Aesthetic Management of Anterior Teeth: A Case Series
Rukhsaar Akbar Gulzar1, Subash Sharma2*
1 Post Graduate Student, Department of Conservative and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and
Technical Sciences, Saveetha University, Chennai, India.
2 Head of Department, Aesthetic Dentistry, Saveetha Dental college and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha
University, Chennai, India.
*Corresponding Author
Subash Sharma,
Head of Department, Aesthetic Dentistry, Saveetha Dental college and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India.
Tel: 9884533118
E-mail: drsubashsharma@gmail.com
Received: September 13, 2021; Accepted: September 23, 2021; Published: September 24, 2021
Citation:Rukhsaar Akbar Gulzar, Subash Sharma. Aesthetic Management of Anterior Teeth: A Case Series. Int J Dentistry Oral Sci. 2021;8(9):4713-4718. doi: dx.doi.org/10.19070/2377-8075-21000958
Copyright: Subash Sharma©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Facial aesthetics plays an important role in the psychosocial well being of a person. The value of the appearance of one's teeth has taken up great importance. The advances made in adhesive materials have shifted the trend towards a more conservative approach that is also aesthetically pleasing. The following is a series of five cases that discusses the various treatment modalities based on the demands of a case for the aesthetic management of anterior teeth. The first patient reported with a severe generalised attrition and erosion It was observed that the crown height was compromised and there was a reduction in overjet and overbite. An endodontic treatment was planned for 11 and 21 followed by fibre post and full veneer crowns and veneers were planned for 12 and 22. The second patient reported having fractured 11, 21 and 22. It was observed that 22 was previously endodontically treated and 21 was slightly extruded and required plane correction. An endodontic treatment was planned for 21 followed by indirect veneers for 11 21 and 22. The third case report is about a patient who reported with acrylic crowns and metal pins in 11 and 21 with previously initiated endodontic therapy that wasn't completed. A retreatment was done followed by custom made metal post and PFM crowns. The fourth patient reported with dislodged crowns in 31, 41 and 42. It was observed that 31 41 and 43 were previously treated and had a highly compromised crown structure. A custom made metal post was fabricated for the teeth followed by rehabilitation with PFM crowns. The fifth patient reported with discoloured non vital teeth which was conservatively managed with non vital bleaching.
2.Introduction
3.Materials and Methods
3.Results
4.Discussion
5.Conclusion
5.References
Keywords
Cast Post; Full Veneer Crowns; Indirect Veneers; Lithium Disilicate; Non Vital Bleaching.
Introduction
Facial aesthetics plays an important role in the psychosocial well
being of a person [1]. The value of the appearance of one's teeth
has taken up great importance. The traditional domain of a dental
practitioner that was once centered around eradication of the
diseased state of tooth, now also includes enhanced aesthetic corrections.
Dental aesthetics was defined as ‘visual perception’ for
the first time in 1947 by Lombardi which had two major aspects:
composition and proportion [2]. The discord in the perception
of what is deemed aesthetically pleasing by the layman and professional
has been well documented [3]. The patient’s perception
of smile alters based on various factors such as gender, age, ethnicity
which can be challenging while attempting to create an ideal
smile [4]. A practitioner aims mainly at achieving a balanced smile
through harmony between the hard and soft tissue [5] while also
keeping in mind the patients' needs.
In a quest to improve the facial and dental appearance the pioneering
work of the likes of Pierre Fauchard spurred the development
of a special dental discipline specialising in the treatment
of functional and aesthetic dental deficiencies [6].
The advent of bonded ceramics and resin composites have altered
the way dentistry was practiced with a significant breakthrough in
the 20th century. The advances made in adhesive materials have
shifted the trend towards a more conservative approach that is
also aesthetically pleasing [7].
Previously our team has a rich experience in working on various research projects across multiple disciplines [8-22]. Now the
growing trend in this area motivated us to pursue this project.
The following is a series of five cases that discusses the various
treatment modalities based on the demands of a case for the aesthetic
management of anterior teeth.
Case Series
Case I
A male patient aged 38 reported with severe generalised attrition
and erosion and wanted an aesthetic correction for the appearance
of his maxillary anterior teeth. It was observed that the patient
had reduced overjet and overbite (Fig1a). There were no periodontal
pockets or mobility. The patient was offered the choice
of rehabilitation of bite however the patient rejected that option.
