Half the population of America is unhappy with their smiles1 and will be looking to their dentists for solutions. To help fill the patient quest for the perfect smile, clinicians require the capability to deliver aesthetic restorations that mimic natural tooth structure without sacrificing strength and durability, and the overall health of the patient. Patients not only want the most aesthetic, durable restoration possible, they want it at a reasonable price with a minimum number of appointments.
Currently, there exists a wide range of materials and methods to provide patients with excellent cosmetic and functional results. However, traditional treatment can be costly and inconvenient for patients, and does not always provide the long-term durability or aesthetics desired. Today, advancements in imaging, coupled with state-of-the-art technology, allow us to meet our patients’ needs with single-visit computer-generated restorations that look, wear, and feel like real teeth.
This article presents a case report in which computer-generated veneers were used to meet the patient’s aesthetic demands.
THE TECHNOLOGY
The technology used in this case was CEREC CAD/CAM (Sirona), which offers chairside design and fabrication of highly aesthetic, extremely durable single-unit restorations—including crowns, veneers, fillings, inlays, and onlays—for immediate placement and finishing in one visit. CEREC has over a decade of clinical research and documentation to support the technology. The first patient treated with the CEREC system was at the University of Zurich in 1985. Since then, the technology has been continuously enhanced through ongoing research and development. The most recent product enhancements are found in Sirona’s CEREC 3 model, a compact, user-friendly, Windows-based system.
Since 1996, my personal experience with over 2,500 CEREC restorations with up to 5 years of in-function history has produced a less than 3% failure rate.
CASE PRESENTATION
The patient was a 46-year-old business owner who has been concerned with his smile for quite some time. He found himself unwilling to smile for pictures or in personal, social, and business situations. He had resin-bonded restorations placed on teeth Nos. 8 and 9, which had failed. He presented with a strong desire to correct his maxillary teeth.
The patient had three separate consultations with other “cosmetic” dentists before seeing me, and was on his way to another office after my consultation. He had thought about his potential treatment for several months and was very discerning about what he wanted. He was specific about his desire to correct the irregularities in arch form and crowding and to have whiter teeth.
Diagnosis
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| Figure 1. The before smile is forced, with no confidence. | Figure 2. Closer examination shows defective restorations, crowding, tissue level discrepancy, and irregular arch form. |
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| Figure 3. Left side close-up view; note excessively open embrasures. | Figure 4. Right side close-up view; note incisal edge irregularities. |
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| Figure 5. Crowding of lower anteriors and severe lingual placement of tooth No. 23. | Figure 6. Maxillary incisal arch form misalignment. |
The patient presented for a quick, complimentary cosmetic evaluation that revealed the need for the correction of gingival contours, arch form, and crowding. He consented to a complete, comprehensive examination with full-mouth radiographs, periodontal and occlusal evaluation, cancer examination, and evaluation of existing restorations and decay. Defective restorations on teeth Nos. 6, 8, 9, 14, and 15 were noted, as well as discrepancies in arch form in both arches, including significant crowding of the four lower anterior incisors. Periodontal measurements and cancer examination were normal. The health history and parafunctional habits were negative. Posterior occlusal relationships were acceptable. Irregularities in gingival contours resulted from the crowding of teeth Nos. 24 through 26 and the severe lingual positioning of tooth No. 23. Evaluation of the buccal corridor showed excessive occlusal embrasures, giving the patient a very “fangy” appearance from the side view (Figures 1 through 6). He also expressed a desire to whiten his teeth.
In order to fully evaluate the treatment potentials for meeting the patient’s aesthetic requirements, a complete resin mockup was scheduled a few weeks later for the upper and lower arches. This allowed for full evaluation by the patient of the final tooth contours.
Treatment Plan
The differential diagnosis in this case included problems with gingival contours, crowding, arch form, color, and defective restorations. A treatment plan was developed to address all of the patient’s concerns. After the resin mock-up, veneers for teeth Nos. 4 through 13 were planned to correct color, contour, arch form, and buccal corridor appearance in the maxillary arch. Significant translucency was planned for teeth Nos. 7 through 10 to create a natural smile that would exhibit the impression of lingual incisal thinning and wear. For this reason, the material of choice was the Vita Mark II ceramic blocks (Vident) that are compatible with the entire Vitadur Alpha system of porcelains (Vident). Ten veneers for the mandibular arch were offered, but veneers Nos. 23 through 26 satisfied the patient’s requirement for the lower arch; however, to be sure that adequate length of the lower teeth was created, gingival recontouring was planned with a CO2 laser. Evaluation of the available tissue depth showed that there would be no compromise to the biologic width. Teeth Nos. 14 and 15 were planned for a CEREC onlay.
The patient decided to proceed with restoration of the maxillary arch, and chose to postpone the mandibular veneers and the onlays for Nos. 14 and 15. An impression for a lower whitening tray was taken and delivered with Nite-White tooth whitening system (Discus Dental). Following the completion of the whitening process, the patient decided to complete the entire treatment plan with the four lower anterior veneers, but expressed a strong desire to have the entire aesthetic treatment completed prior to Christmas. The holiday was drawing near, and this complicated our scheduling, as our office was to be closed from December 16 through 26. We were able to offer him the option of single-visit treatment on December 13 and 14 with CEREC to meet his time request.
