Treating the Amelogenesis Imperfecta Patient

INTRODUCTION
Amelogenesis imperfecta (AI) represents a group of inherited conditions that affect the structure and appearance of the enamel of all or nearly all the teeth, with a prevalence in the United States of approximately one in 14,000 people.1,2 The variable range of AI enamel defects involve abnormalities that are classified as hypoplastic (defect in quantity of enamel), hypomaturation (defect in final growth and development of enamel crystallites), and hypocalcified (defect in initial crystallite formation followed by impaired growth), with diagnosis traditionally determined by clinical presentation.2,3 Four main types of AI classifications exist and are based on the type of enamel defect; 14 unique subtypes exist and are based on clinical appearance and mode of inheritance.3,4

CASE REPORT
Diagnosis and Treatment Plan

Our 14-year-old patient presented with 2 major dental problems (Figure 1), AI as well as generalized severe wear.

This patient’s hypoplastic enamel contributed to the discolored appearance of her teeth and approximately 50% of tooth height had been lost due to the wear and defective enamel (Figures 2 and 3). Although there was no sensitivity with the wear, there was an obvious aesthetic deficit. The preoperative photos demonstrate how porous and stained the enamel was due to the AI. Our patient was self-conscious about the appearance of her teeth and desired a more attractive smile.

Figure 1. Frontal view at initial pre-op visit.
Figure 2. Retracted frontal and right and left lateral views of the malformed enamel due to amelogenesis imperfecta (AI), and also showing the severe wear (approximately 50% of tooth height).
Figure 3. Smiling view showing the classic look of enamel pitting due to AI.

Defective enamel was a functional, aesthetic, and psychological concern to address. The severe wear and subsequent passive eruption caused the entire maxillary ridge to supraerupt. A maxillary incisal edge discrepancy with the lower lip-line existed due to the outline of the flat maxillary incisal edges being horizontal and not having a rounded gull-wing shape and harmony with the lower lip-line.

Knowing that we needed to postpone final restoration until this patient had reached her growth potential, we decided to first begin by increasing restorative space. An initial gingivectomy followed by placing composite veneers (Renamel Microfill [Cosmedent]) on teeth Nos. 6 to 11 provided our patient with an immediate aesthetic improvement until definitive restorations could be placed to enhance her smile. After reaching her growth potential, we would proceed with crown lengthening, followed by preparation for 24 single-unit Captek (Argen Corporation) restorations.

Clinical Protocol: Definitive Restorative Treatment
She returned 6 years later, at age 20 years, ready for the definitive restorations (Figure 4). The composite restorations held up well during the previous 6 years, and now the time to restore her teeth had arrived.

Figure 4. The patient returned 6 years later at age 20, ready to have her teeth repaired.
Figure 5. Occlusal view of the maxillary arch demonstrates the effects of AI. Figure 6. Crown lengthening was done in the maxillary arch.
Figure 7. The 3-bite technique of capturing vertical dimension of occlusion and centric relation was utilized. This photo shows the third bite (O-BITE [DMG America]) taken with both posterior quadrants prepped. Figure 8. Maxillary and mandibular provisional restorations (Luxatemp [DMG America]) in place.
Figure 9. Twelve Captek (Argen Corporation) mandibular restorations on master model. Figure 10. Twelve Captek maxillary restorations on master model.
Figure 11. Lingual view of restorations mounted on the SAM 3 Articulator (Great Lakes Orthodontics).

In order to address the 50% loss in tooth height, crown lengthening was necessary. This allowed us to maintain her existing vertical dimension of occlusion (VDO) while achieving a more appropriate and aesthetic width-to-height ratio of the dentition, as captured with our initial diagnostic wax-up. Ideal width-to-height ratios of aesthetically perceived maxillary anterior teeth range from 75% to 80%.5 This ratio was considered in her smile design; however, the patient’s unique facial dimensions and characteristics and upper and lower lip positions ultimately dictated the width-to-height proportions.

