Enhancement of the aesthetic zone is a common reason for patients to seek dental care. This article describes a protocol for the examination, assessment and treatment planning for a patient seeking a solution to an aesthetic concern. The technique of undertaking an intra-oral ‘mock-up’ using resin composite as a diagnostic approach can be particularly helpful when planning for future prosthodontic rehabilitation. The latter can allow the operator and patient to visualize crudely what is aesthetically and functionally possible, given the constraints imposed by that patient. The patient has ultimately managed in a minimally invasive manner.
Clinical Relevance: It can be very tempting for a dental operator to impose his/her concepts of the ‘artistic ideal’ when planning for care in the smile zone. Such ideals are largely based on established universal aesthetic principles of tooth colour, size, shape, form, position, symmetry and proportion. However, beauty is a very subjective matter. It is essential for the operator to listen attentively to his/her patient's concerns. Meticulous patient examination and assessment are absolutely critical factors in attempting to attain a successful outcome. The use of reversible, chairside intra-oral mock-up techniques can not only help with the transference of essential information to the dental technician when planning for restorative intervention in the smile zone, but can also allow the patient to gain an insight and indeed contribute his/her views to the possible restorative endpoint, respectively.
Article
Dental patients may frequently attend expressing a desire to improve the aesthetics of their ‘smile’. Indeed, it has been reported that the latter is an increasingly important factor in a patient's decision to seek dental care. This has resulted in many practitioners devoting a considerable proportion of their clinical time towards providing aesthetic dental care.
Aesthetic dentistry involves the harmonious integration of the principles of smile design, material selection, and patient communication in order to satisfy the expectations of today's increasingly educated dental patient. This is accomplished by the operator having an in-depth knowledge (and experience) of facial aesthetics, tooth morphology, communication skills, and appropriate restorative material application technique.1 According to Goldstein, ‘aesthetic dentistry is the art of dentistry in its purest form’.2
The successful resolution of any aesthetic problem for a given patient is reliant on the need for a detailed patient history and meticulous assessment, which will pave the way for an accurate aesthetic diagnosis.3 Open-ended questions should be asked, to allow the patient to define ‘What they want’, enabling optimal communication between the dentist and the patient.
As part of a methodical approach to smile assessment, the appropriate use of dental photographic technology will allow relevant areas of the aesthetic zone to be viewed in an enlarged format. The patient's facial, dentofacial, dental and gingival perspectives can be further analysed with the application of the aforementioned technology, and the fundamental principles/guidelines of aesthetic design applied, sometimes with the aid of digital smile imaging technology to illustrate possible aesthetic changes.4
Baseline study casts may also be advisable (perhaps mounted on an appropriate form of dental articulator). Where there is a need to alter the existing size, shape, form and position of the existing dentition, the undertaking of diagnostic ‘wax mock-ups’ on duplicate casts is worthwhile. A primary limitation of diagnostic wax-ups is the inability to relate the mock-up to the clinical scenario – what may appear appealing extra-orally may be inappropriate or fail to satisfy the patient's aesthetic (and functional) requirements clinically. One approach to resolving the latter is to apply tooth-coloured, resin-based materials crudely (either composite resin or appropriate provisional crown and bridge resin materials) to the involved teeth by the means of a silicone template formed from the wax-up or a thermoplastic vacuum-formed template (fabricated on a stone duplicate cast of the diagnostic wax-up). A direct aesthetic mock-up can therefore be created and modified appropriately. This way aesthetic parameters can be checked and tested before going on to more definitive treatment.5
For some cases, a direct aesthetic mock-up with resin may be undertaken prior to fabricating an extra-oral mock-up, whereby resin composite may be applied to a dried tooth surface (without the application of any adhesive interface). The latter is commonly referred to as a ‘dry-and-try’ approach. With this approach, the clinician may provide further information to the dental technician to form a wax-up based on the patient's aesthetic, phonetic and occlusal constraints6 (by taking an impression with the trial material in situ). The wax-up may ultimately be used to help plan and place the definitive restorations, as illustrated by the case report below.
The patient's decision-making process in cosmetic improvement is a subjective and complex matter. A direct composite mock-up to assess the proposed aesthetic improvement is in many ways far superior to any form of digital imaging.7 Photographs and an explanation of concepts are good, but when the patient can see and feel the proposed treatment, it becomes a powerful tool!4
All treatment options should be considered in detail and the ultimate, consented treatment plan should be based on a predictable approach. Using a methodical approach to identify the problem, visualize the solution, and choose the most appropriate technique creates a system necessary for predictability.4 The most ‘appropriate technique’ is often chosen by working backwards from the visualized solution and finding the most conservative solution to get there.4
Direct composite resin bonding – a non-invasive aesthetic solution
Dental ceramics and resin composite are the most commonly used restorative material in aesthetic dentistry. Advances in bonding technology, and the availability of contemporary composite resin materials with superior aesthetic and mechanical properties compared with previously available products have changed the way dentists currently practice.
