Maximum Success in an Anterior Makeover Using the Minimum Number of Restored Teeth

The contemporary approach to most generalized aesthetic problems in the maxillary anterior teeth is to place six ceramic laminate veneers. From a dentist’s perspective, this treatment plan offers several advantages, such as relatively conservative tooth preparation, compelling control of sizing, contour, and color, minimization of pulpal or periodontal encroachment, limited disruption of harmonious occlusion, and a favorable fee for service as a function of chairtime.1,2 However, from a patient’s perspective, a more favorable approach often involves a lesser, more selective number of maxillary anterior teeth to preserve healthy tooth structure and minimize treatment cost. In these taut economic times, with the advent of the new computerized shade-matching systems3 combined with the color modifying stratification technique,4,5 three to four ceramic laminate veneers in combination with two to three natural teeth, that are either recontoured or bleached, can often produce an aesthetically pleasing result within the patient’s budget. This case report provides photodocumentation of an anterior aesthetic makeover that was successfully accomplished by utilizing less than the usual number of restored teeth, and the specific clinical procedures necessary to predictably achieve the final outcome.

CASE REPORT

Figure 1. Pretreatment smile photograph. Figure 2. Pretreatment photograph of anterior teeth.
Figure 3. Pretreatment photograph of discolored direct resin veneer on No. 7 (maxillary right lateral incisor).

A 32-year-old Spanish actress sought to upgrade her flawed smile, which was inconsistent in color, length, and sizing, as economically as possible. Figures 1 through 3 illustrate her pretreatment appearance. A thorough diagnostic evaluation revealed:

•A major disparity between the maxillary right and left lateral incisors, due to the overcontoured, discolored direct resin bonding on the shorter maxillary right lateral incisor in linguoversion, contrasting with the longer incisally edge-shortened (on the distal one half) left lateral incisor. Colorwise, the lateral incisors neither matched each other nor the central incisors.

•The gingival levels of the maxillary right anterior teeth (Nos. 6 through 8) were more incisal than the gingival levels of the maxillary left anterior teeth (Nos. 9 through 11). This condition, combined with the right central incisor being slightly shorter than the left central incisor at the incisal edge, and the right first premolar in the right canine position being decidedly shorter incisally than the left canine because of wear, and because it was a premolar not a canine, made the maxillary right anterior teeth look collectively shorter than the left anterior teeth.

•The presenting occlusal relationship between the maxillary right lateral incisor and the mesioincisal corner of the mandibular right canine and the distoincisal edge of the mandibular right lateral incisor was essentially edge-to-edge, disenabling any edge-lengthening of the maxillary right lateral incisor without initiating an interference that could lead to fracture.

•Presumably from bruxism, occlusal edge wear on the maxillary right first premolar not only aesthetically compromised the tooth lengthwise, but also transformed anterior guidance into group function and shallowed the vertical “lift” when the teeth disoccluded in right lateral excursion, thereby increasing the potential for occlusal interference between the maxillary right lateral incisor and the mandibular right canine and lateral incisor previously described.

•The maxillary left central incisor and the maxillary left canine were aesthetically acceptable to the patient in all dimensions including color.

•The maxillary right first premolar was in the position of the maxillary right canine because the maxillary right canine was extracted after a horizontal impaction 18 years ago. (Throughout the article, No. 6 refers to the maxillary right first premolar, since it is in the position of the maxillary right canine and will be transformed to a canine shape with a forthcoming ceramic laminate veneer restoration.)

The remaining dentition of the patient was within normal limits. Her limited number of restorations were functionally sound and free of any recurrent decay. Her natural dentition was caries-free, and her occlusion, though exhibiting some anterior wear, displayed no posterior interferences or joint symptoms. The periodontal condition around her maxillary anterior teeth was good, with normal sulcular depths and osseous architecture.

Figure 4. Aesthetically improved model (AIM).

Diagnostic data obtained included full-mouth radiographs, mounted maxillary and mandibular pretreatment stone models on a Protar articulator (Kavo America) from an Arcus ear bow apparatus (Kavo America), a complete clinical exam including a six-point periodontal probing, bone-sounding depths on all anterior teeth to be restored,6 and an occlusal analysis including point of first contact, centric contacts, border movements, wear facets, and TMJ muscular palpation. Once these data were obtained, an aesthetically improved model (AIM) was formulated in stone (Figure 4) to assist the patient in visualizing three- dimensionally aesthetic and functional improvements proposed for her smile. This important “preview” model not only serves as a tangible guide for the patient to better comprehend the nature of the beneficial changes intended for her, but also serves as a tooth preparation guide, a matrix for provisional restorations, and an important communication source for the laboratory technician to use in fabricating the case. After viewing the AIM (Figure 4), the patient affirmed the proposed treatment plan of utilizing only four hand-stacked ceramic laminate veneers on the maxillary right central incisor, lateral incisor, and first premolar (Nos. 6 through 8), and the maxillary left lateral incisor (No. 10) to effectively upgrade color coordination, tooth-sizing, tooth length, and arch alignment.

