Written by Michael Apa, DDS Tuesday, 30 September 2008 19:00
With advances in science and technology, aesthetic dentistry continues to evolve. This is also a direct result of the advances in the abilities of the doctor-ceramist team, and what they can create together. The doctor-patient-laboratory relationship has become more clearly defined due to a better understanding of the limitations and expectations of what the ceramist can produce. New temporary materials, impression materials, cements, etc., have made attaining superior aesthetic results much more predictable. This article will demonstrate a step-by-step approach to creating the most naturally enhancing aesthetics in a very easy-to-follow format.
THE KEY TO PREDICTABLE AESTHETIC RESULTS
The most important part of predictable aesthetics is diagnosis (examination and case selection) and treatment planning. It is important to be able to visualize the final result in order to properly and accurately describe the proposed treatment to the pa-tient. Listening to the patient’s concerns and effectively communicating shape, size, and color are all significant factors in a successful result. One way that this can be accomplished is by doing a composite resin mock-up directly in the patient’s mouth. Another way would be by using an accurate digital imaging program, such as Envision A Smile (envisionasmile.com). This software was designed by Dr. George E. Kirtley, who is an accredited member of the American Academy of Cosmetic Dentistry (AACD).
|Figure 1. Preoperative, full-face.||Figure 2. Preoperative, full-face, left lateral.|
|Figure 3. Preoperative, full-face, right lateral.||
Figure 4. Preoperative, 1:1 smiling.
Figure 5. Preoperative, 1:1 smile, right lateral.
|Figure 6. Preoperative, 1:1 smile, left lateral.|
First, we looked at the patient in her entirety. We examined how the teeth played within her face. While observing her speech and function, we were mentally visualizing how we could improve her overall appearance. Once we had formulated some thoughts regarding our treatment approach, we moved to the mouth to further visualize the possibilities. In looking at full-face pictures of our patient, we immediately decided to close the gap (Figure 1). We also noted that the position of tooth No. 6, as well as the appearance of a missing tooth in the upper left, were distractions to the eye. After examining the full-mouth radiographs, we found tooth “No. 13” to actually be a deciduous first molar. Next, we examined the patient intraorally to begin to finalize our treatment plan. Her existing tooth shades were flattering and worked well with her surrounding facial colors. By establishing a more uniform blend of color, the hypocalcifications were something that we could certainly improve upon aesthetically (Figures 2 and 3). To obtain one color, minimal preparation would be required. This was good for a couple of reasons: more conservative dentistry always reduces the chance for postoperative problems, and it allows our ceramists to create the most lifelike aesthetics by using the underlying natural tooth structure to illuminate vitality into the overlying porcelain veneer.
Our treatment goals were to close the diastema between teeth Nos. 8 and 9, and to create harmony from anterior to posterior by giving more width to our patient’s smile. Not every patient needs to have his or her buccal corridor built out. However, if we look at the width of this patient’s cheekbones and jawline in comparison to the width of her smile, a negative space is immediately seen by the eye (Figures 4 to 6). The final treatment plan was to place ceramic veneers on teeth Nos. 4 to 12. An all-ceramic inlay would be done on the deciduous first molar, in combination with some soft-tissue modification using a diode laser (Biolase).
Preparations and Impressions
|Figure 7. Preparations showing bulk reduction.||Figure 8. Soft-tissue modification has been performed with a diode laser (Biolase).|
Figure 9. Completed final preparations.
Before beginning any preparation, we must be able to visualize the final result. To help accomplish this, one can request a diagnostic wax-up accompanied by a preparation model and preparation guides. To begin, bulk reduction to establish arch form was done (Figure 7). The goal is to bring the patient right side (tooth Nos. 4 to 7) apically by reducing from the incisal and gaining tooth structure apically with the diode laser. After bulk reduction, all soft-tissue modifications were performed (Figure 8). Once this was done, the margins were finished while keeping in mind placement of interproximal elbows for optimal aesthetics, the path of insertion, the occlusion, and a slight subgingival placement of the preparations between teeth Nos. 8 and 9 in order to properly close the diastema (Figure 9). At this point, temporaries are usually fabricated from a silicone putty (Sil-Tech [Ivoclar Vivadent]) stent made from the diagnostic wax-up, giving the practitioner another chance to check for sufficient reduction. In this case, a wax-up was not fabricated for this patient.
After preparation, it is important to obtain clean, high quality impressions. Tissue management is a key factor in obtaining a great impression. In this case we chose a cordless retraction technique (Expasyl [Kerr]), which is an easy technique to perform. Expasyl was placed in the sulcus of the prepared teeth and then the provisionals were seated on top of the teeth. This helps to push the Expasyl putty-like retraction material further subgingivally. After 5 minutes, it was rinsed thoroughly away exposing clean margins with no bleeding and thereby providing a clean field for easily obtaining the final impression. A polyvinyl siloxane (PVS) impression material (Take 1 Advanced [Kerr]) (light body) was then syringed around the margins and a tray loaded with a heavy-bodied PVS impression material (Take 1 Advanced [Kerr]) was seated.