The selection of composite materials now available offer a variety of shades and opacities of enamel and dentine, allowing dentists to achieve a natural colour and aesthetically pleasing teeth in a relatively short, simple and predictable manner. Most cases are accomplished in one visit, with minimum tooth intervention, no local anaesthesia and at a reduced cost to the patient.8
The technique can be applied to patients of all ages and the results can be quite aesthetically astounding. Patients appreciate the one visit procedure, the resulting immediate aesthetic improvement and are grateful that the integrity of their tooth-enamel has been preserved.8 Contra-indications such as the lack of available high quality and copious quantities of tooth enamel, inability to attain adequate moisture control and allergies to resin-based products may be factors to consider when contemplating the use of resin composite. Patients must also be advised of the risks of bulk fracture, staining and wear of resin composites. However, the ability to repair readily, polish and re-surface previously placed restorations may be very appealing.
Composite veneers have the potential to fulfil numerous requirements of minimally invasive aesthetic dentistry, producing predictable aesthetic and functional results.9
Case presentation
A 23-year-old female patient presented dissatisfied with her existing teeth, with a central diastema between the first maxillary incisors, excessively rounded mesio-incisal corners of the same teeth and an open bite in the front region (Figure 1). She primarily desired the diastema to be closed, but she was also interested in how her appearance could be enhanced with a full smile make-over creating a ‘perfect smile’.
Figure 1. Pre-op full facial view.
Examination
Patient history and initial consultation
After gaining personal information, the patient completed a motivation questionnaire which clearly indicated that she was concerned about her oral health, and wished to have her appearance improved by a more aesthetic smile. Her medical history was uneventful. Her dental history consisted of 6-monthly check-ups and regular visits to the hygienist. Regarding her social history, she had been working as a personal trainer at the gym of a popular spa hotel. She led a very healthy lifestyle and was greatly concerned about her appearance as her job required regular interpersonal communication and close contact with her clients.
The first consultation took place in a relaxed manner getting to know the patient and understanding her primary concerns. Careful listening and the use of photographs, books on smile design, and fashion magazines were helpful in understanding the patient's expectations.
Clinical examination
Routine extra-oral examination revealed no obvious anomalies. Clinical intra-oral examination revealed a healthy dentition with fully erupted third molars and no existing restorations. Soft tissues appeared normal. The patient maintained very good oral hygiene – the BPE scores in all sextants were 0 on periodontal examination.
Occlusal examination10 revealed Class I incisor relationships with an approximately 1 mm open bite in the anterior region. At maximal intercuspation no contact was possible for the anterior teeth. During lateral excursions the patient exhibited first and second premolar and first molar group guidance bilaterally. Upper and lower impressions for study models were taken with facebow registration for detailed occlusal assessment. The models were mounted on a Hanau semi-adjustable articulator.
An ocular shade assessment11 was carried out using a Vita Classic shade guide. The teeth had a high value and low chroma – they appeared brighter than the B1 tab of the shade guide (Figure 2). An instrumental shade assessment was also carried out using a SpectroShade spectrophotometer (SpectroShade, MHT Optic Research, Niederhasil, Switzerland) in the presence of the dental ceramist (Figure 3). The shade appeared 1M1 in the apical and middle thirds and 0M3 in the incisal third. Shade was also assessed by applying a small amount of composite material onto the upper left first incisor, which was light cured for ten seconds without etching and bonding. Triad VLC Provisional Material in Ivory Light shade (Dentsply) was chosen for the intended composite mock-up.
A physiognomical attempt to judge the patient's character subjectively by the appearance of her face would have signified youth, health and positive thinking. From the also subjective typological perspective, her face could have been assigned to the ‘lymphatic’ category (rounded, full features, with a timid personality). Morphophysiological equilibrium was realized as the upper, middle and lower facial thirds appeared to be equal. The right and left facial halves appeared symmetrical. The interpupillary and incisal plane lines were parallel, and perpendicular to the facial midline at the rest position. The youthful appearance of her face was overall in harmony with her bright, glossy teeth when smiling (Figure 4).
The dentofacial composition (Figure 5) revealed a flat incisal plane in conflict with the lower lip curvature during a relaxed smile. Bilateral negative spaces appeared minimal.
