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 dentists 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 veneer 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 dentist 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 crown 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.