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Strategies for Consistent Aesthetics and Function

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Strategies for Consistent Aesthetics and Function 108 AESTHETICS Strategies for Consistent Aesthetics and Function INTRODUCTION A Kois deprogrammer was utilized to take a centric relation Joyce L. Bassett, DDS Many patients present with both functional and aesthetic prob- bite, and models were mounted. A functional analysis showed lems. The dentist must first listen to the concerns of the patient, that the first point of contact in centric relation (CR) was the then evaluate the clinical findings in order to correctly apply maxillary and mandibular right lateral incisors. This finding dental facial treatment planning principles. When appropri- confirmed the diagnosis of a constricted chewing pattern. ate, minimally invasive techniques using a multidisciplinary The first step in dental facial treatment planning is evalu- approach should be presented. This article shows the step-by- ating the incisal edge and gingival position of the maxillary step thought process and treatment sequence for replacing and incisors (Figure 1). There are 4 ways to reposition the incisal restoring a 20-year-old feldspathic minimal preparation veneer edge: perio-restorative dentistry, orthodontics, orthognathic case. Verbal communication and clinical adjustments during surgery, or a combination of both orthodontics and orthogna- each phase were critical to the successful outcome, including thic surgery referred to as distraction osteogenesis. All options after the final cementation of the porcelain restorations. Col- were discussed with the patient. If no orthodontic treatment laboration with the patient invested her as an active participant was provided, the perio-restorative option of crown lengthen- in her aesthetic outcome and enhanced her satisfaction with ing and subsequent tooth shortening would increase both the both the process and the end result. biomechanical and periodontal risk since significant tooth structure removal would be required and the crown-to-root CASE REPORT ratio would become less favorable due to the removal of facial Diagnosis and Treatment Planning alveolar bone. A 45-year-old female patient presented with a chipped inci- The patient agreed to an orthodontic consultation. The ortho- sal edge of her tooth No. 7 veneer. She was unhappy with the dontist recommended correcting the deep overbite, unconstrict- bulkiness, color, and shape of her 20-year-old veneers. She ing the chewing envelope, and intruding the maxillary incisors remembered that her original dentist performed minimal in relation to her upper lip in repose (Figure 4). This treat- preparation, and there was no composite temporization after ment plan was accepted by the patient and would be imple- tooth preparation while she was waiting for the veneers to be mented using SureSmile (Dentsply Sirona) lingual technology seated. She was concerned with the bulkiness and monochro- (suresmile.com) linked with CBCT digital design. matic appearance and was looking for a more natural and life- SureSmile technology entails moving the teeth virtually like aesthetic result. (vertically and horizontally) and analyzing tooth mass and size She reported a history of mitral valve prolapse, and her phy- from the maxilla, as compared to the mandible. All possible sician stated that antibiotic premedication was not needed. Her options can be seen on the computer, which minimizes errors yearly physical had been recently completed, stating that she in the mouth and shortens the overall treatment time. Preop- was in good overall health. erative evaluation reveals which arch needs recontouring or A comprehensive dental exam was performed, which slenderizing, and which arch may be left with excess space. included a full-mouth series of radiographs, periodontal chart- This case presented with excess tooth mass on the maxilla. The ing, and clinical photos. Evaluation of the photographs revealed goal was to finish treatment with the ideal tooth size that would that the edges of her maxillary incisors were hidden below her match the face, with minimal need for restorative intervention lower lip and she had excessive gingival display (Figure 1). The when the orthodontic treatment was completed. Due to previ- mandibular anterior region presented with mild crowding, ous symptoms, she was informed that her temporomandibu- incisal wear, rotations, recession, and previously placed Class V lar joint function would be monitored and that possible splint composites. The mandibular incisal plane was uneven, with therapy could be necessary either during or after the orthodon- the mandibular anterior segment (teeth Nos. 22 to 27) posi- tic treatment. tioned 2.0 mm incisal to the posterior occlusal plane (Figure 2). The clinical evaluation also revealed a deep bite, with no Pre-Restorative Orthodontic Phase canine protection of the anterior teeth in lateral excursions (Fig- As predicted, 6 months after the orthodontic phase was started, ure 3). She exhibited a parafunctional grinding habit in lateral the orthodontist requested assistance with narrowing the ante- excursion and protrusive, where she habitually ground on her rior teeth via interproximal reduction (IPR) because they were canines and incisors. She presented with late clicking in both too wide and bulbous in relation to her facial contours (Figure 5). the right and left temporomandibular joints and a Class II Divi- The ideal length-to-width ratio of the central incisor has a range of sion I malocclusion. 