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CASE PRESENTATION: Esthetic and Functional Smile Design

Categories: Restorative Dentistry

Author(s): PEARL ZADEH, DDS

Date: 02-15-2021 12:02:56 pm


A healthy 53-year-old female presented with the chief complaint of pain in the maxillary left quadrant. She also stated that she wanted to improve her smile (Figure 1). She reported that her last dental visit was over 5 years ago. When she was in her 20s, her maxillary second molars were extracted and third molars were orthodontically moved anteriorly into their positions. She expressed that her occlusion has been unbalanced since the orthodontic repositioning of her molars. Clinical examination revealed the presence of multiple carious lesions. An implant that had been in place in the maxillary anterior area for 15 years had defective restoration margins (Figure 2).

Diagnostic study models, bite registration, face-bow (Figure 3), and pretreatment photos (Figure 4) were used as the basis of discussion between the restorative dentist and the lab technician. Custom shade was taken by the lab technician. In creating the diagnostic wax-up, the functional objectives were evaluated for occlusion; esthetic concerns of the patient were addressed by correcting the midline discrepancy, shading, closing interproximal embrasures, and correcting all chipped incisal edges. Full mouth cosmetic wax-up, preparation guide, and silicon putty for chairside provisional fabrication were provided by the lab technician.

Treatment began with the maxillary arch. Upon caries excavation, the extent of caries in the maxillary left molars rendered their prognosis poor. They were recommended to be extracted and replaced with implants (Astra Tech, Dentsply Sirona). Since only minimal caries were found around the maxillary left incisor and canine, minimally invasive veneers were planned for those teeth. After all teeth were prepared, a double cord technique was used for soft-tissue retraction (Figure 5). Photographs were taken of the stump shade using the IPS e.max stump shade guide (Figure 6). Each tooth had a different stump shade. Relaying this information accurately to the lab technician was crucial for ingot selection to achieve uniform shade for those teeth. Provisional restoration was fabricated chairside by using the silicon putty made over the diagnostic wax-up (Figure 7).

Three types of restorations would be fabricated— veneers, full crowns, and an implant restoration—with varying preparation thicknesses and on different substrates with distinct stump shades. Consultation with the patient and lab technician allowed for preselecting restorative material to meet esthetic goals.

Prior to delivering the restoration, all provisionals were removed and the teeth were thoroughly debrided using pumice. Consepsis (Ultradent) was used to further clean the tooth preparations to improve the bonding efficacy. Vital teeth were treated with GLUMA (Kulzer) to desensitize them and increase bond strength. Try-in paste was used beginning with translucent shade. For final cementation of all natural teeth, a total-etch technique was used (Select HV Etch, BISCO), followed by primer, bond (CLEARFIL SE BOND, Kuraray), and milky bright cement (Choice 2, BISCO) preheated on Calset (AdDent). Lastly, DeOx (Ultradent) was applied and cured. For the cementation of the implant restoration, a replica of the abutment was fabricated with polyvinyl siloxane bite registration material. This technique was used to extrude excess cement extraorally prior to intraoral cementation.

The lab technician was present during the restorative delivery to adjust the restoration contours and make custom characterization of the restorations (Figure 8). However, no adjustments were required in this case, which was a success thanks to thorough discussion with the patient to understand goals, careful photographic documentation, and close communication between the patient, dentist, and lab technician (Figure 9).
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GO-TO PRODUCTS USED IN THIS CASE

SELECT HV ETCH
Used to condition the tooth structure before bonding adhesives, composites, or sealants, Select HV Etch is a 35% phosphoric acid etchant available with benzalkonium chloride (BAC), an antimicrobial agent. Blue in color for easy visualization and contrast, Select HV Etch is specially formulated for maximum working time and ideal handling, pinpoint placement, and the elimination of run-off material onto the dentin surface.

CHOICE 2​
A light-cured luting cement with ideal physical properties, Choice 2 is designed specifically for the cementation of porcelain and composite veneers. The material exhibits color stability in a range of VITA or chromatic shades, allowing clinicians the flexibility to achieve high esthetics. This highly filled resin cement enhances the overall strength of the restoration, while low film thickness ensures the veneers are completely seated.
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