The International Journal of Periodontics & Restorative Dentistry

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The International Journal of Periodontics & Restorative Dentistry Ohyama.qxd 12/7/06 4:38 PM Page 61

Recreating an Esthetic Smile: A Multidisciplinary Approach

Hiroe Ohyama, DMD, MMSc, PhD* The esthetic restoration/rehabilitation Shigemi Nagai, DDS, MS, PhD* of a patient with a functionally com- Hiro Tokutomi, RDT** promised dentition frequently involves Michael Ferguson, DMD*** a multidisciplinary approach. The successful integration of esthetics and function does not emerge by chance, but rather as a result of the meticulous development of clearly defined ana- Today’s dental patients are demanding a youthful, attractive smile. The esthetic tomic parameters and their subse- rehabilitation of patients with functionally compromised dentitions frequently quent incorporation into the design of involves a multidisciplinary approach. The realization of esthetic objectives in mul- the prosthesis.1–4 tidisciplinary cases represents a considerable clinical challenge. To a great extent, The restorative and periodontal proper case selection and careful multidisciplinary treatment planning can govern the predictability of procedures. A team approach that includes the clinicians, the elements, such as incisal length, incisal laboratory technician, and the patient is essential to achieve the desired results. plane, incisal profile, incisal display, This clinical report demonstrates a successful multidisciplinary approach to re- tooth shape and color, tooth propor- creating an esthetic smile of a patient whose anterior maxillary dentition had been tion, tooth-to-tooth proportions, gin- functionally and esthetically compromised by prosthetic and periodontal prob- gival architecture, and gingival display lems. (Int J Periodontics Restorative Dent 2007;27:61–69.) should be considered in the creation of a pleasing smile. The incisal plane should be harmonized with the lower lip in proper incisal length and profile. The incisal display should also take into account the patient’s age and gender. Ideally, tooth-to-tooth proportions *Instructor, Harvard School of Dental Medicine, Department of Restorative Dentistry and should follow the golden proportion.5 Biomaterials Sciences, Boston, Massachusetts. **Cusp Dental Laboratory, Malden, Massachusetts. Periodontal treatment provides part of ***Associate Clinical Professor, Department of Prosthodontics, New York University College the solution to commonly encountered of Dentistry, New York, New York. esthetic issues,6 such as excessive gingival display,7–11 asymmetric gingival Correspondence to: Hiroe Ohyama, Harvard School of Dental Medicine, Department of 12–14 Restorative Dentistry and Biomaterials Sciences, 188 Longwood Avenue, Boston, MA architecture, the loss of papil- 02115; fax: +617-432-0901; e-mail: [email protected]. lae,15,16 and the exposure of root sur-

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Fig 1 Pretreatment clinical appearance, frontal view. A healthy, 68-year-old male patient presented with the desire to improve the esthetics of his maxillary dentition.

faces.17,18 An evaluation of the gingival preoperative treatment plan allows the architecture and any subsequent plans clinician to identify areas of concern, for its modification should be consid- outline the desired protocol for restora- ered based on the amount of gingival tions, and communicate desired para- display and ability to achieve a desir- meters to a laboratory technician.19 A able gingival architecture and tooth team approach by clinicians, laboratory proportion. For instance, in the pres- technicians, and the patient is neces- ence of a good crown-to-root ratio, sary to achieve desired results when a esthetic crown lengthening can pro- multidisciplinary approach is indicated. vide an opportunity to develop appro- This clinical report demonstrates a priate proportions of the anterior teeth, successful multidisciplinary approach along with pleasing gingival symmetry. to recreate an esthetic smile in a Appropriate case selection and patient whose maxillary anterior den- careful treatment planning are critical tition had been functionally and esthet- to a successful outcome and patient ically compromised as a result of pros- satisfaction in multidisciplinary cases. thetic and periodontal problems. Prior to finalizing the esthetic design, a treatment plan should be developed with comprehensive examinations and smile analysis, as well as a good under- standing of the patient’s expectations. The use of diagnostic elements and a

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Figs 2a and 2b Pretreatment facebow registration. The study casts were mounted on a semiadjustable articulator via a facebow transfer.

