Minimizing Patient Visits During a Pandemic: Demonstration of a Combination-Technique Protocol

During this COVID-19 pandemic, it’s important to approach cosmetic dentistry using innovative methods. Because we must minimize the potential spread of the coronavirus in dental offices, it’s important to minimize the number of patients being seen daily. Decreasing the number of patients each day is good practice for both our patients and our dental treatment teams. Therefore, it makes sense to schedule multiple procedures within the same appointment, or as few appointments as possible, when possible. In this article, a case report is presented that outlines how cosmetic techniques and laser dentistry were used in combination, and at the same appointment, to obtain an optimal, long-term outcome.

CASE REPORT
Diagnosis and Treatment Planning
A 46-year-old female presented in general good health. The patient no longer liked her smile as it had become aged and worn over time (Figure 1). The patient had orthodontic treatment as a teenager to correct missing upper lateral incisors; the canines were moved into the lateral incisor position to compensate for the congenitally missing lateral incisors. This approach to orthodontic treatment was quite common in the 1980s. However, as we know now, this was not the best solution from the perspectives of aesthetics and occlusion. Now the patient wanted to have her smile corrected so that it would appear “more normal” and natural.

First, a diagnostic workup was completed. This included a comprehensive oral exam, a periodontal exam, an aesthetic dental analysis, a facial analysis, and a full-mouth radiographic series. In addition, a comprehensive occlusal analysis was done to determine how to integrate the cosmetic dentistry needed into her current malocclusion issues.¹ The patient stated that she was not interested in having any orthodontic treatment and wanted to correct her dental problems with cosmetic restorative methods. In addition, her right canine (tooth No. 6) was severely darkened, but upon evaluation, it was determined that it did not require endo­dontic treatment (Figure 2).

After mounting diagnostic models on a semi-adjustable articulator (Denar [Whip Mix]), a diagnostic wax-up was done in the dental laboratory. It was important to do this since the teeth shapes, sizes, and proportions would be drastically changed into a new aesthetic smile design. To meet her desired aesthetic outcome, the teeth display and contours would need to be addressed. In addition, her gingival display would need to be optimized via a minimally invasive (MI) gingival surgical correction.²

Combined Veneer Preparation and MI Laser Correction
MI methods for gingival surgical correction can be done using laser-assisted dentistry. With an understanding of the dento-gingival complex, predictable healing of gingival tissue can be attained with MI surgical procedures.^3,4 Using the state of the art in laser dentistry, we are able to make soft- and hard-tissue corrections using a closed-flap technique.

Aesthetic crown lengthening procedures exhibit a higher degree of precision when done using lasers.⁵ Depending on the type of tissue needing to be modified, different lasers are able to achieve predictable corrections. In the case of this smile makeover, gingival tissue and alveolar crestal bone needed to be removed to design a new gingival margin outline and dento-gingival complex. Using the Er,Cr:YSSG laser (Waterlase [BIOLASE]), an Okuda Closed-Flap Surgical Procedure was done to remove both hard and soft tissue to re-establish the new position of the dento-gingival complex (Figure 3).^6-8 Use of the Er,Cr:YSSG laser results in minimal to no bleeding, less wound contraction, and less pain in comparison to using a scalpel.⁹ It is important to note that the clinician must understand the diagnostic criteria, treatment planning process, and biologic parameters involved in order to attain predictable outcomes when using these laser techniques in the aesthetic zone.

By understanding the biologic parameters of healing, we are able to establish the restorative margin location in advance at the time of the surgery. In addition, we predictably know how gingival tissue healing will take place based on our understanding of altering gingival levels.^3,4,10

Combining MI Veneer Preps and an Internal Masking Procedure
At the same appointment, after altering gingival tissue for optimal aesthetics to the new gingival margin position, MI porcelain veneer preparations were done on teeth Nos. 4 to 13. Using a diamond depth-cut bur (Porcelain Veneer Kit [Komet USA]), approximately 0.5 mm of enamel was removed on all teeth except tooth No. 6. Because of the dark shade of tooth No. 6, and for the aesthetic technique that the ceramist needed to use to correct the shade challenge, a 0.7-mm depth-cut bur was used to create a slightly deeper preparation (Figure 4).

To create a natural result, a modified subopaqueing procedure needed to be done to mask out the dark internal shade. Without this sub-opaquer, an opaque lining would need to be used in the porcelain veneer to mask this dark internal shade of this tooth. Fabricating opaque porcelain veneers reduces the natural coloration and depth of shade of the veneer as it doesn’t allow natural light to penetrate the underlying tooth structure.¹¹ Opaquers in porcelain veneers create a harsh, deadened, unnatural appearance.

