Creating Beautiful Smile Symmetry: Tissue Considerations

Incorporating clinically proven restorative materials and state-of-the-art technologies into the dental practice can help dentists elevate the level of care that they provide their patients. By using metal-free and highly aesthetic leucite ceramics that can be pressed to thin and conservative dimensions, and preparing the gingival architecture that is to surround these restorations using a soft tissue diode laser, dentists will be offering not only necessary treatments, but also desired services.

CHOOSING THE RIGHT AESTHETIC MATERIALS
From a material standpoint, adhesively bonded all-ceramic veneers have a clinically proven track record,^1,2 and pressed leucite-reinforced ceramics enables clinicians to realize conservative preparation designs whenever and wherever possible.^3,4 Equally significant to selecting the right materials for highly aesthetic cases is the fact that proposed restorations can be fabricated to resemble the beauty of natural dentition.⁵ It is also important to note that the wear characteristics of pressed leucite all-ceramic materials closely mimic those of natural enamel, thus reducing the wear of the opposing dentition. In addition, the marginal integrity of these restorations (eg, at 70 µm) allows for supragingival preparations, without concern of marginal show-through or breakdown.

Before. Preoperative natural smile. Chief complaint: repeated fractures of tooth No. 9, and dissatisfaction with the overall color of teeth.	After. Postoperative views showing that tooth No. 10 has been brought back into proper arch form to follow the lip line, and the patient was given a fuller, larger smile.

ADVANTAGES IN USING A DIODE LASER
In terms of state-of-the-art technology, a soft-tissue diode laser enables less invasive, more precise, and significantly more efficient completion of procedures associated with aesthetic and restorative dentistry.⁶ For example, in the case presented here, the soft tissue laser was indispensable for enhancing the aesthetics of the patient’s smile in a minimally invasive way through gingival recontouring. Patients typically experience little postoperative discomfort when a soft tissue laser is used, since the lasers produce immediate hemostasis and only affect the targeted area.⁶
Currently, patients are looking for advancements in dentistry that will enhance their treatment outcomes and dental experience. According to a recent article by Lowe,⁷ an estimated 90% of cosmetic dentistry cases involve cosmetic gingival contouring that is completed using a soft-tissue diode laser.⁷ It is also interesting to note that the concept of aesthetic treatments that incorporate lasers is considered favorable by patients.⁷
This article describes the combined use of pressed ceramic veneers and a soft-tissue diode laser to address a patient’s functional and aesthetic concerns. The restorative is­sues were addressed using a pressed leucite reinforced all-ceramic, and soft-tissue asymmetries/compromises were corrected prior to tooth preparation using the soft-tissue diode laser.

CASE REPORT
A 55-year-old female presented with Class II occlusion and chipped front. Her chief complaint was that tooth No. 9 had been repaired repeatedly in the past and continued breaking (Before). She also mentioned that she had never been satisfied with the overall color of her teeth, and she felt that tooth No. 10 was impinging upon her lower lip.

Diagnosis and Treatment Planning
After a thorough examination, several functional and aesthetic areas requiring treatment were identified. These included the following:
Tooth No. 9 and the anterior teeth were flared and discolored.
Both lateral incisors were flared facially, while the buccal corridor was collapsed with hypocalcification in the cervical areas (Figure 1).

Figure 1. Close-up preoperative natural smile view showing fractured mesial-incisal edge on tooth No. 9 and yellowing of anterior teeth.	Figure 2. Deficient buccal corridors needed widening. New incisal edge positions, as well as canine guidance, would be re-established.

There was gingival asymmetry on teeth Nos. 6 to 11. In particular, upon smiling, tooth No. 7 demonstrated a prominent amount of gingival tissue display compared to the contralateral side.
The treatment plan included raising the tissue level on tooth No. 7 using a soft tissue diode laser and correcting the gingival asymmetry of teeth Nos. 6 to 11 where possible (Figure 2). Also, because tooth No. 7 was slightly rotated, and its gingival tissue appeared out of proportion, a soft-tissue diode laser would be used to balance the right and left sides. The buccal corridors would be widened and new incisal edge positions as well as canine guidance would be re-established.⁸ By improving the arch form, and establishing canine guidance for excursive movements, we would place the patient’s teeth in a better functional position and lower the risk of future breakdown of the anterior teeth.
To accomplish the treatment plan, several options were discussed with the patient. She could have orthodontics to bring the teeth into proper occlusion, or she could have 10 pressed all-ceramic veneers placed on teeth Nos. 4 to 13.
In cases like this one, where the patient presents with anterior spacing concerns and/or rotated or malpositioned teeth, orthodontics is always proposed as the initial treatment of choice. This enables the clinicians to be more conservative in preparation designs. However, in this particular case, the patient was not interested in orthodontics due to her age. Furthermore, she wanted to change the shape and color of her existing dentition. As a result, the patient opted to have teeth Nos. 4 to 13 restored with veneers to improve not only their shape and her arch form, but also to create a more youthful looking and whiter smile that she desired. Because there would be sufficient tooth structure remaining after preparations were completed, the proposed porcelain materials could be used to develop her anterior guidance while correcting the spacing concerns.⁹