As the teeth wear down and get shorter, due to an increased rate of attrition caused by AI, the passive eruption process brings the alveolar bone and gingival tissue in an incisal direction, as seen in Figure 4. Elongation of the dento-alveolar process matched the lost VDO of the abraded teeth.6 The dimension from a fixed bony landmark to the occlusal surface remains constant with severe wear, but the measurement from a fixed bony landmark to the cemento-enamel junction increases.7 The occlusal view demonstrates the effects of AI on the integrity of the enamel and the incisal and occlusal surface wear (Figure 5).

To obtain the desired gingival architecture, crown lengthening was done on the maxillary teeth Nos. 2 to 15 and tooth No. 23 (Figure 6). Due to the linguoversion of No. 23, the restorative margin required an apical placement that would have impeded biologic width if crown lengthening was not performed. The periodontist was provided with a translucent surgical stent fabricated from the diagnostic wax-up to locate the gingival zeniths.

Following preparation of teeth Nos. 2 to 15 for full-coverage crowns with a tapered round-ended diamond (No. 112-5161 [Henry Schein]), mandibular preparation began using the same bur. Part of the preparation of the mandibular arch involved a gingivectomy on tooth No. 23 to establish a more balanced gingival zenith. In preparing the mandibular incisors, our first objective was to create a uniform and smooth arch form. The lingual aspect of each incisor was reduced until we created an even curve, then the facial aspect was reduced and the preparations completed. The following 3 aids can be used when preparing teeth: (1) a clear thermoplastic stent (UltraVac [Ultradent Products]), which allows the clinician to see the entire aspect of each prep—sometimes small holes can be made in the stent to allow a periodontal probe to measure the depth of the preparation; (2) an incisal edge putty matrix (Sil-Tech Putty [Ivoclar Vivadent]), which allows the clinician to see how much incisal reduction has been made; while (3) the prep guide fabricated from the same material is used to evaluate facial reduction. We utilized the 3-bite technique of capturing VDO and centric relation. Using this technique, the anterior teeth were prepared first and a closed bite was taken utilizing O-BITE (DMG America) bite registration material. Next, each of the remaining posterior quadrants were prepped, one at a time, and the anterior bite registration material was placed back onto the anterior teeth while obtaining a bite on each side, one side at a time (Figure 7).

Figure 12. (a) Facial view and (b) right and (c) left lateral views of the restored worn dentition.

A thermoplastic stent (UltraVac) was made to use in fabrication of the provisional restorations based upon the model of the diagnostic wax-up of the mandibular teeth. Figure 8 shows both the maxillary and mandibular provisional restorations (Luxatemp [DMG America]) in place. The Luxatemp provisional material was simply placed into the tray and then inserted over the preps. After the material hardened, the stent and Luxatemp were removed, trimmed, and the bite adjusted.

All 12 mandibular restorations are Captek crowns (Figure 9). These crowns were designed to have facial collars of porcelain for aesthetics and an exposed gold collar on the medial, distal, and lingual surfaces slightly below the gingiva to achieve optimal periodontal health. The high noble gold content of the copings demonstrates a bacteriostatic nature that is beneficial in reducing bacteria and aiding in periodontal health. The posterior restorations were designed similarly to the anterior restorations.

The case was mounted on a SAM 3 articulator (Great Lakes Orthodontics) using 3 separate bites to capture centric relation at her given vertical dimension. The facial view of the finished Captek restorations mounted on the SAM 3 Articulator can be seen in Figures 9 and 10. Figure 11 shows the porcelain butt margins on the lingual of the molars and premolars. We consider this area to be the most overlooked aesthetic zone in the mouth. All too often, a thick gold collar is placed on this lingual area and can easily be seen; however, the lingual gold collars on the anterior teeth are not visible. Figure 11 shows the margin design of the porcelain lingual butt margins on the posterior teeth and lingual gold collar on the anterior teeth. The restorations were bonded into position using the 4th generation bonding system, OptiBond FL (Kerr) and Calibra Esthetic Resin Cement (Dentsply Sirona).

Figure 13. Preoperative photo. Figure 14. Postoperative photo our very pleased patient.

The treatment outlined was effective in restoring the defective worn dentition, and in creating natural color and shape to her teeth (Figure 12). Although these restorations had only been in place for one month, the gingival tissue looked much improved. The pre-op and post-op photos (Figures 13 and 14) demonstrate how the natural smile can be restored even in the presence of amelogenesis imperfecta, extreme wear, and elongation of the dento-alveolar process.

