Patients often present with multiple complications and factors that can affect the final outcomes of aesthetic-related dental treatment. If all the factors present are not identified, treated, and resolved, the clinician may be able to make some improvements, but the case will not be ultimately and completely successful.1 Identifying all of the factors that may be important to success and involving the patient in a discussion about the required treatment goals are essential.2-4
CASE REPORT
Diagnosis and Treatment Planning
The patient in this case report presented with a restored dentition that lacked a comprehensive aesthetic focus (Figure 1). She was displeased with the canting of her maxillary central incisors and the variation in color of her teeth and desired an aesthetic improvement to her smile (Figures 2 to 4).
A thorough aesthetic and functional assessment requires a systematic approach to resolving all apparent and hidden factors. To develop a comprehensive organized treatment plan, the patient’s casts were mounted in centric relationship (CR) on a SAM 3 Articulator (Great Lakes Orthodontics). Then a list of what was aesthetically and functionally present or absent was made. At first glance, functional and aesthetic issues that needed to be addressed included a canting to the left of the axial inclination of teeth Nos. 8 and 9, which resulted in a lower incisal edge position of tooth No. 8. Tooth color variations were present, due to the use of several material systems as well as a slightly more apical gingival zenith of tooth No. 9 compared to No. 8. An irregular occlusal plane, due to a curve of Spee that dipped down on the left, and irregular maxillary incisal edge position and incisal embrasures created asymmetry. It was also noted that the patient’s oblique smile resulted in a higher upper lip posture on the left compared to the right (Figure 2).
A comprehensive temporomandibular joint (TMJ) examination should always be completed during the diagnostic phase. A stable Piper Stage I TMJ diagnosis was confirmed for both right and left TMJs after negative muscle palpation. She had no history of clicking or symptomatic joints. TMJ Doppler auscultation, CR load testing, and normal range of motion testing were also completed.5,6 Six structural elements—disc alignment, disk shape, ligament anatomy, masticatory musculature, joint space, and condylar bone anatomy—were assessed as normal.5,6
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| Figure 1. Full-face view: the patient was dissatisfied with her smile. |
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| Figure 2. Frontal view of the patient’s smile. | Figure 3. Frontal, retracted view, showing multiple functional and aesthetic issues to address. |
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| Figure 4. Full-face view, demonstrating canting of the midline. |
A diagnostic wax-up was done to correct the midline and canting of teeth Nos. 8 and 9, the incisal edge position and incisal embrasures, and the dip in the left curve of Spee and the occlusal plane (Figure 5). A diagnostic wax-up is much like a GPS navigation system in that it provides the clinician with a path of treatment goals to follow to the destination of aesthetic and functional harmony. Without the diagnostic wax-up, we cannot be assured of where to begin and what the end point of treatment looks like. This patient’s occlusal plane needed to be addressed first to lay the foundation for a functional and aesthetic smile. Occlusal planes are often off due to a previous extraction, resulting in supra-eruption of the opposing tooth and mesial migration of the tooth distal to the extraction site. In this patient’s case, tooth No. 20 had been previously extracted, resulting in the supra-eruption of teeth Nos. 13 and 14 and the mesial migration of tooth No. 19 as well. Establishing the correct occlusal plane is essential in the wax-up and was achieved using the Wynne 2000 occlusal plane analyzer adapter (Great Lakes Orthodontics) for the SAM 3 Articulator (Figure 6). This occlusal plane analyzer identifies on the flag atop the articulator at the intersection of two 4-inch arcs. One arc’s center originates at the incisal tip of the mandibular canine, with the other arc’s center originating from the most distal cusp of the last mandibular molar. From the point of intersection of the two 4-inch arcs, a new 4-inch arc’s center will touch the cusp tips of the premolars and molars, indicating any shortening or lengthening of cusps that will be necessary to form the proper curve of Spee. This necessary step allows harmony to exist between the anterior teeth and condylar guidance by eliminating excusive interferences and obtaining a more predictable occlusal relationship.7 The wax-up with ideal occlusion, including anterior and posterior centric stops with right and left canine guidance, directs the clinician in the preparation and provisionalization phases of treatment (Figures 7 to 9). As was apparent from the lingual view of the patient’s teeth, severe tetracycline staining was present. So, a ceramic system that blocked out the discoloration and was not overly opaque was desired. The Authentic (Microstar) pressable ceramic system using the Authentic BOO+ ingot (Jensen Dental) was chosen for 8 all-ceramic crowns (teeth Nos. 6 to 11 and Nos. 28 and 29), 6 veneers (teeth Nos. 22 to 27), 4 onlays (teeth Nos. 4, 5, 12, and 13), and one 3-unit Authentic-Pressed-to-Galileo high noble PFM bridge (teeth Nos. 18 to 20). This pressable, all-ceramic system was selected due to its strength, excellent optical properties, and the ability for the material to accommodate conservative preparation designs.