A diagnostic impression was taken and a wax mockup was done
on the cast for the rehabilitation of 12 11 21 and 22, that would
help in achieving an optimum aesthetic outcome. For the correction
of his overjet, endodontic treatment was planned for 11 and
21 followed by placement for fiber reinforced post and full veneer
emax crowns whereas emax veneers were planned for 12 and 22.
Horizontal and incisal depth cuts were made for 12 and 22 using
the depth cutting diamond bur (ShofuTM) and a conservative veneer
preparation was done limiting it to the enamel. A traditional
preparation was done for 11 and 21 to receive full veneer crowns
(Fig1b). The preparation margins were placed equigingival. Double
cord technique using 00 followed by 000 cord impregnated
with lignocaine was used to achieve gingival retraction before taking
the impression. A two stage putty impression was taken. The
first impression was taken using putty (ZhermackEliteTM) with a
spacer. This was followed by removal of the 000 cord and injection
of the light body elastomer (ZhermackEliteTM) around the
preparation and on the tray before repositioning it. Shade selection
was done using the VITA shade guide. For temporization,
a putty index was made using the mock up and the teeth were
temporized using protemp by 3M ESPETM. IPS EmaxTM restorations
were fabricated using lithium disilicate to obtain maximum
aesthetic outcome (Fig 1c). Prior to cementation, the occlusal,
extrusive and protrusive movements were checked for any discrepancies.
The internal surface of the crowns and veneers received
9.5% hydrofluoric acid treatment for 20 seconds followed
by application of silane coupling agent. The teeth were isolated
using rubber dam and the surfaces were etched using 35% phosphoric
acid. This was followed by bonding protocol (3M ESPE
Single Bond Universal Adhesive). The crowns were cemented
first followed by veneers. A translucent resin cement (3M ESPE
RelyXTM U200) was the choice of luting material. Tact cure was
done for 5 seconds followed by removal of the excess resin cement
and full cure for 30 seconds on both the buccal and lingual
sides. After the removal of the rubber dam, the excess cement
was removed using a no 12 BP blade. Figure 1d and Figure 1 e
show the post operative outcome.
Case II
A male patient aged 44 reported for aesthetic correction of fractured
11 21 and 22 (Fig 2a). Upon clinical and radiographic examination
it was observed that 22 was endodontically treated, whereas
21 was extruded and required plane correction. To achieve
adequate plane correction, endodontic treatment was performed
for 21. This was followed by taking a diagnostic impression and
preparing a wax mockup so as to design veneers for 11 21 and 22.
A conservative veneer preparation was done by placing the horizontal
and incisaldept cuts using the dept cutting diamond bur
(ShofuTM). The margins were placed equigingival. Double cord
technique using 00 followed by 000 cord impregnated with lignocaine
was used to achieve gingival retraction before taking the
impression (Fig 2b) A two stage putty impression was taken. The
first impression was taken using putty (ZhermackEliteTM) with a
spacer. This was followed by removal of the 000 cord and injection
of the light body elastomer (ZhermackEliteTM) around the
preparation and on the tray before repositioning it. Shade selection
was done using the VITA shade guide. For temporization,
a putty index was made using the mock up and the teeth were
temporized using protemp 3M ESPETM. IPS EmaxTM restorations
were fabricated using lithiumdisilicate to obtain maximum aesthitc outcome (Fig 2c). Prior to cementation, the occlusal, exclusive
and protrusive movements were checked for any discrepancies.
The internal surface of the crowns and veneers received
9.5% hydrofluoric acid treatment for 20 seconds followed by application
of silane coupling agent. The teeth were isolated using
rubber dam and the surfaces were etched using 35% phosphoric
acid. This was followed by application of the bonding agent (3M
ESPE Single Bond Universal Adhesive). A translucent resin cement
(3M ESPE RelyXTM U200) was the choice of luting material.
Tact cure was done for 5 seconds followed by removal of the excess
resin cement and full cure for 30 seconds on both the buccal
and lingual sides. After the removal of the rubber dam, the excess
cement was removed using a no 12 BP blade. The post operative
outcome is seen in Fig 2d.
Case III
A male patient aged 67 reported for the aesthetic correction of
maxillary central incisors. Upon clinical examination it was observed
that 11 and 21 had acrylic crowns with metal pins protruding
out (Fig 3a). Radiographic examination revealed previously
initiated endodontic treatment however the canals were not obturated.
