Esthetic Re-Treatment of Anterior Teeth Restored Following Trauma

In some cases, the soft and hard tissues surrounding teeth restored after trauma continue to undergo processes related to the injury, such as root resorption, which can necessitate re-treatment at a later date. Add the presence of failing restorations to the case, and the complexity increases even further. Thanks to advances in interdisciplinary dentistry, there are numerous treatment options for patients to choose from, and general dentists are learning from amazing centers, institutes, and academies in order to deliver these complex treatment options. Ultimately, however, the patient decides what path to take, and the end result may meet his or her expectations even if it is not what the clinician considers to be the most ideal.

The following case report demonstrates the development and execution of a viable treatment plan for restoring the compromised teeth, failing restorations, and hard- and soft-tissue defects associated with a patient's previous trauma-related dentistry. By selecting the use of a fixed prosthetic unit that incorporated pink porcelain, the busy patient was able to significantly reduce the treatment time as well as keep the cost of the treatment in a range that she was prepared to handle.

A 55-year-old female patient presented to the practice for the first time. Teeth Nos. 7, 8, and 9 had received root canal therapy and been restored with porcelain (Figure 1 and Figure 2). The patient stated that she had been in a car accident about 30 years ago and that this dentistry was the original that had been performed right after the accident. Pretreatment radiographs showed significant resorption associated with teeth Nos. 7 and 8 (Figure 3). Surprisingly, the patient was not concerned about her current esthetics, even with the significant color difference in the pink porcelain that was used on tooth No. 7, the addition of composite on the facial surface of the veneer on tooth No. 8, and the significantly stained margins around the veneer on tooth No. 9 (Figure 4). However, she was concerned with the grave prognosis for teeth Nos. 7 and 8 and that she could lose them at an inopportune time from the severe root resorption.

In order to help determine possible treatment options, the patient was first sent to an orthodontist. Knowing that the bone and tissue complex follows teeth as forces are placed on them,² one thought was to evaluate if teeth Nos. 7 and 8 could be extruded in order to move the surrounding bone and tissue incisally to help fill in the significant hard- and soft-tissue defects as well as correct the alignment of the upper and lower teeth (Figure 5). This could facilitate extraction and the placement of implants with less bone and tissue augmentation, minimizing the amount of restorative dentistry.³ It could also create better scaffolding for a fixed bridge.

Next, the patient was sent to a periodontist. This examination was to evaluate if, after brackets, treatment could include extracting teeth Nos. 7 and 8, socket preservation, a tissue graft for ridge augmentation, implant placement at site No. 8, and crown lengthening on teeth Nos. 10 and 11 in order to idealize the gingival architecture. The esthetic ideal places the gingival margins of the centrals and canines at the same height and the gingival margin of the laterals 1-mm incisally to that of the centrals and canines.⁴

The final restorative plan that was presented to the patient included keeping her on an ongoing 3-month recall for periodontal maintenance due to some localized posterior periodontal disease as well as her tendency to quickly build up calculus. Restoratively, tooth No. 8 would be replaced with an implant supported crown that would cantilever a pontic for tooth No. 7, and tooth No. 9 would be restored with a new veneer. Considering that her adjacent teeth were healthy and unrestored, the option of working with both the orthodontist and periodontist would minimize the amount of restorative dentistry needed and increase the overall esthetics. The patient understood that by using the teeth that had a poor prognosis orthodontically, the sizeable hard- and soft-tissue defects could be best corrected, permitting the use of an implant to replace the failing teeth and facilitating a conservative final restorative result.

After the patient fully understood the investment in time that the orthodontic treatment would take, she expressed that she was not interested in making that commitment and moving forward with orthodontics. With that part of the interdisciplinary treatment and team removed, the remaining treatment options changed significantly. It is important for clinicians to be flexible and open to all possibilities because not every patient will be in a position to accept the most ideal treatment. Offering implants to this patient would now come with a much higher risk, if not a guarantee, of creating a less esthetic outcome.⁵ When she smiled, the patient showed the entire crown and several millimeters of soft tissue. With the bone level being significantly diminished in the area of teeth Nos. 7 and 8, the implant placement would not be at the level of the adjacent teeth. The abutment and implant crowns would need to be significantly long, which would create a highly unesthetic appearance. Once the patient understood the esthetic risk, she did not want to pursue the use of implants.⁶