CLOSING COMMENTS
In this case, all of our efforts were aimed at restoring proper tooth form, function, color, as well as gingiva-osseous contours. After a multidisciplinary treatment plan consisting of numerous appointments during an extended period of time, we were able to accomplish our goals and to exceed our patient’s aesthetic expectations.


References

  1. Aldred MJ, Savarirayan R, Crawford PJ. Amelogenesis imperfecta: a classification and catalogue for the 21st century. Oral Dis. 2003;9:19-23.
  2. Witkop CJ, Sauk JJ. Heritable defects of enamel. In: Stewart RE, Prescott GH, eds. Oral Facial Genetics. St. Louis, MO: Mosby; 1976:151-226.
  3. Witkop CJ Jr. Amelogenesis imperfecta, dentinogenesis imperfecta and dentin dysplasia revisited: problems in classification. J Oral Pathol. 1988;17:547-553.
  4. Wright JT. The diagnosis and treatment of dentinogenesis imperfecta and amelogenesis imperfecta. Hellenic Dentistry Journal. 1992;2:17-24.
  5. Cooper GE, Tredwin CJ, Cooper NT, et al. The influence of maxillary central incisor height-to-width ratio on perceived smile aesthetics. Br Dent J. 2012;212:589-599.
  6. Dawson PE. Functional Occlusion: From TMJ to Smile Design. 3rd ed. London, England: Elsevier Health Sciences; 2007.
  7. Crothers A, Sandham A. Vertical height differences in subjects with severe dental wear. Eur J Orthod. 1993;15:519-525.

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 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. Dr. Wynne has published numerous articles on aesthetic dentistry, occlusion, and eating disorders. He can be reached at (919) 851-3716.

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 faculty 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..

Disclosure: The authors report no disclosures.

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Creating a More Youthful Appearance: Multidisciplinary Treatment Planning

INTRODUCTION
If Ponce de Leon failed to discover the fountain of youth, it was not for a lack of trying. Nor have people ceased in their quest throughout time to seach for ways to rejuvenate their appearance or “turn back the clock.” Today, many people are living longer lives and are therefore looking for ways to reverse the effects of aging and to improve their appearance. In these times, dentists play an important role in helping them to achieve their goals. Together with orthodontists, oral surgeons, periodontists, and plastic surgeons, restorative dentists can, through a coordinated multidisciplinary team approach, address many of the aesthetic issues that concern their patients.

According to Dr. Richard Erlichman, a member of the American Society for Aesthetic Plastic Surgery, statistics show that the number of cosmetic surgery patients older than age 65 years has grown more than 350% in the last 5 years. In another survey, of 5,053 American females 55 to 64 years of age, 85% said that they were unhappy with at least one body part. It is not surprising that—with the increasing role that social media plays, the information that is readily available on the Internet, the less invasive and more conservative nature of many procedures, and the marketing by healthcare professionals to the general public—the number of people requesting cosmetic enhancement continues to rise. Statistics show a 39% increase in cosmetic procedures during the last 5 years (2011 to 2015), with surgical procedures up 17% and nonsurgical procedures up 44%.1,2

As people age, there is often a disconnect with how they feel about themselves on the inside and with what they see in pictures of themselves or in the mirror. Frequently, an unattractive smile is one of the first things that they will notice. Conversely, an attractive smile can play a significant role in increasing self-confidence and self-esteem. An independent study3 conducted by the American Academy of Cosmetic Dentistry discovered the following:

  • 99.7% of people interviewed believed the smile is an important social asset.
  • 96% of adults believe that an attractive smile makes a person more appealing to members of the opposite sex.
  • 74% of adults feel an unattractive smile can hurt a person’s chances for career success.

And, in response to the question, “What would you most like to improve about your smile?” the most common answer given was, “Whiter, brighter, straighter teeth.”3

As is often the case with older patients, multiple procedures may be necessary to achieve the desired outcome; therefore, a multidisciplinary treatment approach is often indicated. That is why it is so beneficial for the restorative dentist to be part of an interdisciplinary team that can work together to satisfy the highest of patient expectations.

The following case report will illustrate how a coordinated multidisciplinary treatment plan was developed and executed to address a patient’s concerns and to achieve the desired outcome.

