Written by Ara Nazarian, DDS Thursday, 30 November 2006 19:00
Today more and more people are becoming aware of what cosmetic dentistry has to offer. We see people in television, magazines, and movies with straight, white, perfect teeth. More than ever before dentists are challenged to create these “Hollywood” smiles. Patients are insisting on extremely white teeth and are demanding treatments be done as soon as possible. Occasionally, we are faced with the challenge of using a rapid restorative solution instead of traditional methods to satisfy these patients’ needs. The introduction of adhesion dentistry has opened a realm of treatment options.
In the case presented in this article, the patient was informed of all the treatment options, and it was recommended that he consult an orthodontist. The patient found the treatment time of 12 to 18 months unacceptable and insisted on proceeding with the option of porcelain restorations. Consequently, a mutual decision was made for minimal selective tooth reduction to achieve the result the patient was seeking.
|Figure 1. Retracted view of maxillary anterior teeth.||
Figure 2. Retracted view of prepared maxillary anterior teeth.
A young man in his early 30s presented to the practice for an aesthetic consultation. The patient was not pleased with his smile and did not feel comfortable in social circumstances. In particular, the patient was dissatisfied with the size, shape, spacing, and color of his teeth (Figure 1). Upon clinical examination, his anterior maxillary teeth exhibited multiple diastemas. The length of the teeth could tolerate widening and lengthening. After considering the obstacles, a diagnostic wax-up was fabricated to help visualize the solution. By visualizing the case on the preoperative models, the patient was able to begin with the end result in mind. In order to satisfy the patient’s demands, porcelain veneer restorations (IPS Empress [Ivoclar Vivadent]) would be placed on teeth Nos. 6 to 11.
Once informed consent was obtained from the patient, treatment was initiated. Since the preparations were very conservative, no anesthetic was necessary for margin placement. Using a No. 4 round diamond bur, a slight margin was placed at the gingival margin and wrapped around the incisal edges (Figure 2).
Following sequential preparation of the maxillary teeth, a stick-bite registration was taken. This stick-bite would aid the technician in preparing the model and mounting the case. It also communicated to the ceramist the orientation of the interpupillary line so that the incisal edges of the final restorations would not appear canted.
Impressions were taken using a fast-setting polyvinyl material (Take 1 Super Fast [Kerr Corporation]). Using a siltec matrix (Ivoclar Vivadent) of the proposed wax-up, the provisional restorations were fabricated using a bleach shade.
Figure 3. Facial view of porcelain veneers.
Figure 4. Lingual view of porcelain veneers.
Color photographs and diagnostic data were also obtained and forwarded to the laboratory for the fabrication of the final restorations. During the laboratory phase, the full-arch polyvinyl siloxane impressions were used to create a master model on which the restorations would be based. The master model was segmented into individual dies that were trimmed and pinned to determine the manner by which the final restorations would integrate with the soft tissue. A silicone incisal matrix of the wax-up was created to guide the placement of the incisal effects and edge position in the subsequent ceramic buildup. A shade of Bleach 010 on the Chromascope shade guide (Ivoclar Vivadent) was selected to meet the patient’s expectations of a white smile (Figures 3 and 4).
Before try-in of the definitive restorations to verify fit and shade, the provisional restorations were removed, and any remaining cement was cleaned off the prepared dentition. After the patient was shown the retracted view for acceptance, the cementation process was initiated. The restorations were treated with 37% phosphoric acid for 20 seconds, rinsed, silanated, and allowed to air-dry for one minute. The prepared dentition was cleaned with chlorhexidine 2% (Consepsis [Ultradent Products]) for 15 seconds and rinsed to remove any contaminants from the temporary phase. The preparations were etched for 10 seconds and rinsed thoroughly.
Two coats of dental adhesive (OptiBond Solo Plus [Kerr Corporation]) were placed on the preparations, and high-speed suction was used to ensure that the material had evaporated. The adhesive was light-cured for 10 seconds per tooth with the L.E.Demetron curing light (Kerr Corporation). A coat of adhesive was also applied to the inner aspect of the restorations.
Variolink II opaque shade (Ivoclar Vivadent) was applied to the restorations. The restorations were then placed on the preparations, and while firmly holding the restorations in place, a rubber tip applicator removed all excess luting cement from the margins. The restorations were tacked at the gingival margin.
Figure 5. Retracted view of restored maxillary anterior teeth.
Figure 6. Lingual view of restored dentition.
While the restorations were still firmly held in place, the restored dentition was flossed, and any excess luting cement was carefully removed. When most of the excess cement was removed, the restored dentition was completely light-cured from both facial and lingual sides. Any residual cement was removed with a No. 15 scalpel or finished with a fine diamond. After complete polymerization of the restorations, the occlusion was verified and adjusted. The overall health and structure of the soft tissue and restorations were very good. The patient was extremely satisfied with the definitive results (Figures 5 and 6).
Completion of this aesthetic challenge with a quick restorative solution satisfied the patient’s demands for straight, white teeth. By using bonded porcelain restorations, a substantial improvement was achieved quickly. It is important that dentists ensure that their patients are completely informed of all risks, benefits, and alternatives before initiating treatment. By having patients act as partners in exploring various treatments, a dentist will not merely meet patients’ expectations, he or she will surpass them.
A special thanks to Burbank Dental Lab (Burbank, Calif) for the beautiful restorations shown in this article.
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