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Introduction

 Creating a beautiful smile with indirect porcelain veneers and crowns can be one of the most rewarding experiences for both the dentist and the patient. As more and more patients demand the “perfect smile” influenced by the media, marketing and in-office patient education, more and more companies have provided dentists with better, more life like materials that can change the shape, color and alignment of the existing dentition. These restorations provide long-term wear, strain resistance and translucency that closely mimic the natural tooth structure.

 History

 The patient was a 22 years old female in excellent health. Although she had been through many years of orthodontic treatment, she was still unhappy with her smile. She presented with asymmetrical smile. The midline was off to her right by approximately 1mm. The left central was 1.5 mm wider than the right central. The axial inclinations of # 6, # 10, & # 11 were flared. Gingival architecture was uneven, which further accentuated the size discrepancy of the central incisors. # 6 & # 7 were shorter at the incisal edges than # 10 or # 11. # 11 was very prominently positioned labially due to its rotation. The patient wanted a more uniform, symmetrical whiter smile.

 Clinical Exam

 Clinically all soft and hard tissues were within normal parameters. Radiographs indicated sound bone support. Periodontally the patient had healthy gingival tissues with no significant pocketing and minimal bleeding upon probing.

 Her tempromandibular joint was asymptomatic with no internal derangement and no criptis or clicking of the joint. She had a class I occlusion with moderate overjet and overbite relationship. The entire dentition was caries free, with no tooth mobility, and radiographs revealed no periapical pathology. Patient had some wear facets and was aware that she grinds her teeth at night.

 Clinical examination revealed the following:

• The midline was off to her right by approximately 1mm.
• The left central was 1.5 mm wider than the right central.
• The axial inclinations of # 6, # 10, & # 11 were flared.
• Gingival architecture was uneven, which further accentuated the size discrepancy of the central incisors.
• # 6 & # 7 were shorter at the incisal edges than # 10 or # 11.
• Some crowding of lower incisors.
• Left cuspid very prominently positioned labially due to its rotation.
• Well developed buccal corridor (this enabled us to concentrate on the six anterior teeth in our restorative efforts as we would not have to widen the arch or fill the buccal corridor restoratively).

 Diagnosis

 The diagnosis for this patient was an unattractive and asymmetrical smile due to midline discrepancy variation in the size of the 2 centrals, flare in the axial inclination of 6, 10 & 11, uneven gingival architecture in addition to some discrepancy in the length of the cuspids and lateral incisors.

 Treatment Plan

 A complete set of records were taken which included full radiographs, study models and set of 35 mm digital photographs  showing all twelve views as recommended by the AACD. Face bow transfer (Denar) CR records, facial height and width measurements (True bite Tooth Indicator, Dentsply) and periodontal chart were taken. The models were mounted on a semi-adjustable articulator (Denar) and checked for occlusal discrepancy.

 The treatment plan for this patient was as follows:

1.            Development of a composite mock-up on study casts to evaluate proper tooth morphology and tooth length for best esthetics, proper gingival contours and improved smile line which was presented to the patient utilizing preoperative models to assist in determining the options and course of treatment.

2.            Using the composite mock up model to fabricate:

·        Sil-Teck Putty anterior incisal template,

·        a reduction guide (pinhole preparation guide) to help in proper tooth reduction at the preparation appointment, and

·        A polyvinyl siloxane putty for creation of accurate temporaries from the mock up.

3.            Preparation of teeth # 6 to # 11 for Feldspathic Veneers.

4.            Bleaching of her teeth. Patient wanted her veneers to be whiter than her natural teeth, since she was planning to have veneers on her lower anteriors in the future. She chose 0M3 (Progressive Shade) - knowing that it will be lighter than her actual teeth even after beaching, and she was OK with that - and 1M1 at the cervical 1/3 of # 6 & 11 to blend better with her posterior teeth

