Often, the cosmetic patient presents as the most demanding in our practice, and success hinges upon what we do before we ever pick up the handpiece. Planning, vision, experience, and confidence are some of the keys to creating an excellent cosmetic result, and obtaining a great result is more than just imagination; it’s a combination of more tangible things. Thorough diagnosis, understanding patients’ desires, tempering expectations, prudent tooth preparation, accurate dental laboratory records, and proper handling of tissues and materials are all critical to success.
Experience allows us to envision the finished case before we even start, and proper planning then brings the vision to fruition. From these, we form a blueprint that keeps us going down the right road to minimize issues that create stress and lead to failure. Know before you go.
CASE REPORT
Diagnosis and Treatment Planning
A patient recently came to the office stating that she wanted her teeth to be less square, a lighter color with a more feminine look, and to have an implant restored (Figure 1). She had composite veneers previously placed on her laterals and cuspids (Figure 2). An implant was placed for an upper molar (Figure 3), several anterior teeth had interproximal lesions upon examination of the radiographs, and she showed signs of bruxism.
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| Figure 1. Worn, square teeth with uneven color were the patient’s chief complaints. | Figure 2. Composite veneers on several teeth with interproximal decay or restorations. |
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| Figure 3. The patient desires to have a more feminine smile with the restoration of an implant. |
During this initial consultation appointment, a few images were taken (using a Nikon D7100 with a Nikkor 85-mm lens and Metz wireless flash) so that the patient and the dental team could discuss her desires and how they blend in with clinical findings. There is a very powerful effect when patients see their own teeth enlarged on a 32- to 45-inch high-definition monitor for the first time. It seems like the desire to accept treatment is often proportional to the size of the images shown to the patient. We discuss findings and treatment the way we see it, while looking at the images one at a time (Figure 4). With the full-face image on the large monitor, we discuss the alignment of the teeth to the face, placing an emphasis on what the patient does not like in the close-up smile. We also talk about how many teeth to treat in the side smile. As we come closer to the teeth and look at the occlusal view, the patient has a much better understanding of realistic expectations, and we point out things the patient never thought of while we show the reality of his or her dentition. The power of large images cannot be underestimated for planning and tempering expectations.
After the consultation, Dr. Griffin, his dental team, and the patient decided together on the basic shade of the aesthetic restorations from tooth No. 3 to tooth No. 13. A full series of digital images was then taken. Photos obviously document the condition of the teeth before you do any work (Figure 5). This is important! Have you ever had a patient forget how bad his or her teeth looked before you started? Good images document the bite, soft-tissue health, and original color. There is never a second chance to get pre-op images! Shade documentation was done for the laboratory team (Pacific Aesthetic Dental Studios in Roseville, Calif) and to help in their consideration of material and technique options (Figure 6). An alginate substitute (Silginat [Kettenbach LP]) was used to take impressions for accurate pre-op models. These were sent to the lab team with the complete digital photo series of the patient.
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| Figure 4. At the work-up appointment, the plan is finalized, impressions are taken, a full dental exam done, and a full series of photos is shot. |
Confident visualization will happen from a thorough exam, quality photos, and accurate communication with the dental laboratory team. This will minimize stress for both the clinician and the patient. Co-planning the case with the lab team is paramount for success. Before doing any extensive patient case, a detailed letter with information about the doctor’s and patient’s desires is sent to the lab team along with diagnostic models and photos. The lab team then provides us with a wax-up, reduction guide, temporary matrix, any important preparation suggestions, and a measured soft-tissue recontouring plan. The material option chosen for this patient was lithium disilicate (IPS e.max [Ivoclar Vivadent]) restorations from second bicuspid to second bicuspid and a monolithic, full-contour zirconia implant crown (Bruxzir II [Glidewell Laboratories]).
By knowing the materials before doing the preparations, the preparation design can be done appropriately for the material being used (prep versus material thickness requirements, aesthetic issues unique to specific materials, etc) than for a clinician as opposed to having no idea of the final materials to be used by the lab team. So, visualization involves seeing the final restorative/aesthetic outcome and knowing the materials that will be needed before the preparation of teeth begins.
Clinical Protocol
Gingiva is always (in some way) involved in treatment. What guides laser gingivoplasty is a combination of photographic analysis, recommendations by the lab team, and biological principles. We mark the desired changes on photos with a pen, then sound the bone using a perio probe, keeping final margins 2.5 to 3.0 mm away from the bony crest. The dento-gingival complex must be understood and respected for the best long-term health. The diode laser (Picasso Lite [AMD LASERS]) is invaluable in aesthetic cases, and the results of its use are very predictable, as long as the principles described above are maintained (Figure 7).