In the first visit the metal pins were retrieved and the
acrylic crowns were removed using a diamond bur (MANITM). It
was observed that the coronal tooth structure was compromised.
An endodontic treatment was done for 11 and 21 in two visits.
To reestablish the crown height and to correct the alignment
of the teeth, a custom made cast post was fabricated. Post space
was prepared using peeso reamer upto size 4. A metallic sprue
was trimmed and placed in the canal followed by a radiograph to
ensure adequate space around the sprue for the pattern resin to
flow. The canal was coated with liquid paraffin. The powder and
monomer of pattern resin (GCTM) were mixed on a glass slab
and placed in the canal by coating it around the sprue (Fig 3b).
Once the pattern set, it was removed and polished and cast into a
custom designed post. In the fourth visit, the custom fabricated
posts were checked for the fit, sandblasted and cemented using
Type 1 GIC cement (Fig 3c). Double cord technique using 00 followed by 000 cord impregnated with lignocaine was used to
achieve gingival retraction before taking the impression. A two
stage putty impression was taken. The first impression was taken
using putty (ZhermackEliteTM) with a spacer. This was followed
by removal of the 000 cord and injection of the light body elastomer
(ZhermackEliteTM) around the preparation and on the tray
before repositioning it. Shade selection was done using the VITA
shade guide. The teeth were temporized using acrylic crowns. In
the third visit, the PFM crowns were cemented using type 1 GIC
(Fig 3d). Prior to cementation, the occlusion was checked in centric
position, protrusive and lateral movements.
Case IV
A male patient aged 61 reported with dislodged crowns in 31 41
and 42 (Fig 4a). Radiographic observations revealed endodontically
treated teeth with no periapical pathology (Fig 4b). There were
no pockets or mobility and the patient was asymptomatic. Clinical
observation revealed compromised coronal tooth structure.
The treatment plan involved rehabilitation of the crown height
with custom fabricated metal post followed by PFM crowns. Post
space was prepared using peeso reamer (MANITM) upto size 3. A
metallic sprue was trimmed and placed in the canal followed by a
radiograph to ensure adequate space around the sprue for the pattern
resin (GCTM) to flow. The canal was coated with liquid paraffin.
The powder and monomer of pattern resin were mixed on a
glass slab and placed in the canal by coating it around the sprue.
Once the pattern set, it was removed and polished and cast into a
custom designed post. In the second visit, the custom fabricated
posts were checked for the fit, sandblasted and cemented using
Type 1 GIC (GCTM) cement (Fig 4c). Double cord technique using
00 followed by 000 cord impregnated with lignocaine was used
to achieve gingival retraction before taking the impression. A two
stage putty impression was taken. The first impression was taken
using putty (ZhermackEliteTM) with a spacer. This was followed
by removal of the 000 cord and injection of the light body elastomer
(ZhermackEliteTM) around the preparation and on the tray
before repositioning it. Shade selection was done using the VITA
shade guide. The teeth were temporized using acrylic crowns. In
the third visit, the PFM crowns were cemented using type 1 GIC
(Fig 4d). Prior to cementation, the occlusion was checked in centric
position, protrusive and lateral movements.
Case V
A male patient aged reported for the aesthetic correction of discoloured
21 which was endodontically treated and had a sound
tooth structure (Fig 5a). A minimally invasive approach to alter
the discolouration via non vital bleaching was planned. The original
colour of the tooth was recorded and the guttapercha was
removed to approximately 2 mm from the cemento enamel junction
in the apical direction. A millimeter explorer and radiograph
was used to demonstrate this depth. A barrier of GIC was placed
in this space to seal the dentinal tubules. Non vital internal bleaching
was done using sodium perborate and 20% liquid hydrogen
peroxide. The bleaching agent was replaced twice to obtain the
desired colour with an interval of one week between the two visits
(Fig 5b). One week after the bleaching procedure, the cavity was
sealed with composite restoration.
Figure 1a. Preoperative Clinical Picture.
Figre 1b. Tooth Preparation and Cord Packing.
Figure 1c. Emax Veneers and Crowns.
Figure 1d. Cementation of Veneer and Crown.
Figure 1e. Postoperative Smile.
Figure 2a. Preoperative Clinical Picture.
Figre 2b. Veneer Preparation with Cord Packing.
Figure 2c. Veneer fabrication.
Figure 2d. Post Operative Smile.
Figure 3a. Preoperative Clinical Picture.