Clinical Protocol
Gingival recontouring on teeth Nos. 6 to 11 was performed using a soft-tissue diode laser (Odyssey [Ivoclar Vivadent]), being careful to maintain 3.0 mm of free gingival tissue (Figure 3).7 In this case, the initiated soft tissue laser fiber tip contacted the tissue to make an incision in Continuous Wave mode, beginning at 0.8 W. Lasing proceeded in order to raise tissue zenith and to refine the mesial papilla of tooth No. 7 (Figure 4).

Figure 3. Before using the Odyssey (Ivoclar Vivadent) soft-tissue diode laser, tissue levels were sounded to bone using a periodontal probe. During the laser recontouring procedure, care was taken to maintain 3 mm of free gingival tissue.	Figure 4. View of patient after laser recontouring of tooth No. 7. Note the more balanced gingival symmetry from teeth Nos. 6 to 11. Note also how much longer/more prominent tooth No. 7 is compared to preoperative condition.

Figure 5. Conservative preparations were completed in enamel for teeth Nos. 6 to 11. Decay was removed in the premolar area, and prepared for veneers accordingly.

One of the treatment goals was to correct the patient’s arch form. Following the recontouring of the gingival tissues, teeth Nos. 6 to 11 were conservatively prepared in enamel (Figure 5). Any decay was removed from the premolar area, and those teeth were then prepared accordingly. In general, teeth Nos. 4, 5, 12, and 13, were prepared for veneers that would wrap over the buccal cusps.
Full-arch upper/lower impressions (Virtual Fast-Set [Ivoclar Viva­dent]) were taken. A bite registration and bite stick registration were also taken. This information was sent to the dental laboratory, along with diagnostic photographs of the preparations and tooth shades (dentin [stump] and enamel shades).

Figure 6. The incisal edge position—as well as the expansion of the buccal corridor—were verified and worked out in provisional restorations.

Provisional restorations (Lux­atemp Bleach Shade [DMG America]) were then fabricated, with the desired shape, length, and contour of the desired definitive restorations being worked out at this stage (Figure 6).10-11 Models of the temporaries were also taken and sent to the laboratory to use as a template for fabricating the final restorations. The patient was asked to return in one week to make any needed adjustments, as well as to obtain photographs of the incisal edge position/lip position when her lip/mouth was not anesthetized.

Figure 7. Final veneers on the working model to verify fit and shape, as prescribed and outlined by the provisional restorations, photographs, and dental laboratory prescription.	Figure 8. Alternate view of the definitive pressed all-ceramic veneers fitting perfectly on the model. Note the colors/contours of the incisal edges.
Figure 9. The preparations were cleaned with a chlorhexidine/pumice mixture (Consepsis Scrub [Ultradent Products]). The 37% phosphoric acid gel was placed on teeth for 10 seconds.	Figure 10. A desensitizer (Systemp Desen­sitizer [Ivoclar Vivadent]) was applied to the preparations and lightly air dried to help control and reduce sensitivity.

When the definitive restorations (IPS Empress Esthetic [Ivoclar Vivadent]) were returned from the laboratory, their fit and shape, as well as the color and contours of the incisal edges, were verified by trying them on the working model (Figures 7 and 8). At the seating appointment, the temporaries were removed and complete isolation was achieved (OptraDam [Ivoclar Vivadent]). The preparations were then cleaned with a chlorhexidine and pumice mixture (Consepsis Scrub [Ultradent Products]). Next the teeth were total etched with a 37% phosphoric acid gel for 10 seconds. The etchant was rinsed off with water and lightly dried, leaving the teeth slightly moist (Figure 9). A desensitizer (Systemp Desensitizer [Ivoclar Vivadent]) was then applied to the preparations and lightly air-dried. This serves to rehydrate the teeth and control/reduce postoperative sensitivity (Figure 10).
A liberal amount of bonding agent (ExciTE [Ivoclar Vivadent]) was then applied as directed to the preparations. A glossy appearance confirmed adequate and complete coverage (Figure 11). The bonding agent was left on for 10 seconds, lightly air-dried, and then light-cured.