The dissimilarity in gingival levels of the right side anterior teeth to the gingival levels of the left side anterior teeth was to be corrected by gingivectomy and gingivoplasty on the right side teeth, and the potential occlusal interference around the maxillary right lateral incisor (No. 7) was to be eliminated by reducing and recontouring in enamel the mandibular right lateral incisor and the mandibular right canine (Nos. 26 and 27). (Figures 19 and 20 illustrate the pretreatment appearance of the lower anteriors followed by the recontoured appearance of Nos. 26 and 27 to eliminate occlusal interference.) The maxillary right lateral incisor edge was also placed more labial than its pretreatment location, to facilitate this correction. (Figure 18 shows the posttreatment appearance of the completed case.) Finally, the maxillary left central incisor and the maxillary left canine (Nos. 9 and 11) were not altered in any way including color, in accordance with the patient’s desires.

Figure 5. Pretreatment color analysis of No. 9 (maxillary left central incisor) using Vita Classic shade tabs. Figure 6. Computerized color analysis of No. 9 using Shade Scan chairside camera.
Figure 7. Computerized color analysis print-out of No. 9 from ShadeScan. Figure 8. Prepreparation photograph of No. 7 after removal of old direct resin veneer. Note spacing and linguoverted alignment.

Prior to initiating treatment, since No. 9 and No. 11 were to remain unchanged including tooth color, a slide of No. 9 was taken using the time-honored approach of communicating its color with two Vita classic shade guide buttons to the laboratory technician (Vita A2 for the approximate cervical one-half color and Vita D2 for the approximate incisal one-half color) (Figure 5). The same method was adopted for the color of the maxillary left canine. Additionally, a sophisticated computerized color analysis of tooth No. 9 (ShadeScan, Cynovad/Cortex Machina) was attained utilizing the chairside computerized “slave” to formulate a very accurate print out of the hue, chroma, value, and opacity/translucency of teeth Nos. 9 and 11 along with its correlated feldspathic ceramic powders (Figures 6 and 7). By means of this new method of precise color communication, very close color matches of Nos. 9 and 11 were anticipated for the veneer restorations for Nos. 6 and 8. Since the resultant color for No. 8 veneer restoration could be appropriated for Nos. 7 and 10 veneer restorations, it was anticipated that the four incisor teeth would demonstrate a very accurate color match. Also, the maxillary right lateral incisor was stripped of its bulky, discolored direct resin veneer to expose the underlying natural tooth. The tooth color was computer analyzed prior to veneer preparation to provide additional color information for the restoration of this tooth (Figure 8).

PREPARATION

Figure 9. Ceramic laminate veneer preparations of Nos. 6 through 8 and No. 10 after crown-lengthening gingivectomy on No. 7 and gingival cord retraction on Nos. 6 through 8.

In the first treatment appointment, Nos. 6 through 8 and No. 10 were prepared conservatively with the Nixon PV II Kit (Brasseler, USA) for ceramic laminate veneers (Figure 9), after gingivectomy/gingivoplasty were performed on Nos. 6 and 7. All prepared teeth, particularly the gingivectomized teeth, were then treated with the bland hemostatic gel, Tissue Goo (Clinician’s Choice) to arrest hemorrhage, the gingival tissues were retracted with fine, untreated cord, and all anterior teeth were cleansed of tooth debris, residual hemorrhage, and salivary contaminants with Detail cleansing liquid (Clinician’s Choice) in anticipation of taking final impressions. After teeth Nos. 26 and 27 were recontoured and polished (as previously discussed) for occlusal harmony, a maxillary full-arch impression was taken with a combination of Affinity (Clinician’s Choice) VPS Light Body HF and Heavy Body tray material to achieve a highly detailed, dimensionally stable master impression. Enhanced hydrophilicity attributable to a grafted hydroactive surfactant permits accuracy even in the demanding postgingivectomy environment presented in this case (Figure 9). Technique-designed viscosities and independent working and curing times, especially the fast-set formula, translates to personalized technique convenience combined with no wasted chairtime. Affinity Quick Bite registration material (Clinician’s Choice) was utilized to accurately relate the mandibular full-arch model to the mounted maxillary master model.

PROVISIONALIZATION

Figure 10. RSVP-clear PVS matrix being loaded with RSVP-light provisional veneer resin—LC during fabrication of provisional veneers for Nos. 6 through 8, and No. 10.