CASE REPORT
Diagnosis and Treatment Planning

A 62-year-old female was referred to the author for a restorative consultation by the orthodontist who was coordinating a multidisciplinary treatment plan. Previously, the patient had been referred to the orthodontist by another dentist for evaluation of her Class II malocclusion as well as other appearance-related concerns.

It is important in multidisciplinary cases that one member of the team assume the role of “quarterback” in order to ensure a well-designed treatment plan and to lead a coordinated effort. Just as the quarterback of a football team must see the whole field and understand everyone’s role, so must the interdisciplinary team quarterback. Furthermore, this dental quarterback must have an understanding and the working knowledge of what the other specialists do and how each professional’s role contributes to the success of the case. The other members of the team, in addition to the orthodontist and restorative dentist in this case, included an oral surgeon and facial plastic surgeon.

Figure 1. Pre-op full-face smiling.
Figure 2. Pre-op maxillary occlusal view. Figure 3. Pre-op mandibular occlusal view.
Figure 4. Pre-op profile, showing mandibular deficiency. Figure 5. Pre-op lateral ceph, showing Class II relationship and constricted airway space.
Figure 6. Pre-op smile, showing flat smile arc and insufficient incisor display. Figure 7. Pre-op retracted, showing unaesthetic tooth size, shape, and color.
Figure 8. Pre-op full-face, showing loss of skeletal support, drooping eyelids, deep nasolabial folds, and “marionette lines” (corner of the mouth to chin) and “jowling.”

The orthodontist, serving as the quarterback, had utilized digital imaging software to demonstrate choices to the patient with realistic outcomes, and after the patient had expressed an interest in proceeding, had begun to develop an overall treatment plan with input from the other team members.4,5 The agreed upon sequence of treatment was as follows:

  • Orthodontics to position the teeth for orthognathic surgery and aesthetic finishing (Figures 1 to 3).
  • Oral surgery to move the mandible forward in order to improve jaw relationship, soft-tissue support, and airway space (Figures 4 and 5).
  • Restorative dentistry to improve smile aesthetics (Figures 6 and 7).
  • Facial plastic surgery including a rhytidectomy (facelift), blepharoplasty (eyelids), lip augmentation, and a platysmal lift (neck) for facial rejuvenation (Figure 8).6

After completion of the orthognathic surgery and aesthetic tooth repositioning, the patient was ready to begin the restorative treatment (Figures 9 to 11).

At the consultation appointment for the restorative phase, the patient stated that she was unhappy with the appearance of her smile, specifically the shape and color of her teeth (Figures 12 to 14).

Figure 9. Orthognathic surgery and aesthetic tooth positioning completed. Figure 10. Maxillary occlusal view, post-orthodontic treatment.
Figure 11. Mandibular occlusal view, post-orthodontic treatment.
Figure 12. Patient ready for aesthetic finishing and facial plastic surgery.
Figure 13. Smile post-orthodontic treatment. Note the improved smile arc and incisor display. Figure 14. Retracted post-orthodontic treatment view, ready for restorative phase.

Like so many patients with worn and discolored teeth, she said that she wanted a whiter, brighter smile. This, once successfully completed along with the soft-tissue procedures, made her feel that she would then have a more youthful looking appearance. The patient, having already been prepared by the orthodontist as to what to expect,6 accepted the proposed treatment plan of 12 maxillary restorations (teeth Nos. 4 to 15) and 8 mandibular restorations (teeth Nos. 21 to 28), and the first appointment was set up to begin the restorative phase of treatment.

Clinical Protocol
At the first appointment, diagnostic information was gathered and forwarded to the dental laboratory team with instructions to fabricate a diagnostic wax-up, prep guides, and a putty matrix for provisional fabrication.

The patient returned 2 weeks later for the preparation appointment. Since there was an existing PFM bridge on teeth Nos. 13 to 15, and because tooth No. 13 was in the aesthetic zone, it was decided to include the bridge in the treatment plan. The restorative work would include: lithium disilicate crowns (IPS e.max Press [Ivoclar Vivadent]) on teeth Nos. 4, 5, 6, and 12; lithium disilicate (IPS e.max Press) veneers on teeth Nos. 7 to 11 and 22 to 27; lithium disilicate (IPS e.max Press) onlay veneers on teeth Nos. 21 and 28; and a zirconia bridge (IPS e.max ZirCad [Ivoclar Vivadent]) layered with a fluorapatite glass ceramic (IPS e.max ZirPress [Ivoclar Vivadent]) on teeth Nos. 13 to 15.

