The Aesthetic Zone Challenge

INTRODUCTION
On a scale of one to 10, the number 10 seems always to be the optimal numerical value when quantifying excellence. When smiles are designed and considerations of change in shade, alignment, architecture, and anatomy present, we often think of the involvement of the upper 10 teeth (second bicuspid to second bicuspid) that are predominately exposed in the normal animations of smiling, speaking, and laughing. Variations of course exist, but I believe most clinicians would agree on the upper 10. It presents the aesthetic dentist with the ultimate palette of creativity. Shade, alignment, gingival architecture, and anatomical shape of the teeth can all be designed to the ideal wants and desires of the patient and doctor alike. But it is not always the number that is realistic for the patients or doctor due to considerations of cost, age, fear, etc.

Aggressive reduction of teeth, particularly in a younger patient, is always something we must try to avoid. The advent of procedures and techniques that are more additive than subtractive are the most desirable option when they can deliver the results desired by the patient and doctor. Treating 10 teeth surely gives us that latitude; however, cost, age, or the desire and/or need to remain conservative can all become challenges to deliver an aesthetically desirable result.

CASE REPORT
Diagnosis and Treatment Planning
A 16-year-old patient presented with congenitally missing right and left lateral incisors (teeth Nos. 7 and 10), deficient thickness of alveolar ridge, along with discolored and mottled enamel in the existing dentition (Figure 1). She expressed a desire to replace her missing teeth, to have an overall improvement in the color of her teeth, and to have a fuller smile.

For this patient, the cost of treatment was a concern. So, to give the patient and her parents (who would be paying) an idea of the treatment options and outcome that could be attained, a thorough radiographic and clinical exam, along with cosmetic imaging, was done.

The shade of her natural dentition and her gingival architecture were both compromised. Deficiencies in the buccal palatal width of her alveolar ridge in the proposed implant sites were noted. Her overall arch form was good due to recently completed orthodontic treatment. There had been previous communication between the orthodontist and the restorative dentist regarding maintaining the lateral incisor space. The parents and patient were interested in entertaining all possibilities to attain optimal aesthetics in this case. The use of cosmetic imaging (Envision a Smile [Envision a Smile]) allowed us the opportunity to accurately depict a preoperative visual of what would be attainable.

Figure 1a. Full-face pretreatment photo.	Figure 1b. Frontal retracted view, pretreatment.

In this case, 2 images were created for presentation to the patient and her parents during a treatment planning consultation appointment (Figure 2). The first treatment option (Figure 2a) shows the case involving color change, proportion change, and placement of virtual teeth in the No. 7 and 10 edentulous areas to involve the 10 upper teeth with implants in the No. 7 and 10 positions, along with minimal to no preparation veneers in the No. 4, 5, 6, 8, 9, 11, 12, and 13 positions.

The second treatment option (Figure 2b) would involve the placement of implants in the No. 7 and 10 positions, restorations of the implants along with bleaching of the natural adjacent dentition. The patient and her parents did not entertain consideration of any bridge designs. This second treatment option for a more conservative approach was accepted.

Clinical Treatment Begins
A coordinated multidisciplinary approach between the implantologist and the aesthetic restorative dentist is paramount in predicting treatment success. A mounted diagnostic wax-up was done to establish aesthetic preoperative proportion and to evaluate the ideal functional position. The mounted diagnostic wax-up provided a reference to the implantologist as to how the desired result would appear and to aid in the placement of the implants.

The patient was referred to the implantologist (Dr. Jay Beagle, Indianapolis, Ind) for placement of implants in the positions of Nos. 7 and 10. Evaluation of the implant sites revealed a deficiency in the horizontal (facial palatal) width of the alveolar ridge requiring augmentation using the guided bone regeneration technique with an autogenous bone graft (Figure 3). The area was revisited for implant placement after 7 months of healing. A 10-mm Narrow Connection Bone Level Straumann Implant was placed in the No. 7 position and a 12-mm Narrow Connection Bone Level Straumann Implant was placed in the No. 10 position. The sites were also augmented with autogenous bone and BioCol. (BioCol is a material that is used in conjunction with autogenous bone post-extraction and in implant placement.)

Figure 3. Retracted view of the augmented ridge.

Figure 4a. Provisional abutment refining cervical contour.	Figure 4b. Close-up view of provisional abutment in place.

Figure 5. Retracted view, showing healing tissues around abutments.	Figure 6. Close-up photo of one of the healed implant sites.

The patient’s appointments were coordinated so that upon completion of the placement of the implants, the patient would immediately come into our office for design of custom provisional restorations. Certain occasions allow the immediate placement of provisional restorations on the implants. There are several advantages to immediately loading an implant:

1. There is only one surgical procedure for the patient.
2. Treatment time is shortened, as there is no need to uncover the implant.
3. Fixed provisionalization is possible.
4. It allows the aesthetic restorative dentist to effectively design the provisional abutment/temporary crown with the proper emergence profile and soft-tissue support.

This is particularly pleasing to the patient in that removable (Essex, flipper) appliances do not need to be considered, nor does the patient need to go without restoration for the duration of healing.

Figure 7a. View of zirconia abutments on the model.

Figure 7b. Close-up right lateral of the lithium disilicate (IPS e.max [Ivoclar Vivadent]) restoration on the model.	Figure 7c. Close-up photo of the left lateral IPS e.max restoration on the model.

