Esthetic Rehabilitation with Lingual and Facial Veneers after Orthodontic Treatment Clinical and Technical Diagnostic Esthetic Approach

Giuseppe ROMEO - CMDT Oral Design Center Clinical Assistant Professor, Division Restorative Science; University of Southern California, Los Angeles | USA Torino, Italy | [email protected]

ABSTRACT In the present scenario, the people’s esthetic requirements and expectations have increased substantially. Hence, the are faced with ever increasing demands to provide their patients with highly esthetic, durable tooth-colored restorations while maintaining a conservative approach to tooth reduction. Over the past 25 years, porcelain veneers can be used for changing the shape or color of the teeth, aligning the teeth, and replacing a pre-existing composite for better esthetics. Patients seek such restorations for a variety of reasons ranging from a minor diastema to a complex malocclusion. Although many patients choose this treatment purely for cosmetic purposes, the should aim at both functional and esthetic purposes. Therefore, dentists should perform a complete examination of the patient before selecting and planning treatment. For optimum results, unaesthetic treatment plan must take into account whether orthodontic movements will enhance the success or stability of the definitive restorations. The combining procedures such as orthodontics and porcelain veneers provide conservative, predictable, esthetic, and functional results. Thus, the aim of this study case was to emphasize the importance of orthodontic treatment in improving esthetic results obtained by porcelain veneers prior to their placement.1

KEYWORDS Orthodontics, Veneer, Esthetics, Individual Shape.

INTRODUCTION Porcelain veneers are being widely used in improving In case of substantial difference in length and smile aesthetics. gingival contour of the maxillary incisors, the esthetic appearance can be unsatisfactory depending on the However, it is necessary the appropriate clinical steps to teeth displayed on smiling. achieve the best outcomes.2 The discrepancy in crown length is accentuated if an This review specifically examines the treatment steps incisor is abraded or fractured; the gingiva around the required before veneer placement in order to address tooth moves along with the dental units in the direction various anatomical deviations and achieve the best of the orthodontic tooth movement. results in terms of smile esthetics and functionality. The esthetics can be improved through a slow extrusion Smile esthetics depends on a several factors, including or selective intrusion of the appropriate teeth taking the display and architecture of apparent gingival tissue in consideration the incisal edge can be reduced or and contour. restored.3-4

The appearance of the gingival contour follows the Previous studies have also shown that orthodontic underlying bone architecture and is influenced primarily treatment followed by restoration with veneers yields by details such as tooth position, type of periodontum, good results in case of asymmetrical gingival line and tooth form and design of the cement-enamel junction. teeth position.5

| 10 | Smile Dental Journal | Volume 15, Issue 1 - 2020 CASE REPORT Patient of 30 years old had the first visit in the office complaining about her smile and teeth shape. (Fig. 1-2a). (Fig. 1) Smile of the patient Furthermore she was affected of severe erosion in the where is noticeable lingual area and her concerning was also in finding the open bite a solution to protect the palatal zone of the six frontal discrepancy in the units. (Fig. 2b) upper frontal zone

The prescription of the dental office was to make in the beginning a facial diagnostic wax up of the 4 frontal units trying to get the suitable and harmonious smile and esthetics. (Fig. 2a) Preoperative case The first esthetics technical evaluation was about the facial view with position of the four incisors, the level of the gingival open bite issue and design and the open bite discrepancy. unesthic appearance

Based on the situation both dentist and dental technician planned the possibility to also build up lingual veneers in the beginning after the orthodontic treatment to cover the patient erosion taking in consideration to carefully restore the entire occlusion and frontal function. This minimally invasive procedure rehabilitates the patient affected by severe dental erosion maintaining the tooth structure and its vitality.6

The dentist sent to the laboratory impressions for diagnostic wax up, face bow and pictures documentation for the technical diagnostic esthetic approach.

Technically was analysed the importance to have an orthodontic extrusion treatment of the two centrals maxillary incisors unit to achieve better position for the (Fig. 2b) Preoperative case lingual view with in its aesthetic future veneers rehabilitation. deficiency With the original position of the units it is almost impossible for the dental technician to realize an esthetic rehabilitation.

