INTRODUCTION
Developments in cosmetic dentistry now enable us to help patients achieve beautiful smiles that can mimic and sometimes even improve upon Mother Nature’s work. There continues to be strong demand for cosmetic dentistry and increased patient awareness of the possibilities.
A complete examination is required to determine the treatment options available. Then, a thorough discussion with the patient of the findings and treatment options, along with the proper informed consent, is carried out before beginning any clinical procedures. Considerations include the patient’s goals, oral health status, risk factors or oral disease, prevention needs, home care, and nonclinical factors such as the patient’s financial and scheduling constraints.
When extensive restorative rehabilitation is indicated, the pros and cons of the various options must be carefully weighed with the patient’s goals in mind. Implants and bridges offer long-term success for tooth replacement, and endodontic therapy also has a high success rate. Partial dentures are still also considered an option. All-ceramic dental materials have played a major role in treatment successes involving the anterior smile zone. High-strength (500 MPa) lithium disilicate (all-ceramic) restorations, used for the clinical case described in this article, match the aesthetic characteristics of natural teeth closely,1 and are among the most aesthetic restorations currently available in dentistry.
CASE REPORT
Diagnosis and Treatment Planning
Our patient, a 24-year-old female, had been referred to us for cosmetic and restorative rehabilitation requiring a staged, multidisciplinary approach to meet her treatment needs and desired aesthetic outcomes. She had grown up in a non-fluoridated community where her dental care was limited, and she had arrived in the United States as an exchange student 11 years previously. A combination of factors including finances and time had prevented her from focusing on her dental needs. Only recently had she been able to start focusing on these. Her chief complaint was her smile that included misaligned, broken, and chipped teeth. She desired a more pleasing smile that would allow her to enjoy the company of friends and family “without the worry of how my teeth look.” The patient was a healthy adult with no known medical conditions, allergies, or contraindications to treatment.
A comprehensive examination was performed, including appropriate radiographs and clinical images in line with current recommendations. The patient presented with multiple defective restorations, missing teeth, and malocclusion. Her anterior restorations were discolored, poorly contoured, exhibited poor marginal integrity and recurrent caries, and impinged on the interdental papillae (Figures 1 to 3). Tooth No. 7 was protruded and had previously received endodontic treatment, a post-and-core, and a composite resin restoration. Its prognosis was poor due to recurrent caries. Tooth No. 14 had extensive caries, discoloration, and was fractured, while tooth No. 19 had received endodontic treatment and exhibited recurrent caries. Teeth Nos. 29 and 30 had previously been extracted, and teeth Nos. 31 and 32 had tipped in the intervening years (Figures 4 to 6). Tooth No. 16 was impacted, while the other wisdom teeth had erupted and were asymptomatic. Despite the presence of defective restorations and overhangs, the patient had managed to maintain relatively good oral hygiene. She presented with a deep bite, no soft-tissue lesions, and no temporomandibular joint pain, clicking, or popping.
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| Figure 1. Frontal preoperative smile. | Figure 2. Pre-op frontal view, retracted smile. |
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| Figure 3. Pre-op frontal view, anterior segment. | Figure 4. Pre-op occlusal view, maxillary arch. |
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| Figure 5. Pre-op occlusal view, mandibular arch. | Figure 6. Pre-op retracted right lateral view. |
The examination findings and all treatment options were discussed with the patient. She indicated that, above all else, she wanted aesthetic enhancements that included bigger anterior teeth and a fuller smile. Her preference and goals were to treat carious teeth, restore and aesthetically enhance the maxillary teeth, receive regular care with the dental hygienist, and to improve her oral hygiene. She indicated that she wanted to delay other treatment (such as implants and orthodontic treatment to upright tooth No. 31) until a later time when finances permitted. Informed consent was obtained for the near-term treatment plan.
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| Figure 7a. Oral-B Genius (Oral-B) power brush. | Figure 7b. Smartphone app showing length of brushing time. |
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| Figure 8. Gingival revision and provisionals. | Figure 9. Post-op retracted smile. |
Aesthetic rehabilitation would include crown lengthening of the upper anterior teeth to proportionally enlarge their clinical crowns and reduce gingival display,2 extraction of tooth No. 7 with ridge augmentation and connective tissue grafting, fabrication of indirect restorations, direct veneers, and placement of posterior composite restorations. Since she had extensive caries on all anterior teeth, and considering all factors, it made the most sense to place a bridge to replace the extracted lateral incisor. In-office and at-home whitening were also recommended and accepted. The patient would additionally have endodontic treatment on tooth No. 10, extraction of teeth Nos. 14 and 19 by an oral surgeon as they had extensive deep recurrent caries and were considered unsalvageable, and a consultation regarding the future extraction of her third molars, which currently posed no significant concern.