Figure 15. Full-face smile after restorative phase and plastic surgery.
Figure 16. Smile after aesthetic finishing. Figure 17. Retracted after aesthetic finishing.
Figure 18. The 1:1 photo of the completed maxillary restorations. Figure 19. The 1:1 photo of the completed mandibular restorations.
Figure 20. Postoperative profile showing improved jaw relationship and soft-tissue support. Figure 21. Lateral ceph, showing improved occlusion and an increase in airway space.
Figure 22. Full-face view after plastic surgery showing soft-tissue improvements in the eyes, face, lips, and neck. Figure 23. Final result. Combined effort equals happy patient.

Lithium disilicate is a proven and excellent restorative material due to its strength (400 MPa when pressed) and fracture toughness, aesthetics (especially when cut back and microlayered), and versatility. It can be used for veneers, thin veneers, onlays, crowns, anterior 3-unit bridges, and implant abutments, making it ideal for these types of cases when a variety of restorations are required.7

Before beginning tooth preparation, some minor gingival recontouring was done with a diode laser (Picasso Lite [AMD LASERS]) to create ideal gingival height symmetry. Before taking final impressions, this diode laser was also used for troughing of the soft tissues around the margins of the crown and bridge abutment teeth. After removing the PFM crowns on teeth Nos. 4, 5, 6, and 12; the PFM bridge on Nos. 13 to 15; and any existing old filling materials or recurrent decay; buildups were done using a universal adhesive (ALL-BOND UNIVERSAL [BISCO Dental Products]) in the self-etch mode and a flowable composite (BEAUTIFIL Flow Plus [Shofu Dental]); then the tooth preparations were completed. Next, teeth Nos. 7 to 11 and 22 to 27 were prepped for veneers, and teeth Nos. 21 and 28 were prepped for onlay veneers. Full-arch polyether impressions were taken (Impregum [3M]), and provisionals (Tuff Temp Plus [Pulpdent]) were fabricated using the putty matrix that had been previously provided by the dental laboratory team. Additionally, an occlusal record, stick bite, face-bow, preparation shades, central length measurement, and impressions of the provisionals were taken. This information was then forwarded to the laboratory team, along with a detailed written prescription requesting the materials and shades for the final restorations with instructions to follow the provisionals as a guide for size, shape, and contour. It is important to note that well-done provisionals are critical in smile design cases. This is because they serve as an important communication tool with the patient and, once approved, also give the laboratory a blueprint to follow.

The patient returned 2 days later for a postoperative evaluation to check the occlusion, to discuss the appearance of her smile (including the shade), and to make any changes, if required. After patient approval, photographs of the provisionals were taken and the files were emailed to the laboratory team along with the preoperative and prep shade photos.

The patient returned 3 weeks later for adhesive bonding of the lithium disilicate veneers and crowns, and for the conventional cementation of the layered zirconia bridge. The temporaries were removed and the teeth were cleaned with hydrogen peroxide and an antimicrobial rinse (Consepsis [Ul­tra­dent Products]) in preparation for bonding. All the restorations were tried in to evaluate fit and contacts. Then, after cleaning the intaglio surfaces with a universal cleaner (Ivoclean [Ivoclar Vivadent]) (per the manufacturer’s instructions) to remove any contaminants, the lithium disilicate veneers and crowns were silanated (PORCELAIN PRIMER [BISCO Dental Products]) and set aside, organized by tooth number. The layered zirconia bridge (teeth Nos. 13 to 15) was cemented first using a bioceramic cement (Ceramir [Doxa]) so that the remaining teeth could be isolated with a rubber dam for the adhesive bonding of the lithium disilicate restorations. After isolation, the teeth were prepared for adhesive bonding utilizing a total-etch technique with a universal adhesive (ALL BOND UNIVERSAL) and a light-cure resin cement (eCement Kit [BISCO Dental Products]) for the veneers, and a self-etch technique with the same universal adhesive and a dual-cure resin cement (eCement Kit) for the crowns. Next, the process, with the rubber dam placed, was repeated in the mandibular arch using the total-etch technique and a universal adhesive, and a light-cure resin cement for the veneers (Nos. 22 to 27) and dual-cure resin cement for the onlay veneers (Nos. 21 and 28). After cleanup was done, the occlusion was checked and adjusted with the aid of a digital occlusal analysis system (T-Scan [Tekscan]) and then the restorations were polished with rubber points (Ceramiste [Shofu Dental]).