Clinical report Periodontal evaluation erally, a Class I canine relationship on the right, and an end-to-end canine Patient description and The patient showed generalized gin- relationship on the left. Overbite was examination gival inflammation and generalized 1 mm, and overjet was 1.5 mm. mild horizontal bone loss, with probing Maximum intercuspation and centric A healthy, 68-year-old male patient depths ranging from 1 to 3 mm, except occlusion (centric relation) were coin- presented with the desire to improve at the distal aspects of the mandibular cident. Bilateral partial group function the esthetics of his maxillary dentition. right and left second molars, which was observed on lateral excursions A clinical examination revealed sev- exhibited probing depths of 4 mm and with nonworking interferences. The eral fractured teeth (maxillary right and bleeding on probing. The patient had incisal edges of the mandibular incisors left central incisors, right lateral incisor, an adequate amount of keratinized guided against the lingual surfaces of and right first premolar); defective gingiva in the maxillary anterior and the maxillary incisors during protru- restorations (maxillary right first mild gingival recession in the mandibu- sion, although posterior interferences and second molars, right second pre- lar anterior. were present. The patient had exten- molar, left lateral incisor, left first and sive incisal occlusal wear in both arches second premolars, left second molar, (see Fig 1). However, the patient was mandibular left first and second Occlusal evaluation comfortable with the present vertical molars, left second premolar, and right dimension and had no muscular dis- second molar); and caries lesions (max- The study casts were mounted on a comfort or clicking/crepitus in the tem- illary right and left canines) (Fig 1). No semiadjustable articulator via a face- poromandibular joints. The patient intraoral pathology was noted clini- bow transfer (Fig 2). The patient had reported no parafunctional habits. cally or radiographically. Angle Class I molar relationships bilat-

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Fig 3 Pretreatment clinical appearance, smile in frontal view. Note the revealing asymmetric gingival architecture and the moderate amount of gingival display upon smiling.

Smile analysis positioned 1.5 mm to the right of the midfacial vertical plane, and the Objective smile analysis mandibular midline was 2 mm to the The patient presented with a high left of the midfacial vertical plane. smile line and moderate gingival dis- Fractures and discoloration of maxil- play of 2 mm when smiling (Fig 3). lary anterior restorations and mis- The incisal edges of the maxillary matched crown colors also compro- anterior teeth were not in harmony mised his smile (see Figs 1 and 3). with the lower lip line, and there was no incisor crown display in rest posi- Subjective smile analysis tion. The patient had a sufficient quan- The patient was unhappy with the tity of keratinized gingiva in his max- appearance of his maxillary anterior illary anterior region, but the gingival teeth. He did not like the short crowns, marginal line was not harmonized with discoloration, and mismatched color of his upper lip. The ideal height-to- his anterior crowns. He wanted to cor- width ratio of the maxillary central rect the fractures and wear of his teeth incisors is 75% to 83%, yet the patient and desired a more youthful smile. The had a 100% ratio. The short clinical resin composite restorations in the crown height of the maxillary incisors maxillary incisors had fractured several compromised his esthetics. Maxillary times during the previous 5 years, and and mandibular midlines were not the patient desired a longer-lasting coincident. The maxillary midline was restorative solution.

