Sagar Abichandani
Aesthetic & Functional Smile Enhancement using Digital Occlusion Equilibration & Smile Designing concepts – A Clinical Report
A 26-year old patient came to the dental clinic with a chief complaint of poor appearance with bulky, unpleasant veneers in the upper front teeth. She had a past dental history of undergoing ceramic veneers at another clinic wherein she was dissatisfied with the approach & result of the final restorations and wanted us to fix the issue.On further discussion, it was found out that the patient earlier had spacing with upper front tooth area which she wanted to close aesthetically. On further discussion, she informed about non-usage of a mouthwash or dental floss and also brushes once a day.
Extra – oral Examination ( figure 1):
No pain, clicking, crepitition or deviation of the mandible was noted.
The facial profile , dental and facial midline were parallel and was perpendicular to the interpupillary line. The patient had competent lips and had prominent chin. But there was an increased upper lip support due to the maxillary teeth.
Intra-oral Examination (figure 2):
On Intraoral examination, generalized gingival inflammation was seen alongwith stains and calculus present with soft edematous gingiva. Disappropriately fabricated veneers from 13 to 23 with no shade matching and missing smile curve. Dental caries with 17. Deep developmental pits with 12, 22.
Periodontal Assessment :
BPE
Patient had a canine guided Class I molar malocclusion .
Investigations:
Radiograph Report:
No periapical lesion and widening of periodontal ligament. Dental caries with enamel and dentin with 17. Deep pit involving enamel dentin with 12,22.
Diagnosis:
• Chronic generalized gingivitis.
• Disproportionate veneers with 13,12,11,21,22,23.
• Dental caries with 17.
Prognosis:
The prognosis is favourable after scaling and root planing with restoration of optimal health.
Prognosis is favourable after the replacement of old veneers and restoration of smile.
Treatment:
Options Presented To Patient:
· Scaling and root planing for oral prophylaxis.
• Replacement with new ceramic veneers for upper front teeth.
• Composite fillings with 17 and palatal pits in the cingulum area relation to 12,22.
Treatment Plan:
– Oral prophylaxis with scaling and root planing.
– Evaluation of occlusal prematuries ( if any) with T-Scan and elimination of the same before any definitive work begins.
– Replacement of existing veneers with ceramic veneers & including both premolars too in the planning phase for maintenance of symmetry, proportions and balance in the smile.
– Gingivectomy to balance the gingival zeniths on the left and right.
– Composite filling on the occlusal surface of 17 and pits in the cingulum in relation to 12,22.
Treatment Sequence:
Patient’s Bite analysis was carried out with T-Scan to remove any prematurities which was found to be in relation to tooth 16 (figure 3a). Periodontal probing was carried out to identify the probing depth and if any gum corrections would need osseous recontouring as well (to maintain the biological width).
A complete set of photographs were taken alongwith diagnostic casts mounted on a semiadjustable articulator using a facebow record. Two sets diagnostic impression was recorded with a combination of putty consistency elastomeric impression (Affinis, COLTENE) and light body consistency elastomeric impression (Affinis, COLTENE) was taken with double mix – single stage technique.
The patient’s occlusal pattern was noted before the waxup for the upper front 10 teeth.
Oral prophylaxis was carried out in the form of scaling & root planing. Composite fillings was done on the occlusal surface of 17 and pits in the cingulum area in relation to 22,12.
Since the patient was highly apprehensive as to how she would look, we decided to use Dental GPS concept for getting the patient acceptance & commencement of the treatment( figure 3b). Since the dimension ratio of present veneers were not appropriate and the patients smile line extends till the premolars, patient accepted, consented for ceramic veneers from 15 to 25 alongwith gingivectomy in relation to 13,15,23,24,25.
