Dentistry has entered a very exciting time in the aesthetic arena. The wave of technology allows us to provide aesthetic and restorative treatment with a myriad of improved materials and techniques as well as an advanced armamentarium. As our patients become increasingly more demanding with regard to their aesthetic and restorative care, dentists must incorporate these advancements into their practices in order for success to be achieved.
From bleaching procedures, adhesives, and composites incorporating nanotechnology, to the variety of ceramic materials currently available, it is sometimes difficult to determine what products and procedures to utilize and where to utilize them. There may not be an ideal material when restoring all our patients’ teeth. However, case selection, preparation designs, adhesive techniques, laboratory communication, and experience with the newer materials are some of the more critical elements in achieving our goal of clinical success when providing indirect tooth-colored restorations.
As we strive to provide metal-free restorations and excellent aesthetics, all-ceramic crowns have become a popular option among patients. These materials exhibit desirable properties such as biocompatibility, color stability, and low thermal conductivity.
The following case report demonstrates the use of current materials and clinical techniques to achieve patient/clinician objectives of aesthetics and function.
MY PATIENT: BILL
 |
 |
| Figure 1. The patient presented with a desire to rejuvenate his smile. | Figure 2. As shown, the restorations that were placed just a few years earlier did not meet the patient’s expectations. |
“I hate my smile,” said a 41-year-old male who was unhappy with the appearance of his smile when he presented to our office. His smile slanted up toward his left side and also displayed a “worn” look (Figures 1 and 2). He wished to rejuvenate the appearance of his teeth. Friends of his, who are also patients of our office and who had cosmetic treatment years ago, had referred him. The patient presented without medical problems, with the exception of iodine and shellfish allergies.
 |
 |
| Figure 3. Right view: ill-fitting and broken porcelain veneers. | Figure 4. Left view: failing porcelain veneers and irregular gingival architecture. |
The comprehensive examination revealed ill-fitting crowns on teeth Nos. 7 and 13, as well as ill-fitting and broken veneers on teeth Nos. 6 and 8 to 11 (Figures 3 and 4). Large, worn amalgam restorations on teeth Nos. 21 and 28 were recorded, as well as advanced incisal wear on teeth Nos. 22 through 27. Uneven anterior gingival aesthetics was observed, which included 3 mm of recession on tooth No. 11.
Impressions for diagnostic models were completed, and photographs of the patient’s teeth were taken. The patient was informed that after the diagnostic models were poured and mounted, we would evaluate the models, photographs, and x-rays and develop the appropriate treatment plan.
To evaluate the case, a pre-prep evaluation form was used to check the following:
(1) Occlusion—measure overjet, overbite, and centric.
(2) Midline—is it adequate or is a shift needed?
(3) Smile line—ensure it follows the curve of the lower lip.
(4)Arch—determine whether it is going to be widened or left as is.
(5) Labial contours of teeth—too bulky? lingual version?
(6) PDL (a term used by Dr. Gerard Chiche):
•Proportion—evaluate width versus length.
•Display—refers to how much of the incisal edge is revealed at rest position after pronouncing the letter m. Males typically show 2 to 3 mm of incisal edge, while females measure 3 to 4 mm.
•Length—assess length preoperatively. Leave alone, increase, or decrease? The Tooth Indicator Guide (DENTSPLY) provided a reference of the potential length of the central incisors.
 |
|
Figure 5. A diagnostic wax-up was developed based on detailed pre-op information and the patient’s aesthetic desires. This was all related to the lab along with photos.
|
The models were sent for a diagnostic wax-up to Jurim Laboratories. The laboratory script was sent with the pre-op photos and all the information from the pre-prep form. The diagnostic waxed models were presented to the patient, comparing the pre-op models to what we would like to accomplish based on the diagnostic wax-up (Figure 5). The patient was shown how he needed gingival recontouring to balance the gingival architecture. A graft procedure was indicated on tooth No. 11; however, the patient declined this treatment because he did not have a high smile line and the recession was not visible.
Full-arch rehabilitation of both arches would be ideal. How-ever, the patient had a budget that we had to work within. The patient approved the ap-pearance of the waxed teeth and signed the consent forms for treatment.
The proposed treatment in-volved all-ceramic crowns (Cre-ation, Jensen) for teeth Nos. 3 to 14 as well as teeth Nos. 21 and 28. The reason for considering full coverage in this case was a lack of appropriate tooth structure under the old veneers. Porcelain veneers would be placed on teeth Nos. 22 to 27.
