Smile Enhancement Using Multiple Modalities

Dr. Ross W. Nash


Diagnosis and Treatment Planning

A young woman presented to my office with a desire to improve her smile (Figure 1). In the retracted facial view (Figure 2), one can see that she had a maxillary right peg lateral incisor that had a previously placed direct composite veneer. Her congenitally missing left maxillary lateral incisor had been replaced with a Maryland bridge. Her mandibular incisors were slightly crowded, and the maxillary central incisors showed chipping of the incisal edges. The preoperative occlusal view of the maxillary arch and the mandibular occlusal view can be seen in Figures 3 and 4. Clinical and radiographic examination revealed that she had good periodontal health and no active caries.

Figure 1. The patient’s smile before and after treatment.

It was explained to the patient that the chipping of the incisal edges of her maxillary central incisors may have been due to the unequal contact of her opposing, crowded incisors. While implant placement was an option for replacing her missing maxillary lateral incisor, she stated her preference for a fixed bridge. She decided upon porcelain veneers for the other maxillary central and canine teeth, along with a full-coverage, all-ceramic crown for the right peg lateral incisor.

She was informed that her mandibular incisors could be straightened in a matter of weeks using a removable device called an Inman Aligner. The Inman Aligner was invented by Don Inman of Inman Orthodontic Laboratory (Coral Springs, Fla). It is an ingenious removable appliance that can correct protrusion or the crowding of anterior teeth that have crowding of 3.0 mm or fewer. Most cases can be finished in as little as 6 to 18 weeks. It has NiTi coil springs that power 2 aligner bows that oppose each other: one on the lingual and one on the facial. The gentle forces are active over a large range of movement, which is why the device works so quickly. Slight interproximal reduction (IPR) is accomplished with diamond-coated strips during office visits every 2 weeks, and composite buttons are added as needed. After proper tooth position has been accomplished, fixed or removable retention is required.

The patient decided to have me align her mandibular incisors and then place all-ceramic restorations to improve the appearance of her 6 maxillary anterior teeth.

The Inman Aligner: Clinical and Dental Laboratory Protocols
During her first treatment appointment, accurate impressions of both arches were taken. For a mandibular impression, an A-silicone material (Panasil monophase Medium [Kettenbach LP]) was used in a full-arch tray. For the opposing maxillary impression, a medium viscosity A-Silicone alginate substitute (Silginat [Kettenbach LP]) was used in a full-arch tray. Silginat offers the unique benefit of allowing multiple pours by the dental laboratory team and, in addition, with no shrinkage, unlike conventional alginates. An accurate occlusal registration was taken (Futar Fast [Kettenbach LP]), and the patient was appointed for delivery. The impressions, occlusal registration, and laboratory prescription were all sent to Inman Orthodontic Laboratory for the design and fabrication of an aligner.

At the laboratory, the impressions were poured and scanned. The aligner was designed with the help of digital technology, and a printed model of the end result was fabricated. The Inman Aligner itself, along with a lab prescription for exactly where and how much to strip during IPR and directions for proper placement and timing of the composite buttons, was delivered back to my office.

Figure 2. The retracted facial view before treatment. Figure 3. The maxillary incisal view before treatment.
Figure 4. The mandibular incisal view before treatment. Figure 5. The facial view of the Inman Aligner in place at delivery.
Figure 6. The incisal view of the Inman Aligner in place at delivery. Figure 7. The incisal view of the Inman Aligner at 8 weeks.

Figure 5 shows the facial view of the Inman Aligner in place at the delivery appointment. Figure 6 (incisal view) clearly shows the degree of crowding. Interproximal stripping was accomplished with diamond-coated strips (FitStrip [Garrison Dental Solutions]) per the prescription provided by the dental laboratory team. A composite resin “button” was placed on the lingual of the right central incisor as directed by the lab. Where stripping was accomplished, the tooth surfaces were polished smooth using aluminum oxide strips (EPITEX [GC America]) and a fluoride varnish was applied. The patient was instructed about aligner placement and removal techniques. She was asked to make sure that she wore the appliance a minimum of 16 hours per day, removing the appliance for 4 to 8 hours each day. She was appointed in 2 weeks for evaluation and adjustments, if needed.