The first step was to study digitally the face of the patient and subsequently planning the individual tooth shape based on the face characteristics taking in consideration the bifrontal, bizigomatic and bigonatic areas.7 (fig 3) After this step a digital smile planning was performed and sent to the office for patient show and to keep informed the dentist what could be the hypothetical final solution involving the ortho and the prostho treatments.8-10 (fig 4-5-6)

Based on the digital plan the patient approved for the consequent wax up for the future pre-visualization. The diagnostic models were mounted in articulation with the face bow and the dental technician practically started (Fig. 3) Individual tooth planning based on facial details this manual project of the future rehabilitation.

Smile Dental Journal | Volume 15, Issue 1 - 2020 | 11 | Nowadays we prefer to create a dynamic harmony between the asymmetrical face details of the patient and the individual tooth anatomy that will sit in the mouth. Face has asymmetric areas and also natural teeth are not anatomically the same and symmetric in their position, facial transition lines and incisal margin. The wax up was created (Fig. 4) Digital teeth design planned in the right position to intraorally perform a mock up with an hypothetical where extrusion ortho treatment is necessary orthodontic extrusion of the two centrals and subsequent ideal position of the tissues level. (Fig. 7-10)

(Fig. 7) Preoperative case with diagnostic models in relation and the visible open (Fig. 5) Intraoral digital new teeth design completed in the bite right position and right soft tissues contour level

(Fig. 8) Diagnostic wax up of the units and wax up of the soft tissues in a new position

(Fig. 9) Silicon index of the mock up carefully (Fig. 6) Digital smile design completed in the new harmonius designed in the teeth position cervical area on the diagnostic model

Based on the facial details and the possibility to create and individual tooth shape that could match into the face of the patient, a dental anatomical combination (Fig. 10) technique using facial transition line segmentation of the Silicon index of the teeth were created.11 mock up made with 2 putty materials to The basic principle of this system is based on have more precise segmentation and recombination of two or even three anatomy details principal tooth forms.

This topic was already explained in several articles already published. A lingual wax up was also necessary to plan the future The operator took in consideration that the future lingual erosion coverage, to improve the occlusion and harmonious smile shouldn’t be straight and symmetric. the function of the frontal zone. Orofacial analysis has been used by dentist for many The diagnostic wax up was ready to be delivered to the years applying mathematical rules and geometrical dental office for the pre-visualization in the mouth and 12 principles. clinical evaluation.

These procedures created mathematical smiles with no We would like to focus our attention that making a wax dynamic effects and all the teeth are at the same incisal up on the preoperative diagnostic cast and doing ceramic level with flat anatomy. onto the final preparation are two different situations.

| 12 | Smile Dental Journal | Volume 15, Issue 1 - 2020 Furthermore in this case we have to take in consideration Once the extrusion of the two maxillary incisors were that an ortho treatment will be done and spaces and done in the suitable position the dental office was ready teeth position will change. to schedule the prosthetic rehabilitation.

This laboratory limitation, based on the physiological The orthodontist carefully achieved the good position of preoperative situation, sometime will force the dental the vertical midline and the incisal margin position of the technician to add few changes on the final appearance upper centrals. of the esthetic rehabilitation compared to the initial technical diagnostic wax up planning. The new incisal margin position of the #8 (#11) and #9 (#21) will allow the dentist to be conservative with The clinician will execute the orthodondic and esthetic minimum prep in that area during the preparation and mock up in two steps: the dental technician will have enough space to reproduce 1. Pressing resin only on the teeth to simulate the future the incisal margin layering ceramic. (Fig. 13-13a) new position of them and hypothetical anatomy shape of the veneers. 2. The dentist will layer with a free hand technique the pink resin composite to simulate soft tissues level. This two steps mock up are useful to simulate not only the final esthetics but also to sensitive the patient in how much is important to proceed with an orthodontic treatment in order to best achieve the final esthetic and functional result. (Fig. 11-12)

The patient accepted to have an orthodontic treatment because the result of the mock up was for her more than acceptable. (Fig. 13) From the preoperative situation to the final solution with the orthodontic treatment . Extrusion and new position of the units in the esthetic zone

(Fig. 11) Pre-visualization of the wax up made by laboratory establishing the new smile redefinition

(Fig. 13a) Upper and lower orthodontic treatment

The case was analyzed more after the orthodontic treatment making a little bleaching in the esthetic zone. A second mock up with the natural teeth in a new position was executed to manage better the case in order to realize the future veneers.

