Written by Sam Simos, DDS Sunday, 28 February 2010 19:00
Because of their beauty and strength, today’s porcelains offer unparalleled options for different cosmetic and restorative challenges. Researchers and manufacturers have been very effective in developing and providing modern materials that yield excellent bond strengths to tooth structure. In fact, we are doing things with restorations today that we would have only dreamt about just 2 decades ago. Because of our success with bonding techniques, we have the ability to cosmetically enhance smiles using either direct/indirect composite resins or porcelain veneers.
PREOPERATIVE CONSIDERATIONS: MATERIAL SELECTION
Prior to case preparation, it is important to plot the smile design of the case so one can achieve a predictable and long-lasting result. It’s also equally important to think about the type of porcelain that you will use in order to achieve the optimal aesthetics desired.
Before Image. Preoperative portrait view.
After Image. Facial view of postoperative smile.
For this patient, we wanted to use high quality porcelain that would exhibit optimal aesthetic characteristics. Any porcelain to be considered for use in a highly aesthetic situation must possess certain characteristics: a chameleon aesthetic effect when placed into the mouth, and the ability to exhibit adequate luminescence and fluorescence causing the porcelain to react to light the same way a natural tooth does, thereby creating a harmonious blending of natural to veneered teeth.
Diagnosis and Treatment Plan
Allison, a 32-year-old female, presented with a history of existing restorations on her maxillary lateral and central incisors (Before Image and Figures 1 and 2). They were placed when she was a teenager due to the presence of “peg” laterals and a slight diastema that had existed between her central incisors. Allison disliked the way her restorations had discolored over the years and thought that her front teeth were disproportionately short. This made her self-conscious about smiling. She wanted a long-lasting solution that would address her “fang-like” canines, disproportionate teeth, and “dingy” appearing smile.
Figure 1. Preoperative closeup.
Figure 2. Preoperative maxillary arch.
According to Allison, “It is time to start feeling good about my smile again!”
Treatment Planning: Smile Design
When preparing the smile design, consideration must be given to the desires of the patient. However, a high degree of scrutiny needs to be placed on bite functionality as well. Allison presented with an atraumatic Class II Div II occlusal relationship and an overall healthy oral environment.
Figure 3. Retracted view, teeth apart used to evaluate proportions.
Figure 4. Preoperative central length.
Figure 5. Preoperative central width.
Further evaluation of her smile design (Figures 3 to 5), using the SMILES acronym developed at LVI (Las Vegas Institute for Advanced Dental Studies, Las Vegas, Nev), is as follows:
Prior to initiation of this case, a standard protocol of information was gathered. This included a photo release and informed consent. These were reviewed with, and signed by, the patient. Pretreatment photographs were taken. Tooth shape and shade were discussed with her. High quality pretreatment vinyl polysiloxane (VPS) impressions (Flextime [Heraeus Kulzer]) and bite registration were taken. A symmetry bite [CLINICIAN’S CHOICE]) was also taken in order to evaluate the case and to construct a lab-fabricated pretreatment wax-up, temporary stent, and reduction guide that followed the smile design that we had selected.
Figure 6. Preoperative wax-up width.
One of Allison’s goals in pursuing her smile rehabilitation was to have whiter teeth. Since we were veneering only the maxillary central and lateral incisors, whitening prior to initiation of veneering needed to be considered. Customized take-home whitening trays were fabricated and a 16% take-home carbamide peroxide gel (Venus White [Heraeus Kulzer]) was used to obtain the final desired shade. It took approximately 3 weeks to reach the whiter shade that Allison loved. Allison was instructed to discontinue whitening 2 weeks prior to the preparation appointment in order to account for any rebound that often occurs after the whitening process is completed. During the last whitening check, we showed the lab-fabricated diagnostic wax-up to Allison (Figure 6). She approved of the design and was excited to go to the next stage of preparation.