5.            Fabrication of an occlusal guard.

 Armamentarium

• 20D EOS Digital Camera (Cannon)
• Vita 3D Shade Guide
• Septocaine with 1:100,000 epinephrine (Septodont; New Castle, DE)
• The Wand (Milestone Scientific; Livingston, NJ)
• Jeltrate Plus Alginate (Dentsply / Caulk; Milfrd, DE)
• Yellow Stone
• Morely Anterior prep and contouring kit (Brassler; Savannah, GA)
• Brasseler diamond Burs 6844 0141, 6844-016, 6850-014, 6850-018
• Gingival Retraction Cord (Ultradent)
• Impergum impression material (3M ESPE)
• Sil-Tech putty impression Material (Ivoclar Vidadent; Amhers, NY) 
• Ultra – etch 35% phosphoric acid (Ultradent)
• Optibond solo plus (Kerr; Orange, CA)
• Optilux 501 Curing Light (Kerr)
• Sensimatic Electrosurge (Porkell Electronics; Farmingdale, NY)
• Gluma desensitizer (Heraeus Kulzer)
• Luxatemp Temporary material shade B1
• Flexistrips & Flexidiscs (Cosmodent)
• Vision Flex diamond strips (WS37ET) Brassler
• Porcelain Diamond polishers (Brassler)
• De-Ox (Ultradent)
• Blue and pink cups and points (Cosmodent)
• Bard Parker Scalpel (Franklin Lakes, NJ) #12 blade
• Supaeroxol (EPR Industries Chemists; Pennsauken, NJ)
• Vaccum-formed Copyplast stent for temporary fabrication (Scheu Dental)
• Vacum-formed copyplast pin hole preparation guide (Scheu Dental)
• Porcelain etch gel (Puldent Products; Watertown, MA)
• Polyvinyl Siloxane impression material (Splash Discuss)
• Silane (Mirage)
• Articulator (Denar)
• Semi-adjustable articulator (Denar)
• Truebite Tooth Indicator (Dentsply)
• Enamelizer composite paste (Cosmodent)
• Vaseline
• Clear temp bond (Kerr)

 Preparation

 On the day of the preparation patient was given a sneak preview of her new smile by lubricating the teeth with Vaseline and shade B1 Luxatemp was injected into the clear stents which were made off the diagnostic wax up and placed over her teeth. This gave the patient a rough idea of how her new smile would be like after the procedure was done.

 The teeth were anaesthetized with lidocaine 2% with 1:100,000 epinephrine and the teeth preparation was initiated using a 6850-018 diamond burr (Brassler). The use of reduction templates (pin hole preparation guide) ensured proper tooth reduction.

 Preparation was extended 0.5 mm subgingival with a 1.0 mm chamfer margin on the facial. The preparation extended lingually over the incisal edge ending in a 1.0 mm shoulder just above the cingulum. The teeth were prepared in such a fashion as to give the laboratory 2mm of incisal and 1.5mm of facial room to develop subtle internal characterizations with the porcelain. The gingival proximal area extended lingually at the crest of the papilla to provide adequate porcelain to eliminate black triangles.

 Preparations were polished to round off any sharp line angles or point angles. Stump shades were chosen and photographs were taken of the preparations with stump guides in view for the laboratory’s use. A small amount of gingival contouring was also done with electrosurge. Supaeroxo was used to control any slight hemorrhage or gingival seepage. Supaeroxo was rinsed off thoroughly before impressions were taken. An Impergum impression was taken blowing the impression material into the sulcus. A face bow transfer of her maxillary teeth was taken to aid the laboratory technician mounting her cast.

 Using the Polyvinyl Siloxane impression off the mock up study casts and with the use of Luxatemp shade B1, the provisional restorations were made, trimmed, polished and cemented on patient’s teeth with clear temp bond (Kerr). The occlusion was adjusted and post op instructions were given. Patient was scheduled for post-op appointment next day for any possible adjustments and temporary night guard was given to her due to bruxism.

 Next day when patient came she was very excited about her new smile, except for very minor adjustments. She had no discomfort and was very pleased with how they look.

An alginate impression of her upper and lower provisionals was taken, poured up in stone to be sent to lab.

 Photographs of her provisionals and her face with the provisionals were taken for better communication with the lab.