According with the patient, the clinician evaluated to include both sides premolars to improve the buccal corridor and the color of these teeth.

(Fig. 12) Intraoral mock up with the new position of the Before to start the preparation of the teeth for the future maxillary upper incisors. The soft tissue are remodelled adding veneers a new wax up for a second revisualisation was pink composite directly in the mouth simulating the final requested by the dental office.(Fig 14-15) situation with the orthodontic extrusion

Smile Dental Journal | Volume 15, Issue 1 - 2020 | 13 | Few details recommendation from the dentist were sent to the laboratory to make some modifications for the (Fig. 14) final ceramic veneers. Diagnostic model for a new wax up after The first part of the all entire ceramic rehabilitation was ortho treatment. focused on the lingual upper veneers because of the The incisor are in erosion issue. suitable position This alternative procedure is a conservative approach that enables the clinician to preserve tooth tissue which is the goal today’s world of conservative dentistry. The dentist took a manual impression with retraction (Fig. 15) cord and sent to the laboratory for the palatial veneer Wax up of the fabrication. (Fig. 18) esthetic area with a new shape configuration The units were made in monolithic lithium disilicate restoring the occlusion in relation with the lowers and the function in protrusion, left and right laterals guidance.16 (Fig. 19-20) In this new situation, that is the result of the orthodontic The lingual veneers were tried in in the mouth and then treatment, the dental technician evaluates how to cemented using the rubber dam. (Fig. 21-22) proceed with the new wax up for the future mock. Based on the new position of the teeth few anatomy After cementation the dentist controlled the occlusion changes comparing with the first wax up were made. and the function. A new silicon index on top of the new wax up was executed and delivered to the dental office for the second pre-visualization.13

The dentist pressed resin in the mouth and showed the new project to the patient that approved the quality of the smile. (Fig. 16-17)

(Fig. 18) Palatal area with the retraction cord ready to be impressed (Fig. 16) Intraoral pre-visualization with new esthetic appearance

(Fig. 19) Lingual veneers glazed and manually polished on stone cast (Fig. 17) Patient new temporary look: relation between the face and the custom (Fig. 20) planning smile Lingual veneers ready to be delivered to the dental office

| 14 | Smile Dental Journal | Volume 15, Issue 1 - 2020 (Fig. 21) Lingual veneers cementation procedures totally isolated (Fig. 26-28) Sectionned silicon index to check intraorally (Fig. 22) calibrated spaces Lingual veneers reduction cemented, final check occlusion and function

Next appointment was for facial veneers preparation.

When the laboratory delivered to the dental office the six lingual units made a vestibular wax up on the plaster with the lingual veneers in position. calibrated geometrical shape of the prepared tooth. With the help of the silicone indexes the clinician can This step was necessary to create a new silicon index accomplish a precise calibrated preparation of the teeth, used in the mouth to press resin for the future provisional which results in the desired smooth providing enough after the preparation. (Fig 23-24) space for the thickness of the porcelain, in order to exploit all the benefits that this material has to offer. (Fig. Furthermore a new silicon sectioned keys were made for 29-32) space checking.17

These indexes were executed with different cuts in order to allow the dentist to check all the spaces in a different view during the preparation. (Fig. 25-27)

This procedure shows the effect that the silicone index has on the clinician’s ability to appropriately perform the preparation procedure and achieve the desired

(Fig. 23-25) Facial wax up for future temps with lingual veneers in position and new silicon index to press resin intraorally

(Fig. 29-32) Facial preparation using the sectioned silicon keys to make a calibrated preparation

Smile Dental Journal | Volume 15, Issue 1 - 2020 | 15 | After the impression the dentist took an impression with polyether material and sent to the laboratory together with a new face bow recording.