After tooth preparation for tooth No. 6 was done using the 0.7-mm depth-cutting bur, an additional 0.3-mm preparation was done along the facio-axial surface to create additional space for the subopaquing procedure (Dr. Okuda Minimal Invasive Dark Tooth kit [Komet USA]) (Figure 5). Using the latest generation of dentin adhesives (All-Bond Universal [BISCO Dental Products]), a strong adhesive bond was created along the area where the internal mask would be placed. Then an opacious dentin composite resin (G-ænial Injectable Flo AO-2 [GC America]) was sculpted to the facio-axial surface to internally mask the dark stump shade of tooth.^6,12,13 Using this technologically advanced nano-hybrid composite resin to neutralize the dark internal tooth shade has been found to be a viable long-term solution (Figure 6).11,13 The opacious dentin shades are very dense in color pigmentation, so they have an appearance similar to natural dentin. With 0.3 mm of thickness of this material, the clinician is able to effectively mask the darkened tooth discoloration. Because these composites have excellent depth of shade, there is good, natural color blending with teeth.^12,13 By increasing the value and neutralizing the dark internal shade, a non-opaque veneer can be fabricated, resulting in a natural appearance.

Next, the preparations were finished and marginated with tapered chamfer diamond burs (850.FG.014 [Komet USA]). Whenever possible, it is good to leave enamel intact for optimal porcelain-to-tooth bonding. This helps increase the long-term success of bonded porcelain restorations.

Final Impressions and Provisionals
Since we can predict where the gingival tissue will heal prior to the actual healing process, final impressions (Impregum [3M]) were done on the same day as the laser surgery. A rigid bite registration (Blu-Mousse [Parkell]) was taken to accurately mount the case in the proper occlusal relationship. In addition, a face-bow measurement (Denar Slidematic Facebow [Whip Mix]) and internal shades of the prepped teeth were taken. The internal shades are particularly important because the ceramist needs to see the value and shade of all the underlying teeth preparations in order to neutralize the varying internal shades and to have the final external coloration result appear uniform. Based on the wax-up, the prototype veneers (TurboTemp 3 [Zest Dental Solutions]) were hand-sculpted. The temporary prototypes were designed to support healing of the gingival tissues, meet the aesthetic expectations of the patient, and satisfy the requirements for a proper occlusion (Figure 7).

Meeting the patient’s aesthetic expectations is particularly important as the success of the case always needs to meet the patient’s desired vision. In comparison to using computer software, artistic time was spent with this patient blending the correct contours, proportions, and colors to maximize her facial balance and facial aesthetics.¹⁴ Hand-sculpting techniques were used to accentuate the contours of her temporary prototypes to match her personality, lip curvature, and unique facial features (Figure 8).

Delivery of the Final Restorations
Along with the lab prescription, a customized color map and texture map were sent so the ceramist could artistically create layered feldspathic porcelain veneers (Figure 9). After receiving the restorations from the laboratory team, an initial evaluation of the porcelain veneers was done. Then the temporary prototypes were removed and the surfaces were cleaned with a plain flour of pumice slurry using an ICB rotary brush (ICB Brush [Ultradent Products]). Optimal gingival tissue healing was seen as a result of performing the Okuda Closed-Flap Surgical technique using the Waterlase (Er,Cr:YSSG) laser (Figure 10). To reduce gingival crevicular fluid contamination, a thin gingival cord (4-0 suture cord [Patterson Dental]) was gently placed. The veneers were first checked with different try-in pastes from the porcelain veneer cementation kit (Choice 2 [BISCO Dental Products]). The veneers were evaluated for fit, accurate margins, and proximal contacts. The external coloration was scrutinized carefully to be sure it would have a uniform shade. The try-in pastes (Choice 2 try-in pastes) are the same coloration as the final light-cure luting cement resins. Next, the porcelain restorations were cleaned and prepared using a ceramic etchant. Then a silane coupling agent (Bis-Silane [BISCO Dental Products]) was applied to the intaglio surfaces per the manufacturer’s instructions. After air drying, a thin layer of bonding resin (Porcelain Bonding Resin [BISCO Dental Products]) was placed along the intaglio surface of the veneers to optimize the adhesive strength.¹⁵ To seat the veneers, a Rapid Seat Technique was used. To improve access, visibility, and efficiency, an OptraGate (Ivoclar Vivadent) was placed. Once again, a slurry of plain flour pumice was used with an ICB brush for the final cleansing of the prepared, prepped surfaces. Next, chlorhexidine digluconate (Cavity Cleanser [BISCO Dental Products]) was used as an initial disinfectant. A 32% phosphoric acid (Select HV with BAC [BISCO Dental Products]) was placed on enamel using a select-etch technique for 20 to 30 seconds, then thoroughly rinsed with water. A desensitizer (MicroPrime G [Zest Dental Solutions]) was swabbed for 20 seconds prior to placing the dental adhesive (All-Bond Universal). Several layers of this adhesive were placed, blown thin with a dedicated oil- and water-free air source (A-dec tooth dryer), and then light-cured (Bluephase Style [Ivoclar Vivadent]) (Figure 11). Using the rapid seat technique, all 8 porcelain veneers were loaded with a light-cured luting resin (Choice 2 Translucent [BISCO Dental Products]), then placed, positioned, and tack-cured for 2 seconds (Figure 12). Gentle flossing was done through all the proximal contacts, and then all the veneers were light-cured over all surfaces. After the final light-curing, all sides of the margins of the veneers were finished using a curved scalpel blade (No. 12 Bard-Parker [Aspen Surgical]). Then the margins were finished using carbide finishing burs (H50A.FG.010 and 8379.FG.012 [Komet USA]) (Figure 13). Finally, a Diamond Ceramic Polishing Kit (4533C.RA [Komet USA]) and polishing paste (micro-diamond polishing paste [Ultradent Products]) were used to create a final, beautiful luster (Figures 14 and 15).

