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Addressing multiple factors in an esthetic rehabilitation

Jan. 1, 2006
It is amazing to me to still see that the most common esthetic procedure done for smiles is six veneers.

By Kevin Winters, DDS

It is amazing to me to still see that the most common esthetic procedure done for smiles is six veneers. I see this in pictures, on patients who come into my office, and certainly in dental laboratories. How can so many dentists feel that your smile only goes from canine to canine? It seems as though much of this influence comes from dental schools. In the limited coverage given to smile enhancement, the topic of six veneers seems to exist.

If any additional training was completed, dentists would find many courses available to help them learn some “smile basics.” This would help with the problem of dentists tackling cases for which they are not quite ready. Too often, dentists promote that they are “cosmetic dentists” when, quite possibly, all they have done in the way of training is attend a seminar or two and read some articles. You know as well as I that this happens across the nation. I feel that most dentists do not value investing in CE. Dentists, for the most part, want to get by spending as little as possible on CE, technology, etc. I’ve seen a lot of dentistry done by “cosmetic dentists” that was nothing more than PFM crowns. Now certainly, PFM crowns done properly by a handful of great ceramists can certainly be cosmetic, but most are not. Most are just your average, unnatural looking crowns.

Dentists who strive to be better clinicians know that what we learned in dental school is not enough. Our diplomas have done nothing more than provide us with the opportunity to begin learning.

I want to share with you an example of what at first appears to be a very straightforward case. However, after a little closer look, you will see several things that may have not been initially apparent. Recognizing these areas can make or break a case.

Case study

This attractive lady in her middle 30s presented for a consultation to improve her smile. She had received some “cosmetic dentistry” a few years ago, but she just was not happy with the results (figure 1). Upon closer examination of her smile, you can begin to see where the deficiencies are.

Figure 1

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I think many dentists would look at this and think a good solution might be six or eight veneers (figures 2, 3). However, after you’ve been trained to look for things more closely, you can see we have many things to address.

The shape and length of the centrals are completely different. Centrals that are identical duplicates of each other are very nice to have and set the tone for the rest of the smile.

On both sides of the smile, beyond the canines, we can see what is called negative space. This is an area where a “darkening” in the smile can occur. Many times it goes unnoticed or something is noticed without it ever being realized. Additionally, we can see an excessive amount of gum tissue shown in the smile.

Symmetry of a smile is something we strive for in an ideal design. When you look at this smile, you can see drastic differences in the shape and symmetry from right to left.

An established norm for the length to width ratio has been set at 75 to 80 percent. The lower the value, the longer and thinner the tooth appears. The higher the value, the more square the tooth appears. Teeth in the range of 75 to 80 percent appear to have the most esthetic appeal.

Figures 2-7

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An area that goes unnoticed many times is the gingival shape and contour surrounding the teeth. The crest of the tissue on the centrals should be just distal of the midline. The crest of tissue should be at the midline on the laterals and just mesial of the midline on the canines. The premolar tissue height should be just a bit lower than the canine and even with each other.

When we look at the color of the veneers on #7 and #8 compared to #9, you can see they are different. The color of #7 and #8 blends pretty well with #6, but not so well with the teeth on the other side. Not only is the color an issue, the margins of the veneers are visible and rough.

Arch form and alignment play a big role in a great smile (figure 4). This patient has a rotated lateral, a premolar that is set to the lingual, and also spaces distal to both canines. We must take all of this into consideration in designing our preps.

The process of evaluation is critical in determining what it is you want to do in a case. After you have collected this information, it is possible then to relay it to your ceramist so he or she can provide you with an ideal wax-up. This wax-up will be your architectural blueprint for the entire case. Preparation reduction stents and temporary stents are both made off of this wax-up (figure 5).

Now it’s time for the preparation appointment. First, we will use a soft-tissue laser to even out the tissue (figure 6). Next, depth guides are placed. A .6mm guide is used to establish a uniform facial reduction (figure 7). The teeth with previous veneers are treated just like they were virgin teeth.

In order to correct the problems previously noted with tooth position, arch form, previous dentistry, etc., it was decided to prepare the teeth more similar to 3/4 crowns than traditional veneer preparations. Dentists often become leery in preparing the teeth adequately, wanting to remain very conservative because it is a “veneer” case. I agree in being as conservative as possible, but not at the expense of the esthetic outcome of the case. No matter what, from now on, each tooth will have to have some type of restoration on it. If we adequately prepare each tooth now, quite possibly the esthetic outcome will be good enough where this restoration will accomplish two things - esthetic acceptability and longevity (figures 8, 9, 10).

To help in the buccal placement of the lingually placed premolar, notice how the lingual reduction allowed for the tooth to “move” to the buccal (figure 11).

Everyone knows a key to a successful outcome with any indirect restoration is the quality of the impression. This technique shown has allowed for very predictable impressions on everything from single units to full arches.

Figures 8-13

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First, a retractor, the SeeMore (Discus Dental), is used to help isolate the teeth. Next, after scrubbing the teeth with chlorhexidine and rinsing thoroughly with water, a light-bodied syringeable polyvinyl siloxane material, Take 1 wash (Kerr), is expressed around the teeth. The tray material, also Take 1, is applied, then more wash material is placed before applying the tray in a vertical fashion to the teeth (figures 12, 13, 14, 15).