To formulate provisional veneers rapidly and with minimal finishing of troublesome flash, the RSVP (Rapid Simplified Veneer Provisional) System (Cosmedent) was used. A firm, clear polyvinylsiloxane matrix of nine maxillary teeth (maxillary right first molar to maxillary left first premolar) on the aesthetically improved model (Figure 4) was made with the RSVP Matrix material (Cosmedent) (Nos. 6 through 8, and No. 10 prepared teeth, and the two teeth distal to Nos. 6 and 10, which act as stops). The RSVP Matrix material was trimmed to cover the incisal two thirds of the prepared teeth, and the prepared tooth shells were filled with flowable, but thixotropic RSVP-light provisional resin (Cosmedent) (Figure 10). The prepared teeth were isolated, cleansed again with Detail (Clinician’s Choice), and spot-etched in the facial center of Nos. 6, 8, and 10 with a 2-mm diameter “dot” of 37% phosphoric acid for 10 seconds. The prepared teeth were then thoroughly rinsed to remove the acid, dried completely, and the entire prepared tooth surface lightly coated with an unfilled dentin/enamel adhesive, All Bond II dentin/enamel adhesive (Bisco), and light cured for 10 seconds. DO NOT USE ANY DENTIN PRIMER SUCH AS ALL BOND II A OR THE PROVISIONAL VENEERS WILL HAVE TO BE GROUND OFF.

Figure 11. RSVP resin provisional veneers on teeth Nos. 6 through 8, and No. 10.

The trimmed RSVP Matrix, loaded in the prepared tooth shells with RSVP-light resin, was carefully seated over the nine maxillary anterior teeth, the uncured cervical excess carefully removed, and the RSVP was light cured through the clear matrix for 5 seconds only facially and incisally with a halogen curing light. Peripheral flash, if there is any, is removed with a sharp scaler or a Bard Parker No. 12 scalpel. The uncovered cervical one third of the prepared teeth was then filled in and sculpted to exact marginal placement and facioproximal contour with RSVP-heavy (Cosmedent), a putty-like, light-curable provisional resin material, with a thin-bladed instrument like an IPC carver, and light cured for 20 seconds per tooth. There should be minimal or no flash trimming except at the facial junction of the RSVP-light and RSVP-heavy. Any excess contour or marginal excess that does exist was trimmed with appropriate fine diamond or ET carbide burs (Brasseler, USA). To eliminate tedious, time-consuming fine finishing and polishing, one or two thin coats of light-curable Temp Glaze (Clinician’s Choice) was placed over the unpolished, but contoured, provisional veneer surfaces and light cured for 10 to 15 seconds. A very aesthetic high gloss will result from light wiping of this material with a cotton roll, requiring no finishing, because of the minimal air-inhibited layer. As seen in Figure 11, the RSVP provisional restorations are virtually identical to the aesthetically improved stone model, biocompatible in contour, and easily and quickly fabricated.

PLACEMENT OF VENEERS

Figure 12. Four hand-stacked ceramic laminate veneers on the die model for teeth Nos. 6 through No. 8, and No. 10. Figure 13. No. 8 ceramic laminate veneer shell being loaded with a water-soluble, non-light reactive Prevue try-in gel color.
Figure 14. Initial Prevue gel color, Clear, produces a veneer color that is too light (too high in value).

The finely crafted, hand-stacked feldspathic ceramic laminate veneers (DaVinci Dental Studios, West Hills, Calif) (Figure 12), as shown on the die model, demonstrate accurate color matching, aesthetic contours and alignment, and precise marginal adaptation. The RSVP provisional veneers were readily removed from the prepared teeth with a universal scaler. The teeth were then isolated, cleaned of debris, and dried. To fine-tune the color match, initiated by the highly accurate computerized color analysis, a 0.2-mm die spacer except at the margins was instituted in the veneer fabrication. This stratification concept permits the resin cement to influence the general veneer color to a much greater degree. Once the prepared teeth were isolated and cleansed, the ceramic laminate veneers were color evaluated with the low glycerin content, water-soluble Prevue try-in gels (Cosmedent) that closely match the light-polymerized color of the resin cement they are keyed to, which is Insure Universal Cementation System (Cosmedent). After several Prevue gel colors were dispensed into the veneer shells with the new, no-waste syringe tip (Figure 13), it was discovered that Insure regular resin cement shade Yellow-Red light (Cosmedent) was the cement color of choice, because of the accurate match of the veneers to the tooth color of Nos. 9 and 11 (Figure 14).

Using conventional ceramic laminate veneer cementation technique, all prepared teeth were pumiced and scrubbed with Detail (Clinician’s Choice) to remove all surface contaminants. Retraction cord was placed to prevent gingival encroachment, and the veneers were tried in individually and collectively, and adjusted as needed. The veneers were then removed, the etched surfaces decontaminated with 37% phosphoric acid (etch-37%, Bisco) for 30 seconds, rinsed, and dried thoroughly. The etched veneer surfaces were then silanated, coated with a thin layer of unfilled light-curable resin bonding agent  (All Bond II dentin-enamel adhesive, Bisco), and placed into a light-shielded container, but not light cured at this time.