Clinical Procedures
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| Figure 7. Tissue level realignment with CO2 laser on day one. | Figure 8. Full resin mock-up of ten maxillary veneers at the end of day one, following placement of mandibular veneers. |
The first step on the first treatment day was to create a new lower mock-up to determine the extent of tissue recontouring that was desirable. This mock-up would also serve as the guide for the creation of the final veneers using the “Correlation” mode of the CEREC 3. Bilateral blocks were placed following the mock-up, and the tissue sculpting was accomplished with the laser. The laser leaves no bleeding and well-defined tissue margins (Figure 7). Approximately 1 mm of tissue “rebound” is generally expected. The veneer preparations were accomplished, and the design and milling of the restorations were done with the CEREC 3. The milled veneers were tried in and then characterized with the addition of surface staining and glazing, as no significant incisal translucency was desired. The veneers were prepared for adhesive placement by etching with 5% hydrofluoric acid and application of Ceramic Silane Primer (3M ESPE). Final placement and finishing was accomplished using Excite (Ivoclar Vivadent) and translucent Variolink (Ivoclar Vivadent) as the luting system. This first visit was concluded by etching teeth Nos. 4 through 13, and placing and contouring a complete resin mock-up of the maxillary arch for the patient to evaluate overnight (Figure 8). This allowed both him and his wife to view the aesthetic plan within his own facial frame of reference and prepare for the placement of the remaining 10 veneer units the following day.
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| Figure 9. Ten maxillary veneers milled and ready for glazing and layering of incisal effects on day two. | Figure 10. Final retracted view of completed case; note incisal effects and modification of incisal embrasures. |
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| Figure 11. Right close-up view highlighting incisal translucencies. | Figure 12. Left close-up view highlighting incisal translucencies. |
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| Figure 13. Realignment of lower anteriors and labial placement of No. 23. | Figure 14. Maxillary anterior arch form correction. |
The next morning, he arrived with an approval of the resin mock-up, and preparation was begun on Nos. 4 through 13. The veneers were prepared and milled sequentially (Figure 9). The posterior units Nos. 4 through 6 and Nos. 11 through 13 were planned for routine surface stain and glazing. As the posterior units were milled and fitted, they were glazed and seated. The anterior six teeth were planned for more significant characterization, so they were all tried in together, and a “cut-back” technique was accomplished to allow for the application of translucent porcelain. The six units were fired together and then glazed and seated together. Final cleanup, occlusal adjustments, and polishing were accomplished, and the patient was dismissed. Embrasure forms, contours, color, and arch form were all addressed and satisfied. The patient was overwhelmed with the aesthetic result and the incredible change accomplished in his smile in such a short time with long-lasting laboratory-quality materials (Figures 10 through 14).
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| Figure 15. A very happy, nonforced smile at the end of day two; note incisal form mimicking lower lip. |
He returned in early January to have the onlays on teeth Nos. 14 and 15 placed with CEREC. He related the satisfaction that both he and his wife now have with his wonderful new smile (Figure 15). He told us that he had always frowned in photographs and would not smile. Over the holidays, he had the occasion to have a photo taken by his wife, but would still not smile. His wife asked why he didn’t smile and he replied, “I have been so used to hiding my teeth that I forgot to smile!” He then beamed an ear-to-ear smile and proudly showed off his new pearly whites! He said that this treatment has changed his life.
CONCLUSION
The past 2 decades have brought the development of direct metal-free restorative options. This new generation of technology has evolved through time, making it now capable of producing outstanding clinical results in a wide variety of applications in a single visit, meeting the demands of today’s fast-paced, beauty-conscious society.
As dentists, we possess the ability to impact the lives of our patients in far-reaching ways. For some, we instill fear and apprehension; to others, we are pain relievers and correctors of functional problems; and for a select group, we change lives and personalities. This last group is one that can provide us with some of the most rewarding aspects of dental practice. Our ability to enhance a patient’s self-esteem and confidence is an awesome privilege. The benefits and convenience to the patient of a single-visit procedure is an especially valuable service.
Reference
1. American Academy of Cosmetic Dentistry Survey. Press release, June 26, 2001, Madison, Wis. Available at: http://www.aacd.com/press/releases/1999/08-05. asp. Accessed May 6, 2002.
Dr. Masek maintains a private practice in San Diego, Calif, specializing in metal-free dentistry and aesthetic smile design. He is the president of the Academy of Computerized Dentistry, an accredited member of the American Academy of Cosmetic Dentistry, and a founding member and past president of the Southwest Chapter of the AACD. He is a general member of the Academy of General Dentistry, ADA, California Dental Association, and various other professional organizations. Through his continuing education company, Dentistry by Design, Inc, he presents seminars and hands-on workshops on cosmetic, computerized, and CEREC dentistry. He can be reached at (619) My Smile (697-6453) or visit the website www.mysmile.com.
Disclosure: Dr. Masek is an ISCD-certified basic and advanced clinical instructor for the CEREC System.