In the patient mouth was subsequently pressed resin for the temporarization. (Fig. 33) (Fig. 33) Smile of the patient Once the laboratory received the impression developed with the latest the master dies and the model works. provisional in the mouth The stone casts created were the alveolar model to build up ceramic and the solid model to place the veneer for the final control.

The feldspathic veneers were fabricated on the refractory dies and then removed to the master dies using the microscope to achieve to suitable precise fit.

Final anatomy details, according to the clinician, were produced to finalize the rehabilitation in order to fulfill the patient’s high esthetic demands.

The final polishing of the veneers was manually done in order to create a natural surface texture. (Fig. 34-37)

The veneers arrived in the office for the try in and eventually for the final cementation.

The cementation was done using the rubber dam and the units were bonded one by one using the microscope in a total isolation.18-19 (Fig. 38-39)

A manual finishing touch with a knife instrument was executed using the microscope to improve the angle and the emergence profile of the cervical finish line.21(Fig. 40)

The esthetic restoration of this case constitute one of the greatest challenges in restorative dentistry.20

In this context porcelain veneers are an increasingly popular treatment option for establishing unaesthetic teeth.

Currently, the use of adhesive procedures makes this treatment possible with the preservation of as much tooth structure as is feasible while satisfying the patient’s restorative needs and esthetic desires.22 (Fig. 41-42)

Porcelain veneers should be used as a solution to esthetic problems, involving morphologic modifications as in relation to tooth color, shape, contour, size, volume, and positioning.23-25 (Fig. 34) Veneers terminated on the plaster (Fig. 35) Veneers texture manually done Moreover, veneers may be indicated to have a place in the restoration of loss of tooth structure due to disease or (Fig. 36) Incisal smooth effects in the final rehabilitation trauma. (Fig. 37) Veneers texture ready to be delivered to the dental office

| 16 | Smile Dental Journal | Volume 15, Issue 1 - 2020 (Fig. 38-39) Veneers cementation procedure with total isolation of the units

(Fig. 40) Margin precision result: both dentist and dental technician used magnification during their workflow

(Fig. 43-45) customised smile of the final rehabilitation

(Fig. 46-47) Patient look initial and final situation: the clinical and technical workflow cooperated together to achieve the demanding esthetic and functional result asked from the patient

(Fig. 41-42) Posteroperative at 2 weeks from final cementation facial and lingual sides

Therefore, the aim of this report was to present an esthetic approach to reestablishing the esthetics and balance of the smile with orthodontic treatment and porcelain veneers lingual and facial as the restorative strategy. (Fig. 43-47)

