Written by Ross W. Nash, DDS Friday, 31 October 2003 19:00
Orthodontic treatment is usually the best alternative for closing spaces. However, some situations do not lend themselves to tooth movement. Tooth size discrepancies can make total space closure impossible. Treatment with laminate veneers or full crowns can sometimes be used for aesthetic treatment when these situations occur. This article describes a clinical case where a pressed ceramic material was used to close a large diastema.
|Figure 1. The patient’s smile before treatment.||Figure 2. Retracted frontal view showing diastemas and PFM crown.|
|Figure 3. Preoperative incisal view.|
A female patient in her middle 30s presented with an unusually large central diastema in the maxillary arch and small diastemas in the mandibular anterior area. A porcelain-fused-to-metal crown had been used to restore the left central incisor, as seen in Figure 1 (the patient’s smile before treatment). The retracted frontal view (Figure 2) reveals that a very prominent labial frenum was attached near the incisal papilla between the central incisors. The teeth had a slightly orange hue. She exhibited class I stable occlusion and her general dental health was excellent. Except for the restored maxillary central incisor, she had no restorations in her dentition and no caries was present. Her periodontal condition also was very good. Some wear facets existed in the anterior region because of normal function, as can be seen in the incisal view in Figure 3.
The patient was entering a beauty contest and wished to have improved aesthetics in a very short time. The small mandibular spaces were not a concern to her, but she felt that the large maxillary diastema detracted from her appearance. She wished to have porcelain veneers placed on the rest of the teeth in her smile zone to improve the overall color and contour of her maxillary teeth.
High-strength pressed ceramic crowns (Eris, Ivoclar Vivadent) were chosen for the 2 central incisors. The crowns would be overcontoured to close the central diastema. Eris veneers would be placed on the laterals, canines, and premolars to lighten the color and increase the facial contours.
|Figure 4. Laser treatment to remove labial frenum.||Figure 5. Mesial half of right central incisor
prepared for Eris crown.
|Figure 6. Working model of prepared teeth, incisal view.|
The patient was anesthetized and the porcelain-fused-to-metal crown was removed from the left central incisor. A diode tissue contact laser (Biolase) was used to reduce the labial frenum (Figure 4). The right central incisor was prepared by reducing 1.0 mm in the axial direction and 1.5 mm from the incisal. A rounded shoulder margin was prepared at the height of the tissue. In Figure 5, the mesial half of the tooth has been prepared. The teeth to receive veneers were prepared with 1.0 mm of facial and incisal reduction with rounded shoulder margins. The preparations were carried onto the occlusal surfaces of the second premolars. In Figure 6, the working model can be seen from the incisal view, and the preparations can be readily visualized.
A full-arch final impression was taken using a vinyl polysiloxane impression material. An opposing impression was also taken. An occlusal registration and a face bow transfer record were made for mounting the working models on a semiadjustable articulator (Denar, Waterpik). Provisional restorations were fabricated using a bisacrylic material. The crowns were cemented to place using a noneugenol temporary cement. The provisional veneers were cemented with a resin cement after spot-etching the preparations, rinsing, and drying.
|Figure 7. Final restorations on the working model, facial view.||Figure 8. Final restorations on the working model, incisal view.|
|Figure 9. Final restorations, internal etched surfaces.||Figure 10. Close-up view of the Eris crowns.|
|Figure 11. Internal surfaces of Eris crowns.|
Digital photographs were sent to the dental laboratory (Dental Arts Signature Laboratory, Peoria, Ill) along with the written prescription requesting the Eris restorations. The final restorations can be seen on the working model from the facial view in Figure 7 and from the incisal view in Figure 8. The etched internal surfaces of the restorations can be seen in Figure 9. A close-up view of one of the central incisor crowns is illustrated in Figure 10. Figure 11 shows the crowns from the internal angle. Notice the cantilevered surfaces that gently curve to the mesial from the incisal margins.
At the placement appointment, the patient was anesthetized, the provisional restorations were removed, and the preparations were thoroughly cleaned. The final restorations were tried in using a drop of water as a temporary luting agent. The fit and aesthetics were approved, and the restorations were removed, cleaned, and dried. Silane was placed on the internal surfaces of the restorations and allowed to remain for 30 seconds before drying with a stream of air.
|Figure 12. Prepared teeth, facial view with retraction cord.||Figure 13. Prepared teeth, incisal view with retraction cord.|
Retraction cord was placed in preparation for the restoration placement, as can be seen from the facial view in Figure 12 and from the incisal view in Figure 13. The prepared teeth were treated for 15 seconds with 37% phosphoric acid gel to etch the enamel margins and remove the smear layer from the prepared dentin. The etching gel was thoroughly rinsed and the prepared teeth were left slightly moist for wet bonding. A one-step dentin and enamel bonding agent (Excite, Ivoclar Vivadent) was liberally applied to the etched surfaces and dried with a stream of air. A glossy surface remained, indicating that the hybrid layer had been formed on the dentin surfaces. A dual-curing composite resin luting agent (Variolink, Ivoclar Vivadent) was applied to the internal surfaces of the restorations, and they were seated on the prepared tooth surfaces. Excess luting agent was removed with a sable brush, and the resin luting agent was light-cured with a visible light-curing unit.
Excess luting resin was removed with a small carbide finishing bur in a high-speed handpiece, and the margins were polished using a rubber polishing cup in a slow-speed handpiece. Excess interproximal resin was removed with a diamond-coated metal strip, and the interproximal surfaces were polished with aluminum oxide coated strips. Articulating paper was used to check the occlusion, and slight adjustments were made using fine finishing diamonds, a 30-bladed carbide finishing bur, and porcelain polishing points and cups.
THE FINAL RESULT
|Figure 14. Final result, retracted facial view.||Figure 15. Final result, incisal view.|
|Figure 16. The patient’s new smile.|
The final result can be seen from the facial view in Figure 14. Notice how the diastema was closed, with only a slight dark triangle at the proximal/gingival area. Also note that the removal and healing of the labial frenum formed a pseudo-papilla, further improving the aesthetic result. The incisal view is seen in Figure 15. Here the improved arch form can be visualized. Figure 16 shows the patient’s new smile.
While she did not win the beauty contest, the patient was the first runner-up. She said that she attributed part of her success to the increased self-confidence resulting from her improved smile.
While orthodontic tooth movement is preferred in many cases where diastemas exist, restorative treatment can sometimes be used to improve aesthetics where tooth movement is not possible or not desired. High- strength all-ceramic materials that mimic natural tooth structure while providing enough strength for function are now available for cases such as this. The preceding case study illustrates a situation where the restorative option was chosen and a successful result was obtained.
Dr. Nash is president of the Nash Institute for Dental Learning in Charlotte, NC, and a clinical instructor at the Medical College of Georgia School of Dentistry. He maintains a private practice in Charlotte, where he focuses on aesthetic and cosmetic treatment. He is a member of the Esthetic Dentistry Research Group, which publishes Reality. Dr. Nash is a fellow in the American Academy of Cosmetic Dentistry and an accredited member of the American Society for Dental Aesthetics. He lectures internationally on cosmetic and aesthetic dentistry and is a consultant to a number of dental products manufacturers. He can be reached by calling his director of operations at the Nash Institute, Mark J. Cody, at (888) 442-0242 or by visiting his Web site at nashinstitute.com.
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