The teeth generally appeared feminine and youthful with their bright shade, transparent incisal thirds, curvaceous outlines, sharp, well-defined incisal embrasures, and mesially inclinated lateral maxillary incisors. However, the central incisors were not sufficiently dominant, they appeared small and short with excessively rounded mesio-incisal corners and a 0.5 mm diastema between them. The lower incisors were slightly crowded. An open bite of approximately 1 mm was present at the front region at the maximal intercuspal position (Figure 6).
The periodontal tissue biotype appeared normal, and the bioform was of a ‘normal scallop’. There were no ‘black triangles’ present. The gingival aesthetic line was Class III, low smile line with no gingival exposure (Figure 7).
Figure 7. Gingival perspective.
Treatment planning
Treatment plan options were discussed with the patient with the help of study models and the photographs taken during examination. The options included no treatment, minimally invasive diastema closure with composite resin, direct resin bonding or porcelain veneers to correct the size and the shape of the central maxillary incisors only, or a full smile make-over using direct composite resin veneers or porcelain veneers correcting the size and shape of all upper and lower front teeth, creating a more aesthetic smile line and closing the frontal open bite. Whitening was not recommended as the patient was happy with the natural brightness of her teeth. The patient was fully informed of the parameters of all treatment alternatives – sequence, duration, costs, and prognosis. A sequenced direct composite mock-up was carried out to enable the patient to visualize the aesthetic outcomes of all treatment alternatives.
Direct composite mock-up, diagnostic wax-up, indirect bis-acryl trial mock-up
The teeth were prepared for the direct mock-up by adding bonding agent (Ex-Bond, UnoDent) without etching. Composite material (Triad VLC Provisional Material, Ivory Light, Dentsply) was applied, shaped and light-cured sequentially for the accurate representation of all different treatment alternatives, which were the following:
Restoration of the central maxillary incisors only by direct resin bonding or porcelain veneers (Figure 9), or
A full ‘smile lift’ with 12 porcelain or direct composite resin veneers (Figure 10). Photographs of all options were taken for further evaluation and discussion.
Figure 8. A direct composite mock-up representing diastema closure.Figure 9. A direct composite mock-up representing the restoration of the central maxillary incisors only by direct resin bonding or porcelain veneers.Figure 10. A direct composite mock-up representing a full ‘smile lift’ with 12 porcelain or direct composite resin veneers.
The patient was most pleased with the last option which represented a ‘smile-lift’ using 12 porcelain or direct composite resin veneers on the maxillary and mandibular front teeth, perfecting their size, shape and alignment, creating a more aesthetic incisal plane, a fuller smile, and eliminating the frontal open bite. Impressions of this last version were taken to communicate the desired shape and size of teeth to the lab and a diagnostic wax-up (Figure 11) and silicone matrices of the wax-up were requested.
Figure 11. The diagnostic wax-up.
An indirect bis-acryl trial mock-up was made with the help of the silicone matrices and the study models (Figure 12). After re-evaluation, the patient consented to a treatment plan for six maxillary direct composite resin veneers and no treatment of the lower anterior teeth. She felt that this could provide a satisfactory aesthetic improvement, and was not concerned by having her anterior open bite fully closed.
Figure 12. Dental view of the indirect bis-acryl mock-up.
The main reasons for her decision were that treatment could be accomplished in one visit with minimal intervention, without anaesthesia, and at a reduced cost. She was happy with this option as she understood that direct composite veneers could be not only highly aesthetic but they are also reversible and repairable.
Non-invasive treatment: six maxillary direct composite veneers
Shade was again assessed by applying a small amount of different shades of composite material onto the upper left first incisor (Figure 13). Tetric EvoCeram (Ivoclar Vivadent) material was selected in Bleach L shade as it appeared to be matching the 0M3 shade and translucency of the incisal third. The translucency of the incisal enamel appeared homogeneous, hence a single shade was chosen.
Figure 13. Shade assessment with composite resin in situ.
The teeth were pumiced to remove the pellicle layer and allow for improved enamel bonding. The lips were retracted with an OptiView (Kerr Hawe) retractor and isolation was provided with cotton rolls. During treatment, both a high volume vacuum and a saliva ejector were used, the former held by the dental nurse, the latter placed in the corner of the mouth.
The buccal and incisal surfaces of the six anterior maxillary teeth were etched for 30 seconds with a 37% phosphoric acid-containing gel (UnoDent). The gel was thoroughly removed with water spray. After drying, the surfaces had a chalky white appearance. Bonding agent was applied (Heliobond, Ivoclar Vivadent), thinned by air-blowing, and light-cured for 10 seconds.
