Managing a Diastema Case with Porcelain Veneers

By Martin B. Goldstein, DMD

About the author:

Dr. Martin Goldstein, a member of the International Academy of DentoFacial Esthetics, practices general dentistry in Wolcott, CT, USA. Noted as a Dentistry Today CE Leader for the last five years, he lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. A regular contributing editor for Dentistry Today, he has also authored numerous articles for multiple dental periodicals both in the US and abroad. He can be contacted at martyg924@cox.net. His current speaking schedule can be found at www.drgoldsteinspeaks.com.

An attractive 24-year-old woman presented to my office in search of a more appealing smile. She makes part of her living as a personal trainer, and wanted a smile more in keeping with her professional image. Looking at figures 1 and 2 (figure 2 being more of a 3D look in stone), youll note a sizable diastema that is partially reduced with composite (#9) as well as advancing incisal wear on #s 9-11. Dont miss the abfractions on #8-#12. A clinical exam revealed an otherwise sound dentition that exhibited the telltale signs of bruxism.
Figure 1

#9. After a brief discussion of a full blown periodontal surgical revamping of the architecture, it was decided that she would be content with making the papilla pointy like the others albeit at a slightly lower height than the other papillae. I explained to her that I would be able to affect that outcome via a combination of electrosurgery and temporaries that would help to reshape the tissue. A follow-up visit presented her with a Smile Vision simulation (www.smilevision.com) of the rehab that we had laid the groundwork for during our initial visit. She viewed the projected outcome of placement of 8 porcelain veneers accompanied by electrosurge tissue management of the papilla between 8 and 9. (See figure 3) At the same time she had been shown a simulation that involved only #7-#10 that differed in shade as the tooth color was kept in line with the color of her existing dentition. (See figure 3A) It was explained to her that an eight unit solution would allow for more slender central incisors as well as the ability to punch up the smile to a brighter shade. Side by side simulations demonstrated this. After some discussion, she opted for the 8 unit solution.

Figure 2

Comfort Zone Cosmetics

What follows is my everyday protocol for performing anterior cases and is a mini-look at the type of material that is covered in my Comfort Zone Cosmetics presentations and workshops. As referenced above, the process begins with the digital smile simulation from Smile Vision. Once the patient approved the case, Smile Vision is provided models upon which they construct a wax-up that is made to resemble what is seen in the simulation. (See figure 5) Upon viewing the wax-up online and approving it, the wax-up is converted to the Resin Replica as seen in figure 6. This resin-based mock up will be the foundation for the templates to follow as well as provide an attractive 3D look for the patient of what she might expect. Figure 7 demonstrates a stone version of the mock up upon which is setting a reduction template useful for determining if tooth preparation is adequate. Keep in Figure 1 mind that the faithfulness of the finished case to the mock up is dependent upon proper tooth preparation. Use of this clear template allows us to pre-determine tooth preparation before impression-taking. It is an essential part of the process. Cases such as this are two visit affairs. I schedule a full morning session to prepare, impress and temporize the case and about the same to remove the temp and deliver the case; typically 4 weeks between visits.
1

Pre-op portrait

Figure 3

After completing the initial exam, the very next thing we did was take a digital portrait of her smiling. We studied it together. I took this opportunity to discuss the challenges and limitations that might enter into her smile rehab. We agreed that she had what might be called a gummy smile. I explained to her that this was a skeletal issue (in lay terms, of course) and that correction of this was beyond the realm of porcelain veneers. Fortunately, she did not object to her soft tissue Figure 3A display. We then looked more closely at the gum tissue itself and noticed that the papilla between 8 and 9 was blunted and lower than the flanking papillae. (7/8, 9/10) The 8/9 papilla also featured an asymmetrically located bump on the mesial-gingival aspect of

Figure 5

Figure 6

Figure 7

Figure 8

Finally, notice that the preps are just slightly supra-gingival. As we werent in need of masking any dark coloration, this is a perfectly acceptable place to put veneer margins. Ultimately, the gum tissue is forever grateful. Please note that these are not crown preps but rather are a combination of veneer preps that are specifically designed to allow the laboratory to deliver on the simulations (and my own) promise. Planning them in advance of tooth preparation will put the operator in a more comfortable place when it comes time to prepare the teeth.