In Figure 7, the aligner can be seen in place during her fourth appointment at 8 weeks when the alignment process was complete. The patient was informed that she could have a removable, clear plastic retainer or a fixed-wire retainer. She chose the fixed-wire retainer, and an impression was taken and sent to the lab for fabrication. In the meantime, she wore the Inman Aligner full time for retention.

At the dental laboratory, a wire retainer and a jig for placement were designed. When the patient returned, the wire was bonded into place using composite resin (Figure 8). A fine, high-speed diamond bur was used to cut the ends of the wire, and the jig was removed. The patient was instructed on cleaning technique around the wire retainer, which involved daily use of a floss threader. Figure 9 shows the bonded wire retainer in place.

The Maxillary Restorations: Clinical and Dental Laboratory Protocols
Next, a facebow record was taken to position the model of her upper arch on a semi-adjustable articulator (Denar [Whip Mix]). Maxillary and mandibular full-arch impressions were taken using Silginat. A centric relation occlusal registration was also taken using Futar Fast. Then the impressions, occlusal registration, and facebow transfer jig were sent to the dental laboratory team at daVinci Dental Studios in West Hills, Calif. At the laboratory, a wax-up of the proposed contours was performed on the mounted model and a putty stent was fabricated over the wax-up. This would be used to form the provisional restorations.

A close-up pre-op facial view can be seen in Figure 10. The Maryland bridge was removed, and the left central and canine teeth were prepared for abutments for a porcelain-fused-to-zirconia (PFZ) fixed bridge. A fine football-shaped diamond bur in a high-speed handpiece was used at low rpm to prepare an ovate site for the pontic. A soft-tissue diode laser (Picasso [AMD LASERS]) was used to cauterize the tissue in this area.

The right central incisor and canine teeth were prepared for porcelain veneers, and the right peg lateral incisor was prepared for a 360° laminate. Figure 11 shows the prepared teeth from the facial view, and Figure 12 shows the incisal view. An occlusal registration was made using Futar. The final impression was taken with Panasil A-silicone impression material (Kettenbach LP), using Panasil Putty (Kettenbach LP) in the tray for the heavy body and with Panasil Initial Contact XL (Light Body) (Kettenbach LP) being injected around the sulcus areas of the prepared teeth. By using this technique, I find that the heavy body tends to drive the light body into the sulcus, and excellent impressions are the norm.

Figure 8. The incisal view of the wire placement and jig in place. Figure 9. The bonded lingual wire in place.
Figure 10. The preoperative view of the maxillary anterior teeth. Figure 11. The facial view of the prepared teeth.
Figure 12. The incisal view of the prepared teeth. Figure 13. The provisional restorations in place.

The laboratory team fabricated the putty stent, made from the diagnostic wax-up model, that was used to fabricate the provisional restorations. The provisional material (Visalys Temp [Kettenbach LP]) was injected into the stent, and it was placed over the prepared teeth and allowed to set. Next, the stent was removed, leaving the temporary restorations in place on the teeth. The margins were trimmed in place using a small carbide finishing bur (Brasseler USA). These are more than just temporaries, as they become the prototypes for the final restorations. To adjust for desired contours or occlusion, the provisional material can be reduced or additions can be made using a flowable composite. Any changes can and should be communicated to the laboratory team before the final restorations are fabricated. Figure 13 shows the prototype restorations in place. In this case, no changes were required or desired.

At the dental laboratory, IPS e.max (Ivoclar Vivadent) was used to fabricate the lithium disilicate all-ceramic veneers and a 360° laminate. A zirconia oxide foundation was fabricated for the 3-unit bridge and layered using the same porcelain as for the lithium disilicate restorations. The final restorations can be seen on the working model in Figure 14 and are shown photographed on a mirror surface in Figures 15 and 16.