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Considerations in treatment Occlusal harmony planning The patient had bilateral partial group Complex treatment plans frequently function and posterior interferences on require multidisciplinary therapy. The protrusion and lateral excursions. One of establishment of an esthetic scheme the ultimate goals was to establish a must be considered an integral com- functional occlusion by eliminating inter- ponent of the diagnostic phase. Once ferences and creating a mutually pro- esthetic objectives are defined, adjunc- tected occlusion. In this case, the verti- tive treatment considerations are cal dimension of occlusion (VDO) would developed to support the desired be maintained because the patient was restorative outcome.3 In the present comfortable with the current VDO and case, fractured teeth, defective restora- the VDO–vertical dimension of rest tions, short clinical crowns, excessive relationship was within normal limits. gingival display, asymmetric gingival Because the patient originally presented architecture, presence of interferences with extensive wear facets, broken teeth, with excursions, and an unesthetic and fractured restorations, a probable smile were addressed in preoperative parafunctional habit had to be consid- treatment planning. ered, even though the patient denied having any parafunctional habits.

Prosthetic and periodontal esthetics Treatment plan

The treatment goals were to provide Upon consultation with the patient, proper restorative treatment, achieve the following treatment plan was gingival symmetry, minimize exces- formulated: sive gingival display, eliminate posterior interferences, and improve the • Initial periodontal therapy and re- esthetic appearance of the smile. A evaluation crown-lengthening procedure was • Esthetic crown lengthening from planned to meet the esthetic goals, the maxillary anterior to the pre- since the patient had sufficient kera- molar regions tinized gingiva. In addition to estab- • Placement of porcelain-fused-to- lishing gingival symmetry and elimi- metal (PFM) restorations in the nating excessive gingival display, maxilla from the right second pre- crown lengthening would facilitate the molar to the left second premolar achievement of a proper height-to- • Full–cast gold restorations for max- width ratio for the anterior teeth, as illary and mandibular molars well as increased retention of the (patient’s preference) definitive restorations. • Occlusal stabilization via elimina- tion of interferences while main- taining the current VDO • Occlusal guard

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Fig 4 A diagnostic waxup was performed Fig 5a The esthetic crown-lengthening Fig 5b A surgical stent was used to on the study casts using ideal esthetics and procedure was planned to achieve gingival ensure ideal crown length and adequate function. The golden proportion was estab- symmetry, minimize excessive gingival dis- gingival height. lished for the maxillary central and lateral play, and improve the esthetic appearance incisors and canines. of the patient’s smile.

Fig 6 (left) Minor gingival recontouring was performed to establish symmetric gingival architecture.

Fig 7 (right) Final preparations for the maxillary teeth. Teeth in the esthetic zone were prepared for PFM crowns with slightly subgingival moderate chamfer margins. The preparations were modified after crown lengthening.

Treatment outcome and width ratios, axial inclination of teeth, in the esthetic zone (Fig 5). Bone archi- discussion proper gingival contours, the golden tecture was defined for gingival health proportion, incisal plane, gingival har- and esthetics. Three months after Diagnostic waxup mony, and occlusal function (Fig 4). crown lengthening, additional minor gingival recontouring was performed A diagnostic waxup was developed to to establish symmetric gingival mar- reflect any contributory adjunctive pro- Preparation and esthetic crown gins (Fig 6). The depths of postsurgical cedures that were contemplated as lengthening crevices were measured to ensure that part of the multidisciplinary treatment the final restorative margins would be plan and to establish an esthetic The teeth in the esthetic zone were within the crevices. The depths were 1 restorative design at the wax stage prepared for PFM crowns with moder- to 2 mm, and the final moderate cham- that would closely resemble the ate chamfer margins at a slightly sub- fer margins were kept slightly subgin- desired definitive treatment out- gingival level. Provisional restorations gival to prevent overextension of mar- come.20 Crown lengthening was per- were fabricated for the prepared teeth, gins apically beyond the limitations of formed preoperatively on study casts and esthetic crown lengthening was the crevices. After healing and matu- prior to the diagnostic waxup. performed. A surgical template was ration of soft tissue, preparations and Consideration was given to length-to- used to ensure proper gingival height provisional restorations were modified