Figure 15. After acid etching, No. 8 is primed for adhesive cementation with All Bond II primer. Figure 16. The ceramic laminate veneer for No. 8 is loaded with Insure Yellow-Red light resin cement, after silanation, in preparation for cementation.

The teeth prepared for ceramic laminate veneers, Nos. 6-8 and 10, were isolated, cleared of any residual water-soluble Prevue try-in gels with a copious water spray, cleansed again with Detail (Clinician’s Choice), and acid-etched with 37% phosphoric acid for 15 to 20 seconds per tooth. All four teeth were dried but not dessicated. Each tooth was rewetted to a moist state with a cotton applicator, and a fourth-generation bonding agent, All Bond II (Bisco), was applied in compliance with manufacturer’s instructions (Figure 15). The All Bond II light-curable dentin-enamel adhesive was applied in a thin coating on all four teeth as the final application of the All Bond II adhesive sequence, but not light cured, and the dental headlight was lowered to chin level to avoid premature polymerization. The four etched, silanated, veneer shells, coated with bonding agent, were then filled with Insure Regular light-curable resin cement—shade Yellow-Red light (Figure 16) with the new dispensable tip, which permits controlled delivery without any wasted resin cement oozing out of the syringe. All four ceramic laminate veneers were carefully positioned for accurate seating, and the gross uncured excess resin cement removed with a thin-bladed instrument like an IPC carver. The veneers were spot-cured in the center of the facial surfaces for 10 seconds with the 3-mm turbo tip of a halogen curing light, while the veneers were held firmly in the fully seated position. With all four veneers now spot-cured into place, fine acrylic brushes such as the No. 3 and No. 1 brushes (Cosmedent) were used to delicately remove the remaining uncured resin cement excess along the margins. A heavy liquid glycerin was then placed over all the veneer margins to inhibit formation of the oxygen-inhibited layer, and the veneers were light-cured on the linguoincisal and facial surfaces for 45 seconds per surface with a 13-mm halogen curing light tip.

Final finishing and polishing were carried out with appropriate rotary disks, carbide-tipped hand instruments, Bard Parker scalpels (Nos. 12 and 12A), and D-Fine diamond polishers for porcelain (Clinician’s Choice) until seamless margins and smooth glossy surfaces were achieved. The occlusal contacts were marked and any necessary adjustments performed.

CASE RESULTS

Figure 17. Posttreatment smile photograph. Figure 18. Posttreatment photograph of anterior teeth.
Figure 19. Pretreatment photograph of mandibular anterior teeth prior to recontouring of Nos. 26 and 27. Figure 20. Posttreatment photograph of mandibular anterior teeth after recontouring of Nos. 26 and 27.

The case result (Figures 17 and 18) displays the aesthetic improvements and occlusal corrections (Figures 19 and 20). Cutting-edge materials, savvy clinical technique, and discerning analysis of patient needs and preferences combined to generate a dazzling smile makeover and, most importantly, a very happy patient!

Acknowledgment

The author wishes to acknowledge the stellar ceramic artistry of Mr. Daniel Materdomini, CDT, of DaVinci Dental Studio, West Hills, Calif, in the fabrication of the ceramic laminate veneers, and Mr. Steve Youngerman, CDT, of DaVinci Dental Studio, for his color analysis of the patient’s natural teeth utilizing the ShadeScan.


References

1. Belser U, Magne P, Magne M. Ceramic laminate veneers: continuous evolution of indications. J Esthet Dent. 1997;9:209-219.

2. Nixon RL. Porcelain veneers: An esthetic therapeutic alternative. In Rufenacht CR. Fundamentals of Esthetics. Chicago, Ill: Quintessence Publishing Co; 1990:330-332.

3. Freedman GA. Communicating color. Dent Today. 2001;20(9):76-80.

4. Nixon RL. Building natural color into porcelain laminate veneers. Pract Periodont Aesthet Dent. 1990;2(4):22-26.

5. Terry DA, McLaren EA. Stratification: Ancient art form applied to restorative dentistry. Dent Today. 2001;9:66-71.

6. Kois JC. Altering gingival levels: the restorative connection. Part 1:Biologic variables. J Esthet Dent. 1994;6(1):3-9.



Dr. Nixon is a fellow of the American Society for Dental Aesthetics. He has written numerous articles on aesthetic dentistry and is codirector of the Center for Esthetic Excellence in Chicago, Ill. He maintains a dental practice emphasizing quality-oriented aesthetic dentistry in Beverly Hills, Calif. He can be contacted at (310) 859-1697.

Disclosure: Dr. Nixon is a consultant for Cosmedent and Clinician’s Choice.