Figre 3b. Resin Pattern.
Figure 3c. Cast Post Cementation.
Figure 3d. Post Operative Smile.
Figure 4a. Preoperative Clinical Picture.
Figre 4b. Preoperative Radiograph.
Figure 4c. Cast post cementation.
Figure 4d. Crown Cementation.
Figure 5a. Preoperative Clinical Picture.
Figre 5b. After bleaching.
Discussion
Our institution is passionate about high quality evidence based
research and has excelled in various fields [12, 23-32].
Adhesively bonded direct and indirect dental materials can restore
aesthetics and create a pleasing smile with minimal invasiveness
and limited sacrifice of natural tooth structure for malformed,
malpositioned, or slightly damaged teeth. Indirect ceramic veneers
have developed as one of the best methods of conservative anterior
aesthetic rehabilitation. Among the various material options,
Emax veneers made of lithium disilicate promises high aesthetics
due to its high translucency and light transmitting properties [33].
Besides the optical characteristic similar to the dental structure,
glass-ceramic materials have good bonding characteristics to the
dental structure. The longevity and success of veneers majorly
depends on the bonding to the tooth surface which is governed
by the surface treatment of ceramic and the tooth surface as well
as the choice of adhesive and resin luting cement. Further, the
bond strength is higher when the preparation is limited to the
enamel [34]. Hence it requires a minimum preparation that does not extend to the dentin. It is recommended that for a lithium disilicate
restoration, etching with 9.5% hydrofluoric acid for 20 seconds
should be followed by application of silane coupling agent
[35]. A light-cured resin-based cement is an appropriate choice for
luting indirect veneers in terms of bond strength and increased
working time [36-37]. Further the shade of the luting cement is
another factor that governs the post cementation appearance of
the veneer since choosing a darker shade luting cement can alter
the shade of the veneer. Hence a light cure translucent shade was
used for luting the veneers.
The restoration of a badly broken down endodontically treated
molar tooth is a challenging task. There is an increase in the demand
on dentists to restore structurally compromised teeth, and
increase the life expectancy of such teeth The restorability of
structurally compromised endodontically treated teeth depends
on the tooth position, quality of the endodontic treatment, root
length and anatomy, periodontal support, presence of ferrule
and remaining crown structure [38]. When the remaining coronal
tooth structure to support an artificial crown is compromised, a
post is placed to resist rotation of the prosthesis. The cast post
and core is custom fitted to the prepared root canal space and designed
to resist torsional forces [39]. In anterior teeth with more
than 50% tooth structure loss, post and core followed by full coverage
restoration is mandatory [40]. Post and cores that are custom
fabricated using the standardized fabrication technique have
good long term prognosis [41]. A success rate of more than 90
% in a retrospective study of 96 teeth treated with cast posts and
cores was recorded by Bergman et a1., and they concluded that
the traditional custom cast post and core can be recommended
[42]. In the cases reported in the present literature, the root had
adequate length and diameter and there was an optimum ferrule
present so as to receive a custom designed post. Either an all ceramic
crown with a zirconia coping or PFM to mask the discolouration
would be the choice of crown in these cases. Keeping
the patient`s affordability in mind, PFM crowns were chosen as
the final restoration.
In all the cases, a double cord retraction with impregnated cord
was used to ensure optimum recording of the margins and control
of bleeding [43, 44].
In discoloured endodontically treated teeth with intact coronal
tooth structure, non vital bleaching offers a conservative. However
bleaching techniques should consider the biological safety. The
walking bleach technique was introduced in 1967 by Nutting and
Poe where 30% hydrogen peroxide was used along with sodium
perborate [45, 46]. However considering the probability of occurrence
of external cervical resorption, saline was used along with
sodium perborate to avoid the damage caused by high concentration
of hydrogen peroxide. Further, placing a barrier of GIC
ensured further protection [45].
However, the achievement of ultimate long term success of an
aesthetic treatment requires patient education and motivation and
the periodic control by the dentist.
Conclusion
Dental aesthetics is becoming one of the leading reasons that
patients now attend a dental practice. Treatment planning based
on optimum clinical evaluation is imperative to ensure long term
prognosis. The treatment must aim at providing the most conservative
therapy whenever possible. In cases of endodontically
treated teeth, the success not only depends on the endodontic
treatment but also on the post endodontic management especially
when there is substantial damage to the tooth structure. The aim
must be to establish both aesthetics and function.
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