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Fig 8 Final provisional restorations were Figs 9a and 9b Facebow registration with fabricated to establish optimal esthetics the provisional restorations was performed and function. After crown lengthening, the as a reference to establish functional occlu- provisionals were gradually modified until sion. all the objectives for optimal definitive restorations had been achieved.

several times, up to 32 weeks after factor for periodontal health. The restorations.21 Another facebow trans- crown lengthening. Figure 7 shows the emergence profile and the margins of fer was performed with the provisional final preparations of the maxillary teeth the provisionals were modified several restorations as a reference to establish in the esthetic zone. times to achieve the best gingival functional occlusion. This remounting health and esthetics. Canine guidance with the final provisional restoration and a mutually protected occlusion casts was a very important process for Provisional restorations were established with the provisional the clinician and the technician to com- restorations. Once this was accom- municate about the desired functional The diagnostic waxup, which reflected plished, the functional and esthetic and esthetic outcome (Fig 9). the planned adjunctive procedures, outcome could be defined in the final A final full-arch impression was was used as a basis for the fabrication provisional prosthesis, creating a tem- taken using polyvinyl impression mate- of the provisional prosthesis. Integrity plate from which the design of the rial (EXAFLEX putty and injection type (Dentsply Caulk) provisional fixed par- definitive restoration was generated material, GC America). Metal copings tial denture material was used with a (Fig 8).3 Measures must be taken to were fabricated and tried in, and a vacuum-formed shell. ensure that the definitive restorations pickup impression was obtained to The gingival contours of full-cov- replicate the anatomic details devel- produce a soft tissue cast. erage restorations are an important oped with the finalized provisional

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Fig 10 (above) Definitive restorations, frontal view, at 1 week after placement. A natural appearance is apparent, with healthy gingivae and symmetric gingival architecture. Slight inflammation at the gingival margins resolved within 2 weeks.

Fig 11 (right) Postoperative appearance of the definitive restorations. Note the har- monious dentolabial composition and gingival display. An esthetic smile has been achieved.

Definitive restorations canine disclusion upon right and left disciplinary cases represents a consid- excursions, with metal–natural tooth erable clinical challenge. The clinical Figure 10 shows the retracted view of contacts rather than porcelain–natural challenge consists of ensuring that the definitive restorations. Noritake tooth contacts to prevent further esthetic goals will be preserved Porcelain Super EX-3 (Noritake Dental wear.22 A functional occlusion was re- through the various therapeutic phases, Supply) was used for the PFM crowns. established with the definitive restora- leading to completion of a definitive The definitive restorations exhibited a tions. The gingival tissue showed a restoration that satisfies all functional vital and natural appearance, with stippled appearance, illustrating excel- requirements. In this case, the patient’s proper gingival contour and a gin- lent health. The patient’s specific specific esthetic expectations were suc- givoincisal blend of color, as well as esthetic expectations were successfully cessfully met with a team approach optimal incisal translucency. Subtle sur- met with a team approach. The patient that included the clinicians, laboratory face textures were added to produce reported that he felt much more con- technicians, and the patient, in which a more natural appearance. The length fident with his new smile (Fig 11). communication and coordination were of the incisal edge of the maxillary crucial in achieving the desired esthetic incisors is critical for an esthetic out- result in the anterior maxilla. come. This was determined by the Conclusions upper lip position, the lower lip’s position on smiling, phonetics, the golden Today, more than ever, patients are Acknowledgment proportion, and the height-to-width demanding youthful, attractive smiles. ratio. The worn look and excessive The esthetic restoration/rehabilitation The authors are grateful to Dr Hans-Peter gingival display were eliminated, and of a patient with a functionally com- Weber, Professor and Chair, Department of Restorative Dentistry and Biomaterials and a lighter but natural tooth color was promised dentition frequently involves Sciences, Harvard School of Dental Medicine, used. As a result, a more youthful a multidisciplinary approach. The real- for his help in the preparation of the manuscript. appearance was achieved. There was ization of esthetic objectives in multi-

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