pISSN, eISSN 0125-5614 Case Report M Dent J 2019; 39 (2) : 53-63 Esthetic treatment of anterior spacings in a patient with localized microdontia using no-prep veneers combined with periodontal surgery: A clinical report Pajaree Limothai, Chalermpol Leevailoj Esthetic Restorative and Implant Dentistry, Faculty of Dentistry, Chulalongkorn University Objectives: This case report describes the treatment of a patient with maxillary anterior spacings, resulting from microdontia, using a multidisciplinary approach to improve her esthetic appearance. Materials and Methods: A 23-year-old Thai female patient had multiple spaces between her maxillary anterior teeth with a high smile line and an unsymmetrical gingival level. The Recurring Esthetic Dental (RED) proportion was used to determine the widths of maxillary teeth and Bolton’s analysis was used to confirm the RED results, after that a diagnostic wax-up model was fabricated. Esthetic crown lengthening was performed from the right maxillary canine to the left maxillary canine to reduce excess gingival exposure and increase the length of the teeth according to the proportion acquired from the calculation. After complete gingival healing, no-prep ceramic veneers were placed on the maxillary anterior teeth using the IPS Empress® Esthetic ceramic system. Results: The no-prep veneers preserved all tooth structures and gave a satisfactory esthetic result. The patient was satisfied with the outcome. The final restorations closed the spaces with the natural appearance the patient desired. The function and occlusion of the restorations were good. The veneers and the periodontal tissues were in good condition at the 1-year recall. Conclusion: The multidisciplinary approach and no-prep ceramic veneers used in this case restored the maxillary anterior spacing and provided an excellent esthetic outcome. However, successful treatment in the anterior esthetic zone requires a thorough diagnosis and meticulous step-by-step treatment planning. Keywords: ceramic veneer, maxillary anterior spacing, microdontia, no-prep veneer How to cite: Limothai P, Leevailoj C. Esthetic treatment of anterior spacings in a patient with localized microdontia using no-prep veneers combined with periodontal surgery: a clinical report. M Dent J 2019; 39: 52-63. Introduction clinical outcome, both dental practitioners and laboratory technicians must carefully consider the available treatment options that provide long-term People have become increasingly concerned success and outstanding esthetic results. [1] about esthetics. Therefore, a perfect smile can give Anterior teeth spacing is a type of malocclusion patients more confidence and feel comfortable in whose effect is mostly esthetic. Microdontia is a social situations. Esthetic dental treatment plays condition in which the teeth are smaller than average an important role in improving a personal appearance due to the underdeveloped permanent teeth and through a great smile that also has good clinical typically creates gaps in the dental arch. Abnormal function. Thus, esthetic dental treatment is a tooth morphology, including tooth shape and combination of art and science. To obtain the desired size, result from genetics, specific syndromes, Correspondence author: Pajaree Limothai Esthetic Restorative and Implant Dentistry, Faculty of Dentistry, Chulalongkorn University 34 Henri-Dunant Road, Patumwan, Bangkok, 10330, Thailand Tel: 02-218-8664 Fax: 02-218-8664 Mobile: 083-429-9917 E-mail: [email protected] Received : 5 April 2019 Accepted : 5 June 2019 Pajaree Limothai, et al environmental factors, trauma, medication use, In 1955, acid etching of the enamel surface and radiation patients receive while their teeth was introduced by Buonocore. [16] Subsequently, are developing. [2-4] Previous studies found Bowen developed the first bonding system. that 5.7–7.98% of females were affected by [17, 18] Due to improvements in ceramic materials microdontia and hypodontia, which was higher and bonding procedures, patients can now than that of males (3.1–5.8%) [5-8] receive bonded restorations that do not require Selecting the appropriate treatment preparing sound tooth structure. This allows modalities for anterior teeth spacing caused dentists to fabricate ceramic restorations that by microdontia requires the expertise of the are very thin (0.3 mm thick). [19-21] Thus, no-prep dentists and a multidisciplinary approach. veneers can be either partial or complete facial Orthodontic treatment alone cannot completely coverage veneers. close these spaces while maintaining the correct This clinical case report describes the occlusion and a satisfactory esthetic result. sequence of conservative treatment procedures According to Fekonja et al., 37.9% of subjects performed