 Laboratory Instructions:

 A complete laboratory prescription with the following items was sent to the laboratory:

• Color map drawing
• 35 mm digital photographs showing:
  1. all the pre-operative 12 views as recommended by the AACD,
  2. prepared teeth with chromscopic stump shade guide,
  3. patient’s face, height and width with interpupilar horizontal bite stick,
  4. Patient’s full smile and face with the provisionals.
• Original face bow mounted casts
• Bite fork with maxillary teeth prepared.
• Bite registration
• Upper provisionals

 During the 3 weeks that the case was being prepared in the laboratory, the ceramist and I spoke over the telephone few times. The lab e-mailed me the photographs of the finished case and we discussed any needed changes before I received it.

 Cementation

Three weeks after the preparation appointment the patient was seen to seat the restorations. The patient was anaesthetized. Patient rinsed with Peridex then the provisionals were removed and teeth were rinsed with conscpcis (Ultradent) and each veneer was checked individually on the teeth then they were checked again on the prepared teeth as a group. Inter proximal contacts were checked and adjusted as needed. When patient saw them she was very pleased and she approved the final cementation.

 Teeth were cleaned with micro etch (Danville Engineering) to remove any remaining cement. Teeth were then etched with 35% phosphoric acid for 15 seconds and then rinsed with water. Maintaining moistened surface, a dentin sealer was placed (Gluma). A dentin primer and adhesive (Optibond Solo Plus, Kerr) was placed on the surface of the teeth then cured with 501 optilux light for 20 seconds. Feldspathic Veneers were silenated (Mirage) and when ready, a coat of Prime and Bond NT was applied to all inner surfaces. Relyx luting cement (Tr shade) was used to bond the teeth. The centrals were seated first, excess cement was removed. Teeth # 7, 10, 6, 11. were bonded respectively. Each restoration was then light-cured with optilux 501 power tips for 3 seconds. All the excessive luting cement was cleaned. To avoid an oxygen inhibited layer, DeOx glycerin gel was then applied to all veneer margins and then each tooth was light-cured for an additional 40 seconds on the facial and the lingual. Excess cement was carefully removed using a Bard Parker Scalpel # 12. The margins were polished with diamond polishing paste, Enamelize (Cosmodent) and prophy cup. Slight occlusal adjustment was then made, and those surfaces that needed adjustment were polished once more using the Dialite polishing system (Brasseler).

 An occlusal guard was also made for the patient in order to protect the Porcelain restorations.  Patient was advised to wear it every night to maximize the longevity of her new restoration.

 Summary and Conclusions

 Combining art and science is not only fulfilling to the dentist but at times it is life changing to the patient. By changing the patient’s asymmetrical smile and misaligned teeth to her new smile she was extremely happy with her new image that gave her more self confidence in both her personal and professional life.

 It is an exciting time for dentists who have life-like all-ceramic materials which allow them to mimic nature and provide patients with long lasting beautiful smiles.

References

Jimmy Eubank, Jeff Morely, UCLA Esthetic Continuum, Level I (July – September 2001)

Jimmy Eubank, Jeff Morely, Advanced Anterior Esthetics, Hands-on Lectures (February - April 2005)

American Academy of Cosmetic Dentistry (AACD). Diagnosis and Treatment Evaluations in Cosmetic Dentistry: A guide to accreditation Criteria, Nashville, 2005

Frank Spears, DDS, MSD, Occlusion in the Clinical Practice, Seattle, WA (January, 2004)

Frank Spears, DDS, MSD, Advanced Esthetic & Restorative Management, Seattle, WA (May, 2004)

Frank Spears, DDS, MSD, State of the Art Esthetics, Seattle, WA (October, 2004)

Peter E. Dawson, DDS, “Combining Smile Design with Function”, AACD, Nashville, 2005.

Michael Sesemann, DDS “Accreditation Case Type I – Six or More Indirect Restorations”, AACD Nashville, 2005

Nils W. Olson, DDS, “Essential Keys for Successful Restoration of teeth with Porcelain Veneers”, AACD, San Diego, 2006.

Douglas A. Terry, DDS, “Imagination + Form + Color = Natural Esthetics”, AACD, San Diego, 2006.