Figure 11. A moderate amount of bonding agent (ExciTE [Ivoclar Vivadent]) was applied to all preparations.	Figure 12. Using the Variolink Try-In paste (Ivoclar Vivadent) in shade +1 Value, the veneers were tried in the mouth to check the color.

A try-in paste (Variolink Try-In [Ivoclar Vivadent], in a shade matching the proposed final cement shade, was placed on the veneers and tried in (Figure 12). It was determined that the correct cement shade should be +1 Value, which was used for the definitive seating of the restorations. The pressed all-ceramic veneers were then rinsed, silanated (Monobond-S [Ivoclar Vivadent]), followed by a thin coat of ExciTE.

Figure 13. A 0.016 fine diamond was used to smooth/clean excess cement at the veneer margins.	Figure 14. Diamond polishing paste and polishing wheels (OptraFine [Ivoclar Vivadent]) in a slow speed handpiece were used for final polishing.
Figure 15. Postoperative view of the 10 pressed all-ceramic veneer restorations (Empress Esthetic [Ivoclar Vivadent]). Note excellent tissue health and that the gingival contours are more in harmony with the contra-lateral side. Also, note the wider buccal corridor.	Figure 16. The natural smile. Overall aesthetics were improved with a brighter smile.

The veneers were seated one at a time. Each was lightly tack-cured to hold them in place while clean-up was accomplished. In order to smooth and clean any excess cement from around the margins, a 0.016 fine diamond (Maxima Diamond bur [Henry Schein]) was used (Figure 13). Removing as much cement as possible before final curing facilitates easy clean-up. The veneers were then polymerized completely and occlusal adjustments were then made where necessary.
For final polishing, a diamond polishing paste and polishing wheels (OptraFine [Ivoclar Vivadent]) were used in a slow speed handpiece, progressing through the grits as directed (Figure 14). Upon examination of the definitive results, it was apparent that the pressed leucite-reinforced ceramic veneer restorations demonstrated a natural appearance and translucency in the incisal edge, and that the light reflecting off the central incisors was identical (Figure 15).
Our patient was asked to return in one week for final photographs and any necessary adjustments. Overall, her objective of achieving a whiter, brighter smile had been achieved (Figure 16).

CONCLUSION
Incorporating clinically proven restorative materials and state-of-the-art technologies into the dental practice can help doctors elevate the level of care. This article has demonstrated the combined use of pressed leucite-reinforced all-ceramic veneers and a soft-tissue diode laser to successfully address both the functional and aesthetic concerns of a patient (After).

References

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4. Nash RW. Porcelain ve­neers: a clinical perspective. Contemp Esthet Restor Practice. 2006;10:52-58.
5. Hastings JH. Conservative restoration of function and aesthetics in a bulimic patient: a case report. Pract Periodontics Aesthet Dent. 1996;8:729-736.
6. Stabholz A, Zeltser R, Sela M, et al. The use of lasers in dentistry: principles of operation and clinical applications. Com­pend Contin Educ Dent. 2003;24:935-948.
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Dr. Meeks is a junior instructor for Dr. Larry Rosenthal and Aesthetic Advantage at the Rosenthal Institute in New York City, and he has been the dental health expert on the local PBS Healthline TV show since 2007. He is in private practice in Fort Wayne, Ind. A graduate of the Indiana University School of Dentistry, Dr. Meeks is a member of the American Academy of Cosmetic Dentistry, ADA, the Indiana Dental Association, and the Isaac Knapp Dental Association. He has performed hundreds of laser procedures, from frenectomies to extensive gingival recontouring. A dental product tester for Ivoclar Vivadent USA, he also is the team dentist for Indiana University-Purdue University Fort Wayne. He can be reached at (260) 432-8700 or via email at tmeeksdds@aol.com.

Disclosure: Dr. Meeks reports no conflicts of interest.