Photography by the authors.
Case Presentation Patient Complaint, Examination, and Diagnoses:
The patient presented with concerns about his smile’s esthetics. His chief complaints were the small size and shape of his anterior teeth and the minimal amount of tooth exposure when he smiled; he also wanted improved color.
Dentolabial analysis: Dynamic evaluation of the lips and the lower facial third while speaking and smiling provides invaluable information about tooth exposure, guiding the correct orientation and integration of the esthetic restorative treatment. In this particular case, the amount of exposure at rest position appeared to be below the normal range. The smile evaluation revealed an average convex smile line and parallel orientation to the concavity of the lower lip.
Restorative Treatment Goals
In this case, early intervention was a reasonable approach because the treatment would require little or no tooth reduction. In fact, after removing the preexisting defective composite restorations, only additive bonding procedures would be needed to restore the tooth structure. The proposed restorative esthetic treatment had the following goals:
- Establish a correct maxillary incisal profile in harmony with the vermillion border of the lower lip.
- Improve the shape of the maxillary anterior teeth.
- Reduce the overbite.
- Restore the anterior guidance while correcting the linguoversion of the lower anterior teeth.
- Balance the lower facial third with the middle third, while creating a pleasing smile in harmony with the patient’s gender, personality, and expectations.
- Achieve the esthetic improvements in harmony with the new occlusion.
- Meet the patient’s esthetic color change requirements.
Treatment Workflow/Prosthetic Design: Mock-up: After completing the preoperatory evaluation, the next step was to create a three-dimensional (3D) mock-up prototype. Accordingly, intraoral scan and interocclusal records were taken with an intraoral scanner. The files were imported to computer aided design (CAD) software to design a digital mock-up.
3D-printed prototypes: Once the digital design was completed, the prototypes were 3D-printed in microfilled hybrid resin. High-accuracy dental model resin was used to generate the printed models of both arches in order to verify the adaptation of the prototypes on the models. This digital mock-up was placed in the patient’s mouth over the existing teeth, with no tooth reduction, for esthetic and functional evaluation.
Intraoral scan and bite registration: Once the patient and restorative team were satisfied with the new VDO and mock-up modifications, the shape and interocclusal relation were intraorally scanned to serve as a reference for the subsequent procedures. In addition to the digital data, a conventional bite registration with the prototypes in place was also taken for the laboratory to utilize during the mounting procedures.
Preparation Guide: After corrections during the try-in, the upper prototype was rescanned and superimposed on the initial prototype virtual design to transfer the corrections and develop the preparation guide that would be used in the patient’s mouth. After the guide was 3D-printed, the proper reduction was made in the laboratory on a diagnostic model. The space was checked in relation with the prototype. The guide was tried intraorally to verify fit, and the palatal-incisal reduction was performed using a fine diamond bur.
Since a “sandwich” approach was the restorative choice for the maxillary anterior teeth, the palatal restorations were then tried and bonded. Occlusal images of the upper and lower occlusal onlays and palatal veneers after bonding.
Facial references were taken with a facial scanner. The purpose of the intraoral marker is to achieve a correct position of the maxillary virtual model with the virtual craniofacial reference; the forehead marker is necessary to align the scans that reproduce lip dynamics, which are taken without the intraoral device.
3D-printed models with removable dies were fabricated. Before proceeding further, these printed models were verified for accuracy by superimposing the digital data of the printed alveolar model rescanned using the laboratory scanner and the dentition data. This correlation process was done for both the upper and lower 3D-printed alveolar models.
Digital data of the printed alveolar model and the intraoral data superimposed to verify the accuracy of the 3D-printed models.
Silinization and Acid Etching: The veneers were checked carefully to ensure marginal fit, proper esthetics, and color integration. After try-in and esthetic evaluation, the restorations were acid-etched with hydrofluoric 9% acid gel for 20 seconds and washed abundantly with water; 35% phosphoric acid was applied to the etched surfaces for one minute. After being rinsed with water and steam cleaned, they were placed in an ultrasonic bath with distilled water for five minutes. After air-drying, the intaglio surface was silanized with two coats of silane and heat-dried for 60 seconds. The internal surface was coated with an adhesive system with no polymerization.
Outcome: Minimal occlusal adjustments were performed with a fine diamond bur and polishing system for ceramics. The patient was pleased with the final outcome, which exhibited a natural-looking integration of the ceramic veneers with the soft tissue and lips, as well as teeth sized and positioned to blend harmoniously within his face.
Summary:
This case presented a protocol with three focal points—diagnosis, function, and esthetics—to develop a full-mouth esthetic rehabilitation following a minimally invasive approach. Detailed treatment planning and efficient communication are essential for successful results that meet patients’ esthetic demands as well as the restorative teams’ goals to achieve conservative, predictable outcomes with superior esthetics, functionality, and periodontal health.
This article was extracted from the full-length feature in the AACD Journal of Cosmetic Dentistry, Volume 37, Issue 4. To read this article in its entirety, plus access all benefits of membership, join AACD. The American Academy of Cosmetic Dentistry helps dental professionals go further, faster.
Dr. Bologna is an associate professor in the graduate aesthetic program at Central University of Venezuela and the implants program at University of Santa Maria, both in Caracas, Venezuela. She owns and practices in a private practice focused on cosmetic dentistry, oral rehabilitation, and implants in Caracas.
Dr. Laplana is an associate professor in advanced programs in aesthetics, restorative, and implant dentistry at Central University of Venezuela. He owns and practices in a private practice in Caracas, Venezuela, with a focus on cosmetic, complex restorative, and implant dentistry.