (Figure 8). When case preparation is more complex and requires direction preparation, the initial mockup may not provide the most ideal final provisional design; this is due to the need for more enameloplasty (or arch realignment) prior to placing the depth cuts. In such cases, the operator suggests doing a second mockup toward the end of the preparation stage of the appointment, prior to making a final impression. The second mockup can then be prepared into for ideal prep design similar to the first mockup. This provides a double check for the ideal reduction needed for cases that have any uncertainty prior to impressioning and provisionalization.

After the teeth were prepared, a final impression was taken using a vinyl polysiloxane impression material (Virtual [Ivoclar Vivadent]) and a preparation bite in silicone bite registration material (Futar D [Kettenbach LP]). Preparation shades were recorded for the laboratory using a preparation shade guide (IPS Natural Die Material Shade Guide [Ivoclar Vivadent]).

Once the records were completed, the provisionals were fabricated using a shrink-to-fit technique. The operator performs this technique as follows: the teeth were isolated (OptraGate [Ivoclar Vivadent]), then the preparations were cleaned with a 2% chlorhexidine gluconate disinfecting solution (Consepsis [Ultradent Products]). (In preparations where the operator breaks contacts, no “spot” etching is necessary to help retain the provisionals.) After the 2% chlorhexidine gluconate was rinsed and the teeth dried, a glutaraldehyde-containing desensitizer was scrubbed onto the teeth (GLUMA Desensitizer [Heraeus Kulzer]) for its desensitizing and bacterial static properties. Next, the desensitizer was suctioned off the tooth and blot dried, rather than blown onto the soft tissues. The preparations were then wet with a primer solution (OptiBond FL Primer [Kerr]). It is the author’s opinion that the primer helps to add some adhesion and adaptability of the bis-acryl to the preparations in the shrink-to-fit technique. The prepared teeth in the matrix were then filled with the correct color of bis-acryl material (Venus Temp 2, bleach shade) and seated over the teeth for 2 minutes. After 2 minutes, the matrix was removed and any bis-acryl flash cleaned away. Any voids were filled with a flowable composite resin (Venus Diamond Flow [Heraeus Kulzer]), light-cured, and the margins trimmed with a Safe End Needle Carbide (H134 ET6 014 [Brasseler USA]). The contact areas were then opened up with a mosquito diamond (8392.31.016, Fine Needle Mosquito Diamond [Brasseler USA]) and checked with floss threaders (Super Floss [Oral-B]) to confirm that the patient could carry out proper hygiene at home.

While the provisional design corrected the proportions of the anterior teeth in this case, there was a lack of wow factor. This was determined to have come from the patient’s desire for a brighter color, slight cant in the incisal plane, as well as some shape improvements that could be made to the existing provisionals (Figure 9). Rather than simply assuring our concerned patient that she would like the lab-fabricated ceramics and sending her home, she was brought back to the office for a contour session to directly add some composite and to contour the provisionals until a result that was more pleasing had been achieved. Nanohybrid composite (Venus Pearl [Heraeus Kulzer]) was added to the provisionals in a direct veneering method. This was performed without the need to etch or place adhesive to the bis-acryl material. We were able to create slightly more volume, brighten the color, and change the shapes (Figure 10). An impression was then taken of the approved provisionals for the laboratory team to follow closely as they created the restorations in all-ceramics.

The pressed lithium disilicate (IPS e.max [Ivoclar Vivadent]) restorations were created in a way to closely resemble the new provisionals, with only slight improvements detailed in the laboratory script. IPS e.max was chosen for its strength, aesthetics, and its optimized translucency. In the posterior, it is routinely chosen by the author due to its flexural strength (360 to 400 MPa) when fabricated as a full-contour monolithic restoration.8

At the cementation appointment, the provisionals were removed, the preparations cleaned, and the all-ceramic restorations were tried in to check the fit and contacts. Next, the aesthetics were evaluated using try-in pastes that resembled the final color of the restorations. Digital photos were taken in the studio before bonding in the restorations to allow the patient to see what the before and after would look like. It should be noted that the patient evaluation part of this process can take up to 45 minutes to ensure that there has been adequate time to see the restorations in the mouth and to address all of the patient’s concerns. The ceramics were bonded in with a light-cure resin cement (Variolink Esthetic LC [Ivoclar Vivadent]) utilizing the tack-and-wave technique. The excess cement was then removed, the occlusion adjusted, and the ceramics polished. In one week, the patient returned for a postoperative visit to address any remaining potential aesthetic concerns, check for any excess cement, finalize the occlusion, and to complete a post-op digital photo series in the studio (Figure 11).

CLOSING COMMENTS
While it is true that the clinician should not expect all patients to cry with happiness upon seeing their new smile in the mirror, we do have the ability to control patient expectations. This is done by first analyzing the principles of smile design with the patient and then thoroughly discussing any areas of limitation that may prevent us from achieving an ideal smile. Although surprises can sometimes be a good thing related to matters outside of dentistry, the patient and the entire dental team benefit from more predictable outcomes.


References

  1. Kois DE, Kois JC. Comprehensive risk-based diagnostically driven treatment planning: developing sequentially generated treatment. Dent Clin North Am. 2015;59:593-608.
  2. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51:24-28.
  3. Misch CE. Guidelines for maxillary incisal edge position—a pilot study: the key is the canine. J Prosthodont. 2008;17:130-134.
  4. Duchenne GB, Cuthbertson RA. The Mechanism of Human Facial Expression. New York, NY: Cambridge University Press; 1990.
  5. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics: Volume 1, Esthetic Analysis: A Systematic Approach to Prosthetic Treatment. London, England: Quintessence Publishing; 2004:21-56.
  6. Coachman C, Calamita M. Digital smile design: a tool for treatment planning and communication in esthetic dentistry. Quintessence Dent Technol. 2012;35:103-111.
  7. Olitsky J. Seven worst violations of smile design. Inside Dentistry. 2015;11:60-68.
  8. Guess PC, Zavanelli R, Silva N, et al. Mouth motion fatigue and durability study [executive summary]. June 20, 2009. ivoclarvivadent.us/emaxchangeseverything/durability-study/summary.php. Accessed April 8, 2016.

Dr. Olitsky, a 2001 graduate of Temple University School of Dentistry, maintains a private practice in Ponte Vedra Beach, Fla. He is past president of the Florida Academy of Cosmetic Dentistry and an accredited member of the American Academy of Cosmetic Dentistry. An accredited Digital Smile Design Master, he is director of aesthetics for Clinical Mastery Series, teaching portrait and clinical photography and live-patient anterior aesthetics courses. He is a clinical adjunct faculty with the Arizona School of Dentistry and Oral Health as well as a clinical consultant with THE DENTAL ADVISOR. He can be reached via email at This email address is being protected from spambots. You need JavaScript enabled to view it..

Disclosure: Dr. Olitsky reports no disclosures.



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