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| Figure 1. The patient’s smile before treatment. |
CASE REPORT
Diagnosis and Treatment Planning
This case involves a young woman who wanted to improve the appearance of her smile. Radiographic and clinical examination revealed no active periodontal disease. She had a Class I occlusion with anterior crowding in maxillary and mandibular arches. There was incisal wear on the central incisors in both arches. There were some well-placed composite resin restorations at the disto-occlusal of the right first premolar, the mesio-occlusal-distal of the left first premolar, and the mesio-inciso-lingual of the right canine. Slight proximal decay existed at the mesial and distal of all 4 maxillary incisors. There was a Class V abfraction lesion on the facial of the right canine. The patient’s oral hygiene was good.
I photographed her smile and teeth so that she and I could evaluate them together. My treatment coordinator entered the photographs into a file, and the images were displayed on a computer screen in front of me and the patient. Her smile, as she presented, is shown in Figure 1. The retracted facial view can be seen in Figure 2, the maxillary incisal view is shown in Figure 3, and the mandibular incisal view can be seen in Figure 4.
As we looked at the images together, the patient stated that her goal was to have the appearance of properly aligned anterior teeth that were lighter in color. While she knew that orthodontic treatment would be the most conservative approach, she was more interested in having porcelain restorations placed for their immediate results and predictable shade. A combination of all-ceramic veneers and crowns were chosen as the treatment for the 8 maxillary anterior teeth.
CLINICAL PROTOCOL
Preoperative impressions were taken with a vinyl polysiloxane (VPS) alginate substitute impression material (Silginat [Kettenbach LP]). A centric relation (CR) bite registration was taken (Futar [Kettenbach LP]) as well as a face-bow record (Denar Slidematic Facebow [Whip Mix]). These records were sent to the dental laboratory team, and a diagnostic wax-up was created using the pre-op models. A putty impression of the completed wax-up (Panasil Lab Putty [Kettenbach LP]) was made for the chairside fabrication of the provisionals required after preparation of the teeth. A duplicate hard model of the diagnostic wax-up was fabricated, and a clear vacuum-formed stint was made over the model to serve as preparation guide.
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| Figure 2. The retracted facial view before treatment. | Figure 3. The maxillary incisal view before treatment. |
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| Figure 4. The mandibular incisal view before treatment. | Figure 5. The retracted facial view of the prepared teeth. |
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| Figure 6. The incisal/occlusal view of the prepared teeth. | Figure 7. Lithium disilicate (IPS e.max [Ivoclar Vivadent]) restorations on a mirror surface. |
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| Figure 8. The facial view of the Inman Aligner at delivery. | Figure 9. The incisal view of the Inman Aligner at delivery. |
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| Figure 10. The incisal view of the aligned teeth. | Figure 11. A stent for retainer wire placement. |
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| Figure 12. The retainer wire in place. | Figure 13. The incisal/occlusal view of the finished result. |
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| Figure 14. The retracted facial view of the final result. | Figure 15. The new smile. |
Preparation
At the following appointment, the 8 maxillary teeth were prepared for lithium disilicate all-ceramic restorations (IPS e.max [Ivoclar Vivadent]). The preparations included the areas of caries and previous composite restorations. Margins were prepared on the facial, at the height of the tissue, with a definitive chamfer. Facial and lingual preparation design was determined by the arch form developed in the diagnostic wax-up. The prep guide, previously made by the lab team from a stone model of the wax-up, was placed over the prepared teeth to verify the prep design and for proper reduction. The completed preparations can be seen in Figures 5 and 6. After completion of the preparations, a diode laser (Picasso [AMD LASERS]) was used for tissue contouring and hemostasis.
Impressions
An occlusal registration was taken (Futar). Next, Panasil A-Silicone Extra Light (Kettenbach LP) was injected around the margins at the gingival of each tooth while the assistant mixed the Panasil A-Silicone Putty (Kettenbach LP) and placed it in a full-arch maxillary tray. Then the tray was inserted and held in place for 5 minutes before removing it.
Prototypes
Provisional restorations were fabricated using a multifunctional acrylic composite material (Visalys Temp [Kettenbach LP]). The self-curing material was injected into the putty provisional stint (made earlier by the lab team using the diagnostic wax-up) and placed over the prepared teeth. The material was allowed to set completely before the stint was removed. Excess temporary material around the margins was removed using a small carbide finishing bur (#ET 3 [Brasseler USA]), and the occlusion was adjusted using a football-shaped carbide finishing bur (#7408 [Brasseler USA]). The provisional surfaces were polished with an Enhance Cup (Dentsply Sirona). It is important to note that these temporary restorations serve as the prototypes for the final all-ceramic replacements and that well-done provisionals are an absolute must in aesthetic cases since they are a vital communication tool between the clinician, the patient, and the dental laboratory team.
The patient was given a Philips Sonicare toothbrush and Oxyfresh toothpaste, mouthwash, and tissue gel. She was instructed to become an oral care “fanatic” with these for the next 2 weeks and to continue to use them after the final restorations were placed.
Dental Laboratory Fabrication
The final impressions and bite registration, along with (1) pre-op photographs, (2) images of the prepared teeth, and (3) provisional restorations in place, were sent to the dental laboratory team (daVinci Studios, West Hills, Calif). The stump shade (B1) and the desired final restoration shade (OM2 from the VITA 3D shade guide) were noted on the lab prescription. A photograph of the shade tabs in front of the prepared teeth was also included. The lab team was directed to fabricate lithium disilicate (IPS e.max) restorations for the maxillary 8 anterior teeth. The fabricated restorations can be seen photographed on a mirror surface in Figure 7.
