As dentists, we provide services that can transform smiles and lives. We have the ability to solve problems and challenges for our patients that give them the basic ability to smile again, function normally and, best of all, feel good about themselves, both inside and out.
CASE REPORT
Diagnosis and Treatment Planning
Recently, SueAnne presented for a consultation, motivated by what was glaring at her in the mirror (Figures 1 and 2). At 54 years of age, having lived with veneers that had been placed in stages during the last 20 years, her first stated concern was about the obvious recession that had been slowly taking place. SueAnne then discussed her next issue with great intensity and frustration, using descriptive words like yellow, bulky, and huge. She could see that there was nothing proportional or cosmetic about her existing restorations. She said, on the verge of tears, “I take pride in my appearance and have spent a lot of money on my smile over the years, but my teeth are making me look like I don’t care at all!”
 |
 |
| Figure 1. Pre-op photo, anterior retracted view. | Figure 2. Pre-op photo, upper arch occlusal view. |
 |
 |
| Figure 3. Preparations, left side. | Figure 4. Final bite registration (Blu-Mousse [Parkell]). |
 |
| Figure 5. The completed preparations. |
Due to her previous dental experiences, SueAnne also expressed her fear of “pain” and “countless hours” in the dental chair. Also, she was certain this would “take months” to accomplish and wanted a timeline so she could adjust her travel schedule.
Equipped with a full set of digital x-rays, periodontal probings, and digital intraoral photos, I was able to “show and tell” SueAnne that she was periodontally healthy and had a stable bite with the exception of some anterior interference. In reviewing the photos with her, confirmation was given that both the color and proportion of her smile could be greatly improved. And, because of the new all-ceramics that we have available today, the bulkiness issue could be addressed as well. During our conversation, SueAnne responded positively to words like longer, leaner, broader, cleaner, and fuller. I could tell that we were on the right track.
SueAnne was informed that we could have everything completed in 2 appointments, within a 2-week time frame. Within those 2 weeks, she would be wearing her prototype smile, which would permit her to evaluate how her new smile could look. If she wanted to change or adjust anything during this phase, she would have the ability to do so. I assured her that this process would be totally painless, and that we would set aside 2 hours for the first appointment and one hour for the second appointment. I reassured her that during these 2 weeks, and immediately after the first appointment, she would be able to eat and drink as she pleased without any restriction. SueAnne calmly asked, “When can we start?”
 |
 |
| Figure 6. With the patient in an upright sitting position, a facial plane relator device (Symmetry Facial Plane Relator [CLINICIAN’S CHOICE Dental Products]) was used so the lab team would be able properly mount the case in the correct horizontal and vertical planes for the patient. | Figure 7. Symmetry device, lateral view. |
 |
 |
| Figure 8. Shade selection was done. | Figure 9. The completed bis-acryl (Integrity [Dentsply Sirona]) provisionals. |
 |
 |
|
Figure 10. Upper provisionals, occlusal view. |
Figure 11. After try-in was completed, the internal aspects of the restorations were deep cleaned using a phosphoric acid gel and then washed off with water. |
After reviewing the informed consent and answering any final questions, a preliminary vinyl polysiloxane (VPS) impression (Silginat [Kettenbach LP]) was taken of the upper and lower arches and sent out with detailed instructions (including smile design) to the dental laboratory team for a diagnostic wax-up, provisional stent fabrication (of the wax-up), a bite stent, and a prep reduction guide.
Clinical Protocol
Upon receipt of the wax-up, preparation of teeth Nos. 4 to 13 was initiated (Figure 3). The previously placed porcelain veneers on teeth Nos. 9 to 13 were removed (1847KR016C [DENTSPLY Midwest] and the preparations were minimally revised. A diode laser (Picasso Lite [AMD LASERS]) was then used to establish a more pleasing soft-tissue architecture. After tooth preparation and the minimal soft-tissue revisions were completed, an initial VPS bite registration (Blu-Mousse [Parkell]) was taken in centric occlusion. Next, the previously placed porcelain veneers on teeth Nos. 4 to 8 were removed and minimally prepared. Again, the diode laser was used to establish a more pleasing soft-tissue architecture. The previous bite was then reinserted and finalized to include the preparations on the right (Figures 4 and 5). After all of the preparations and soft-tissue architecture were evaluated, the bite was evaluated for adequate prep reduction in preparation for the temporaries and eventual restorations. Taper, marginal integrity, and prep design were also taken into account.
 |
 |
| Figure 12. Arranging final restorations in order prior to the resin bonding procedure. | Figure 13. The lithium disilicate restorations (IPS e.max [Ivoclar Vivadent]), occlusal view. |
 |
| Figure 14. The final all-ceramic restorations, retracted anterior view. |
With the patient in an upright sitting position, a facial plane relator device (Symmetry Facial Plane Relator [CLINICIAN’S CHOICE Dental Products]) was used so that the lab team would be able properly mount the case in the correct horizontal and vertical planes for the patient. It is critical that one get the vertical component of the Symmetry bite to bisect the face in half and be vertical to the long axis of the face. Front and side view digital photos were then taken of the Symmetry device in place to sharing with the lab team (Figures 6 and 7). Prior to final impressions, the dentin shade was evaluated and noted. A shade of the desired restoration was noted as well. A photograph of all of the selected shades next to the preparations was taken (Figure 8). A shade map of the desired final restoration was also drawn and sent to the lab team.