Smile Dental Journal | Volume 15, Issue 1 - 2020 | 17 | CONCLUSION 9. Fradeani M. Esthetic Analysis: A Systematic Approach to Prosthetic Treatment. Esthetic Rehabilitation in Fixed The main purpose of the esthetic dental treatment is Prosthodontics. Vol 1. Chicago: Ed. Quintessence, 2004. achieving a beautiful smile. 10. Coachman C, Calamita MA Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic One of the most significant challenges for the clinician is to Dentistry. Chicago: Quintessence, 2012. recreate the beauty of the smile with natural looking teeth. 11. G. Romeo- Jin Ho Phark. Dental Anatomical Combination a Guide of Ultimate Esthetics. Smile Dental Journal. A multidisciplanary approach increases substantially the 2017;12(3):10-20. customised smile esthetics. 12. B. Pereira Silva, E. Mahn, Kyle Stanley, C. Coachman.The facial flow concept: An organic orofacial analysisd the Orthodontic extrusion or intrusion should be considered vertical component. J Prosthet Dent. 2019;121:189-94 for the correction of gingival height asymmetry and 13. Gürel G, Bichacho N. Permanent diagnostic provisional to correct the teeth position prior to porcelain veneer restorations for predictable results when redesigning smiles. placement. Pract Proced Aesthet Dent. 2006;18:281-6. 14. Schlichting LH, Resende TH, Reis KR, Magne P. Simplified Furthermore to achieve the best result in terms of both treatment of severe dental erosion with ultrathin CAD/CAM esthetic and functionality, it is necessary that each case composite occlusal veneers and anterior bilaminar veneers. be carefully planned using appropriate strategies. J Am Dent Assoc. 2014;145:352-4. 15. A. Juneja. Lingual veneers a conservative approach. ACKNOLEDGEMENTS Styleitaliano 2016. 16. S. Hulac. Porcelain Laminate Veneers: Adjunctive Treatment The author is thankful for the team work cooperation of Occlusal Disorders. Compendium. 2013:34(5): 362-6. to Dr. Monica Imelio and Dr. Roberto Perasso for 17. Bajevska J., Gigovski N., Zaturoski G., Bajevska Ja., their efficient clinical orthodontic and prosthodontic Stojanovska A., Peno E., Dodevski V., Bajevska Stefanovska procedures. B., Stavreva N. The use of a silicon index as guidance during tooth preparation. Ukim. 2019;42(1-2):1-7. REFERENCES 18. Jurado CA, Villalobos-Tinoco J, Tsujimoto A, Castro P, 1. Amjad Al Taki, O. Othman, M. Hassan, R.S. Abdelrahman. Torrealba Y. The art of minimal tooth reduction for veneer “Orthodontic Considerations Prior to Ceramic Veneers restorations. Eur J Gen Dent. 2020;9:45-52. Placement: An Updated Review”. EC Denta Science. 19. C Jurado, H Watanabe, J Villalobos Tinoco, H Ureta 2015;3(2):472-82. Valenzuela, G Guzman Perez, and A Tsujimoto (2019) A 2. BT Rotoli, et al. “Porcelain Veneers as an Alternative for Conservative Approach to Ceramic Veneers: A Case Report. Esthetic Treatment: Clinical Report”. Operative Dentistry. Operative Dentistry In-Press. 2013;38(5):459-66. 20. BT Rotoli DANL Lima NP Pini FHB Aguiar GDS Pereira 3. Máyra Reis Seixas, et al. “Gingival esthetics: An orthodontic LAMS Paulillo. Porcelain Veneers as an Alternative for and periodontal approach”. Dental Press Journal of Esthetic Treatment: Clinical Report.Operative Dentistry. Orthodontics 2012;17(5):190-201. 2013;38(5):459-66. 4. BJÖRN U, et al. “Repositioning of the gingival margin 21. D. Massironi, R. Pascetta, G. Romeo. Book: Esthetic and by extrusion and intrusion”. Formerly World Journal of Precision, 2004. Quintessenze International Publishing Orthodontics 2003;4(1):72-7. Books. 5. Ittipuriphat I and Leevailoj C. “Anterior space management: 22. Pini NP, Aguiar FHB, Lima DANL, Lovadino JR, Terada interdisciplinary concepts”. Journal of Esthetic and RSS, & Pascotto RC (2012) Advances in dental veneers: Restorative Dentistry. 2013;25(1):16-30. Materials, applications, and techniques Clinical, Cosmetic 6. F. Vailati, U. Belser. Palatal and facial veneers to treat and Investigational Dentistry. 4:9-16. severe dental erosion: a case report following the three- 23. Belser UC, Magne P, & Magne M Ceramic laminate veneers: step technique and the sandwich approach. The European Continuous evolution of indications Journal of Esthetic journal of esthetic dentistry. 2011;(3):268-78. Dentistry. 1997;9(4):197-207. 7. Rufenacht CR. Fundamentals of Esthetics. Chicago: 24. Radz GM Minimum thickness anterior porcelain restorations Quintessence, 1990. Dental Clinics of North America. 2011;55(2):353-70. 8. Coachman C, Van Dooren E, Gürel G, Landsberg CJ, 25. Strassler HE Minimally invasive porcelain veneers: Indications Calamita MA, Bichacho N. Smile design: From digital for a conservative esthetic dentistry treatment modality treatment planning to clinical reality. Interdisciplinary General Dentistry. 2007;55(7):686-94; quiz 695-686,712. Treatment Planning. Vol 2: Comprehensive Case Studies. Chicago: Quintessence. 2012:119-174.

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