The patient's photographs were reviewed with her again, and it was explained that a removable prosthesis or a fixed partial bridge were the options left for her to choose from. A removable prothesis would allow her to have the nonrestorable teeth replaced in the least amount of time with the least amount of appointments to commit to, and it would be the least expensive of all of the options. However, she did not want anything removable because she thought she was too young; the idea of a removable reminded her of her grandfather and his denture. She remembered him taking it out to eat and was concerned that the same thing could happen to her, so she decided on a fixed partial bridge. Considering the integrity of tooth No. 9, which had already been treated with root canal therapy, and the bone loss on the mesial side of its root, it was explained to the patient that tooth No. 10 would now have to be included with No. 9 as part of a double abutment in order to add strength and distribute stress forces.⁷ After looking at her smile again from an esthetic point of view, the patient also decided to add a conservative, nearly prepless veneer to tooth No. 11 in order to create better symmetry with the contralateral side. The hard- and soft-tissue defects were still going to present an issue that would need to be addressed, so the periodontist was consulted, and it was decided that once teeth Nos. 7 and 8 were removed, a significant connective tissue graft would need to be placed to try to fill the void. After taking all the choices into consideration, the patient stated that she understood the risks and chose to move forward.

The patient presented for diagnostic wax-up records for teeth Nos. 6 through 11, which included photographs, upper and lower vinyl polysiloxane (VPS) impressions (Imprint^™ II and Imprint^™ 3, 3M), facebow records (Kois Dento-Facial Analyzer System, Panadent), and a deprogrammed centric relation bite (Blu-Mousse^®, Parkell). The wax-up would be the blueprint for the temporary restorations and, ultimately, the final restorations as well as a tissue guide for the periodontist. The discussion with the ceramist included that pink-colored porcelain would likely be needed to hide the soft-tissue void.

To further improve the esthetics of her smile, the patient elected to have the rest of her teeth whitened with an in-office whitening system. After the tissue barriers were cured, three 20-minute sessions using 40% hydrogen peroxide gel (Opalescence^® Boost^™, Ultradent Products, Inc.) lightened the shade of her teeth. During the whitening appointment, the wax-up was reviewed as well as the process that would be followed on the day of treatment spent between the restorative dentist and the periodontist.

The patient was seen by the periodontist for the extraction of teeth Nos. 7 and 8 and tissue augmentation with a connective tissue graft. Following the procedure, she was immediately sent to the restorative dentist for the preparation of teeth Nos. 6, 9, 10, and 11. A silicone preparation matrix made from the wax-up was used to place a bis-acryl transfer onto the unprepared teeth, and full-coverage crown preparations were completed on teeth Nos. 6, 9, and 10, ensuring the proper thickness for an esthetic zirconia bridge. Practicing responsible esthetics, tooth No. 11's structure was then minimally prepared for a veneer. During preparation, incisal, lingual, and facial silicone matrices were used to visualize the proper reduction, ensure sufficient clearance, and minimize the chance of over-reduction. Shade preparations were recorded and photographed. Because the soft-tissue graft needed time to heal, the final impressions would be taken at a later date.

Using the silicone guide from the wax-up again, a temporary bridge and veneer were fabricated from provisional material (Luxatemp^®, DMG America). Teeth Nos. 7 and 8 were added using an add-on resin (LuxaFlow^® Ultra, DMG America) and cured to create ovate pontics. Given the swelling that was occurring, time and great care were taken to ensure that the pontics would not interfere with the healing tissue. The provisional bridge was placed using a temporary cement (Provicol^® QM, VOCO). To bond the provisional veneer, tooth No. 11 was first spot etched with phosphoric acid and rinsed. After the provisional veneer was lined with a light-cure adhesive (All Bond Universal^®, BISCO, Inc.) and loaded with restorative composite (Filtek^™ Supreme Ultra Flowable, 3M), it was tack cured, the excess flowable was removed with a clean microbrush, and then it was finally cured. The provisional occlusion was adjusted to have contact on the distal-lingual aspect of the canines. With the patient sitting up, she was given a piece of gum to chew, and articulating paper (Articulating Papers, Bausch) was placed in 200 µm segments in the anterior while she chewed to see if there were interferences. All marks on teeth Nos. 7 through 10 were removed to avoid creating a constricted chewing pattern. This allowed for the lower anterior teeth to have enough room to fit behind the lingual aspects of the upper anterior teeth without friction when the back teeth came together. Having sufficient room prevents premature wear on the facial aspects of the lower anterior teeth as well as fatigue or wear on the lingual aspects of the upper anterior restoration.⁸

After 8 weeks of time, the connective tissue graft had diminished in size, and there was still a significant defect. To further improve the defect, she chose to undergo another tissue augmentation procedure with an additional graft. The provisional bridge was easily removed by the periodontist for the tissue graft procedure, and then it was recemented for an additional period of healing.