Preparation, Impressions, and Temporization
Prior to initiation, topical gel (FTP Gel [Flourish Pharmacy]) was placed on the buccal tissue to optimize comfort when administering the local anesthetic. Injection of 2 carpules of lidocaine (1:100,000 epinephrine) was given using an anesthetic delivery system (The Wand [Milestone Scientific]). A final shade was then taken of the still hydrated teeth and recorded prior to initiation of the preparation (Figure 7).
Figure 7. Preprep shade match.
Figure 8. Preprep laser initiation.
Figure 9. Preprepped sculpted gums.
Figure 10. Removal of restorations.
Figure 11. Finalizing the preparations.
Figure 12. Presymmetry bite.
Figure 13. Enamel and dentin shade with stumpf shade.
Figure 14. Isolated dentin shade.
Figure 15. Provisional restorations.
Next, gingival recontouring was performed with the diode laser (BIOLASE) prior to removing the existing restorations (Figures 8 and 9) and following the guidelines set in the smile design (SMILES). By conservatively recontouring the gingivae, the gingival zeniths of all of the incisors were corrected. Also, Allison’s concern about her “gummy” appearing smile was addressed by conservatively reshaping both lateral incisor areas, giving a more elongated appearance of the lateral incisors and a more pleasing overall look.
Tom M. Limoli, Jr
The bleaching of vital teeth, in most cases, is considered cosmetic in nature. However, there are benefit plans in the marketplace that cover bleaching and/or bonding for other than purely cosmetic reasons. Reimbursable liabilities include severe tetracycline staining, severe fluorosis, hereditary opalescent dentin and amelogenesis imperfecta.
When the patient presents with these clinical conditions, the third-party payer will need radiographs, diagnostic photographs and a narrative report. Remember that some plans specifically exclude benefits for the correction of congenital conditions.
When bleaching is purely cosmetic in nature, the associated components of the procedure are not reimbursable benefits. To deceptively use code numbers for diagnostic casts, night guards, stents, or individually fabricated trays is a fraudulent and unprofessional attempt to secure money from the benefit plan that is simply not payable. Expect limited or no reimbursement from the third-party payer.
Gingivectomy is usually not reimbursable when it is performed for aesthetic rather than anatomical reasons. For example, it may be considered a cosmetic exclusion when the recontouring of the gingival line produces a more pleasingly complete clinical crown. In short, it is not a covered benefit if you are simply correcting a “gummy smile.” A crown with a 50/50 anatomical contour is not 60% long and 40% wide. Removal of a wedge of gingival tissue to achieve an anatomically aesthetic objective, in the absence of pathology, is considered a cosmetic exclusion.
The patient returned to the office 2 weeks later for removal of the provisional restorations and for bonding of the porcelain veneers.
Figures 16 to 18. Preseat model check.
|Figure 19. Closeup of postoperative smile.|
The veneers were evaluated and measured on the model one week prior to patient arrival (Figures 16 to 18). The restorations were perfectly proportioned and stained as specified in the instructions given to the laboratory. The restorations were tried in the mouth for shade match, contact evaluation, proportionality, and overall look of the restorations blending into the natural dentition. The patient was given the opportunity to view the restorations prior to permanent placement, giving her final approval to her aesthetic presentation. The restorations were removed and cleaned with a 37% phosphoric acid gel (Ultra-Etch [Ultradent Products]). Then, they were rinsed, dried, and silanated for placement.
There are many factors to consider when restoring an anterior cosmetic case. First, the smile design must be addressed in order to achieve long-lasting functional results. Second, when considering cosmetic results, one must consider the material of choice for the restorations. With so many material choices today, it is important to have an understanding of the porcelain system that you are using because this can have a profound effect on the outcome of your case. Choosing a quality porcelain system, using sound preparation, temporization, and bonding techniques, and choosing a quality-minded laboratory team will address the cosmetic challenges of any anterior case. In this way, you too can create a natural, long-lasting smile that your patients will feel confident in showing off for years to come.
Acknowledgement: The author would like to thank Hamid Babaeian, CDT, and team at Pacific Dental Laboratory, Thousand Oaks, Calif. They were chosen due to their extensive knowledge of, and experience with, the Venus porcelain system used to complete this case.
Disclosure: Dr. Simos reports no conflicts of interest.
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