Clinical Protocol
The first step was to help the patient establish a proper home care routine. We typically recommend that our patients use 0.4% stabilized stannous fluoride toothpaste (Crest Pro-Health [Procter & Gamble]) and an oscillating-rotating power toothbrush. The oscillating-rotating brush is clinically proven to be superior to a manual brush,3 it’s easy to use, and we have witnessed great patient results. With the introduction of an intuitive and intelligent oscillating-rotating brush (Oral-B Genius [Oral-B]) there are additional benefits, including a Bluetooth-enabled feedback mechanism that lets patients know if they are brushing long enough, missing any areas, or using too much pressure (Figure 7). Our patients like these features and have told us that they feel their brushing technique has improved.
Due to a history of caries, and to help prevent future recurrent caries, it was also recommended that this patient use a daily fluoride rinse along with a paste containing casein phosphopeptide-amorphous calcium phosphate (MI Paste Plus [GC America]). Studies have shown the benefits of using fluoride rinses on a daily basis, as well as the paste, in patients at risk for caries.4,5
To begin the restorative process, diagnostic models, bite records, and facial analyzer information were collected and used
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| Figure 10a. Post-op frontal view, anterior segment. | Figure 10b. Post-op radiograph of teeth Nos. 6 to 8 fixed partial denture. |
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| Figure 10c. Right lateral view of lithium disilicate bridge (IPS e.max CAD [Ivoclar Vivadent]). | Figure 10d. Left lateral view of lithium disilicate (IPS e.max Press [Ivoclar Vivadent]) crowns. |
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| Figure 10e. Occlusal view maxillary arch. |
to communicate with the laboratory on our goals and for the cosmetic wax-up. The ideal wax-up along with a clear surgical guide and a putty matrix (Sil-Tec putty matrix [Ivoclar Vivadent]) for reduction and temporization chairside were requested of the lab. A laboratory-fabricated temporary for teeth Nos. 6 to 11 with an ovate pontic at the site of tooth No. 7 was also requested. A referral to a periodontist for consultation and treatment was necessary to help coordinate the extraction of tooth No. 7, tissue grafting, and aesthetic crown lengthening of the anterior teeth. Throughout this patient’s treatment, our communication with the periodontist was vital, and the clear surgical guide duplicating the ideal smile goal was used by the periodontist during the aesthetic crown-lengthening procedure.
Treatment began with shade selection for the anterior restorations by documenting the shade guide tabs against the hydrated dentition before preparation. This provided the laboratory team with valuable information in addition to the written instructions. Topical and buffered local anesthetic (Onset [Onpharma]) was administered, caries were removed from the anterior teeth (except for tooth No. 7, which was planned for extraction), and the teeth were prepped for full-coverage crowns using a diamond bur. Using a chairside anesthetic buffering system reduces injection pain, increases the effectiveness of the anesthetic, and hastens the onset of anesthesia.6 The putty matrix reduction guide helped to ensure that the preparations allowed for proper occlusion and the clearance needed for the crowns and bridgework. During all restorative treatment, isolation (Isodry System [Isolite Systems]) was used to help retract the tongue and provide suction, keep the clinical site dry, protect the patient’s airway, and keep her jaws at rest. The temporization process for this initial phase was not to the new ideal length, as tooth No. 7 still remained. The temporaries were seated with TempBond Clear (Kerr) so that the periodontist could easily remove them. Tooth No. 10 was endodontically treated using a rotary endodontic system (Elements Obturation Unit [Kerr] and EndoTouch TC2 [Kerr]) and filled with traditional gutta-percha. A translucent fiber/resin post (ParaPost Fiber Lux, size 3 [Coltene]) was placed along with a dual-cure, glass-reinforced composite buildup (ParaCore [Coltene]), then the tooth was re-prepped and temporized.
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| Figure 11. Smile design criteria guide (American Academy of Cosmetic Dentistry). |
Next, the patient visited the periodontist for atraumatic extraction of tooth No. 7 together with ridge augmentation and connective tissue grafting. Aesthetic crown lengthening was also done in the anterior sextant with the aid of the clear matrix guide. We had incorporated tissue augmentation to optimize the contours and aesthetic end result, as this has been shown to reduce dimensional changes in alveolar bone following tooth extraction.7 Treatment was coordinated so that the patient would return to our office immediately post-surgery, at which time the custom-fabricated provisional for the anterior sextant was seated using a polycarboxylate cement (Durelon [3M]). The provisional included an ovate pontic at the extraction site which was critical for proper healing and soft-tissue contouring. Tissue healing was then monitored weekly by the periodontist for a period of 6 weeks. Due to the patient’s thin biotype, the soft-tissue response at teeth Nos. 8 to 11 necessitated revision surgery to properly establish the facial biologic width and correct tissue form (Figure 8).