75% to 80%. At this time in treatment, the length was evaluated DENTISTRYTODAY.COM • FEBRUARY 2019 109 Figure 1. Preoperative view: The incisal Figure 2. Note the uneven mandibular Figure 3. The canines do not protect the Figure 4. In this lateral cephalometric edges are hidden under the lower lip, and occlusal plane with crowding, incisal wear, front teeth in lateral excursion. view, note that the central incisal edge excessive gingival display is evident. and recession. position is tucked under the lip. and left untouched because the teeth still required the lower Essix retainer while she slept for 2 weeks types using diamond burs (868D.31.030 [Brasseler intrusion and the aligning of the gingival zeniths of (Figure 11). USA]) across the gingival and middle third to estab- teeth Nos. 6 to 11 (Figure 6). Restorative Phase lish the amount of facial reduction.2,3 Next, 2.0 mm On lingual evaluation, it was noted that porce- The patient was appointed, and a composite shade was removed from the previously approved incisal lain was wrapped interproximally from the original selection for teeth Nos. 22 to 27 was accomplished edge length. A lingual chamfer design was chosen reconstruction (Figure 7). When the IPR was done, by assessing the opacity and shade of the remaining to enhance the resistance form of the preparation4 every effort was made to remove only porcelain and tooth structure at the mandibular incisal edge.1 A as well as to provide increased enamel surface area conserve enamel in order to facilitate an additive and shade A1B Body composite (Filtek Supreme Ultra for increased bond strength. (The prepared teeth conservative approach to the post-ortho restorative [3M]) was chosen. A small increment was placed can be seen in Figure 12.) reconstruction. The central incisors were slender- on the missing portion of tooth and light cured in The following records were taken and sent to ized by removing distal porcelain, using a diamond order to preview and verify that a seamless, unde- the dental laboratory team: a Face-Bow (Panadent), (#8850.31.016 [Brasseler USA]) (Figure 8). tectable transition from tooth to restoration could maximum intercuspation position (MIP) bite regis- The Golden Rule of Proportion in dentistry occur with this shade. The incisal edges of teeth tration (Futar Fast [Kettenbach LP]), vinyl polysilox- states that the width of the lateral is 0.67 times the Nos. 22 to 27 were lightly beveled with a fine dia- ane (VPS) impressions (Honigum [DMG America]), width of the central. The central width was mea- mond to open up the enamel prisms (#850.31.016 provisional models, and detailed photo documen- sured and multiplied by 0.67. This calculated milli- [Brasseler USA]), then followed by micro-etching tation. The lower teeth had a combination of both meter width was then used during the execution of (MicroEtcher IIA [Danville Materials]). A total-etch A1 and B1 shades, and, after the initial mock-up, the the IPR step to obtain the final mesiodistal width of technique was used, placing 37% phosphoric etch patient requested a lighter composite prototype. the lateral. Slenderizing of the interproximal of the first on the enamel circumference and then on the Provisionals were fabricated (shade B1 [Luxatemp]) laterals and canines occurred, followed by flatten- dentin with a microbrush. After 15 seconds, the by loading the provisional matrix with the bis-acryl ing of the anterior teeth. The facial surfaces were etchant was rinsed thoroughly with water, and material and seating it. The resulting provisionals carefully recontoured to retain a thin layer of por- then the tooth surfaces were lightly air dried (not were luted with a combination of spot etching and celain covering the tooth, which prevented darker desiccated), intentionally leaving a moist dentin bonding using veneer cement (Duo-Link Universal tooth structure from showing through. surface. A single-bottle light-cured adhesive (ALL- [BISCO Dental Products]) in the center of the prep- The orthodontist was instructed to finish the BOND UNIVERSAL [BISCO Dental Products]) was arations and a temporary cement (TempoCem ID case
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