Enhancing Smile Using Porcelain Laminates after Gingival ...

1 DENTALMATERIALS/ MAT RIAUXDENTAIRESE nhancing Smile UsingPorcelain Laminates afterGingival recontouring : A Clinical Case ReportWinter 2010 Canadian Journal of Restorative Dentistry and Prosthodontics 39By Sandeep Walia, DDS; Marcela Ibarra, DDS; Gildo Coelho Santos Jr, DDS, PhD; Harinder Sandhu, DDS, PhD, Cert. in Perio, FACD, FICD About the AuthorsSandeep Walia, DDS, is in private practice, Toronto, ON. Marcela Ibarra, DDS, isassistant professor, Division of Restorative Dentistry, University of WesternOntario, Schulich School of Medicine & Dentistry, London, ON. Gildo CoelhoSantos Jr., DDS, PhD (pictured), is assistant professor, Division of RestorativeDentistry, University of Western Ontario, Schulich School of Medicine &Dentistry, London, ON. Harinder Sandhu, DDS, PhD, Cert. in Perio, FACD, FICD, isa professor, University of Western Ontario, Schulich School of Medicine &Dentistry, London, may be directed to Gildo Coelho Santos Jr., DDS, MSc, have been used in dentistry and medicine for many years.

2 Currently ceramicrestorative materials possess colour stability, mechanical strength, clinical longevity,excellent esthetic appearance, optimal bond strength to tooth substrate, and arecompatible with the periodontal tissues. Their properties make these materials suitablefor a wide range of clinical applications. The Porcelain veneers are considered an excellentesthetic restorative option for darkened teeth and provide a conservative method ofimproving appearance or contour with high degree of patient acceptance. The present casereport illustrates the results that can be achieved Using Porcelain laminate veneers torestore anterior dentition with a highly darkened tooth and misaligned teeth, presentingdiagnostic casts, conservative preparations, provisional restorations, impressions, andadhesive cementation. R SUM Les c ramiques ont t utilis es en dentisterie et en m decine depuis plusieurs ann mat riaux pour les restaurations en c ramique poss dent la stabilit de la couleur, uneforce m canique, une long vit clinique, une excellente apparence esth tique, uner sistance d adh sion au support de la dent, et sont compatible avec les tissusp riodontiques.

3 Leurs propri t s rendent ces mat riaux utiles pour une vaste gammed applications cliniques. Les restaurations en porcelaine sont consid r es comme uneexcellente option pour des dents d color es et fournissent une m thode conservatriced am liorer l apparence ou le contour des dents. Le pr sent rapport de cas illustre lesr sultats que l on peut obtenir l utilisation de facettes en porcelaine pour restaurer unedent tr s d color e et mal align e, pr sentant un mod le d tude, des pr parationsconservatrices, des restaurations provisoires, des empreintes et le cimentage. 40 Journal canadien de dentisterie restauratrice et de prosthodontieHiver 2010 Enhancing Smile Using Porcelain Laminates after Gingival RECONTOURINGP orcelain veneers have become thestandard of care for esthetic smilerehabilitation. Important factors in theselection of Porcelain veneers as a choice oftreatment are the properties such as colourstability, mechanical strength, longevity,excellent esthetic appearance, optimal bondstrength to tooth substrate, and compatibilitywith the periodontal , itallows the conservation of tooth veneers have traditionally beenmade from aluminous or reinforcedfeldspathic feldspathicporcelains (such as IPS [IvoclarVivadent, Schaan, Lichtenstein], Lumineersby Cerinate [Den-Mat, Santa Maria, CA.)]

4 ], orOmega 900 [Vita Zahnfabrik, Bad Sackingen,Germany]) can be created as thin as feldspathic porcelains (such as IPSE mpress [Ivoclar Vivadent], and OPC[Jeneric Pentron Clinical Technologies,Wallingford, CT]) can be created as thin to mm. Depending on the existingconditions such as severe discolouration,protruding teeth, or crowding and the desiredresult, clinicians have advocated a range ofpreparation techniques for Porcelain veneers:no preparation, enamel-only preparation,varied levels of dentin preparation andinterproximal 7 Conventional feldspathic ceramics can bechosen as well when the tooth is not exposedto functional occlusal loading and presentssevere colour alteration, which could beeffectively masked by the laminate use of a feldspathic Porcelain andrefractory die technique allow different layersof Porcelain to be added to achieve lifelikeshade and translucency. In addition, thepredominant vitreous phase (46 66%) in thistype of ceramic determines its excellentesthetic planning for achieving the desired result,the dentist should analyze the specificcondition of each patient Using a diagnosticwax-up taking in consideration the amountof reduction needed in order to choose thetype of Porcelain .

5 The design of veneerpreparations is case specific if it is to satisfythe final esthetic goals; the design cannot begeneralized as a single protocol to use in 10 The dentist should understand the patient sesthetic objectives and concerns beforeundertaking any procedure, and the patientsshould understand the limitations of thetreatment, especially when limiting options,for example, declining orthodontic treatmentor tissue- recontouring procedures, or by notallowing reduction of a rotated tooth. Theconsensus on the treatment plan can beachieved by means of a mock-up techniquewith direct composite resin which willfacilitate the visual communication andunderstanding of the possible final result. Clinical CaseA 45-year-old female came to SchulichSchool of Medicine and Dentistry s adultclinic at the University of Western Ontario,and requested esthetic dental treatmentbecause her maxillary anterior teeth weremisaligned and central incisor discoloured.

