A 27-year-old man came seeking help for his uneven "gummy
smile." He already had cosmetic bonding as a teenager on his four
maxillary incisors to close the diastema. The composite veneers
were in need of an update, but we both agreed any smile enhancement
would begin with the gums (Figs. 1, 2 and 3).
After meeting with my partner, periodontist Dr. Mark
Margolin, the patient explained he was seeking treatment because
he was unhappy with the appearance of his smile due to the
appearance of his teeth and the "gummy" swollen look of his
gum tissue. He presented with excessive gingival display, gingivitis,
a thick gingival biotype, associated short clinical crowns with
enamelogenesis "imperfecta," the characteristic yellow and
brown coloration and multiple pitted surfaces, and diastema
between his maxillary anterior teeth. He had thick composite
veneers placed on #7-10 to partially close the anterior diastema.
On closure, his mandibular anterior teeth were hidden by the
maxillary incisors due to altered passive eruption (Fig. 4). A more
aesthetic gingival architecture was developed using his study
models. The first stage of treatment involved aesthetic crown
lengthening surgery on maxillary and mandibular arches with
micro-surgery scalpels. The gingival margins were scalloped to
create the desired clinical crown lengths and gingival contours.
Full thickness flaps
were reflected, and
ostectomy was performed
to establish
a 3mm biologic
width between the
desired cementoenamel
junction and
the osseous crest for long-term gingival health and stability.
Osteoplasty was performed on the buccal maxillary bone to create
a more aesthetic gingival contour and remove the thick
appearance of the gum tissues (Fig. 5).
We gave him the PerioScience Antioxidant White Kit, AO
Toothpaste, AO Pro Rinse and AO Gel to use daily. These products,
especially the frequent use of the AO Gel, have been shown
to decrease discomfort, improve and hasten healing.
For two years, he was content with his smile. Then when he
came for his regular three-month check-up and prophy some of
his bonding had continued to deteriorate (Figs. 6, 7 and 8).
Now he was ready to do something. I recommended 10 IPS
e.max veneers to close the spaces, build out the buccal corridor
for a fuller smile and to minimize preparation/reduction of the
teeth. At this stage we discussed various smile designs using the
Smile Style Guide (www.digident.com). Considering the shape
of his present teeth, we chose P2/L2 (Figs. 9a,b).
To further cement the relationship, we did a wax-up and
scalloped silicone splint (Fig. 10). This was filled with temporary
BisAcrylic shade B-1, trimmed, allowed to set and removed (Fig.
11). He loved his Trial Smile and was anxious to begin. We
began with whitening his lower teeth and set aside a morning to
remove the composite and minimally prepare the canines and
bicuspids. With the aid of ViscoStat clear and Expasyl, impressions
and bite registration were taken. This was definitely a case
for Keating Dental Arts and its experienced e.max team. The stumpf and shade photos were taken and e-mailed to Keating
Dental Arts (Fig. 12a). We never use the word "stumpf" in front of a patient. We prefer, "tooth" shade. Temporaries were fabricated
using the Trial Smile splint.
"Our 3Shape software has a great measurement tool that we
often use to incorporate ideal 'Golden Proportions' into our diagnostic
wax-ups to begin these cases," states Shaun Keating.
"However, with this large veneer case Dr. Berland had provisionalized
the patient long term; so we used the 3Shape to match the
length and contours of Dr. Berland's composite veneers precisely,
as we knew they were exactly what was appropriate," Keating
continued (Figs. 12b, c).
"We press all of our e.max restorations, instead of milling, to
take advantage of the additional strength that this process yields
(Fig 12d). Our clients appreciate this additional strength. All
veneers are vulnerable to breakage before they're bonded and we
see less e.max veneers returned broken at the seating appointment
compared to feldspathic (platinum foil) veneers," Keating added.
"We also find the margins to be more accurate with our pressed
e.max restorations than those that are milled, even though we
have Sirona's largest inLab MC XL mill," he concluded.
Nine days later, it's time to "bond." We tried on the e.max
veneers using different try-in gels to verify fit of margins, proportions
and colors. As I usually do, we chose a variety of resin luting
cements. I call this "mix to match." Patients appreciate these
subtle differences and it's necessary to accommodate different
thicknesses of porcelain.
In this case, we went with a higher value for the centrals, a
high value for the laterals and lower value for the canines and
bicuspids (Fig. 13 and 14).
To increase surface area and bond strength, I use the
EtchMaster (www. gromandental.com). We like to call it the airspray
(Fig. 15).
This is followed by etching the teeth for 15 seconds, starting
at the incisals, then the facials, etching enamel before any exposed
dentin (Fig. 16).
The teeth were etched and ready for bonding (Fig. 17). To
ensure proper tissue control and prevent any gingival fluid contamination,
Superoxol is applied with a microbrush to the gingiva
for 15 seconds until the gingiva appears white (Fig. 18). This
is thoroughly rinsed off and dried (Figs. 19 and 20).
The veneers were seated all at once to ensure proper fit and
contacts. Before curing, excess resin cement is removed using a
pointed composite brush interproximally and a flat composite
brush for the buccal gingival and lingual inciso-occlusal margins (Figs. 21 and 22). Curing begins with a wave along the gingival
facial margins of all 10 e.max veneers. This is to prevent any leakage
of subcrevicular fluids under the veneers. The curing continues
with two lights and another assistant to minimize heat as well
as curing time while maximizing the cure.
Further excess is removed using an explorer (Figs. 23
and 24).
Once cured, PerioScience Antioxidant Infused Dental Gel is
applied to the gums to immediately reverse the "Superoxol burn."
Following curing, the lingual margins are refined using football
diamonds on the lingual and needle diamonds interproximally.
Most of the facial excess is removed using a Bard Parker #12
(Figs. 25 and 26). Discs and rubber points are used to refine and
further characterize the angles and refine the margins (Figs. 27
and 28). The veneers and their margins are further polished using
the Twist2it and polishing pastes (Figs. 29, 30 and 31). The 10
e.max veneers were evaluated immediately post-cementation
(Fig. 32). Once again the patient was advised to continue with
the PerioScience daily protocol.
The young man, pre-cosmetic gum lift and after following
whitening the lowers and 10 maxillary e.max veneers (Figs. 33
and 34).
Summary
This case graphically demonstrates the value of a comprehensive
interdisciplinary approach to patient treatment. By utilizing
a talented periodontist and skilled laboratory technicians,
we were able to provide an aesthetic, comprehensive treatment
that exceeded the patient's expectation in the short term and will
serve him well for many years to come.
* Please consult Ivoclar Vivadent for a list of FDA-cleared titanium parts.
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