Dr Pinak Rathi, Dr Janani Iyer, Dr Jyoti Nadgere
Professor and HOD,
Department of Prosthodontics and Crown and Bridge,
MGM Dental College and Hospital, Navi Mumbai
Ceramic veneers are indicated in a wide variety of cases, such as correcting malalignment, diastema, tooth defects and tooth discolouration. Patient esthetics drastically changes even after minor alteration of shape, shade, size and position of teeth. This can be achieved by using diagnostic wax-up and aesthetic pre evaluative temporaries. Esthetic pre-evaluative provisional prepared from the diagnostic wax-up permits the dentist and the patient to evaluate the appearance of the final restorations during smile and function. This paper describes the esthetic rehabilitation and smile designing of a case which has multiple spaces in upper anterior teeth.
Citations : Rathi P, Iyer J, Nadgere J. Smile designing using all ceramic laminates guided through aesthetic pre-evaluative temporaries: a case report. J Prosthodont Dent Mater 2020;1(1& 2): 90-95.
The importance of cosmetic smile to the psychosocial well-being of an individual has been well established. In an esthetic conscious society, ‘beautiful smile’ tends to create a perception of more confident, successful and a good looking individual2. Smile contributes 47% of the overall dentofacial attractiveness.3 Esthetics and function should be in harmony, creating restorations that are indistinguishable from its natural counterpart.
Advent of Lithium di-silicate and bonding protocols led to a conservative approach to correct the appearance and unusual position of anterior teeth by minimising the amount of tooth preparation.4 All ceramic veneers are preferred when major corrections in colour and form of the tooth is to be done because of its better strength after bonding, good marginal fit, biocompatibility and high esthetic value.
The following case focuses on significance of diagnostic wax up, use of Provisionals to guide the tooth preparation and historically acknowledged smile designing principles.
A male patient of 38 years reported with spaces between his upper teeth and wanted closure of those spaces. Patient had square facial form with straight profile. (Fig 1) Extra orally smile line was observed to be medium with adequate lip support. (Fig 2) Intra orally spaces were seen between all six maxillary anterior teeth. 11 and 21 were mesiopalatally rotated (fig. 3). Gingiva was firm and resilient with stippling of attached gingiva. Diagnosis was made as tooth size jaw size discrepancy causing spacing.(Fig 4)
Treatment options given to the patient were, orthodontic treatment to correct the spacing of teeth or Smile designing with all ceramic laminates. Patient did not wanted to go for orthodontic correction of teeth and therefore opted for all ceramic laminates.
Extra oral and intra oral smile analysis was done. After detail case history and clinical examination, diagnostic impressions were made and facebow transfer was done. Diagnostic wax up was done by using golden proportion as a guide (Fig 5). A putty index was made using condensation silicone putty (C-silicon lab putty, ZERMAC). Wax up was transferred in the patients mouth using bis acryl based provisional restorative material (Protemp; 3M-ESPE, St Paul,MN). These provisionals were used to analyse patient’s esthetics, phonetics and function (Fig 6). Patient was re-evaluated after 2 weeks for comfort and function. Patient consent was recorded for final treatment. Impressions were made after doing fine corrections of the provisionals intraorally which was to be used as a guide for the ceramist. Shade selection was done by using spectrophotometer (VITA Easy Shade) by dividing each tooth in three quadrants.
Final tooth Preparation was done using the Aesthetic Pre-evaluative Temporaries (APR) as guide. Facially, grooves of 0.5 mm depth were made using depth cutting bur in 2 planes. Incisal depth grooves of 1 mm were made. These grooves were highlighted using carbon pencil. The temporaries were then removed and only the areas which were highlighted by the carbon pencil were reduced using round ended tapered fissure bur (Fig 7). Remaining tooth structure was left as it is and thus a conservative approach was followed.
The preparation was extended palatally up to incisal 1/3 rd to make a wraparound preparation design. Chamfer finish line of 0.5 mm depth was given at the level of marginal gingiva. Finishing of the preparation was done using yellow banded tapered fissure burs. Chemico-mechanical method of retraction was followed using double cord technique (MEDIPAK “00”) and 25% aluminium chloride (MEDICEPT) as a homeostatic agent. Retraction cord was placed in mouth for 4 minutes. (Fig 8) Outer cord was removed from the sulcus and impression was made using a two stage impression technique by Addition silicone impression material. (GC FLEXCEED)
Impression was poured in type IV gypsum product (Kallabhai) and dies were prepared. (Fig 9). Wax pattern was fabricated and Lithium di silicate glass ceramic was pressed. Bisque trial of the laminates was done to check the marginal fit, shape and contour of the laminate and once found satisfactory the laminates were stained and glazed and made ready for cementation (Fig 10).