6 Afull examination, including examination ofsoft tissue, periodontal and dentalexamination, radiographs and photographsof the anterior teeth (Figure 1), wasperformed. During clinical evaluation it was observedthat she presented a class I skeletal profilewith 50% overbite, 2 mm over-jet, and thatteeth 13, 21, and 23 were discoloured. Tooth12 was proclined and presented with a carieslesion at the labial surface. The patient hadno parafunctional habits such as clenching orbruxism. The periodontal tissue was thickand pink but irregularly scalloped in themaxillary anterior area; depth of probingvaried from 2 mm from the distal of tooth#13 to 1 mm at the distal of tooth #23. Therewas discrepancy in the height of clinicalcrowns between right and left maxillaryanterior segments. The information gathered, combined with acomplete diagnostic wax-up of the proposedrestorations, allowed a thorough diagnosisand comprehensive treatment plan to bepresented and was discussed with the Porcelain laminate veneer preceded bygingivoplasty was the treatment of choice tocorrect position, length, and colour mismatchof the anterior dentition.

7 Gingivoplasty wasselected instead of regular crown lengtheningbased on the existence of the sufficientthickness of the attached gingiva and therestoration margins were prepared at thegingival crest. No further surgicalintervention was deemed surgery was performed (EllmanAutomatic Dento-Surg 90 FFP, EllmanInternational INC, Hewlett, NY, USA) onFigure 2. Pre-operatory view with red marksaround the Gingival margin determining theamount of tissue 3. Gingivectomy completed withelectrocautery to correct tissue 4. Gingival aspect after the 60-day 1. Frontal ET 13, 12, and 11 to mimic the gingivalheights with teeth 21, 22, and 23 (Figures 2and 3). The patient was reassessed after a 60-day healing period presenting an esthetic gum line (Figure 4). after discussing the treatment plan againwith the patient, the informed consent wasobtained to perform the tooth reduction forsix Porcelain veneers.

8 The teeth were reducedapproximately mm of the labial surfaceusing fine diamond burs with the aid of aputty matrix obtained from the diagnosticwax-up and with a finishing chamfer marginjust below the Gingival margin (Figure 5). Theincisal edge of each tooth was reduced mm in order to have an incisal overlap,which would allow proper seating of theveneers. Tooth 21 was reduced mm inorder to increase the thickness of theporcelain to block the the final impression, a knitted gingivalretraction cord (# 00 Ultrapack, UltradentDental Products, South Jordan, UT)impregnated with hemostatic solution(Hemodent, Premier Dental Products Co,Plymouth Meeting, PA) was packed insidethe Gingival sulcus and left in place for sixminutes in order to ensure that a secularspace was kept for the impression final impression of the prepared teethwas made with polyvinylsiloxane impressionmaterial (Take 1 heavy and light body, Kerr,Orange, CA) on a stock tray.

9 after the cordwas removed, a low viscosity material (lightbody) was injected onto the prepared toothand a high viscosity material (heavy body)was injected onto the tray, which wasimmediately carried to the patient s mouth(Figure 6). An impression of the opposingarch and the occlusal registration was takenand the casts were mounted on a semi-adjustable articulator with replication of theincisal guidance obtained with the diagnosticwax-up. after the final impression was taken, thesurfaces of the prepared tooth were isolatedwith a glycerin gel and a temporaryrestoration was fabricated with a flowablecomposite resin (Revolution Formula 2,shade A2, Kerr, Orange, CA) to protect dentaltissues and re-establish tooth shape. Only avery small spot in the center of thepreparation was etched and had adhesive(Scotchbond Multipurpose, 3M ESPE, StPaul, MN) applied to it for the compositeresin to adhere. This procedure ensured easyremoval of the provisional restoration at thenext visit without damaging the margins ofthe provisional veneer .

10 The patient wassatisfied with the change in appearance(Figure 7). As close communication with the dentallaboratory technician is essential, impressionsand photographs were sent to the laboratoryalong with the information regarding shadeselection (1M2 [VITAPAN 3D Master, VITAZ ahnfabrik, Spitalgasse, Bad S ckingenGermany]). The veneer was fabricated with afeldspathic Porcelain material (EX-3,Noritake Co., Tokyo, Japan) based on arefractory dye system, following themanufacturer s recommendations. When the Laminates returned from the lab, acareful check was completed of the proximalcontacts, shade match, contour, and marginaladaptation. Each ceramic veneer was etchedfor two minutes with 10% hydrofluoric acid(Vita Ceramic Etch, VITA Zahnfabrik,Spitalgasse, Bad S ckingen Germany),washed with water and dried. A silane agent(Monobond S, Ivoclar Vivadent AG, Schaan,Liechtenstein) was applied to the internalsurface of the veneer , and dried for teeth surfaces were etched for 20 secondswith 37% phosphoric acid and rinsed for 20seconds.