Figure 10. Full-face provisionals.
Figure 11. 1:1 smile provisionals.
Provisionals can be a template and guide for both the ceramist and the patient to use. The patient should have a clear vision of what the final result is going to look like. The ceramist must also be able to have an understanding of the length, width, line angles, and overall shape of the smile (Figure 10). The doctor should spend adequate time shaping the provisionals as anatomically correctly as possible, working out the occlusion, phonetics, and aesthetics in detail to ensure a predictable outcome (Figure 11).
Color is a very subjective issue. We used the lightest color temporary material was used (BL Luxatemp [Zenith/DMG]). This translates into about an OM3 on the Vita (Vident) shade guide. If we think we need to tone down the color, we request B1 in the ceramic. If we need it brighter, we request a mixture of OM2 or OM3. Landmarks to determine the final shade of the smile are the skin, hair, and eyes. Gingival pigmentation will determine the cervical color and the last factor is age. Today, the trend is back to more natural colors rather than the “Hollywood” shades that we have seen previously.
After this information was gathered, we took impressions and poured models of the temporaries. We also measured the length of the provisionalized centrals. Then we took a set of digital photos of the provisionals in place, including: full-face, nose-chin, full-smile, and retracted views. Finally, we sent the case into the laboratory along with a detailed prescription.
Figure 12. Water try-in of the final porcelain restorations.
|Figure 13. Isolation for the cementation procedures is provided by a rubber dam.|
Figure 14. Light-cured.
The provisionals were taken off any residual debris and provisional cement was thoroughly removed. Each laminate veneer was tried in with water to verify fit, contour, and shade (Figure 12). Clear cements hold the truest color to the ceramic shade requested. Colored cements can be used to either brighten or tone down the final veneers. In this case, we used a light-cured resin cement (NX3 [Kerr]) because of its ease of manipulation and reported long-term color stability. We used light-cure cement for everything except tooth No. 13, which required a dual-cured resin cement since it had an inlay component in its design. All the final insertions were done under a rubber dam in order to secure a dry working field (Figure 13). Acid etching and the application of a desensitizer (GLUMA [Heraeus Kulzer]) was performed. Next, priming (Opti-Bond Solo Plus [Kerr]) of the teeth was done according to the manufacturer’s instructions. The resin cement was then applied to each veneer, seated, and the excess was subsequently removed. All of the veneers requiring the use of a light-cured material were seated first (Figure 14), and tacked at margin. Following this, the inlay for tooth No. 13 was seated with a dual-cure cement. Next, all the restorations were cleaned interproximally and the final light curing was completed. The veneers were stripped and polished, and all the margins were finished. Finally, the occlusion was carefully examined to ensure there were no interferences and that guidance was captured.
Figure 15. Postoperative full-face, final.
Figure 16. Postoperative 1:1 frontal.
Figure 17. Postoperative 1:1 left lateral.
Results can be consistently achieved as long as your approach is systematic in restoring these cases. The goal should be a pleasing result that satisfies the patient’s desires and achieves a balanced occlusion for longevity. As we become more confident in our approach, we can then start to focus on the details of making teeth appear and function as natural teeth. This should be the end goal of the practitioner (Figures 15 to 17).
The author would like to thank Dr. Larry Rosenthal for his mentoring and patience throughout the years, and Jason Kim of Oral Design for his continued masterful ceramic work.
Dr. Apa currently practices with the Rosenthal-Apa Group in New York City, New York, where he focuses solely on aesthetic and restorative dentistry. In 2000, he founded NYU’s Aesthetic Dental Society in association with the American Academy of Cosmetic Dentistry. He also completed the one-year honors program at NYU in Aesthetic Dentistry. Upon graduation he was the recipient of the American Academy of Esthetic Dentistry Award and the American Association of Oral and Maxillofacial Surgeons Dental Implant Award. In 2007, he was awarded the Outstanding Young Cosmetic Dentist Award by the AACD; the first award ever given for achievements in the first 5 years of practice. Dr. Apa is an instructor at New York University College of Dentistry, a senior instructor for the continuing education seminar Aesthetic Advantage, and also teaches his technique of Facial Aesthetic Design nationally. His other points of career distinction include being the official dentist of record for Elite and Wilhelmina modeling agencies, as well as features in national publications such as W, Men’s Vogue, Oprah, Marie Claire, Glamour, In Style, Redbook, Forbes, and the New York Post. He has also been featured on The Today Show, Fox and Friends, Inside Edition, MSNBC, Fox 5, VH1, and Extra. He is a member of the AACD, ADA, and AGD. He can be reached at (212) 794-9600 or by sending an e-mail to firstname.lastname@example.org.
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