Dental aesthetics is not just a popular topic within the dental community, it is also at the forefront of public interest. In general this “trend” has been economically beneficial to the profession. However, there have been cases in our practices that we as clinicians wish we had not encountered. Indeed, whenever an aesthetic enhancement is planned, the clinician must first listen carefully to the patient’s concerns and desires, before discussing any possible treatment options. Once the expressed desire of the patient is deemed reasonable and achievable, the clinician and the patient should uniformly arrive at a clear understanding of the possible outcome of the treatment before continuing.
Before proposing any treatment modalities, the doctor needs to consider the limitations and risks inherent with each procedure and communicate these in detail with the patient. This interactive diagnostic approach will most likely result in a satisfactory outcome for everyone and help prevent future problems. In addition, throughout the course of treatment, it is crucial that the doctor takes the time to review the treatment objectives and progress made, every step of the way. Repetitive as it may seem, this extra effort will not only further strengthen the doctor-patient relationship, but it will also help keep everyone on the same page.
This article will illustrate a challenging case involving not only an anatomical obstacle (cleft lip/palate), but a psychological issue as well. This patient management issue was present because the patient had become wary of dentistry due to past dental “cosmetic” treatment failures.1-4
Figure 1a. Full smile before.
Figure 1b. Right lateral smile before.
Figure 1c. Left lateral smile before.
|Figure 1d. Frontal retracted before in occlusion.|
|Figure 1e. Right retracted before.||Figure 1f. Left retracted before.|
|Figure 1g. Upper occlusal view before.|
The patient was 50-year-old Caucasian male in good health. His chief complaint was the unpleasant appearance of his teeth (Figures 1a to 1g). At the initial consultation, the patient expressed his displeasure with his previous “cosmetic” dental treatment. He was seeking assistance to improve his smile. He stated that his appearance had been affecting his personal life. In order to clearly define the patient’s needs and desires, preliminary digital photos were taken. These were then presented on a computer monitor to aid in the evaluation, and to help determine the treatment options. Assisted by this powerful visual aid, we focused our discussion on the following areas of concern: canted front teeth; defective and unattractive old veneers and crowns; off-center midline because of the cleft lip/palate and missing tooth No. 9; unpleasant maxillary arch shape and constricted buccal corridors; and a “gummy” smile in the area of teeth Nos. 4 to 8, 12, and 13.
Figure 2a. Diagnostic model occlusal view.
Figure 2b. Diagnostic model frontal view.
Once these preliminary concerns and possible solutions had been briefly addressed, impressions and a bite registration were obtained for diagnostic study models (Figures 2a and 2b). Afterward, the patient was reappointed for an indepth discussion of the treatment options, respective costs, and the associated advantages/disadvantages. In order to avoid creating any false expectations, the clinician must be absolutely clear and honest with the patient with respect to the anticipated outcome.
In this particular case, the proposed treatment plan involved crown lengthening from teeth Nos. 4 to 8, and teeth Nos. 12 and 13 (to achieve a more pleasing gingival architecture). All-ceramic crowns from teeth Nos. 3 to 14 to correct both frontal and occlusal disharmony. Aesthetic challenges for the dental technician included the following: the tooth replacing missing teeth Nos. 9 and 10 would need to be designed to simulate a central incisor; No. 11 would need to resemble a lateral incisor; and No. 12 would need to be made to mimic a cuspid in appearance).
THE IMPORTANCE OF DIAGNOSTIC STUDY MODELS
As far as treatment planning was concerned, a functional and aesthetic treatment plan could never have been possible without the assistance of a set of properly mounted diagnostic study models. As with most of my cases, I have found it extremely advantageous to mock-up my own diagnostic study models utilizing a composite resin. Not only does it allow me to analyze each tooth in detail, I also get to practice prepping the case and to visualize the tooth reduction needed to optimize the chosen restorative material(s). Another benefit from doing your own diagnostic study models with a composite resin is that you get to improve your direct veneer technique. In conjunction with a full-set of “before” photographs exhibited on the computer monitor, these models allowed us to demonstrate the projected outcome of the treatment
to this patient. We also used them to demonstrate the functional relationships of the masticatory system. Moreover, the models were of great assistance in explaining the crown-lengthening procedure to our patient, as well as the uneven gingival architecture to be expected because of the uniqueness of his condition.
With the patient’s approval and financial details finalized, an appointment was set up for the crown-lengthening procedure, which was the first phase of the treatment sequence.
CROWN LENGTHENING PROCEDURE
Since surgery was involved, the patient was instructed to start taking 875 mg of amoxicillin the day before his appointment (then 1 bid for 7 days), and 3 (4 mg) tabs of Dexamethasone the morning of the surgery, 2 tabs the next morning, and then 1 tab the third and fourth mornings. The intention for this pharmaceutical protocol was to reduce the risk of infection and to minimize any swelling and associated discomfort. In addition, before anesthesia was initialized, the patient was given 2 tabs (200 mg each) of ibuprofen to inhibit the synthesis of prostaglandins from arachidonic acid, thus helping to further minimize discomfort and edema associated with inflammation.5 Moreover, the patient was also given a rinse of 0.12% chlorhexidine gluconate to further reduce the risk of infection.