The Provisional.
Moving along to the provisionals, youll see the soft template component of Smile Visions Hard Soft Template being tried in. (Figure 11) Try to make out how the underlying preps fit neatly into the crown forms of the highly detailed template. In
Figure 13

Lets pick up the case at a point at which the teeth have been prepared where I am reshaping the interdental papilla between #8 and #9. In figure 8, I am using Parkells Sensimatic Electrosurge 600SE with the needle tip electrode to create a pointier papilla. In Figure 9, youll note the loop electrode tip being used to flatten the aforementioned bump, as well as provide additional shaping. In figure 10 youll find the completed tissue-plasty. (The orange color noted is due to the use of Ultradents Viscostat hemostatic to control minor bleeding. It disappears quickly.) Take a look at the preps again in figure 10. They illustrate some points regarding tooth preparation; something that is expanded upon considerably in a full Comfort Zone Cosmetics presentation. First youll notice that interproximal contacts are broken only between 7/8, 8/9 and 9/10. It was determined
Figure 9

in the wax-up stage on the models that slot pres or slice preps would be needed to allow for reshuffling of the tooth mass towards the midline, thus the need to break contacts. It wasnt necessary to break the remaining contacts so traditional elbow preps are used interproximally. This allowed me to conserve tooth structure and reduce the complexity of the provisional. Next take a look at the canines. Youll see that the incisal point has been retained (as opposed to flattening it out). This preparation consideration allows for much better support of the ensuing porcelain veneer. You may also be able to see that the bicuspids have subtle shelves left near the cusp tip to allow for a more positive seat of the veneer. This counters the tendency for such small porcelain veneers to float on top of the luting cement.

Figure 14

Figure 10

Figure 11

Figure 12

figure 12, the Hard and Soft components are tried in simultaneously. The hard plastic shell applied to the softer but more detailed underlying soft template allows for firm pressure application to the seated combination after the templates have been loaded with a quick curing bisacryl material such as Parkells SmartTemp. Significant pressure can be applied to the soft template without it collapsing onto the preps, thus obtaining a nicely detailed provisional that resembles the Resin Replica mock up. In figure 13, observe the preps being spot-etched while in figure 14, youll see the preps coated with an unfilled resin which is subsequently air thinned and then cured. In figure 15, the Hard/Soft template combination has been loaded with Parkells SmartTemp and then firmly seated over the preps as shown in figure 16. Figure 17 demonstrates the completed provisional.

Figure 15

Figure 16

Figure 17

Figure 18

Figure 19

Figure 20

Following placement, 8 bladed carbide finishing burs (ET from Brasseler) and fine finishing diamonds (Alpen finishing diamonds from Coltene Whaledent) are employed to remove all flash and sculpt the papillary spaces so as to allow tissue to regroup; particularly the newly sculpted 8/9 papilla. It is the temporary veneer that will guide tissue regrowth between 8 and 9.

appearing to emerge from the tissue as opposed to looking as if resting on top of it. The final smile is shown in Figure 22 with my patient looking pleased. Compare it to the simulation as seen in Figure 4 and notice the similarities and consistency.

Figure 21

Fast Forward
Four weeks have gone by and the veneers are ready to deliver. In figure 18, the provisionals have been cut off and all flash removed. You may note that the papilla between 8 and 9 is regrouping but signs of inflammation remain at this juncture. (Note: a temporary night guard and night-time mouth breathing contributed to less than ideal tissue character during the provisional phase.) In figure 19, youll observe application of Parkells Brush and Bond to all of the preps. This was preceded by a 5 to 10 second 35% phosphoric acid etch intended solely to clean the tooth surfaces prior to final bonding. (Over the last six years I have found Brush and Bond to virtually eliminate post-placement sensitivity in addition to providing a very reliable bond to tooth structure.) Cosmedents Insure Lite (clear shade) was employed to serve as the luting agent for the new set of veneers. Figure 20 demonstrates the newly placed veneers on day 1, while Figure 21 showcases the completed case at one month post-op. Tissue tone exhibited considerable improvement. Notice the newly shaped papilla between 8 and 9. As promised, a bit lower than the others, but pointy and symmetrical with the centrals

So what can you take away from this article?

Anterior cases can be done predictably with a system in place that removes the guesswork from case delivery: portrait to simulation to mock-up to templates to provisional to completed case. E-surge can be successfully used to sculpt tissue which can in turn be molded by your provisional. Brush and Bond is an excellent way to lute veneers sensitivity-free. Youd better get to one of my seminars to get the rest of the details!

Figure 22

2008 Parkell, Inc.