After another 8 weeks of healing, the extent of the patient's lip mobility was evaluated, and a smaller soft-tissue void was still present in her smile (Figure 6). Although the connective tissue grafts had both diminished with healing,⁹ the periodontist was willing to attempt another graft. The patient asked if there was anything else that could be done. As an alternative, she was shown examples of the pink porcelain now available. Ultimately, she did not want to wait another 3 to 6 months to finish the final treatment, so she chose to proceed with a fixed bridge that would hide her soft-tissue defect using pink porcelain.

To allow additional time for healing, the patient was scheduled to return 4 weeks later. Before dehydration could take place and distort the shades, the final shade of the teeth and gingiva as well as the surface texture were photographed using a shade guide (VITA Classical A1-D4^® Shade Guide, VITA North America) and a gingiva shade guide (IPS d.SIGN Shade Guide Gingiva, Ivoclar Vivadent) (Figure 7).¹⁰ Once profound anesthesia was achieved, both the provisional bridge and veneer were removed, the preparations were pumiced, and the margins were carefully touched up. Next, non-impregnated retraction cord (GingiBRAID+ [Size 1N], Kerr) was packed around teeth Nos. 6, 9, 10, and 11, and an impression of the upper arch was taken using both a heavy body VPS material (Imprint^™ 3, 3M) and a light body VPS material (Imprint^™ II, 3M). The posterior occlusion was not changed, so a full-mouth maximum intercuspation bite was taken (Blu-Mousse^®, Parkell). After the provisional restorations were cleaned and polished, the provisional bridge for teeth Nos. 6 through 10 was recemented using the temporary cement, and the provisional veneer for tooth No. 11 was rebonded with the light-cure adhesive and restorative composite. The occlusion was checked and adjusted to have centric stops on the distal-lingual aspect of the upper canines, and as before, articulating paper was placed in the anterior segment and the patient was given gum to chew in order to identify any interferences on teeth Nos. 7 through 10, which were then removed. Additional facebow records and photographs were taken of the provisional restorations, and then the patient was sent home.

Using photography to effectively communicate with the ceramist as the patient's case was evolving was key to its ultimate success. As the patient went from the possibility of implants to, finally, a tooth-borne fixed bridge and veneer, knowing what the laboratory could and could not provide helped guide the patient in her ultimate decision.

The final fixed bridge was fabricated from zirconia layered with lithium disilicate (IPS e.max^®, Ivoclar Vivadent), and the final conservative veneer was fabricated from the same material. To prepare the final fixed bridge, it was cleaned (Ivoclean, Ivoclar Vivadent), silanated with a universal primer (Monobond^® Plus, Ivoclar Vivadent), and then set aside. The final veneer was pre-etched at the laboratory using hydrofluoric acid. After try-in, it was rinsed, etched with a phosphoric acid etchant, silanated with ceramic primer, coated with a universal adhesive (Scotchbond^™, 3M), and set aside in an orange light filtering box to prevent any curing of the bonding agent.

In the mouth, the teeth were isolated with a latex-free rubber dam using the split dam technique. After tooth No. 11 was etched with phosphoric acid, two layers of the universal adhesive were applied and air-thinned (Warm Air Tooth Dryer, A-dec). Next, the veneer was loaded with a light-cure, methacrylate resin-based luting material (RelyX^™ Veneer Cement [translucent shade], 3M) and placed on tooth No. 11. It was tack cured into place, the excess material was removed, glycerin was placed around the margins, and then the final cure was performed. Once the veneer was placed, the final bridge was loaded with self-adhesive cement (RelyX^™ Unicem 2, 3M), placed on teeth Nos. 6 through 10, and tack cured. The excess material was removed, and then the restoration was fully cured. After a final cleaning, the occlusion was meticulously checked with articulating paper to ensure stable, equal intensity stops on the distal aspects of teeth Nos. 6 and 11. Any interferences on teeth Nos. 7 through 10 were removed, and the restorations were given a final polish (Figure 8 and Figure 9).

Clinicians have many treatment options to offer their patients; however, collaborating with specialists and ceramists can allow for even more treatment choices. Being able to pivot and think outside of what is considered ideal while keeping patients informed about their risks can not only lead to acceptable outcomes but also beautiful, functional smiles. 

Gesica Horn, DDS
Accredited Fellow
American Academy of
Cosmetic Dentistry

Private Practice
North Oaks, Minnesota

The author would like to thank Matt Roberts, CDT, of CMR Dental Lab in Idaho Falls, Idaho, for his beautiful ceramic work on the case.