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| Figure 5. To prevent patient amnesia about a selected and patient-approved shade after the case is completed, the color is documented with a photo and ion writing in the record before any work is done. | Figure 6. All needed information was sent to the lab team for the fabrication of a full wax-up, prep reduction guide, and temporary matrix, along with the plan for materials and tissue re-contouring. |
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| Figure 7. Preparations were conservative and kept in enamel, when possible. | Figure 8. Slice preps were done where restorations or decay existed interproximally, while a full crown prep was done when indicated. |
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| Figure 9. The reduction guide shows less-than-ideal preparations. Therefore, refinements were made to the preps before taking the final impression. | Figure 10. Records of the bite and vertical and horizontal guides (Kois Dento Facial Analyzer [Panadent]) were taken and sent to the lab team. |
Lithium disilicate veneer preps feature smooth surfaces; no sharp internal line angles; and consistent 0.3- to 0.5-mm reduction with subtle, but identifiable, margins. A consistent restoration thickness helps to ensure consistency of the final shade. The preparation is done within enamel whenever possible, and interproximal prepping is kept to a minimum except to cover decay or restorations, move a midline, correct a cant, or hide a margin or color change.
When preparing the teeth interproximally, the slice prep technique is used if lingual restorations do not extend for more than one fourth of the width of the lingual surface from mesial or distal (Figure 8). This interproximal prep design provides an excellent finish line for the lab team as well as a tooth-to-restoration margin on enamel that is easily maintained by the patient. Notice that, in this case, with no decay or restorations between the central incisors and a pre-op midline that was very close to ideal, the contact was not broken, but a finish line was done that hides the margin from view. Slice preps are seen on the cuspids and laterals to cover restorations and decay. They are divergent from the facial with a path of restoration insertion from the incisal-facial direction. The wax-up should also include a preparation reduction guide to help make the preparations and resulting restorations uniform and ideal in thickness for the specific material and technique chosen (Figure 9).
Under and over reduction can be best avoided by using a preparation reduction guide. To be conservative but accurate, a reduction guide is placed on the tooth after preparation. In this case, the guide was placed after preparation and ideal clearance was evaluated, then the distal of tooth No. 11 was reduced further. Despite my best efforts, I under-reduced the distal aspect of both cuspids and the distal facial of the centrals. (This finding exemplifies the need to use a reduction guide!) This is where a good plan and input from the lab team helps to prevent potentially undesirable outcomes. The preparations were then completed, including any corrections per the prep guide. Full-arch impressions, bite registration, alignment guides, photos, desired overall shade (done before preparation of the teeth), and shades of the prepped teeth (stump shades) were sent to the lab team along with a detailed lab prescription. A simplified. but very accurate, guide (Kois Dento Facial Analyzer [Panadent]) was used instead of more complex face-bow and articulator systems (Figure 10).
Temporaries (made from a stint fabricated using the wax-up) were inspected 5 to 7 days after placement, photos were retaken, corrections were made, and all of this was again shared with the lab team. The patient was asked about size, shape, color, speech, bite, and any other areas of stated concern; another step to evaluate the plan in progress—a living plan. This results in less stress and minimal issues when the restorations are tried in the mouth.
Delivery of the Final Restorations
Obviously, dentists examine the restorations when they are returned from the dental lab. However, it is just as important to examine your preparations (Figure 11). In many ways, the lab team is limited by our clinical skills. It is often humbling when I see my own preps close-up on a stone model. It may reveal my inadequacies, but I learn from this self-analysis to decide what I could do better or differently with the next case. Notice that the interproximal restorations on the bicuspid full crown were prepped into the retention of the crown, negating the need to prepare more gingivally to add retention. Likewise, the veneer preps follow the curves of the natural tooth with a flattened incisal edge which gives it a positive seat stop when cementing the veneer (Figure 12).
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| Figure 11. Self-analysis of the preps is a great learning tool for the clinician and may improve the quality of preparations in future cases. |
Figure 12. Conservative, well-planned preps were done according to the requirements of the specific material(s) being used. |
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| Figure 13. Try-in was done using an aluminum chloride hemostatic liquid (ViscoStat Clear [Ultradent Products]) as a medium to check color and opacity and to reduce the risk of contamination via bleeding and/or crevicular fluid during the cementation protocol. | Figure 14. The teeth were cleaned with flour pumice (Preppies [Whip Mix]) and 2% chlorhexidine (CAVITY CLEANSER [BISCO Dental Products]). |
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| Figure 15. Phosphoric acid etch is teased toward the gingival and rinsed after 30 seconds. | Figure 16. A universal bonding agent (ALL-BOND UNIVERSAL [BISCO Dental Products]) was applied and air thinned, leaving a shiny surface. |
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| Figure 17. After bleeding the tube, the light-cure resin luting material (Choice 2 [BISCO Dental Products]) was applied directly to the tooth and the veneer seated onto it. | Figure 18. While holding the veneer with gloved fingers, tacking was done on the facial for 3 seconds, followed by cleanup, flossing, and final curing. |
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| Figure 19. Teflon tape was placed into the screw hole, followed by flowable composite (Beautifil Flow Plus [Shofu Dental]). After try-in, the monolithic zirconia crown (Bruxzir II [Glidewell Laboratories]) was cemented with a bioactive cement (Ceramir [Doxa]). | Figure 20. Self-evaluation at the end of the case (2 weeks post-op) is the key to becoming better for the next one. |
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| Figure 21. Proper planning reduces the stress often associated with meeting the patient’s expectations for an excellent aesthetic result, also helping the doctor and team feel great about a job well done. |
The veneers were tried in to check fit, color, and opacity (Figure 13). Traditionally, try-in pastes or water have been used to see the influence of the underlying prepared tooth color on the restorations. For years, we tried utilizing varying colors, opacities, or consistencies of luting cement with varied results. These days, with the varying opacities of lithium disilicate (IPS e.max [Ivoclar Vivadent]), we find it more accurate to show the lab team the preparation shade and to have the dental technician use the least opaque material that blocks the underlying shade of the prepared tooth structure. I use an aluminum chloride hemostatic agent (ViscoStat Clear [Ultradent Products]) as a try-in liquid. Not only is it a clear solution that is easy to rinse off, but it also helps control gingival bleeding and crevicular leakage. It must be noted that astringent agents containing ferric sulfate are avoided, as the iron may cause darkening under an all-porcelain restoration if not removed thoroughly.