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| Figure 16. The happy and grateful patient. |
Placement Appointment
At the delivery appointment, the provisional restorations were removed and the lithium disilicate restorations were tried in and approved. The internal etched surfaces of the restorations were thoroughly cleaned (Ivoclean [Ivoclar Vivadent]) and then rinsed and dried. Silane Porcelain Primer (BISCO Dental Products) was then painted onto the intaglio surfaces and allowed to dwell there for 30 seconds before being dried with oil- and water-free air from an air/water syringe. Next, the prepared tooth surfaces were treated with etching gel (Uni-Etch [BISCO Dental Products]) for 10 seconds, thoroughly rinsed, and lightly air-dried. A seventh-generation bonding agent (All-Bond Universal [BISCO Dental Products]) was applied liberally to each prepared tooth surface, air-thinned, and cured with an LED curing light (Bluephase 16i [Ivoclar Vivadent]) for 10 seconds. Next, a dual-cure luting composite resin cement (eCEMENT [BISCO Dental Products]) was placed in the restorations, which were then seated. In the gel state, the excess cement was teased away from the margins of the restorations using an explorer. Dental floss was also gently worked into the interproximal areas to remove any unset cement there. After most of the excess cement had been removed, the LED curing light was used to ensure the surface cure of the cement by exposing it to 20 seconds of light. Any set excess composite cement was removed by using small carbide finishing burs. The occlusion was then checked using articulating paper (Bausch Articulating Papers 200 µm). Adjustments were made using a fine diamond bur (# DOS1F FG Fine Football Diamond 379F.31.023 [Brasseler USA]) and then smoothed with a finer diamond bur (# DOS1EF FG Extra-Fine Football Diamond 379EF.31.023 [Brassler USA]), followed by a 30 fluted finishing carbide bur (# OS1UF FG Football Ultra-Fine 30 Blade White Carbide H379UF.31.023 [Brasseler USA]). This series provides a smooth surface, but 3 more steps with porcelain polishing points (W16DG.21 Dialite Blue Point Porcelain Polisher, W16DM.21 Dialite Pink Porcelain Polisher, and W16D.21 Dialite Gray Point Porcelain Polisher [Brasseler USA]) allow for a smooth and glossy appearance and feel.
Mandibular Alignment
The patient was very happy with her new smile, but now noticed the mandibular anterior crowded teeth even more. She chose to continue treatment by having them straightened with a device called the Inman Aligner. The Inman Aligner, invented by Don Inman of Inman Orthodontic Laboratory, is a removable appliance that can be used for the correction of protrusion or crowding of anterior teeth with 3.0 mm of crowding or less. The majority of patients can have their work completed in just 6 to 18 weeks. NiTi coil springs power 2 aligner bows that oppose each other—one on the facial and one on the lingual. This appliance works so quickly because the gentle forces are active over a large range of movement. During office visits every 2 weeks, minor interproximal reduction (IPR) is done using diamond-coated strips, and composite buttons are added as needed. After accomplishing proper tooth position, removable or fixed retention is required.
Inman Aligner Fabrication, Clinical Protocol, and Final Outcome
A maxillary full-arch impression (Silginat alginate substitute) and a mandibular full-arch VPS impression (Panasil monophase Medium [Kettenbach LP]) were taken. An occlusal registration was taken with the Futar bite registration material. The impressions and bite registration were then sent to the Inman Orthodontic Laboratory. They poured the impressions, digitally designed the aligner, and fabricated a printed acrylic model. Then the lab team returned the aligner, printed model, and hard models, along with a prescription for interproximal reduction and directions for button placement.
In Figure 8, you can see the Inman Aligner in place from the facial view. The incisal view at delivery is shown in Figure 9. The patient returned every 2 weeks for IPR; this was accomplished using diamond-coated strips (Gateway Strips [Brasseler USA]) of various grits as prescribed by the lab team. Button placement on the hard model, as marked by the lab team, was also completed. The patient wore the aligner at least 16 hours per day, removing it a minimum of 4 hours per day. After 10 weeks, the teeth were aligned as shown in Figure 10. The patient chose a fixed wire retainer, so an impression was taken and sent to the lab team for fabrication of a stent with a wire retainer (Figure 11). The wire retainer was bonded to place using a flowable composite resin (Estelite Flow Quick [Tokuyama]) (Figure 12).
Figure 13 shows the occlusal view of the IPS e.max restorations bonded into place. Some occlusal adjustment was needed for the lingual area of the maxillary right canine after mandibular tooth alignment. The adjusted area was sealed with composite resin. The facial retracted view is shown in Figure 14. Figure 15 shows the patient’s new smile. A full-face view (Figure 16) shows a happy and grateful patient.
CONCLUSION
By using a combination of ceramic restorations and anterior tooth alignment, we were able to provide the patient with the smile she desired.
Acknowledgment
The author would like to thank daVinci Studios in West Hills, Calif, for its work on this case.
Dr. Nash maintains a private practice in Huntersville, NC, where he focuses on aesthetic and cosmetic dental treatment. An accredited Fellow in the American Academy of Cosmetic Dentistry and a Diplomate for the American Board of Dental Aesthetics, he lectures internationally on subjects in aesthetic dentistry and has authored chapters in 2 dental textbooks. He is co-founder of the Nash Institute for Dental Learning in Huntersville and is a consultant for numerous dental product manufacturers. He can be reached at (704) 895-7660, via email at rosswnashdds@aol.com, or via the website thenashinstitute.com.
Disclosure: Dr. Nash reports no disclosures.
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