Bonding of laminates to the tooth structure was done with light cure adhesive resin cement by following the below protocol. Adjacent teeth were isolated using Teflon. Etching the tooth surface was done with 37% Phosphoric acid (GLUMA) for 20 seconds. Simultaneously etching of laminates was done using 9.6% hydrofluoric acid (Ultradent) for 20 seconds. Frosty Appearance was seen on drying the tooth and the laminates. A thin layer of bonding agent (Monobond 3M ESPE) was applied on the etched tooth surface using applicator tip. Silane coupling agent (Primedent) was coated on the etched laminate surface. Light cure adhesive resin cement was used to lute the laminates (Variolink IVOCLAIR). Excess cement was removed and the prosthesis was light cured for 30 seconds each. Dental floss was passed through each embrasure to remove small chunks of excess cement. The margins of the laminates were finished and polished using yellow banded burs and polishing cups. Result was a pleasing smile and patient was satisfied with the enhanced look and confident gesture. (Fig 11, 12) Patient was recalled after 24 hours and then after 7 days to evaluate dentogingival components and function.
The goal of esthetic rehabilitation is to develop a masticatory system where the teeth and the supporting structures function in harmony as stated by Dawson.5 An attractive smile is a vital asset of one’s personality. Manipulation of colour shape, line angles, contour, proportion and position of tooth can be worked to create a pleasing smile.6–10 An appropriate white and pink balance must be maintained in designing the smile of a patient.
Diastema is a very common occurrence and in adults as it can distort the individual’s pleasing smile.11 Orthodontic correction of spaces or restorative correction or combination of both can be used to correct the problem of diastema.11,12 In the present case patient was reluctant for orthodontic treatment and thus wanted a restorative solution for the problem. Closure of diastema with laminates can result in increased mesiodistal dimensions of the tooth. Therefore, careful planning with the aid of diagnostic wax up helps in maintaining the intradental proportions of tooth as well as inter dental proportion of each tooth.12–14 Along with the aid of anatomic wax up, the esthetics and function was achieved as desired by the patient.
Amendment of dental esthetic inconsistencies demands cautious examination, perfect treatment planning and good communication between a prosthodontist and the ceramist.9,15 Anatomic wax up is one of the most important step in designing the smile of an individual.3,9,16 Every tooth has a unique anatomy and it must be harmonious with the dentofacial complex.10 Proportions of the central incisor must be esthetically as well as mathematically correct. Various guidelines are proposed for establishing the correct proportions of anterior teeth, such as Golden Proportion (Lombardi), Recurring Esthetic Dental proportion (Ward), M proportion and Chu’s esthetic gauge. These ratios help to determine the height and width of the teeth with respect to each other. Golden proportion mathematically divides the tooth in the ratio of 1: 1.618 with its adjacent counterpart. This ratio was achieved by dividing the anterior tooth into grids digitally and wax up was done taking golden proportion as a guide.
Corrected provisionals which are also called as Aesthetic Pre-evaluative Temporaries (APR) are used as guide for tooth preparation.3,9,17 The main goal of this technique is to reduce the actual tooth structure as conservatively as possible.9,16,17 This helps to maintain the enamel layer of the tooth and enhances the bonding ability of all ceramic laminates to the tooth structure.8–10,17 These provisionals also act as a guide for the ceramist in fabrications of laminates.
Shade selection is an important step in smile designing.15 Tooth shade is never monochromatic and therefore should be recorded by dividing the tooth in three parts horizontally.19 Clinical spectrophotometer is a reliable device to evaluate the shade accurately.19,20 Not only the shade but also the various characterisations present on the underlying tooth must be noted down and communicated to the ceramist for its incorporation in the final prosthesis to give a natural appearance to the smile.
The smile we create should be esthetic and functionally sound. It is our duty to deliver the best to our patients, after careful diagnosis and examination. Aesthetic pre evaluative temporaries provides conservative tooth reduction and helps in better bonding. Even though utilising APT sounds like a long and time-consuming procedure, it is not—and it is extremely beneficial to the final outcome.
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