After try-in, the veneers were cleaned (Ivoclean [Ivoclar Vivadent]), then silane was applied to the intaglio surface and dried. The teeth were cleaned with flour pumice (Preppies [Whip Mix]) and 2% chlorhexidine (CAVITY CLEANSER [BISCO Dental Products]) (Figure 14). Phosphoric acid etch was then placed and teased toward the gingiva and rinsed with water after 30 seconds (Figure 15), after which a bonding agent was placed (ALL-BOND UNIVERSAL [BISCO Dental Products]) and thinned with air (Figure 16). After bleeding the delivery cartridge, a light-cured cement (Choice 2 [BISCO Dental Products]) was placed directly on the teeth (Figure 17). Next, the IPS e.max veneers were all placed at once. The excess cement was brushed away and the fit was verified. The veneers were held in place with gloved fingers in the mesial and distal areas (Figure 18). The fingers ensure seating and help block light from curing the interproximal cement. Tack-curing with a 2.5-mm tip was done for 3 seconds on each veneer, and then they were flossed before final light curing was done. The IPS e.max bicuspid crown was cemented with dual-cured self-adhesive cement (BeautiCem [Shofu Dental]).
The titanium abutment was re-torqued in place at 35 Ncm. Teflon tape was placed in the hole and covered with a flowable resin (Beautifil Flow Plus [Shofu Dental]) (Figure 19). The implant crown was cemented with a regenerative (bioactive) cement (Ceramir [Doxa]), followed with careful cleanup of all the excess cement. Finally, the occlusion was checked and adjusted as needed. Before the patient was dismissed, impressions were taken for the fabrication of a nocturnal bruxism splint to be delivered at a subsequent appointment.
Postoperative Evaluation
Post-op photos were taken 2 weeks after delivery of the final restorations (Figure 20). Again, just like learning about our preparations placed in the models returned from the dental lab (or in digital impressions), the photo series are always studied and used in self-analysis of our clinical work. Self-evaluation, reflection, and change are what can bring us closer and closer to the never-ending goal of perfection. However, in the end, it’s about natural looking restorations that make me and my team happy, and meeting our patients’ expectations to make them happy (Figure 21).
CLOSING COMMENTS
Nothing can replace the phases of excellent communication, such as listening to the patient, showing them how we see the case, co-planning with the dental lab team, and the correct handling of the hard-and soft-tissue and restorative materials. Developing aesthetic visualization involves many of these aspects, as discussed in this article. Doing so will help reduce the stress that is often involved with patients demanding excellent aesthetics and, at the same time, it will increase the satisfaction that accompanies the best possible outcomes.
Acknowledgment
The author would like to thank the Pacific Aesthetic Continuum (thepac.org) for the principles used in this case and Pacific Aesthetic Dental Studios (Roseville, Calif) for their excellent case planning and restorations.
Dr. Griffin earned his DMD from Southern Illinois University (1987) and completed a general practice residency at the University of Louisville, Ky (1988). He has Diplomate status with the American Board of Aesthetic Dentistry (ABAD), accreditation with the American Academy of Cosmetic Dentistry, and a Mastership in the AGD. He has been involved in product improvements with dental companies and has reviewed products for Reality Esthetics, THE DENTAL ADVISOR, the Catapult Group, and others. He is currently one of the clinical directors for the Pacific Aesthetic Continuum and serves the community with a St. Louis County, Mo, practice emphasizing cosmetics and all phases of general dentistry. He can be reached at (636) 625-3380, or by visiting his website at mysmilecenter.com, or by emailing jgriffinjrdmd@gmail.com.
Disclosure: Dr. Griffin has no disclosures.
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