With the restorative dentistry completed, the patient was ready to begin the facial soft-tissue procedures as the final phase of the multidisciplinary treatment plan.

After sufficient time for postsurgical healing, the patient returned for postoperative photos and stated that she was extremely happy with the results, felt more confident in social settings, and loved hearing from friends and family that she looked younger (Figures 15 to 19).

CLOSING COMMENTS
Cosmetic dental procedures have gained a wide acceptance throughout the years for creating results that can often significantly improve self-confidence and self-esteem. In many cases, conservative dental treatment is all that is needed to achieve the desired goals, but sometimes more extensive procedures with a multidisciplinary approach might be required. That is why it is beneficial for the restorative dentist to have access to, or be part of, an interdisciplinary team that can work together to coordinate complex treatment plans.

This case serves to demonstrate how a well-designed multidisciplinary treatment plan can seamlessly allow members of the team to meet the desired objectives and satisfy patient expectations (Figures 20 to 23).

Acknowledgment
The author would like to thank ceramist Gary Vaughn, CDT (Corr Dental Laboratory in Roseville, Calif), for his great work and attention to detail. The author would also like to recognize the outstanding contributions of the other interdisciplinary team members of this case: Dr. David Sarver, orthodontist; Dr. Jon Holmes, oral surgeon; and Dr. Daniel Russo, facial plastic surgeon.


References

  1. Cosmetic Surgery National Data Bank Statistics. New York, NY: American Society for Aesthetic Plastic Surgery; 2015. surgery.org/sites/default/files/ASAPS-Stats2015.pdf. Accessed July 12, 2016.
  2. Plastic Surgery Statistics Report. Arlington Heights, IL: American Society of Plastic Surgeons; 2015. plasticsurgery.org/Documents/news-resources/statistics/2015-statistics/2015-plastic-surgery-statistics-report.pdf. Accessed July 12, 2016.
  3. Cosmetic Dentistry Statistics. Madison, WI: American Academy of Cosmetic Dentistry Scientific Survey; 2009.
  4. Sarver DM. Orthodontics and esthetic dentistry: mission possible! Journal of Cosmetic Dentistry. 2016;31:14-26.
  5. Sarver DM. Soft-tissue-based diagnosis and treatment planning. Clinical Impressions. 2005;14:21-26.
  6. Pessa JE. The potential role of stereolithography in the study of facial aging. Am J Orthod Dentofacial Orthop. 2001;119:117-120.
  7. Tysowsky GW. The science behind lithium disilicate: a metal-free alternative. Dent Today. 2009;28:112-113.

Dr. Dudney is a 1977 graduate of University of Alabama at Birmingham School of Dentistry. He is a member of the ADA, the Alabama Dental Association, and the American Academy of Cosmetic Dentistry. He is also an accredited member of the American Society for Dental Aesthetics and a Diplomate of the American Board of Aesthetic Dentistry. He has served in the past as the clinical director for the Aesthetic Advantage hands-on programs taught by Dr. Larry Rosenthal at New York University and the Eastman Dental Clinic in London, UK, as well as the clinical director for the California Center for Advanced Dental Studies live-patient hands-on programs taught in the United States, Canada, and the United Kingdom. Presently, he is the clinical director for the newly formed Pacific Aesthetic Continuum hands-on programs. In addition to teaching hands-on programs, he has presented workshops and lectures at dental meetings and has authored several articles on aesthetic and restorative dentistry. He can be reached via email at This email address is being protected from spambots. You need JavaScript enabled to view it. or via the website thomasdudney.com.

Disclosure: Dr. Dudney reports no disclosures.

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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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