A further healing period of at least 6 weeks was required. The patient complied with home care and routine hygiene visits. During the healing phase, the planned posterior composite resin restorations were completed in one visit for the upper and lower right quadrants, and on a second visit for the contralateral quadrants. Deeper preparations were lined with Pulpdent Cavity Liner (Pulpdent), and then all were etched. A desensitizer with 4% chlorhexidine (Hemaseal & Cide [Advantage Dental]) was placed to help prevent postoperative sensitivity, followed by primer and a universal adhesive (ALL-BOND 3 [BISCO Dental Products]). The restorations were completed using a nanohybrid resin composite (shade B1) (Beautifil II [Shofu Dental]).
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| Figure 12a. Pre-op frontal full-face photo. | Figure 12b. Post-op frontal full-face photo. |
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| Figure 12c. Post-op close-up photo. |
After healing and establishment of the new gingival contours, the patient returned for the final restorative phases. Digital images were taken of the matching stump shade tabs before administering topical and buffered local anesthetic (Onset). The provisionals were then sectioned and removed. The preparations were refined using a diamond bur and smoothed with a fine diamond. The clear matrix and putty matrix reduction guides were used to recheck the occlusal clearance and that the shape of the diagnostic wax-up would allow for proper porcelain contours and aesthetic requirements. A double-retraction cord (Knit-Pak+ [Premier Dental Products]) was placed delicately in the sulcus of the prepped teeth, and the outer retraction cord removed immediately prior to taking the vinyl polysiloxane (VPS) (Alginate Alternative [Henry Schein]) final impression. A new lower full-arch impression and bite registration (Luxatemp Automix Plus [DMG America]) were also taken. After affirming that all details had been captured, the putty matrix of the diagnostic wax-up was used to fabricate new provisional restorations that were carefully trimmed to maintain optimal gingival health during temporization and refined to closely represent the final restoration. The provisionals were seated with TempBond Clear.
Lithium disilicate (IPS e.max Press [Ivoclar Vivadent]) was selected for the all-ceramic restorations, as this material provides excellent aesthetics, proven high strength (500 MPa), and long-term durability. The patient, assistant, and doctor all agreed on a blend of shade B1/04. Youthful contours were requested along with facial anatomy that would reflect the patient’s young age. Photographs and study models were taken, and accompanying complete instructions were sent to the laboratory team. Upon delivery of the completed IPS e.max Press restorations from the lab, the anterior restorations were evaluated on the model for contacts, size, contours, and alignment.
When the patient presented for placement of her definitive restorations, the topical and buffered local anesthetic were administered and the restorations were tried in and checked. Next, the restorations were shown to the patient in both natural and office light for her approval before being cemented. It is recommended that, whenever possible, these high-strength lithium disilicate restorations be adhesively bonded/cemented. In this case, a universal primer (Monobond Plus [Ivoclar Vivadent]) was applied and dried (as directed) to the intaglio surfaces of the restorations; these restorations were then placed using a self-etch, self-adhesive resin cement (Maxcem Elite [Kerr]). Excess cement was removed after tack-curing (VALO curing light [Ultradent Products]), using an explorer and scaler. Then floss and interproximal strips were used to remove any remaining pieces of cement between the contact areas. The cement was then light-cured along the margins from the facial and lingual aspects of the teeth for an additional 5 seconds. Any remaining excess cement was removed using a thin-tipped diamond bur ET-9 (Brasseler USA) the occlusion was checked and any adjustments needed were made with a fine football diamond before using porcelain polishing discs and pastes to polish these areas (Figure 9).8
Two weeks later, the patient returned for direct composite veneers on teeth Nos. 4, 5, 12, and 13. No local anesthesia was required. The teeth were etched, rinsed, dried, and primed before placing a layer of adhesive resin (ALL-BOND 3). The nanohybrid resin composite (shade B1) (Beautifil II) was placed and cured sequentially for each veneer, then sculpted and contoured using a carbide bur (ET-9) before finishing and polishing the veneers with discs, finishing strips, and rubber cups. Lastly, the restorations were polished with a composite polishing paste (Enamelize [COSMEDENT]) before rechecking the occlusion and taking radiographs (Figure 10).9 Impressions were taken of the patient’s lower arch for fabrication of a soft occlusal nightguard (Essix Nightguard Laminate [DENTSPLY Raintree Essix]). At the 2-week post-treatment evaluation, the soft occlusal guard was delivered, and postoperative images were taken. The patient was instructed to wear the occlusal guard at night to protect her dentition.