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| Figure 5. Diagnostic wax-up, correcting aesthetic and functional issues. | Figure 6. The Wynne 2000 occlusal plane analyzer adapter (Great Lakes Orthodontics) for the SAM 3 Articulator (Great Lakes Orthodontics) allows for fabrication and verification of proper placement of the curve of Spee. |
Clinical Protocol
To establish symmetry with gingival zeniths between teeth Nos. 8 and 9, clinical treatment began with a simple gingivectomy on tooth No. 8. The mandibular arch was then prepared prior to the maxillary arch to establish correct mandibular incisal edge positions and the occlusal plane and curve of Spee (Figure 10).8 A diamond bur (Shank 31-FG, 8878K [Brasseler USA]) was utilized to achieve a facial reduction goal of 1.0 mm with 1.5 mm in incisal reduction. This reduction would allow the dental technician adequate room to build in incisal-edge translucency with a halo effect. All contacts were cleared and external line angles smoothed. Instead of leaving an interproximal preparation margin, the contacts were cleared and the margins placed on the lingual aspects of the teeth. In attending to this detail, porcelain coloration and midline adjustments in the facial gingival embrasures would be more easily facilitated. With the location of the lingual margin, resistance-retention form would be increased. In addition, the patient would more easily be able to maintain ideal oral hygiene with a more accessible lingual margin.1 A stick bite (with the patient standing) was then obtained prior to provisionalization to establish the proper plane of occlusion. A 4.5-inch plastic applicator brush was placed into bite registration material (Futar [Kettenbach LP]) and oriented so as to capture the horizontal plane as it related to the patient’s face and then held in place until the material was fully set. Although the patient’s interpupillary line was accurate, one external auditory meatus was higher on one side, which transfered error to the articulator. To relate this to the laboratory technician and to eliminate face-bow transfer error, the stick bite was placed on the model and elevated on one side of the articulator until the stick bite was parallel to the floor (or horizon) to establish the correct occlusal plane. The incisal edges of the wax-up were indexed using Sil-Tech Putty (Ivoclar Vivadent), which would also be used to serve as a reduction guide during tooth preparation. A Sil-Tech Putty matrix was also fabricated from the wax-up to be used as a provisionalization stint. A quick setting, self-cured crown and bridge resin (ALIKE [GC America]) was utilized for provisionalization. LuxaGlaze (DMG America) was then painted over the resin provisionals to create a lifelike enamel appearance (Figure 11). During the temporization phase of treatment, the patient was provided with Acclean Chlorhexidine Gluconate 0.12% (Henry Schein) to rinse and brush with to ensure excellent gingival health for the delivery appointment.