Preparation
 |
 |
| Figure 6. Adequate tooth preparation is essential for optimal strength and aesthetics of the ceramic restorations. | Figure 7. At the completion of the preparations, a stump shade of the underlying tooth shade was provided to the ceramist. |
The patient completed the initial phase of treatment in 2 appointments with our hygienists for periodontal care and home care instructions. This was followed by the preparation appointment for maxillary teeth Nos. 3 to 14 (Figures 6 and 7). This was to include any tissue changes as well as placing the patient in laboratory-processed temporaries (Bio-Temps, Glidewell Laboratories). The LS-7514 All-Ceramic Prep-aration Kit (Axis Dental) was used to prepare the teeth. The diamond burs in this kit allow for a modified chamfer prep with rounded smooth contours and no sharp line angles. Fol-lowing their preparation, the teeth were cleaned using Consepsis disinfecting solution (Ultradent).
Gingivalplasty procedures were performed in accordance with measurements from the diagnostic wax-ups. This was done with the STT 016 soft-tissue trimming bur (Axis Dental). Any hemostasis that was needed during this phase of treatment was controlled by ViscoStat Plus (Ultradent). Core buildups were placed where needed with Adper Single Bond Plus Adhesive (3M ESPE) as well as Filtek Supreme Universal Restorative (3M ESPE).
Prior to provisionalizing, Gluma Desensitizer (Heraeus Kulzer) was applied to all teeth. The temporaries were cemented with a noneugenol-based cement (TempBond NE, Kerr). The patient left the office with a written handout for home care instructions that my dental assistants reviewed.
 |
| Figure 8. As seen, the provisional restorations have begun the transformation of the rejuvenated smile. It will provide us with the blueprint for the fabrication of the final restorations. |
On the subsequent visit that occurred 2 weeks later, the patient was seen to evaluate the temporaries for aesthetics, phonetics, and occlusal harmony (Figure 8). After reviewing a comparison of pre-op photos and models to the patient’s current state, the patient was quite pleased and wished to proceed with treatment. Since the patient was pleased with the temporaries, we proceeded with taking photographs and models of the temporaries to be utilized for laboratory communication. The patient did not object to tooth No. 11 still remaining slightly longer, as this was not reflected in his smile.
As we would be restoring teeth Nos. 21 to 28 as well, the patient wanted to have some insight as to how they would appear aesthetically. Accordingly, teeth Nos. 21 and 28 were prepared for full-coverage, all-porcelain crowns, and based on the diagnostic wax-up, mock-ups were completed for teeth Nos. 22 to 27 utilizing Filtek Supreme universal restorative. Mock-ups were directly bonded (37% phosphoric acid being applied then rinsed, followed by Adper Single Bond Plus adhesive.) The adhesive was cured with the L.E. Demetron 1 light (Kerr). The composite was then sculptured by placing it into an omnivac stent and seating it on the teeth. The material was then light cured, the stent was removed, and the composite was trimmed and polished. We were able to create the appropriate arch form and shape for teeth Nos. 22 through 27 as well as balance any occlusal clearance needs while the patient was wearing his upper provisionals. Tissue changes were also completed on teeth Nos. 23 to 26 with the STT 016 to increase the clinical crown of these teeth.
Impression Technique for the Upper Arch
 |
| Figure 9. Maxillary master model shows accurate representation of the preparations as a result of good impression technique. |
After the temporaries were removed, the teeth were cleaned with Consepsis scrub and Consepsis disinfecting solution. Note: If hemostasis was needed prior to impressioning, ViscoStat Plus was used. After being applied, this agent is rinsed thoroughly; then the Ultrapak cord is placed using a Fischer’s Ultrapak Packer (Ultradent). Ultrapak Cord size No. 000 (Ultradent) was placed just apical to the preparation. Leaving the cord in place, full-arch impressions were taken utilizing Imprint II Garant VPS Impression Material (3M ESPE) using a one-step technique (light-bodied material syringed around the teeth and a tray material seated over that). Utilizing the Imprint II Garant VPS impression material and this technique results in a model that, in turn, the laboratory can use to fabricate accurate and reliable restorations (Figure 9).
A stick bite registration was taken utilizing MegaBite VPS Bite Registration (Discus Dental) to mark both the midline and interpupilary line. A face bow transfer also was used during this phase of the case. The Slidematic Face Bow (Waterpik) is relatively easy to use and provides consistent results. The laboratory was informed that the existing color (or stump shade) was ST1 and final shading would be A1 with natural incisal transparencies to create a more youthful look. Although tooth No. 7 had a darkened, old metal post, we informed the laboratory so the appropriate amount of opaque could be used to block it out without compromising the aesthetic result. It is at this stage of a case that interdisciplinary communication between the clinician and technician becomes critical for the delivery of well-designed and aesthetic restorations. Future-Dent Creations Dental Lab offers high-quality dental restorations, technical expertise in the various restorative materials, and outstanding customer service. Its team of ceramists would be creating Bill’s new smile.