CLOSING COMMENTS
Completion of the maxillary restorations allowed the patient to achieve the long-awaited aesthetic result she so desired. The metal-free aesthetics and durability of the lithium disilicate restorations gave her a natural, lifelike, and beautiful smile. In turn, the bonded veneers filled the buccal corridors. Increasing the size of her teeth proportionally had enhanced her overall smile and gave her renewed self-confidence. Replacing a missing tooth in the anterior segment with a bridge can be difficult; however, the aesthetic outcome can be excellent when performed by clinicians knowledgeable about smile design principles and cosmetic dentistry. The American Academy of Cosmetic Dentistry’s guide on Contemporary Concepts in Smile Design (Figure 11) is an invaluable resource to understanding the parameters of smile design and the criteria to measure and guide our design process.10 The communication and treatment planning among the restorative doctor, lab technicians, and any specialists involved is also important so that the entire team understands the desired outcome. In addition, ridge augmentation is a valuable periodontal plastic surgery method in the treatment of ridge defects, and the remaining anterior teeth were incorporated at the same time to allow the smile to blend and be proportional during the healing phase. It is also vital to know that the quality of provisional restorations, used throughout the course of treatment and healing, have a huge impact on the result (Figure 8).
As shown in the before (Figure 12a) and after images (Figures 12b and 12c), the change was dramatic. Our patient was more than thrilled with her natural-looking restorations, and her new brighter/fuller and harmonious smile. Five years later, our patient is still delighted with the results and is now ready to invest in her long-term treatment goals, including implant-retained restorations at extraction sites and clear aligner orthodontic treatment (Invisalign [Align Technology]). Her oral hygiene and soft-tissue health continue to be excellent, and the result is a beautiful smile that can be maintained and preserved.
Acknowledgment
The author would like to thank periodontist Dr. Alan Rosenfeld of Oakbrook Terrace, Ill; and laboratory ceramist, Hal Jones, and his team at Summit Lab (Waco, Tex) for their work on this patient’s case.
References
1. Christensen GJ. Zirconia vs. lithium disilicate. Dent Econ. 2014;104:22.
2. Ittipuriphat I, Leevailoj C. Anterior space management: interdisciplinary concepts. J Esthet Restor Dent. 2013;25:16-30.
3. Yaacob M, Worthington HV, Deacon SA, et al. Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev. 2014;6:CD002281.
4. Jenson L, Budenz AW, Featherstone JD, et al. Clinical protocols for caries management by risk assessment. J Calif Dent Assoc. 2007;35:714-723.
5. Gupta N, Mohan Marya C, Nagpal R, et al. A review of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and enamel remineralization. Compend Contin Educ Dent. 2016;37:36-39.
6. Clinical evaluation: Onset (2013 PPL). The Dental Advisor. January/February 2013. dentaladvisor.com/evaluations/onset-2013-ppl. Accessed December 22, 2016.
7. Jambhekar S, Kernen F, Bidra AS. Clinical and histologic outcomes of socket grafting after flapless tooth extraction: a systematic review of randomized controlled clinical trials. J Prosthet Dent. 2015;113:371-382.
8. Smallwood T. Clinical Mastery: Comprehensive Aesthetic Program—Preparation, Cementation. Chicago, IL: Manus Institute; 2009.
9. Willhite C. Freehand composite bonding: the ultimate esthetics course [lecture/workshop]. Presented at: Center for Esthetic Excellence; March 16-17, 2007; Chicago, IL.
10. Finlay S. American Academy of Cosmetic Dentistry (AACD). Contemporary Concepts in Smile Design: Diagnosis and Treatment Evaluation in Comprehensive Cosmetic Dentistry. 2nd ed. Madison, WI: AACD; 2014. aacd.com/guides. Accessed on December 22, 2016.
Dr. Gibson graduated from Boston’s Tufts School of Dental Medicine (1995) as a Merit Scholarship recipient. She practices general dentistry as the owner of Smiles by Dr. Gibson of Promenade Dental in Naperville, Ill. She is an accredited member and president of the American Academy of Cosmetic Dentistry (AACD), a Fellow of the International Academy for Dental Facial Esthetics, and an adjunct instructor at Tufts University School of Dental Medicine in the department of prosthodontics and operative dentistry. She was the president of the Chicago Midwest Academy of Cosmetic Dentistry, an affiliate of the AACD. She can be reached at drchianngibson@gmail.com or the website drchi.org.
Disclosure: Dr. Gibson reports no disclosures.
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