At the delivery appointment, the provisional restorations were removed, and then the final restorations were tried-in. Margins, contacts, and aesthetics were all checked. The patient was shown the restorations at try-in and she approved the appearance. For the IPS e.max restorations, the internal etched surfaces were treated with silane (Porcelain Primer [BISCO Dental Products]) and then air dried. The intaglio surfaces of the PFZ bridge were treated with a zirconium primer (Z-Prime Plus [BISCO Dental Products]) and dried with oil-free air. The 3 teeth that were prepared for e.max restorations were etched with 37% phosphoric acid etching gel (Etch-37 [BISCO Dental Products]) for 10 seconds, rinsed thoroughly with water, and then lightly air-dried. A universal bonding agent (All-Bond [BISCO Dental Products]) was applied liberally to the prepared tooth surfaces and air-dried. The bonding agent was light cured for 10 seconds with an LED curing light. Next, a light-cure composite resin cement (Choice 2 [BISCO Dental Products]) was placed on the internal surfaces of the veneers and the 360° laminate and then placed on the prepared teeth. The LED curing light was then used for only 2 seconds to tack the restorations in place. The excess resin cement at the margins was teased away with a #12 surgical blade. Dental floss was gently worked in between the proximal contacts to remove excess cement there. The LED curing light was used for 20 seconds on facial and lingual surfaces. Excess cured cement at the margins was removed using a small carbide finishing bur (Brasseler USA).

A universal bonding agent (All-Bond Universal [BISCO Dental Products]) was liberally applied to the prepared tooth surfaces of the abutment teeth without etching. The bonding agent was then air-dried and light-cured for 10 seconds with an LED curing light. A dual-cure resin cement (Duo-Link [BISCO Dental Products]) was placed into the internal surfaces of the PFZ bridge, and it was set to place. As the dual-cure resin began to gel, it was gently teased away with a scaler. Floss was gently worked in between the proximal contacts to remove uncured resin there. An LED curing light was used to finish the cure. Excess cured resin at the margins was removed using a small carbide bur. Next, the occlusion was checked and adjusted where needed with fine finishing diamonds, and then the adjusted areas were polished with porcelain polishing points (Brasseler USA).

Figure 14. The final restorations on the working model. Figure 15. The facial view of the final restorations, photographed on a mirror surface.
Figure 16. The internal surfaces, photographed on a mirror surface. Figure 17. The facial view of the final restorations in place.
Figure 18. The incisal view of the final restorations in place. Figure 19. The retracted facial view of both arches after treatment.
Figure 20. The patient’s new smile.

The finished restorations can be seen in place from the facial view in Figure 17. The incisal view after placement is shown in Figure 18. In Figure 19, one can see both arches from the retracted facial view. The patient was extremely happy with her new smile (Figure 20).

By using a combination of tooth alignment, lithium disilicate all-ceramic veneers, and a PFZ fixed bridge, we were able to transform this patient’s smile in a short period of time with restorations that should serve the patient well for many years.

The author would like to thank the excellent ceramists at daVinci Dental Studios in West Hills, Calif, for the superb restorations in this article as well as the lab technicians at the Inman Orthodontic Laboratory in Coral Springs, Fla, for designing the Inman Aligner.

Dr. Nash maintains a private practice in Huntersville, NC, where he focuses on aesthetic and cosmetic dental treatment. An accredited Fellow in the American Academy of Cosmetic Dentistry and a Diplomate for the American Board of Dental Aesthetics, he lectures internationally on subjects in aesthetic dentistry and has authored chapters in 2 dental textbooks. He is co-founder of the Nash Institute for Dental Learning in Huntersville and is a consultant for numerous dental product manufacturers. He can be reached at (704) 895-7660, via email at, or via the website

Disclosure: Dr. Nash reports no disclosures.

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