A female patient, new to the practice, in her early 40s attended for a consultation about the appearance of her upper teeth. She was preparing to get married and wanted a smile makeover.
On examination, I noted porcelain veneers on the upper right canine and upper right lateral incisor. The patient explained that these had been in place for approximately 25 years. Significant gingival recession had occurred, exposing the margins of the veneers, which were also stained. The upper right central incisor had a porcelainbonded
crown, which did not match the surrounding teeth. In addition, the natural tooth enamel appeared mottled. The patient had some lower arch crowding, but was unconcerned by this.
Treatment options
Several treatment options were discussed with the patient, as well as doing nothing. They all included whitening the upper and lower teeth, but this alone would not achieve a satisfactory aesthetic outcome, without replacing the restorations. One alternative was to provide replacement porcelain veneers on the upper right canine and lateral incisor, along with a porcelain-bonded crown on the upper right central incisor.
The most comprehensive treatment plan would also include porcelain veneers for the upper right first premolar, upper left central incisor, lateral incisor, canine and first premolar. The upper right central incisor would be restored with a dentine-bonded crown, to achieve a better aesthetic outcome.
The patient elected for the final option. She felt this would provide the aesthetic result she wanted, by creating greater uniformity in the appearance of her individual teeth. Increasing the buccal contour of the upper first premolars, to create harmony between the canines and first molars, would give her a wider smile.
Crown lengthening procedures were declined, as the patient was happy to accept any minor gingival contour discrepancies. Potential treatment complications and the predicted restoration longevities were explained to her.
Initial treatment
At the next appointment, the patient was provided with basic periodontal treatment, oral hygiene instruction and diet advice. She was given trays and 16 per cent carbamide peroxide to whiten her upper and lower teeth at home. A diagnostic wax-up was fabricated to visualise the proposed changes. A transparent polyethylene stent was constructed on a stone replica model of the wax-up.
Aesthetic, pre-evaluative temporary restorations were fabricated using the stent, which was filled with bisacrylic composite and placed over the unprepared teeth. This allowed the patient to visualise the proposed changes intra-orally. She was very happy with the appearance of these temporaries. Tooth whitening ceased a week prior to the planned preparation appointment, to allow full rehydration of the tooth structure and accurate shade assessment.
Preparation
The temporary fabrication process was repeated and the teeth were prepared through the material. This minimised the loss of tooth structure, as the temporaries resembled the exact contours of the final outcome. The interproximal regions were prepared through the contact points, sometimes called a ‘slice preparation’. This allowed the technician freedom to adjust the contour and position of the teeth. An incisal overlap finish was created, to allow maximum aesthetics in the incisal edge region and a positive seat for placement. Once the preparations were finished, the transparent stent was placed over the teeth to verify the correct depths.
An impression was taken in a special tray using Heraeus Kulzer Flexitime Monophase and Medium Flow. Flexitime impression material was chosen due to its outstanding precision and highly accurate detail reproduction. The Monophase was mixed automatically in the Dynamix Speed dispenser, creating a homogenous material. This was used in conjunction with the Medium Flow ‘wash’, to create a void-free impression. The process was well tolerated by the patient as Flexitime has a smooth texture, with a neutral taste and odour. It also has a favourable setting time and removal is pain free.
Temporaries were fabricated using the stent, allowing the patient to assess the proposed final outcome for a second time. The temporaries were then removed. The veneers and crown were tried in, individually at first, to check the marginal fit, then together to see their overall integration with each other. A sectional rubber dam is often used for isolation, but in this case moisture control was adequately achieved using retraction and cotton wool rolls.
The inside of the veneers and the crown were etched with nine per cent hydrofluoric acid and conditioned with a silane coupling agent. The isolated teeth were etched with 37 per cent phosphoric acid. A bonding agent was applied but not polymerised. The units were bonded in pairs.
The central incisors were fitted first, using a luting composite resin. Then the lateral and canine on one side were fitted, followed by the other side. Polytetrafluoroethylene (PTFE) tape was used on adjacent teeth when bonding. The veneers were tacked by light curing for five seconds in the middle third. Excess cement was removed at the margins and interproximately prior to full curing. The old composite restorations in the upper left central incisor were replaced at this visit, to eliminate a potential bond failure in this region. The occlusion was then checked in intercuspal position and all excursions.
Laboratory work
I would like to thank Phil Reddington at Beever Dental Technology for his superb technical support in this case. The veneers and dentine-bonded crown were fabricated with feldspathic porcelain on a refractory die. A silicone index was used to ensure that the fabricated veneers and crown were a dimensional replica of the diagnostic wax-up. The technician used his ability and artistry to integrate the shades, form, shape and texture.
Clinical outcome
Both the patient and I were delighted with the natural appearance achieved. This was our goal from the outset. The patient said she could not stop smiling and felt that it had transformed her physical appearance and confidence. With meticulous planning and execution, in conjunction with excellent technical support, a predictable outcome had been achieved, resulting in a very happy bride.