Gingivectomy was performed with soft tissue diode laser (Biolase,CA,USA) in relation to 12,15,22,23,25. (figure 4)
Fig. 4Laboratory Steps:
The maxillary cast was mounted using the Face-bow record and the mandibular cast was mounted using the maximum intercuspation record. Programming of the articulator was done based on the zeroing of the articulator first followed by setting the values based on the excursive records. Simultaneously, a Digital Facebow concept (Methot A. Facial Proportions. CJCD 2006) was used to print the M lines (figure 5) and doing a guided wax up with the help of tooth coloured inlay casting wax (Dental restoration material inlay wax, ZOGEAR, China). Silicone index (putty consistency elastomeric impression material) was recorded of the finished wax up for the fabrication of the temporaries and for guiding in the tooth reduction.
Clinical Steps:
The previous veneers were carefully sectioned & removed to prevent any inadvertent loss of tooth structure. On examination, it was seen that tooth preparation was aggressive and patient had sensitivity in few areas of her teeth. The sharp areas of the tooth preparation were finished and polished (no further tooth preparation was carried out)(figure 6)
An immediate chairside mockup was carried out from the new laboratory waxup according to the APT ( Aesthetic Pre Evaluative Temporaries) technique (Galip Gurel’s Concept for evaluation of function, esthetics and phonetics)( figure 7 ). The patient loved the new look and was now confident that her new smile will be better than the existing one.
On subsequent recall, the look and function was acceptable without any discomfort or complaint. The occlusion corresponded to the existing occlusal scheme. The tooth preparation was carried out (figure ) through the temporaries for minimally invasive dentistry protocols to preserve the enamel and be as conservative as possible( after placement of retraction cords) in tooth reduction(figure 8). 2nd set of retraction cords (Ultrapak, Ultradent) impregnated with hemostatic agent (Racestyptine solution, Septodont) were then placed into the gingival sulcus and elastomeric impressions were taken. Irreversible hydrocolloid material was used for a check cast impression and provisionals (Cooltemp, COLTENE) were fabricated, checked for its fit, occlusal interference, esthetics, phonetics, trimmed, polished and cemented (Temposil, COLTENE). Final Impressions were taken with Elastomeric impression materials ( Affinis, COLTENE). Shade selection was done (VITA toothguide 3D- Master, VITA) and temporaries refabricated and spot bonded.
Laboratory Steps :
The master casts were poured with the help of Type IV dental stone (Elite Base, ZHERMACK). Pindex system was used for placement of die pins and sleeves followed by die cutting and die ditching. Monolithic lithium disilicate ceramic veneers (EMax, Ivoclar Vivadent, Switzerland) with an incisal cutback were fabricated . Ceramic layering was done for the incisal one-third of the veneers with a combination of enamel shades, translucent and stains in line with the clinical pictures and lab notes for characterization.(figure 9)
Clinical visit:
Trials for Ceramic veneers were tried in the patient’s mouth to evaluate for the fit and marginal integrity( Variolink try in paste, Ivoclar Vivadent, Switzerland) and occlusal interferences in centric and eccentric positions, which were subsequently removed using the articulating paper. Shade was evaluated and temporaries re-cemented.
Laboratory Steps:
The interfering marks were removed and the final glazing was carried out.
Clinical Visit:
Occlusion was verified again with articulating paper. Ceramic Veneers were cemented using Variolink Veneer Cement ( Ivoclar Vivadent) under rubber dam isolation . Excess cement was removed and dental floss was passed interproximally(figure 10). Oral hygiene instructions were given.
Patient was recalled after 3 month and re-evaluated for maintenance of the oral hygiene instructions.(figure 11)
Discussion:
Since the underlying tooth colour wasn’t planned to be changed, we opted for minimal thickness of monolithic lithium disilicate ceramic veneers with an incisal cutback for incorporation of mamelons and incisal translucency. Dental GPS is not only a simulation software but helps us use the 2D image for 3D planning and execution with precision and accuracy with the usage of printable M lines. It was imperative to win the patient’s confidence after the previous veneers disheartened the patient completely, so a test smile using aesthetic prevaluative temporaries played a key role.
Summary And Conclusion:
Complex procedures like full mouth rehabilitation or smile enhancement with minimally invasive dentistry protocols can be used with precision and success for full mouth occlusal rehabilitation, posterior quadrant restorations and anterior restorations with optimum esthetics and function.