A final VPS impression was taken only after final evaluation of the margins, tissue, line angle of preparation, and complete field of vision of all of the above. A digital photograph was taken for evaluation as well. The final VPS impression (Aquasil Ultra Xtra [Dentsply Sirona]) was taken using a heavy-body/light-body technique with the patient sitting in an upright position. As the assistant loaded the heavy-body material into an already fitted stock tray, the doctor placed the light body around all of the teeth in the upper arch, covering them completely. It is important to keep the material flowing, maintaining it against the tissues in order to capture less air. Once the tray was filled, the assistant handed the tray to the doctor and then it was inserted into the patient’s mouth, making sure that the lips were worked over the tray. Care was taken when seating the tray so that none of the teeth were touching any part of the tray. A timer was used to follow the setting process to the end, according to the manufacturer’s specifications, and the tray was removed for visual evaluation. Evaluation of the impression under loop magnification should reveal all of the landmarks evaluated in the preparations prior to taking the final impression. It is critical that the clarity of all of the margins, as well as the integrity of the preparation within the final impression, are verified. It is also critical that the clinician identify any voids, bubbles, pulls, or tooth/tray interferences. Any of these issues within the final impression could seriously compromise the final restoration fit and, of course, would require taking another final impression.
Temporization was accomplished with a bis-acryl temporary material (Integrity [Dentsply Sirona]) using the provisional stent that the lab team created from the diagnostic wax-up fabricated prior to doing the tooth preparations. Before placing the material, the teeth were cleaned with a solution containing 2% chlorhexidine (CAVITY CLEANSER 2% Chlorhexidine Digluconate solution [BISCO Dental Products]). Due to the nature and shrinkage of the bis-acryl provisional material around the preparations, a temporary cement is rarely needed. The minimal excess material present after seating the provisionals was removed using hand instruments and then a polishing wheel, disc, and/or cup (Enhance [Dentsply Sirona]). (Note: No high-speed rotary drill instrumentation should be used at this point.) The temporaries were characterized as needed with stain, then a clear unfilled resin glaze (PermaSeal [Ultradent Products]) was painted onto the facial surfaces of the temporaries and light cured (Figures 9 and 10). Finally, instructions were given to our patient along with a Waterpik Cordless Waterflosser (Water Pik). (The author gives all his large cosmetic case patients Waterflossers along with detailed instructions for home care. The author figures this cost into the overall cost of care for the patient.) SueAnne was then given an appointment to return 2 weeks later for the delivery of the final restorations.
When the lithium disilicate (IPS e.max [Ivoclar Vivadent]) final restorations were returned from the lab team, they were inspected for marginal integrity, contact integrity, color, and design prior to try-in. Then, at the seating appointment, the temporaries were removed, and the teeth were cleaned with a solution of hydrogen peroxide and 2% chlorhexidine (CAVITY CLEANSER) and then rinsed. The final restorations were tried in with water only. The parameters noted above were all found to be excellent. The patient was then given a chance to look at the color, shape, and overall look in order to approve the final placement of the restorations.
Once approved, the restorations were removed and cleaned with 37% phosphoric acid gel, then rinsed with water (Figure 11) and thoroughly dried. Next, silane (BIS-SILANE [BISCO Dental Products]) was applied to the internal surfaces of the restorations for 60 seconds then dried with water- and oil-free air. Then the restorations were readied for the resin bonding procedure by placing them in order (Figure 12). Once bonded properly into place using a light-cured resin cement (Calibra Veneer Kit [Dentsply Sirona]), excess cement was removed, and then the bite was checked and adjusted as needed. Digital radiographs were taken to ensure complete seat and to be sure that any excess cement had not been left behind. The final lithium disilicate restorations can be seen in Figures 13 and 14.
CLOSING COMMENTS
SueAnne was ecstatic about her new smile, crying and hugging everyone as she walked out our office door. She continues to refer other patients to our practice and lets us know that, every time she smiles, she is thankful for the care that we provided. With proper training that allows us to expand and perfect our technical skills, the choices in modern dental materials, and excellent communication between the doctor and patient and the doctor and dental laboratory team, our patients’ smiles and lives can be changed forever!
Acknowledgement
The author would like to thank the talented dental laboratory team at Aurem Group (aurumgroup.com) for the excellent technical work shown in this case report.
Dr. Simos maintains private practices in Bolingbrook and Ottawa, Ill. He received his DDS degree at Chicago’s Loyola University, and he is the founder and president of the Allstar Smiles’ Learning Center and client facility (Bolingbrook), where he teaches post-graduate courses to practicing dentists on cosmetic dentistry, occlusion, and comprehensive restorative dentistry. An internationally recognized lecturer and leader in cosmetic and restorative dentistry, he can be reached at sam.s@allstarsmiles.com or by visiting allstarsmiles.com.
Disclosure: Dr. Simos reports no disclosures.