Provisional Design
The patient returned to our office immediately after placement of the implants with the healing abutments in place. Provisional implant abutments had been selected. The healing abutments were removed and the provisional abutments placed and hand tightened. A line was gently scribed on each abutment at the gingival margin. The abutments were then unscrewed and removed. Healing abutments were then screwed back into position to aid in maintaining the tissue so as not to allow it to collapse into the implant site. The provisional abutments were then prepared following the scribed outline just above the gingival margin and reduced incisally to provide adequate space for the implant/provisional restoration from the opposing dentition. A smooth chamfer was created. The abutments were coated with an adhesive and a small bead of flowable resin (Venus Flow [Kulzer]). The provisional abutments were then screwed back into their positions, and additional flowable resin was placed in the cervical area and then light cured. This established a favorable supportive and aesthetic contour to promote formational healing (Figure 4). The openings on the lingual of the provisional implant abutments were filled with plumber’s tape to the top of the access opening. The adjacent teeth and sutures were lightly lubricated with Vaseline. A matrix, which had been fabricated from a diagnostic wax-up, was then filled with Venus Temp (Kulzer) and placed in the mouth over the No. 7 and 10 positions and allowed to set for 2 minutes. The matrix was then removed, leaving the provisional/implant restoration in place. An access opening in the lingual was created, revealing the opening of the implant abutment. The plumber’s tape was removed and the provisional implant complex was unscrewed and removed. The healing collar again was placed to support the peri-implant tissues. The provisional/implant abutment was then refined and polished at the margin and interproximally contoured to the ideal form to support the healing tissues and to provide some semblance of shape and form for the patient during the coming 8 to 10 weeks.

Final Restoration
Once the patient was released from the implantologist, the process for final restoration was implemented. An excess of gingival tissues was evident after healing (Figure 5). Reshaping of the gingival margin to the appropriate aesthetic level was established with a soft-tissue (diode) laser (NV Microlaser [DenMat]). An impression of the Nos. 7 and 10 areas was taken with a vinyl polysiloxane (Flexitime [Kulzer]). Bite registrations and a face-bow transfer record were taken utilizing the Artex (Amann Girrbach) articulator system. The provisional/abutment complex was again placed and then screwed into position.

Figure 8a. Close-up right lateral IPS e.max restoration in clinical position.	Figure 8b. Close-up of the left lateral IPS e.max restoration in clinical position.

Figure 9. Our patient’s natural-looking smile.	Figure 10. Full-face photo of our patient’s final aesthetic outcome.

Communication With the Laboratory Team
Maximal opportunity for optimal anterior aesthetics when implants are involved requires the use of custom abutments. All-ceramic zirconia abutments were chosen for this case.

Additional considerations in this case were the challenges of aesthetic ceramic crown design, particularly in a case such as this where the enamel is multicolored and/or is exhibiting a mottled appearance. Attempting to create nature in an all-ceramic restoration to blend with nature is the ultimate aesthetic challenge. The best possible aesthetic outcomes are attained using photography, written communication, an understanding of the optimum material choice(s) and the underlying shade of the preparation (in this case, the abutments).

Delivery of the Final Restorations
The patient returned to our office 4 weeks later. The provisional abutment/crowns were unscrewed and removed showing healthy and well- contoured sites ready for placement of the final aesthetic restorations (Figure 6). The zirconia custom abutments were evaluated on the model, along with the completed lithium disilicate crowns (IPS e.max [Ivoclar Vivadent]) (Figure 7). The abutments were then placed intraorally and tightened to 35 Ncm and again evaluated for shape, width, and margin placement. The all-ceramic e.max restorations were then passively placed and evaluated for fit, shade match, contour support of the interdental tissues, and occlusion. Once confirmed, the zirconia abutment was primed (Z-Prime [BISCO Dental Products]) (2 applications). The intaglio surfaces of the restorations were cleaned after try-in (Ivoclean [Ivoclar Vivadent]), treated with a universal primer (Monobond Plus [Ivoclar Vivadent]), and dried. The restorations were then cemented into place (RelyX UniCem 2 Transparent [3M]).

A one- to 2-second light wave technique was used to gel the cement and then the excess cement was removed from the perimeter of the restoration and all areas subgingivally cleaned. The restoration was then fully cured with the light-curing unit.

Centric occlusion and protrusive with right and left lateral guidance were all evaluated to ensure proper support and aid in the natural protection of the aesthetic implant restorations (Figures 8 and 9).

CLOSING COMMENTS
Certainly, in this case, a more involved and aggressive treatment plan could have been selected, resulting in a more vibrant shade and possible improvements in anatomical design. It must be remembered that aesthetics are subjective. What may be attractive to one person could be challenged by the eye that is influenced by the aesthetic experiences and perspectives of another. As always, what is important is to listen to the needs and desires of the patient and attempt to work within the parameter(s) given. If we adhere to principles of smile design—symmetry, teeth in pleasing proportions to one another and to that which surrounds them, and healthy function—an aesthetically pleasing and long-lasting result is attainable (Figure 10). 

Acknowledgment
The author would like to acknowledge the following people: Jay Beagle, DDS, MSD (periodontist/implantologist, Indianapolis, Ind) for his work on this case; Lauri Dwyer of Envision a Smile (envisionasmile.com) for quality imaging; and Hak Joo Savercool, ceramist of San Diego Aesthetic Dental Studio.

Dr. Kirtley has been involved in the field of cosmetic dentistry since 1985. He completed his DDS at Indiana University and is an accredited member of the American Academy of Cosmetic Dentistry and the British Academy of Cosmetic Dentistry, presently one of a very few dentists worldwide to be accredited in both the United States and the United Kingdom. He is a part of the leading cosmetic teaching institution, the Aesthetic Advantage, located at the Rosenthal Institute in New York City. Additionally, he serves as a visiting lecturer at New York University College of Dentistry. He has positioned himself as an international leader in dentistry through teaching, lecturing, writing, and providing aesthetic smiles seen on patients throughout the United States and Europe. He can be reached by phone at (317) 841-1111 or via email at george@smilesbygeorge.com.

Disclosure: Dr. Kirtley reports no disclosures.

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