Restore Function with Enhanced Esthetics

A 38-year-old patient presented with failing office-milled restorations and inadequate gingival margins around teeth Nos. 5 through 12 (Figure 1). The gingival condition was poor due to the presence of excess cement and the less-than-ideal fit of the ceramic, office-milled veneers on teeth Nos. 5 to 9, 11, and 12. The patient also presented with a fractured ceramic crown on tooth No. 10. Prior to her appointment, she had cemented it with a temporary cement, which left the margins completely exposed.

A treatment plan was presented featuring porcelain veneers (Lumineers^®, DenMat) and two lithium disilicate crowns, spanning from tooth No. 4 to 13. To assist the patient in the decision-making process, a smile preview was generated and included as a part of the case presentation. She expressed that she was thrilled with the potential outcome.

After inspecting the preparation for the missing crown on tooth No. 10, it became clear that the teeth had been overprepared. The remaining tooth structure was less-than-adequate to build upon, and the quality of the patient's gingiva was poor. A diagnosis of the pulpal vitality was completed, indicating a response to cold within the normal limits.

Because of her prior dental experience, the patient expressed concern regarding the esthetics and longevity of the new restorations. The difference between her failed office-milled restorations and the new laboratory-fabricated restorations was explained, and she was assured that the partnering dental laboratory employed highly skilled dental technicians with many years of experience-a unique benefit not offered by office-milled restorations.

Prior to removing the existing restorations, the dimensions, shape, and texture of the patient's desired smile were specified and the diagnostic impressions were sent to the laboratory (DenMat Laboratory). The laboratory created a wax-up of the patient's smile and a clear matrix (Clear Bite^®, DenMat) for a "trial smile." Using the clear matrix, the patient was fitted with a trial smile made from a highly esthetic temporary material (Perfectemp^® 10, DenMat) (Figure 2). After having a chance to preview the trial smile in her mouth, the patient accepted the plan and agreed to continue with treatment.

Using the trial smile as a template, a gingivectomy was performed on teeth Nos. 4 through 13 with a wireless laser ((NV^® PRO3, DenMat) (Figure 3), which is ideal for kinetically cutting tissue with great precision due to its wavelength of 808 nm. The use of a laser is preferred for this procedure instead of a scalpel or electrosurgical instrument because it reduces healing time, ensuring healthy margins in time for delivery of the final restorations.

Next, the existing restorations were removed using a diamond bur (Tapered Chamfer 5856 Coarse Diamond Bur, Komet) (Figure 4). Teeth Nos. 5 through 12 were already prepared, so after marginal healing, only teeth Nos. 4 and 13 would need to be prepared for the minimally invasive veneers. It was noted that tooth No. 11 lacked the dental structural support required to support a veneer and would need to be crowned.

The patient's trial smile was selectively bonded to serve as a provisional restoration while the gums healed (Figure 5). It was seated by spot-etching (Etch ‘N' Seal^®, DenMat) for 20 seconds on the center of each tooth and then applying a bonding agent (Tenure^® MPB, DenMat). To promote healing, the patient was instructed to employ a twice-a-day brush (Fluoridex^®, DenMat) and rinse (Pro-DenRx^® 0.12% Chlorhexidine Gluconate, DenMat) regimen.

Once gingival healing was complete, the trial smile was removed, and the final preparations were made on teeth Nos. 4 and 13. Full-mouth impressions of the preparations were taken and, along with clinical photographs, included with the case instructions, which requested that the trial smile be used as a template for fabrication of the final restorations.

While the intaglio surfaces of the restorations were treated with a porcelain conditioner (Porcelain Conditioner, DenMat) and a ceramic primer (Cerinate Prime^®, DenMat), the patient's trial smile was removed with a Schure 349 Instrument (Lumineers^® Placement Kit, DenMat), and her teeth were cleaned with a polishing brush (9685 Brush, Komet) and a universal diamond polishing paste (9302, Komet).

A try-in paste (Ultra-Bond^®Plus Try-In Paste A1, DenMat) was syringed into each restoration, the excess was removed, and the patient was allowed to preview her smile once more before definitive cementation. Upon patient approval, the restorations were removed from the mouth, and high-speed suction and a wetting resin (Tenure^® S, DenMat) were used to remove the try-in paste from the restorations.

To prepare for bonding, the patient's teeth were cleaned again with a polishing brush and polishing paste. An etchant (Etch ‘N' Seal, DenMat) was applied to each preparation for 20 seconds, then rinsed and air-dried. Next, four to six coats of a total-etch bonding adhesive (Tenure^® MPB, DenMat) were applied, followed by a bond-enhancing resin (Tenure^® S, DenMat), which was applied and then air thinned.

Final bonding was achieved with an application of resin cement (Ultra-Bond^® Plus A1, DenMat) to each veneer. A high-speed suction device (LumiGrip^®, DenMat) attached to a high-volume evacuator was utilized to ease the task of veneer placement (Figure 6). Once placed, the veneers were tack cured for 2 seconds each using a curing light (Sapphire Plus^®, DenMat) fitted with a 2 mm tacking tip (Ceri-Taper, DenMat). Next, a final light cure of all surfaces was performed using a 9 mm tip.

After the excess cement was removed and the lingual occlusion was adjusted for teeth Nos. 4 through 13 (Lumineers^® Finishing Kit, DenMat) (Figure 7), the occlusion was verified, and the patient left-ready to share her new smile with the world.

When the patient returned for a 2-monthpostoperative follow-up appointment, vitality tests performed on tooth No. 10 were within normal limits, indicating a healthy tooth. She noted that the final result (Figure 8) exceeded her expectations.

Apolinar Madrigal, DDS
Private Practice
Turlock, California