Try-In and Cementation
A subsequent appointment was established to try in and verify the aesthetics of the Creation porcelain crowns (Jensen). After the patient approved the case, it was sent back to the laboratory to be completed. Prior to final insertion, all crowns were treated with Scotchbond Ceramic Primer (3M ESPE), and the preps were cleaned with Consepsis scrub and Consepsis disinfecting solution. All crowns were then cemented with RelyX Unicem Self-Adhesive Universal Resin Cement (3M ESPE). 3M’s new self-adhesive resin cement can be utilized for many cementation procedures. The cement is self-adherent and moisture tolerant. Using the transparent shade, crowns were seated 2 at a time. All excess cement was removed prior to curing utilizing sable brushes and rubber tips and then light cured for final set.
After cementation was completed, all crowns were ex-amined for any residual cement, and the occlusion was checked. Upon completion of this step, the patient returned on a subsequent visit for a post-op evaluation. Post-op photos of the maxillary teeth were taken showing a rejuvenated smile. No changes were needed, and the patient was quite pleased with the results and anxious to complete the mandibular teeth.
The Finale
 |
| Figure 10. Lower full-arch impression utilizing Imprint II Garant VPS impression material (tray and light-body wash material). |
We continued with the preparation of teeth Nos. 22 to 27 for porcelain veneers, prepping through our mock-up to the appropriate depth cuts, as we were going to be correcting the crowding and lingual version of certain teeth. Again, prior to impressioning, all teeth were cleaned with Consepsis scrub and Consepsis disinfecting solution. Gluma Desensitizer was applied to teeth Nos. 21 to 28, and impressions were taken in a similar technique as the upper teeth (Figure 10). Temporaries for the veneers were fabricated using Cosmedent’s RSVP kit.
At the insertion visit, teeth Nos. 22 to 27 were cleaned, and the veneers were tried in with RelyX Veneer Try-in Paste (3M ESPE) to verify color. Once approved for fit and color, the veneers then were cleaned and treated with Scotchbond Ceramic Primer. The teeth, starting with the central incisors, were etched 2 at a time, thoroughly rinsed, and moisture blotted until no excess remained. Adper Single Bond Plus Adhesive was applied to those teeth and air dispersed. The adhesive would be cured through the veneers. Following this, RelyX Veneer Ce-ment, shade B0.5 was placed on those veneers, which then were seated. Excess cement was brush-ed away with a sable brush and the veneers tack cured.
Two teeth at a time were treated until all 6 were inserted. Glycerin was applied to all 6, which then were fully cured. Crowns for teeth Nos. 21 and 28 were cemented with RelyX Uni-cem cement according to manufacturer’s directions. All excess cement was removed utilizing NTI Diamond Fine and Ultra-fine finishing burs (Axis Den-tal). All interproximal contacts were verified and polished using the NTI Diamond Strip Assortment Package. The occlusion was checked, and the case was polished.
 |
| Figure 11. The final result. |
 |
| Figure 12.The post-treatment smile demonstrates an aesthetic and natural appearance. The patient was extremely satisfied with his new smile. |
 |
| Figure 13. Left buccal view of case completed. |
 |
| Figure 14. Right buccal view of case completed. |
 |
| Figure 15. Occlusal view shows all-ceramic crowns cemented with Rely X Unicem Self Adhesive Universal Cement (3M ESPE). |
At the final evaluation appointment, Bill was very pleased with his “extreme makeover” (Figures 11 through 15).
CONCLUSION
Our patients’ wishes can be predictably developed once certain protocols are followed, particularly the conversion of the diagnostic wax-up into functioning and aesthetic provisionals. These become the blueprint to the suc-cess of the case. Thorough treatment planning and accurate communication between the team of the patient, clinician, and technician are paramount for a successful case. Further, meticulous impressions and records as well as the transfer of information with photographs to our laboratory technicians are critical for restorative success.
As the world of aesthetic dentistry continues to advance, the treatment opportunities available to our patients also grow. In turn, manufacturers must continue to strive to maintain a level of excellence in the products they develop so we can continue to fulfill our patients’ restorative and cosmetic treatment needs.
Dr. Mohr, a graduate of New York University College of Dentistry in 1983, is the section chief, department of cosmetic dentistry, Jamaica Hospital Center, and a clinical associate professor in the department of dentistry at University Hospital in Stony Brook, NY. His memberships include the ADA, Academy of General Dentistry, American Academy of Cosmetic Dentistry, American Prosthodontic Society, and American Academy of Implant Dentistry. He is also a fellow of the International College of Oral Implantologists. Dr. Mohr has recently been selected as one of America’s Top Dentists by the Consumers Research Council of America. Since 1986, he has maintained a full-time practice in Massapequa Park, NY, emphasizing cosmetic, restorative, and implant dentistry. He has lectured extensively at local and national meetings on the topics of contemporary aesthetic dentistry, dental materials, and conservative restorative dentistry. He can be reached at asmdds@aol.com.
