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Dentistry today, is not just repairing cavities or replacing missing teeth with restorations. In our modern society, modern dentistry is more and more an active part of our esthetic comfort feeling.
Tue. 27 April 2021, 2:00 PM
Combined with plastic surgery or other esthetic treatments, “esthetic dentistry” is one of the most impactful tools to help human beings in feeling beautiful and gaining confidence. When we are looking into esthetics and wellbeing, we automatically associate emotions. So, it would be a more proper way to describe esthetic dentistry as “Emotional Dentistry”.
Why emotional dentistry?
Because most treatments take several weeks to finish before the patient finally receives the outcome he or she was looking for. During this time, emotions are a very important aspect during treatment. We need these emotions to help us to achieve the target outcome and success.
The worst nightmare is when patients literally “freak out” when the first temporary is placed.
So, we already have to pay attention, that the provisional restoration not only looks good, but that the placement procedure is also running smoothly and that we have all the necessary tools, guides and other aids to place a temporary in the correct place. This requires pre-treatment planning and planning of the final outcome from the first moment we start planning the treatment.
In the following case examples, I would like to show how proper treatment planning helps to arrive at a successful final outcome, without stressing the patient’s emotions.
The presented case is a 24-year old photo model who went to Colombia to have his smile corrected. The treatment plan was to minimally prep 10 anterior teeth in the maxilla and veneer via the direct bonding technique with composite. As we can see, the standard at which this was done, would never satisfy a 24-year photo model who’s livelihood is his smile.
After 9 months, he presented himself to one of my clients with whom I do esthetic rehabilitations and explained that he wasn’t happy with his smile and is deeply frustrated and depressed, since he has to hide his smile ever since coming back from Colombia.
The patient was invited to visit me in my laboratory to take initial photos in my photo studio, so that we could evaluate his current situation and start planning (Fig. 1-4).
As we can see, the proportions and positions are grossly misaligned, and the tooth shade is not what the patient wishes for.
Fig. 1 - Initial situation of the first case
Fig. 2 - Initial situation of the first case
Fig. 3 - Initial situation of the first case
Fig. 4 - Initial situation of the first case
Planning started with a smile design and evaluation of the dentition.
Presenting the proposed outcome in a digital manner, allows dentist and patients to get an idea of the final smile, but also gives us technicians a guide which we can use throughout the whole treatment so we do not get lost.
After the digital smile design is approved by the patient, it is printed with a 3D model printer. We need 3 different models to move forward, the current situation, the digitally designed and proposed design and a model with both situations combined. The last model is very important, as it supports the treating dentist in prepping the current teeth as a visual guide. I also prepare silicone matrices of the proposed digital design model. One I leave untouched, the other I cut horizontally into two pieces, this helps to guide during prepping the teeth, so that the exact amount is prepped.
In our case, the treatment team decided for 24 crowns. The reason for not being able to fabricate minimal invasive restorations, was the pretreatment with non-guided preps for composite veneers.
After receiving the impressions, face bow and bite records in the laboratory, models with the Giroform System from Amann Girrbach were fabricated and articulated in the Artex CR articulator. That allowed me to imitate all the patient’s movements properly as they were in the patients’ mouth.
The next step was to scan all the records (Fig. 6) with the Ceramill Map 400 scanner and start on the design. Throughout the design process, the occlusion and function can be fully controlled with the virtual articulator in the Ceramill Mind design software (Fig. 7). For maximum esthetics we decided to fabricate fully layered restorations. But to guarantee stable and long-lasting crowns, the restoration was designed with a minimal cutback for micro layering. Therefore, the digital smile design was digitally overlaid on the actual restorative design, so that the crowns were literally a copy of the smile design and just minimally reduced (Fig. 8).
The case is nested in the Ceramill Match 2 software so it can be milled in Zolid HT+ in the Ceramill Motion2 DNA. I decided in favor of Zolid HT+, because the patient’s stump shade was in the darker range and the targeted final tooth color is OM1.