IN SUMMARY
This article demonstrates how combining clinical techniques can help doctors decrease the number of patient appointments during the COVID-19 pandemic. In this case, by combining multiple procedures—such as the porcelain veneer preparation with the perio-plastic surgical procedures—the number of appointments were minimized. In addition, by scheduling longer appointments, one can reduce the number of daily patient exposures, thus further reducing the risk of contagion to the clinical treatment team.

Acknowledgment:
The author wishes to thank Boca Bella Dental Studios of Culver City, Calif, for creating the exquisite porcelain veneers for this case.

References

1. Chiche GJ, Kokich VG, Caudill R. Diagnosis and treatment planning of esthetic problems. In: Chiche GJ, Pinault A, eds. Esthetics of Anterior Fixed Prosthodontics. Quintessence Publishing; 1994:35-52.
2. Okuda W. Smile design 2.0: evolving from our past to be successful in treating the modern cosmetic patient. Gen Dent. 2016;64:10-13.
3. Kois JC. Altering gingival levels: the restorative connection part 1: biologic variables. J Esthet Dent. 1994;6:3-9.
4. Kois JC. The restorative-periodontal interface: biological parameters. Periodontol 2000. 1996;11:29-38.
5. Lee E. Laser-assisted crown lengthening procedures in the esthetic zone: contemporary guidelines and techniques. Contemporary Esthetics. March 2007:35225626.
6. Dyer BL. Minimally invasive osseous crown-lengthening procedure using an erbium laser: clinical case and procedure report. Journal of Cosmetic Dentistry. 2008;23:84-91.
7. McGuire MK, Scheyer ET. Laser-assisted flapless crown lengthening: a case series. Int J Periodontics Restorative Dent. 2011,31:357-364.
8. Premjith PS, Shetty S, Shetty D, et al. Laser assisted crown lengthening—a multidisciplinary approach: a review. International Journal of Sciences and Applied Research. 2017;4:1-7.
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10. Okuda WH. An innovative approach to complex cosmetic dentistry. Dent Today. 2018;37:70-73.
11. Nixon RL. Masking severely tetracycline-stained teeth with ceramic laminate veneers. Pract Periodontics Aesthet Dent. 1996;8:227-235.
12. Okuda WH. Using a modified subopaquing technique to treat highly discolored dentition. J Am Dent Assoc. 2000;131:945-950.
13. Okuda WH. Minimal invasive correction of the darkened anterior tooth. Gen Dent. 2013;61:18-20.
14. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132:39-45.
15. Suh BI. Principles of Adhesion Dentistry: A Theoretical and Clinical Guide for Dentists. Aegis Publications; 2013:99-117.

Dr. Okuda is the past national president (2002 to 2003) and an Accredited Fellow of the American Academy of Cosmetic Dentistry (AACD). He is also a Fellow of the International College of Dentists and the International Congress of Oral Implantologists. He is currently the esthetic dentistry expert to the National Dental Expert Advisory Board of the AGD and the esthetic columnist for the General Dentistry publication of the AGD over the last 6 years. Over the last 25 years, Dr. Okuda has been a keynote and featured speaker on cosmetic and restorative dentistry at numerous conferences and universities around the world. Over the last 12 years, Dr. Okuda has been one of Dentistry Today’s Leaders in Continuing Education. He is the co-founder of the Give Back a Smile national charitable foundation. In 2007, Dr. Okuda’s practice was awarded the coveted “National Cosmetic Practice of the Year” award by the publication Contemporary Esthetics. Finally, Dr. Okuda is focused on educating the next generation of dentists through the Pan Pacific Dental Academy (panpacdental.com). Dr. Okuda practices at the Dental Day Spa of Hawaii in Honolulu. He may be reached online at okudacosmeticdentistry.com or facebook.com/drwynnokuda or via the Instagram handle @drokuda.

Disclosure: Dr. Okuda reports no disclosures.

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