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| Figure 7. Posterior disclusion achieved with right lateral canine guidance. | Figure 8. Posterior disclusion achieved with left lateral canine guidance. |
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| Figure 9. Protrusive movement discludes the posterior dentition. | Figure 10. Mandibular arch prepared. |
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| Figure 11. Provisionalization of mandibular arch with ALIKE (GC America) resin. | Figure 12. Frontal view, showing final mandibular restorations in place with the corrected curve of Spee. |
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| Figure 13. Right lateral view of the initial preparation of the maxillary arch. Baseplate wax (TruWax Baseplate Wax [Dentsply Sirona]) and rapid set light body VPS impression material (Genie [Sultan Healthcare]) were used to eliminate tooth sensitivity in the mandibular arch. | Figure 14. Frontal view, showing the completed case. |
At the delivery appointment, the classical acid-etch technique was used to bond the restorations in place. Phosphoric acid gel (Etch-Rite 38% [Pulpdent]) was placed on the preparations for 20 seconds, then rinsed and dried. Next, a dentin desensitizer was applied (Dentin Desensitizer [Pulpdent]). A 4th-generation bonding agent (OptiBond FL [Kerr]) was then used by applying a few coats of primer and then a coat of adhesive to the preparations. After air thinning and light curing (Rembrandt Sapphire Plasma Arc curing light [DenMat]) the preparations for 20 seconds, the restorations were cleaned using Ivoclean (Ivoclar Vivadent). It was applied to the intaglio surfaces for 20 seconds and then rinsed with water to eliminate salivary phosphate contamination from the try-in. Next, the intaglio surfaces of the restorations were silanated (Silane Primer [Kerr]), and Calibra Esthetic Resin Cement (Dentsply Sirona) was used to cement the restorations. To finish the margins, a red-striped 30-grit diamond (Brasseler USA), a yellow-striped 15-grit diamond (Brasseler USA), and a white-striped 30-bladed finishing bur (Brasseler USA) were sequentially used. A Shofu polishing sequence was followed using the no-stripe, then the yellow-striped, and finally the white-striped polishing points (Shofu Dental). To ensure no residual interproximal resin cement was left after cementation, a Ceri-Saw (DenMat); a red-striped Gateway flex diamond strip (Brasseler USA); and then blue, green, gray, and tan EPITEX finishing strips (GC America) were utilized.
Occlusal equilibration of the maxillary arch was performed after delivery of the mandibular arch (Figure 12) to avoid altering the occlusal surfaces of the new restorations. Preparation of the maxillary arch was completed the following morning. Due to patient hypersensitivity of the mandibular arch during preparation of the maxillary arch, baseplate wax (TruWax Baseplate Wax [Dentsply Sirona]) with Genie (Sultan Healthcare) rapid set light-bodied vinyl polysiloxane impression material was used to cover the mandibular arch to eliminate sensitivity to air (Figure 13). The case was completed following the identical provisionalization and final restoration cementation protocol used for the maxillary arch.
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| Figure 15. Full-face view, demonstrating the corrected midline placement. | Figure 16. Full-face view of the aesthetic outcome. |
CLOSING COMMENTS
This patient’s aesthetic concerns of midline canting and color variation were addressed, as well as her functional occlusal plane issues, irregular incisal embrasures and incisal edge position, and gingival zenith discrepancy (Figures 14 and 15). Beyond a patient’s chief aesthetic complaint, there are often a number of additional issues to recognize and resolve. By providing the patient with a comprehensive aesthetic and functional solution, all involved with the case were pleased with the final result (Figure 16).
Acknowledgement
The author would like to express his appreciation for the skilled dental laboratory work done by John Wilson of Wilson Dental Arts in Raleigh, NC.
References
- Wynne T, Wynne WPD. A multifactorial approach to restorative dentistry. Inside Dentistry. 2015;11:72-78.
- Johnson PF. Racial norms: esthetic and prosthodontic implications. J Prosthet Dent. 1992;67:502-508.
- Peck S, Peck L. Selected aspects of the art and science of facial esthetics. Semin Orthod. 1995;1:105-126.
- Nanda RS, Ghosh J. Facial soft tissue harmony and growth in orthodontic treatment. Semin Orthod. 1995;1:67-81.
- Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby Elsevier; 2007.
- Dawson PE, Piper MA. Temporomandibular disorders and orofacial pain [seminar manual]. St. Petersburg, FL: Center for Advanced Dental Study; 1993.
- Lynch CD, McConnell RJ. Prosthodontic management of the curve of Spee: use of the Broadrick flag. J Prosthet Dent. 2002;87:593-597.
- Wynne T, Wynne WPD. How proper function dictates restorative success: repairing functional challenges in an esthetically pleasing smile. Inside Dentistry. 2016;12(1):56-62.
Dr. Wynne received his doctor of dental surgery degree (2014) from the University of North Carolina School of Dentistry, where he is also currently an adjunct professor. He practices general dentistry in Clemmons, NC, is a Member of the American Society for Dental Aesthetics, and is a Fellow of the International Academy for Dental-Facial Esthetics. He can be reached at wtwynne@gmail.com.
Disclosure: Dr. Wynne reports no disclosures.
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