After milling, the restorations were sintered overnight, I usually utilize overnight sintering with an 8-hour program, to avoid any chance of stress to the zirconia.
The next day, all copings were seated on the master casts and GC ZrFs porcelain was applied with my own micro layer technique. Before glazing, we went through a bisquebake try in, so occlusion, function and esthetics can be evaluated and minor adjustments were completed before all crowns went through a stain and glaze process.
Finally, our patient got his well-deserved and wanted smile (Fig. 8+9).
Fig. 5 - Scanned models
Fig. 6 - Restorative design
Fig. 7 - Overlay of actual restorative design and the previous smile design
Fig. 8 - Final restoration of the first case
Fig. 9 - Final restoration of the first case
My second case is a combination of tooth borne and implant borne reconstructions. The patient presented with an edentulous posterior region in the maxilla. This resulted in a totally collapsed occlusion (Fig. 10-12). Over the years, the patient had postponed any dental treatment because of her fear of dentists, so it took her years to get comfortable with her current dentist and she was able to start her treatment. Implants were previously placed, two on each posterior side in the maxilla. The collapsed situation over such a long period resulted in excessive wear of the lower anterior teeth.
After evaluating the patient’s photos and speaking to the patient personally, the decision was made to treat the patient with a full mouth rehabilitation in stages. So, a digital smile design was fabricated. With this we were able to decide for a bite opening of several millimeters, so enough space was given for veneers in the mandible anterior area and proper-sized crowns in the posterior area. For the anteriors in the maxilla we decided for crowns and 3-unit implant bridges in the posterior area.
Since the periodontist had to proceed with crown lengthening for the anteriors in the mandible, we started with the maxilla. Not to lose track throughout the treatment is of absolute priority.
Therefore, the dentist took am implant level impression. After model fabrication with the Giroform system the records were scanned with the Ceramill Map400 scanner and the bite opened with the virtual articulator, the same way as with the overlaid digital smile design. At first the 3-unit screw retained implant bridges were designed following an anterior temporary shell.
This process is necessary to start carefully opening the patient’s occlusion before fabricating the final restorations. The digital design is milled with the Ceramill Motion 2 DNA in Ceramill Temp Multilayer.
With this process, we can evaluate the patient’s smile with the executed opening of the occlusion in conjunction with test driving function. To be able to place a combination of implants and temp shells in one arch, we need to fabricate placement guides.
I designed a stent over my final temporary design to help the dentist to seat everything in the perfect location with the planned occlusion.
This stent can be 3D printed or milled. In this presented case, it was 3D printed. After milling the implant bridges, I cemented the bridges to vario bases from Straumann on the master cast to guarantee a perfect passive fit (Fig. 13-14).
After delivering the case to the dentist, she was able to prep the anterior teeth in the maxilla with the help of our printed models of the smile design, the current situation and the overlaid smile design over the current situation. She was also able to utilize all fabricated matrices to guide her through the prep protocol (Fig. 15).
Next, she placed the implant bridges first (Fig. 16), put the temp shells into the 3D printed stent and placed them over the preparations. So, everything was perfectly in place and slight occlusal adjustments were finalized during this temporary fit (Fig. 17-18).
The patient will go through the crown lengthening procedure next before we start the final restorations in the maxilla and mandible.
Both treatments were emotionally very involved throughout the whole process, not just for the patient, but for the whole treatment team.
I want to say thank you for the partnership and exceptional teamwork in both cases to Dr. Rita Dargham, Miami FL, USA and her team as well as the team of Zahntechnique Inc, Dental Laboratory, Miami, FL, USA.
Fig. 10 - Initial Situation second case
Fig. 11 - Initial Situation second case
Fig. 12 - Initial Situation second case
Fig. 13 - Milled temporaries and printed placement guide
Fig. 14 - Milled temporaries and printed placement guide
Fig. 15 - Guided anterior preparation
Fig. 16 - Placed temporary implant bridges
Fig. 17 - Guided anterior placement
Fig. 18 - Guided anterior bridge placement