In the July 1997 issue of Dentistry Today, I presented 2 cases that were outside the usual parameters of everyday dental treatment planning. This article illustrates how these 2 unusual restorative cases have held up throughout 2 decades after they were completed.
In the fall of 1985, a 25-year-old newly graduated attorney presented himself for a second opinion or, in this case, a third or fourth opinion. His appearance was marred by 2 tiny deciduous maxillary canines and 2 fractured upper incisors (the left central and the right lateral). His teeth appeared small and square (Figure 1). Several dentists, who had previously been consulted, agreed upon what was a traditional treatment plan at that time: extract the deciduous canines and make a full-coverage, 8-unit, ceramo-metal bridge, extending to the first bicuspids on each side. The patient and his family found this plan somewhat unsettling, invasive, and expensive.
I had successfully placed porcelain laminates since 1982, and my treatment plan called for an alternative approach. I recommended gingivoplasty, followed by 6 porcelain laminates only on the centrals, laterals, and canines after the preparation of those teeth.
|Figure 1. (Case 1) Original appearance of 25-year-old patient: deciduous canines and a fractured central and lateral.|
|Figure 2. Six upper anteriors prepared for porcelain laminates.||Figure 3. Six porcelain laminates were seated.|
Informed consent, while always important, was critical in this case for 2 reasons: the patient was an attorney, and we were planning to restore deciduous teeth. This would affect the crown-root ratio, and a great deal of lengthening was necessary with at least 4 or 5 mm of porcelain. I explained that in my experience, deciduous canines without permanent successors in place would probably remain in his mouth for another 25 years. Therefore, I proposed rehabilitating his smile with 6 porcelain laminates. However, I cautioned that it was necessary to dramatically increase the length of the canines, thereby increasing the crown-root ratio and consequently placing more torque on the roots. Therefore, to be fair, if the canines came out within the first 2 years, I would credit his fee toward a fixed bridge. The patient accepted the treatment as proposed.
|Figure 4. Dr. Weller and the patient at a presentation during the 1985 Greater New York Dental Meeting.|
At that time, I prepared the teeth at 0.5 mm reduction on the labial and 1.0 mm on the incisal. No incisal reduction was required on the fractured central and lateral, or the deciduous canines, except for the elimination of any sharp corners or edges (Figure 2). If I were to treat that case now, I would leave the incisal edge of the intact central untouched as I did in the following case.
On November 23, 1985, the 6 porcelain laminates were placed with ALL-BOND 2 (BISCO Dental Products) adhesive and CHOICE (BISCO Dental Products) light-cured veneer cement after the enamel was acid-etched (UNI-ETCH [BISCO Dental Products]) (Figure 3). The patient experienced an immediate improvement in personality and self-confidence and came to the Greater New York Dental Meeting to show off his smile when I presented his case (Figure 4). As I mentioned in the 1987 article, he went on to become a successful lawyer and is the happily married father of 3 children.
|Figure 5. Upper left deciduous canine exfoliated 25 years and 2 months after laminate placement.||Figure 6. Thommen implant placed (Thommen Medical).|
|Figure 7. Fixture level impression coping.||Figure 8. Exfoliated deciduous canine.|
|Figure 9. Crown of exfoliated canine with laminate intact bonded in place for emergency temporization.||Figure 10. Closeup of IPS e.max screw-retained crown (Ivoclar Vivadent) implant-supported restoration.|
The patient was seen at regular intervals. Throughout time, there was some gingival recession; however, the laminates remained in place. On January 19, 2011—25 years and 2 months after placement of the restorations—the patient presented with the upper left deciduous canine finally out of his mouth after a period of mobility (Figure 5). The upper right deciduous canine was still present with no mobility, and there was no radiographic evidence of any root resorption. A Thommen implant (Thommen Medical) was placed (Figure 6). The patient firmly insisted he had no need for temporization. After an interval to allow for osseointegration, the healing cap was unscrewed and a fixture level impression coping was placed (Figure 7). A full-arch impression was made, and a full-arch bite record (Aluwax [Aluwax Dental Products]) was taken. At this point, a business opportunity for him required an immediate temporary restoration in a 2-day time frame. The patient was instructed to come to the office with his exfoliated tooth. The laminate on the exfoliated deciduous canine was still firmly bonded in place (Figure 8), providing us with a shortcut to temporization. The root was cut off the exfoliated deciduous canine. Then, the mesial and distal porcelain, as well as the distal porcelain on the lateral, were etched (PORCELAIN ETCHANT [BISCO Dental Products]). The mesial enamel of tooth No. 12 was etched (SELECT HV ETCH [BISCO Dental Products]), and the deciduous canine crown (with the laminate still bonded to it) was luted in place using an adhesive (ONE-STEP PLUS [BISCO Dental Products]) and a flowable composite (AELITEFLO [BISCO Dental Products]). The occlusion was adjusted to minimize occlusal force on the tooth, serving as a temporary pontic (Figure 9). When the laboratory case was completed, the temporary was carefully removed and a screw-retained crown (IPS e.max [Ivoclar Vivadent]) was then placed (Figure 10). The upper right deciduous canine remains with no mobility.