A silicone putty index of the diagnostic wax-up was used to build up the palatal layer and incisal edges of the restorations (Figure 14). Care was taken to leave a minimal space between teeth to prevent the need for interproximal separation. This was followed by the free-hand, incremental build-up of the buccal (and, in the case of the two first incisors, also the mesial) surfaces of each tooth separately.
Figure 14. The use of a silicone index.
A Mylar strip was placed mesial to the left first incisor. It was carefully slid into the sulcus and secured with a small, wooden interdental wedge. An increment of composite was placed and pressed onto the mesiobuccal surface against the Mylar strip and sculpted in place (Figure 15). The so-called ‘Mylar pull’16 was carried out to achieve a convex proximal contour. The method utilizes the Mylar strip as an instrument, not just a matrix. The lingual of the strip was grabbed and slowly pulled all the way through, while a flat composite placing instrument was held on the outside of the strip, gently tucking it in and thus creating a convex contour on the proximal. Adaptation to the palatal layer was ensured, and the buccal contours were adjusted. Having the matrix out of the way made it easier to fine-tune the contours. The first increment was then light-cured for 20 seconds. A Mylar strip was placed and wedged to the distal of the left first incisor and the steps were repeated. The same technique was used to restore all six maxillary anteriors. Each direct composite veneer was light-cured again for 20 seconds from the buccal, and another 20 seconds from the palatal, aspect.
Figure 15. Incremental build-up.
A long, tapered, multi-fluted tungsten carbide bur was used for fine contouring and the finishing of the surfaces. The incisal plane was first adjusted to follow the curvature of the lower lip. Then a flow in the arch was created which was checked from the coronal, sagittal and occlusal views. The emergence profile of each tooth was also checked from all three views and adjustments were made. As the surface texture of the original teeth was smooth and glossy, there was no need for detailed surface characterization (bearing in mind that the irregularity of the surface reduces translucency). The supragingival margins were finished to a fine line for a smooth transition at the composite-tooth junction. Polishing discs and strips (Sof-Lex, 3M) were used for interproximal finishing and the desired positioning of interincisal angles and embrasure areas.
Before final polishing, the static and dynamic occlusal contacts were checked. The anterior open bite was reduced but contact of the upper and lower anterior teeth was still not possible at maximal intercuspation. The direct composite veneers did not change the pre-operative protrusive and lateral guidance.
All surfaces of the restorations were checked for voids prior to polishing. No repair was needed. Polishing was carried out using the Astropol (Ivoclar Vivadent) system. First, the small, flame-shaped grey point was used to create very subtle vertical mountain peaks and valleys to mimic the anatomy. After checking the shape again from all three views, the points were used sequentially (grey – green – pink) to create a high gloss shine (Figure 16).
Figure 16. Post-op dental view.
Appraisal of the treatment results
The patient was very happy with the aesthetic results (Figure 17). To describe it in her words, she felt her new smile was more adult-like compared to her original ‘kiddie’ smile. She found the new shape of her maxillary anteriors comfortable. Phonetics were not altered. She found it very reassuring that no preparation of her teeth was needed and that her veneers were repairable and reversible.
Figure 17. Post-op facial view.
The excellent chameleon effect of the material ensured that the supragingival margins were not visible. There was also no demarcation line detectable at the incisal third. The incisal line followed the curvature of the lower lip and the new shape of the maxillary anteriors complemented the patient's young and soft facial features (Figure 18).
Figure 18. Post-op full smile.
She was advised to return a week later for re-evaluation and for additional polishing. The patient was also advised to keep coming back for her 6-monthly check-ups and hygienist appointments. At the re-evaluation appointment the patient described how much more confident she felt with her new smile and how much her family and friends liked it as well. No changes of the shapes were needed. The restorations were polished again using the Astropol system.
Conclusion
Smile design plays an integral part in the profession of the aesthetically orientated dentist.17
To simplify complex aesthetic dilemmas, treatment planning needs to be considered, along with methods of improving communication with our patients. Using a direct aesthetic mock-up is important, along with diagnosis, treatment planning and patient education and obtaining informed consent.17
The potential for aesthetic disappointment is predictable. There is a need to explore all of our patients' expectations prior to the final phase of treatment planning and implementation. Owing to the nature of aesthetic expectations, emphasis on tooth conservation is crucial.18
Proper patient management ensures an overall aesthetic and functional outcome. Composite veneers fulfil numerous requirements of minimally invasive aesthetic dentistry, producing predictable aesthetic and functional results at a significantly reduced biological cost.19
