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Smile Design by Lorin Berland, DDS, and Shaun Keating, CDT

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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.

Author Bios
Dr. Lorin Berland is an internationally acclaimed cosmetic dentist. He is a fellow of the AACD, the co-creator of the Lorin Library Smile Style Guide; the developer of www.denturewearers.com; the creator of "Biomimetic Same Day Inlay/Onlays," and the founder of Dallas Dental Arts, a multi-doctor specialty practice in the Dallas Arts District that pioneered the concept of spa dentistry. His unique approach to dentistry has been featured on television and in several publications. In 2008, The American Academy of Cosmetic Dentistry honored Dr. Berland with the 2008 Outstanding Contributions to the Art and Science of Cosmetic Dentistry Award.

Shaun Keating is owner and CEO of Keating Dental Arts (KDA) laboratory in Irvine, California. Shaun is a recognized leader in the field of dental technology. He is active in the National Association of Dental Laboratories, while lecturing and publishing nationally. Shaun can be contacted at Shaun@KeatingDentalArts.com.
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