Rita presented with diastemas in the maxillary anterior segment, and right and left peg laterals (Figure 11). She was 15 in the spring of 1990 when she visited my office with a plea: “Please give me a new smile with 6 porcelain laminates, like you did for my mother a few years ago.”
|Figure 11. (Case 2) Pre-op photo of the patient at age 15.||Figure 12. After periodontal surgery.|
|Figure 13. Composite resin was applied for a cosmetic preview.||Figure 14. Pencil marked depth cuts.|
|Figure 15. Completed preparations with incisal edges of centrals untouched.|
|Figure 16. Conventional preparation with incisal wrap.||Figure 17. Recommended preparation when existing incisal edge is in ideal position and condition.|
I explained that, if she waited at least 3 or 4 years, her gums would undergo a natural reduction as passive eruption took place, and that laminates placed at age 15 would not enhance her smile 4 years later when much more tooth structure was exposed. She continued to ask for treatment. “Please,” she pleaded, “my social life is starting and my heart is breaking.” I called Rita’s parents to arrange a consultation and presented what, at the time, seemed like a rather unconventional treatment plan for a 15-year-old. I told her parents that the only way to ensure a long-lasting smile makeover result would be to first send their daughter to the periodontist for gum and bone surgery. To their credit, her parents agreed.
Before she went to summer camp, the late and long respected periodontist, Dr. Joseph Franzetti, performed the surgery as I requested so that the gingival margins after healing were at the cemento-enamel junction. She looked better immediately after the surgery, which effectively eliminated her gummy smile look (Figure 12).
When she returned from camp, and before school started, I placed some composite resin to get an idea how the new smile would look (Figure 13). At that point, I decided that, although her parents had accepted my original treatment plan of 6 veneers, her smile would be great by doing just 4 laminates. In light of her young age, I chose to leave the canines untouched.
Although our initial porcelain laminate preparation for anterior teeth called for 1.0 mm incisal reduction, I decided to leave the incisal edges of the centrals untouched, reducing the labial surfaces at 0.5 mm. My decision was influenced by the observation of incisal wear on lower anterior teeth that opposed upper porcelain restorations. In addition, I noted that the patient’s central incisal edges were in a perfect position for her smile and they had beautiful incisal halos. The right peg lateral was tiny, so the preparation for that tooth featured minimal reduction on the labial and proximal surfaces with some incisal reduction. In this way, the final restoration would resemble a three quarter crown. The left lateral was prepared with 0.5 mm labial reduction and 1.0 mm incisal reduction.
|Figures 18a and 18b. Newly placed laminates.|
|Figure 19. Post-op photo at 23 years. (No gingival recession noted.)|
As I noted in my article in 1997, I routinely used Lasco depth limiting diamonds to start my preparations and, before further preparation, I would use a thin pencil point to mark the bottom of my depth cuts as an aid in managing the minimal reduction (Figure 14). The final preparations with no incisal reduction of the centrals can be seen in Figure 15.
I have been preparing anterior teeth in selected cases without incisal reduction for at least 23 years without one case of incisal chipping/separation. This is contrary to the common belief in the profession that an incisal wrap is indispensable for a durable result. I realize now that the reason for this success can be seen in Figure 15. It is obvious that we have a large band of enamel on the labial surface across the entire incisal portion of the preparation that would have been removed in the traditional preparation (Figure 16). This provides a more secure bond between porcelain and enamel than if the incisal edge was reduced. When the incisal edge is in an ideal position and intact, I prefer this preparation (Figure 17).
Before the school term started, her new smile was bonded in with adhesive (ALL-BOND 2) and (CHOICE) after etching the enamel (UNI-ETCH) (Figure 18).
The amazing aspect of this case is that 23 years after periodontal soft-tissue and osseous surgery, there has been absolutely no gingival recession around the laminates (Figure 19).
Grateful acknowledgement is given to Adrian Jurim, MDT, of the Jurim Porcelain Studio for more than 30 years of porcelain artistry.
Disclosure: Dr. Weller has consulted for many dental companies and laboratories. He received support from BISCO Dental Products for lectures and for this article.