Once vital signs had been obtained and recorded, local anesthesia was administered. Citanest 4% plain (DENTSPLY Pharmaceutical) was initially given for comfort, and Marcaine 0.5% with 1/200,000 epinephrine (AstraZeneca) was administered to ensure a profound and durable anesthesia. With the aid of a surgical stent fabricated from the maxillary diagnostic model, envelope flaps were reflected from teeth Nos. 3 to 8, and teeth Nos. 11 to 14. This was done to verify the location of the CEJ in relation to the osseous crest before any osseous modification was done.6-15
After the necessary osseous recontouring was completed, the flaps were apically adapted at the desired position, guided by the surgical stent and reapproximated with 5-0 vicryl sutures (Ethicon). Once the surgery was completed, the patient was then slowly seated upright, and postoperative instructions were clearly explained, including daily rinses with 0.12% chlorhexidine and with warm salt water. The patient was instructed to gently clean the surgery area only with microbrushes soaked in chlorhexidine for the next 10 days. At that point he was seen again for a postoperative check and suture removal. As far as the surgical treatment is concerned, a specialist could have performed it, with the generalist providing all necessary information, including a precise surgical stent. If an interdisciplinary approach had been chosen, clear communication would again have been imperative.
RESTORATIVE TREATMENT PHASE BEGINS
Figure 3. Occlusal view of preparations.
After a waiting period of 6 weeks and uneventful healing, the prosthetic phase of the treatment was initiated. Once proper consents and local anesthesia had been ascertained, the existing restorations in the area of teeth Nos. 3 to 14
were removed using the appropriate burs. Then, once any necessary build-ups and preparations (Figure 3) were completed, retraction cords (GingiBraid 000 and 00 [Dux Dental]) were placed using the double-cord technique. The preparations were then scrubbed with microbrushes and an antimicrobial solution (Tubilicid Red [Global Dental Products]) to clean off the smear layer and to simultaneously help desensitize the dentin. After this, the preparations were etched with 37.5% phosphoric acid for 15 seconds. A coat of Prime & Bond NT (DENTSPLY Caulk) was then applied and light cured to form a “hybrid” layer to seal the open dentin tubules and, therefore, reduce sensitivity.16-18
The 00 retraction cords were then removed (leaving the 000 cords in place), and an impression was obtained using a full-arch custom tray with a polyvinyl siloxane (PVS) impression material [Genie, Sultan Healthcare]). After verifying that a good impression had been acquired, the temporaries were fabricated using a custom stent and Integrity temporary material (DENTSPLY Caulk). Before temporary luting of the provisional crowns, a stick bite, posterior bite, and facebow record were obtained. Once the temporaries had been properly adjusted, and the occlusion checked with the patient seated upright, the provisionals were cemented with TempBond Clear with Triclosan (Kerr).
Before dismissal, the patient was reappointed for a “refinement” visit within 2 weeks. This appointment is very important because, at this moment, the patient and the clinician should both approve the appearance of the provisionals. This is because they will serve as the template (or “blueprint”) for the final ceramic restorations. Once any modifications are carried out and the final appearance approved, photographs, shade, bite registration, and alginate impressions of the temporary crowns are obtained to provide clear and precise guidelines to the ceramist—another important component of the restorative team. If there is any uncertainty, the patient should be reappointed for another “refinement” visit before proceeding with the final restorations.
THE DELIVERY APPOINTMENT
Figure 4a. Full smile final.
Figure 4b. Right side final.
Figure 4c. Left side final.
Figure 4d. Retracted final.
Figure 4e. Right retracted final.
Figure 4f. Left retracted final.
Figure 4g. Retracted upper final.
Figure 4h. Upper right retracted final.
|Figure 4i. Upper left retracted final.||Figure 4j. Occlusal view final.|
At the tryin and delivery appointment, vital signs were obtained and local anesthesia was administered, and then the interim restorations were sectioned and removed. The preparations were then cleaned again with Tubilicid Red (Global Den-tal Products) and the all-ceramic restorations (IPS e.max Zir Press [Ivoclar Vivadent] were tried in. (IPS e.max Zir Press was chosen for its strength and aesthetic properties. Also, it can be cemented with conventional or resin cements). The patient was then given a hand mirror to evaluate and approve the restorations before final cementation was begun.
The crowns were then blasted with aluminum oxide, rinsed, cleaned with alcohol, dried, and cemented with a self-etching, dual-cured resin cement (RelyX Unicem [3M ESPE]). Following the removal of any excess cement, the occlusion was checked and adjusted with the patient seated in an upright position. Proper occlusal contacts, as well as incisal and bilateral cuspid guidance, were ascertained before the final polishing of the ceramics was done. The patient was then given detailed maintenance and oral hygiene instructions to maximize the longevity of their new all-ceramic crowns. Before dismissal, an appoint-ment was set up within 2 weeks for a post-delivery check and final photographs for documentation (Figures 4a to 4j).
In spite of the complexity of this case, the aesthetic result obtained was very sat-isfactory to both the patient and the clinician. This outcome would not have been possible without careful planning and clear communication at every stage of treatment. Foremost in importance was to understand and acknowledge the patient’s goals and objectives. Without this, failure could have re-sulted because a patient’s aesthetic perceptions do not always coincide with their clinician’s.5,19, 20
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The author would like to thank Ann Le for her ever-present support, Tom Dabrowsky, LDT, RDT, Beatrice Dabrowsky, LDT, RDT, both of B.I.T. Dental Studio, Dillon, Colorado, for the beautiful ceramics, and all his teachers over the years.