The results are great (figure 16). Sharp, accurate margins are captured on all of the teeth. A bite registration and stick bite are also taken. The stick bite is used to relate the restoration’s incisal edges to the horizontal and vertical planes of the face. Facial landmarks such as the interpupillary line are not recommended. Many people have incredible facial asymmetries. Most eyes are not level with each other. Using this to establish your incisal plane may easily result in a cant (figure 17). Take this patient as an example. Compare the stick bite which is parallel to the floor to the patient’s eyes. Her eyes are very uneven and the teeth would definitely have had a cant using them as a reference.

Now we can profit from one of the benefits of having the ideal wax-up completed before the case. A Sil-Tech (Ivoclar Vivadent) temporary splint has been made and relined with a polyvinyl wash material to capture the marginal detail. After applying a coat of Super Seal (Phoenix Dental) to the preps and drying, Luxatemp (Zenith DMG) is placed in the temporary matrix and applied to the preps. When removed from the preps, the clean-up is minimal. Since we have such an accurate capture of the wax-up, the flash is squeezed out and can be easily removed, leaving incredible-looking temporaries (figure 18).

Figures 14-19

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To get the desired outcome from the lab, a detailed lab prescription along with photos, color mapping, impressions and bites, pre-op models, etc., must be sent. The ceramist can then provide for you unbelievable restorations that will mimic real teeth.

When it is time for the seat appointment, there is often much anxiety. The patient and the doctor are unsure what will happen. This should however, be a time to relax and celebrate because the dentist has covered all the details and is confident about what will happen.

After removing the temporaries (figure 19), sometimes you will find “black scuzz.” This staining is nearly impossible to remove. The one product that takes care of this exceptionally well is hydrogen peroxide with a little scrub brush (figure 20). After a few seconds of scrubbing, the surface is clean and ready for bonding (figure 21).

It is very important to try in each veneer to check fit, margins, and contacts. After determining everything is as you want it, the restorations are cleaned by applying phosphoric acid and rinsing and drying. Silane Primer (Kerr) is applied and allowed to sit on the restorations until we are ready for them. This combination product saves a step in combining the silane with some resin to enhance the bond to the porcelain.

Seating the veneers is recommended done under the protection of a rubber dam. By placing a slit in the dam and clamping the tooth just distal to the one on which you are working, you can obtain exquisite isolation. I add a plastic-coated dry angle with some quick-setting bite material to further seal the area (figure 22). One thing you will notice here is the seepage and slight hemorrhage from the tissue. By using Expasyl (Kerr), we are able to obtain slight tissue retraction as well as outstanding fluid control (figures 23, 24).

Figures 20-25

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A time-tested bonding protocol was used utilizing the total etch technique with moist bonding. Optibond Solo Plus (Kerr) and Veneer Cement (3M ESPE), shade B 0.5, were used, curing 40 seconds both buccal and lingual. After finishing the margins, adjusting the occlusion and polishing, the end result was spectacular (figures 25 and 26).

When you examine the case up close, notice the intricate details used by ceramist Juan Olivier, Advanced Dental Design (801-501-7405). You can see hints of bamboo, white, and violet all in the incisal edge area. Within the body of the veneer, you can notice a warm bamboo or orange-ish color to give the tooth more chroma and vitality. The gingival margin area is smooth and imperceptible.

This patient was ecstatic about her new smile. One of the fun ways to capture this feeling is through photography. Offering a photo shoot after each smile makeover case is great for the doctor in that you build a library of great marketing photos to be used both externally and internally. Also, the patient usually loves the session. They have fun and receive a CD full of great portrait type photos (figures 27 and 28).

Figures 26-28

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Taking a comprehensive approach to even seemingly straightforward cosmetic cases will inevitably raise the bar in the outcomes we can achieve for our patients. Being OK with the status quo will just perpetuate mediocrity in our field. If each of us could realize that only through extensive post-graduate training can we provide the best possible dentistry, our patients will be the big winners. Comprehensive programs in advanced approaches are available at places like the Las Vegas Institute for Advanced Dental Studies. Not only are advanced techniques in cosmetic dentistry offered but also occlusion, practice management, perio, etc.

I urge all of you to expand your horizons and find a big course to attend this year. Whether it is in implants, cosmetics, dentures, endo, or whatever, find at least one comprehensive course where you can go and learn how to be the best.

Dr. Kevin Winters graduated from the University of Missouri-Kansas City in 1989. After completing a GPR at the University of Louisville-Humana Hospital, he opened a general practice in Claremore, Okla. After developing a successful general practice and being awarded the Young Dentist of the Year award in 1995, Dr. Winters transitioned his general practice to one that concentrates on esthetics and reconstruction. Dr. Winters is one of the original clinical instructors at the Las Vegas Institute. He also lectures and conducts seminars across the nation. Dr. Winters may be reached at (918) 341-4403 or by e-mail at [email protected].