on a female patient at the Esthetic who were affected by dental anomalies require Restorative and Implant Dentistry clinic at the treatment by dental specialists, including restorative Faculty of Dentistry, Chulalongkorn University. dentists, periodontists, prosthodontists, oral and The patient was chosen because of her dental maxillofacial surgeon. They also found that 92.4% anomalies; microdontia that caused multiple of the patients were satisfied with the treatment spaces in the anterior maxillary region, and an outcome. [9] Treatment options for microdont teeth excessive gingival display. Her treatment included are based on the patient’s complaints and expectations esthetic crown lengthening and no-prep veneers and range from orthodontic treatment, restorative that comprised a combination of partial and treatment, extraction followed by tooth replacement, ultrathin ceramic veneers. or no treatment. [10] To close the spaces, direct composite restorations are the most conservative Clinical report approach because this method can be performed A 23-year-old Thai female presented at the without removing tooth structure. [11] Another Esthetic Restorative and Implant Dentistry Clinic, minimally invasive option is traditional porcelain Faculty of Dentistry, Chulalongkorn University, laminate veneers (PLVs). This is an indirect restorative Bangkok, Thailand with a chief complaint of technique that requires minimal enamel reduction multiple spaces between her upper anterior teeth and gives a superior esthetic appearance, higher which caused by microdontia (Figure 1). Her major abrasive resistance, and good color stability. concern was an unesthetic appearance and she However, the mean enamel thickness at the cervical desired to close these gaps in a manner that area of the central and lateral incisors are 345µm resulted in a natural look. The patient had never and 235µm respectively. Thus, a 0.5 mm chamfer undergone orthodontic treatment and was satisfied preparation creates a dentin exposure at the with her tooth color. A brief evaluation of her porcelain veneer margins. [12] Long-term studies medical history indicated no immediate concerns. reported that the survival rate of porcelain veneers The treatment began with a clinical was 97.5%. [13, 14] In addition, veneers with their examination, and a series of pre-operative intra- preparation margin in enamel are more likely to and extra-oral photographs were taken. These have a long-term success compared with those photographs were used to determine the facial bonded to dentin. [15] profile, smile line, gingiva zeniths, occlusal planes, tooth color, and shape. A preliminary impression 54 M Dent J 2019 August; 39 (2): 53-64 Esthetic Treatment of Anterior Spacings in a Patient with Localized Microdontia using No-prep Veneers combined with Periodontal Surgery: A clinical report was taken with alginate to fabricate diagnostic casts, followed by a facebow transfer and bite registration. Her intra-oral examination revealed generalized spacing and abnormal tooth shape and size of the upper anterior teeth from the right maxillary canine to the left maxillary canine (Figure 2), and mild gingival inflammation due to dental plaque-induced gingivitis. A thick gingival biotype Figure 3 Periapical radiographs of the anterior dentition demonstrated sound maxillary teeth and and high frenum attachment were observed. normal pulp and periapical tissue. Radiographic evaluation revealed a healthy periodontium and a normal pulp and periapical The overjet and overbite were 2 mm. The condition. (Figure 3). The occlusal relationship dental midline was deviated 1 mm to the right classification was class I molar and class I canine. compared with the facial midline. The facial analysis revealed that her interpupillary line and commissural line were parallel to a horizontal line. The patient had a normal profile (skeletal class I). The smile analysis indicated that the patient had a high lip line with excessive gingival exposure and an asymmetrical gingival level between the left and right sides of the upper dental arch at full smile. The curvatures of the upper anterior teeth and the lower lip line were harmonious (Figure4). The evaluation of the inclination and arrangement of the patient’s maxillary anterior teeth revealed that the maxillary lateral incisors had a slight distal flare. Figure 1 A 23-year-old Thai female patient presented with a chief complaint of her anterior teeth The examination of the tooth color and characteristics spacings. Patient’s full-face photographs: (A) found that the maxillary central and lateral incisors Rest position and (B) Full smile. had a light yellowish color, pronounced macro- and micro- texture on the tooth surfaces, and a halo effect at the incisal edges.