Correcting Esthetic and Functional Issues at Georgia Regents University College of Dental Medicine: Using Conservative Veneers and Periodontal Surgery

Barry D. Hammond, DMD | Jae Seon Kim, DDS, MSD, FACP | Jimmy Londono, DDS | Marko Tadros, DMD | Aram Torosian, CDT, MDC, AS

Dr. Hammond is an associate professor and director of Dental Continuing Education, Department of General Dentistry, Georgia Regents University (GRU) College of Dental Medicine in Augusta, Georgia. Dr. Kim is a diplomate, American Board of Prosthodontics; and an assistant professor, Department of Oral Rehabilitation, GRU College of Dental Medicine. Dr. Londono is an assistant professor, Department of Oral Rehabilitation, GRU College of Dental Medicine.

Dr. Tadros is a first-year graduate prosthodontic resident, GRU College of Dental Medicine.

Mr. Torosian is a master dental ceramist at the Goldstein Center for Esthetic and Implant Dentistry, GRU College of Dental Medicine.

Disclosure: The authors did not report any disclosures.

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Facial analysis. Repose (rest position).

Patient’s chief complaint was, “I want to close those spaces.”

The patient had minimal dental restorations and was classified as a low caries-risk patient with visible diastemata mainly in the maxillary anterior region.

Maximum intercuspation.

A diagnostic wax-up was completed with the aid of Digital Smile Design to address the esthetic problems previously described.

Digital esthetic mounting and smile design. Diagnostic wax-up.

Coachman C, Calamita M. Digital Smile Design: a tool for teaching treatment planning and communication in esthetic dentistry. QDT 2012. Hanover Park (IL): Quintessence Pub.; 2012.

A bis-acryl esthetic mock-up based upon the diagnostic waxup was performed to assess the shape, incisal display, and gingival outline, and to give the patient an esthetic preview of the proposed treatment.

Initial intraoral mock-up. Patient in repose with bis-acryl mock-up.

Patient smiling with bis-acryl mock-up.

A full-thickness mucoperiosteal flap was reflected subsequently and bone was removed to establish the patient’s unique biologic width.

Flap elevation prior to bone reduction, showing need for labial osseous reduction.

Osseous crest placed 3 mm from the apical margin of the proposed porcelain veneer margin.

The repositioned free gingival margins will allow for better gingival symmetry and tooth proportions.

Three months post esthetic crown-lengthening surgery.

A second bis-acryl mock-up was used as a guide for the minimal preparation technique as described by Gürel, and Magne and Belser.

Second diagnostic mock-up. Gürel G. Porcelain laminate veneers: minimal tooth preparationby design. Dent Clin North Am. 2007 Apr;51(2):419-31, ix.   Magne P, Belser U. Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Hanover Park (IL): Quintessence Pub.; 2002.

The incisal edges were reduced by 1.0 mm using a high-speed round donut-shaped diamond-coated bur. The depth cuts were connected using a flat-end tapered coarse bur.

Depth guide cuts made through the mock-up.

Pencil markings indicating the minimal amount of preparation needed.

A  mosquito  diamond  was  used  to  round  off  sharp  corners  and  line  angles.    

Final conservative preparations.

Using a silicone matrix fabricated from the definitive wax-up, a cutback was performed to control thickness of the veneering ceramic.

Definitive wax design of the final restorations on the master solid cast.

Labial cutback using silicone matrix as a guide.

Using the marked outlines as a guide, final contour adjustments were made.

Morphological contouring.

To achieve lifelike characteristics of the ceramic, subtle external stains were applied to the surface prior to glazing. A fixation firing was subsequently carried out to freeze the stains in place, followed by glaze paste application and hand polishing with silicone wheels and #3 fine pumice.

Final anterior restorations on solid cast.

A non-latex rubber dam was placed using the slit technique and 000 cords were placed around each preparation to control sulcular fluids and facilitate cement removal.

Rubber dam in place using slit technique.

The teeth were etched using 32% phosphoric acid for 15 seconds and rinsed, followed by adhesive application.

Adhesive application.

The veneers were gently placed on the teeth and excess cement carefully removed, then spot photopolymerized using a 2-mm small light guide for five seconds on the cervical of the veneers to tack the veneers in place.

Tack photopolymerization of the veneers.

Final removal of any residual cement was performed, followed by application of glycerin gel at the margins to prevent formation of an oxygen-inhibited layer.

Application of glycerin gel.

Bergmann P, Noack MJ, Roulet JF. Marginal adaptation with glass-ceramic inlays adhesively luted with glycerine gel. Quintessence Int. 1991 Sep;22(9):739-44.

Definitive photopolymerization was performed for 40 seconds facially and palatally, followed by removal of the retraction cords and careful removal of any remaining resin cement with a #12B disposable scalpel.

Definitive photopolymerization of the resin cement.

An occlusal guard was fabricated and delivered to the patient at a subsequent appointment to provide nighttime protection for the new restorations. The final result met the esthetic and functional results desired.

Final restorations, two months postoperative.

The final outcome was a result of careful diagnosis, treatment planning, and delivery of care in a dedicated environment, and is representative of the level of care that students and residents working together are able to provide through the Goldstein Center for Esthetic and Implant Dentistry at GRU.

_______________________________ The AACD would like to thank the authors of this SlideShare for their work and dedication to the education in esthetic dentistry.  _______________________________

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