A Systematic Approach to Predictable EstheticsUsing Porcelain Laminate Veneers

Tal Morr, DMD, MSD*Harald Heindl, MDT**

With the continual advancement in allaspects of dentistry, esthetics remainsat the forefront for the patient. More

than in the past, today's patients are much moreeducated about the treatment options available.This improved dental knowledge has developedas a result of the availability of information via theInternet, publications, and television. Because ofthis increase in knowledge, patients are now de-manding the highest level of esthetics possible.Although esthetics is certainly crucial, the ulti-

mate objective for any dental treatment should beto restore health, function, and beauty using themost conservative method of treatment availableto achieve the desired result. Bonded ceramic ve-neers are often the restoration of choice from a bi-ologic, functional, mechanical, and esthetic stand-point when the objective is to modify toothposition and/or tooth form, close diastemataand/or cervical embrasures,or change the color ofteeth. All of these options are approached withthe assumption that enough enamel substrate is

*Private practice, Aventura, Florida, USA.

**Aesthetic Dental Creations, Mill Creek, WA, USA.

Correspondence to: Dr Tal Morr, 20760 West Dixie Hwy,Aventura, FL 33180, USA. Fax: 305-935-6753. E-mail:info@tmprosthodontics.com and HaraldHeindl@hotmail.com

available and that the patient does not wish to un-dergo orthodontic treatment.The natural tooth is uniquely made up of two

materials: enamel and dentin. The rigidity ofenamel and the flexibility of dentin create theunique complex of the tooth crown. Studies haveshown that from a mechanical and functionalstandpoint, feldspathic porcelain veneers ade-quately restore the rigidity of the crown whenused as an enamel substituteY From a biologicstandpoint, we know that, because of their es-thetic qualities, bonded veneers do not requirepenetration into the gingival sulcus in every clini-cal situation. This may prevent potential damageto the periodontal tissues.3 Because plaque andbacterial vitality have been found to be signifi-cantly reduced around porcelain veneers,' theserestorations may be biologically beneficial to pa-tients with poor oral hygiene. Porcelain has beenfound to be less susceptible to accumulation ofbacterial plaque than mineralized tooth structure,gold, and composite resin.5.6 Because porcelainveneers have no metal substructure, they allowlight to be absorbed, deflected, and reflected in amanner similar to natural tooth structure. By con-trast, in a restoration with a metal substructure,light traverses the ceramic but is blocked by themetal core, all too often with a resultant grayingeffect of the definitive restoration.

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As with all restorative procedures, a thoroughdiagnosis and treatment plan must be imple-mented with communication occurring betweenall members of the treatment team.7 The initialevaluation should encompass visualization of thefinal esthetic alterations within the mechanical andfunctional parameters. An esthetic interpretationof the final result will help to shape the treatmentplan in relation to proposed changes in tissuelevel, contour, tooth form and arrangement, andpreparation design and will enable the team toachieve the final result.

CASE 1

Esthetic Evaluation

A 28-year-old female, who was a model, presentedfor esthetic improvement of her smile. Her chiefcomplaint was that her teeth were too round andshe was told that they did not reflect light appro-priately; hence, she was asked to pose with herlips closed during photo shoots. The patient wasemphatic about having a long-term esthetic resultthat would not stain and discolor as did her com-posite resin restorations. Before a determinationcould be made about the treatment modality tobe used and the number of teeth to be restored, athorough esthetic evaluation was performed.The patient was asked to say nMn letting her

lips relax naturally (Fig 1a). With the patient's lipsat rest, the incisal edge position of the central in-cisors was evaluated; the position of the maxillaryright central incisor appeared to be appropriatefor the patient in terms of age and gender.8 Someproblems became evident when the patientsmiled, however (Fig 1b). The left central incisorwas slightly shorter than the right central incisor.Both canines were slightly worn and were tooshort in relation to the occlusal plane drawn fromthe right central incisor to the molars. Lengthen-ing of the canineswould level the occlusal plane.The rotation of the maxillary left canine created

severe disharmony in the smile, its distal aspectbeing more prominent than the mesial. A key ele-

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ment of esthetics is that, from a facial point ofview, it is preferable to see the mesial aspect ofthe canine only. This helps to create the transitionfrom the anterior of the mouth to the posterior.The canine is the tooth that defines the arch form,whether square, u-shaped, or v-shaped.Also noted in the examination was the axial in-

clination of the maxillary left lateral incisor. Ratherthan appearing to be tipped toward the mesialfrom a cervicoincisal direction, it was tipped dis-tally. This in turn created imbalance in the smileline. There was also an obvious discrepancy in thebalance of the gingival levels (Fig 1c). Ideally,dental professionals prefer the gingival marginsof the central incisors and canines to be at thesame level while the lateral incisor tissue heightsshould be somewhat more coronal. Although thesoft tissue on both centrals was even, it was morecoronal than that of both canines. The gingivaltissue around the maxillary left lateral incisor ac-centuated the problem by being more cervical tothat of the centrals, and the soft tissue around theleft canine was more cervical than that of theright canine.Another key element that the patient wanted

to address was the diastema (Fig 1d). An attempthad been made at some point to close the di-astemawith composite resin, but at the initial pre-sentation, the composites were discolored andworn. In addition, the central incisors appeared tobe too narrow relative to the lateral incisors andcanines.From the esthetics evaluation, it was deter-

mined that soft tissue correction would be neces-sary to create a more harmonious result. As part ofthe evaluation, a local anesthetic was administeredand the facial aspects of the two central incisorswere probed to determine the location of the ce-mentoenamel junction. Approximately 1.5 mm ofthe crowns (enamel) of the central incisors and theright lateral incisor were covered by the gingiva.The bone was sounded, and the biologic width forthis patient was found to be about 2.5 mm. Thisdetermination would be helpful for bone recon-touring. From a mechanical and functional point ofview, all other findings were within normal limits.

Esthetic Treatment Plan

The problems were discussedwith the patient, andthe objectives for restorative treatment were laidout as follows: (1) to surgically level the soft tissueto create a balanced and harmonious gingivalplane and accompanying tooth length and shape,while maintaining the cervical aspect of the prepa-ration in enamel; (2) to close the diastema be-tween the central incisors so that these teethwould appear more dominant; (3) to correct theaxial inclination of the teeth so that from a cervico-incisal direction they would appear to be tippedtoward the mesial; and (4) to bring the maxillaryright canine more buccal, lengthen both caninesslightly, and rotate the maxillary left canine so thatit would transition from anterior to posterior andcreate a more harmonious arch form. It is impor-tant to note that when severe manipulation of theposition of the teeth is necessary,some dentin ex-posure will result during the preparation.

Porcelain veneers are an ideal restoration forthis type of treatment if the objective is to changethe size, contour, arrangement, and color of theteeth. Not only are they the least invasive type ofrestoration, other than composite bonding, butthey can fulfill all of the objectives of treatment.Composite restorations were not an option be-cause of their inherent problems with staining anddegradation over time. If the objective had beenonly to correct tooth alignment and the diastema,orthodontics would have been the treatment ofchoice.

Diagnostic Waxup

Alginate impressions of the maxilla and mandiblewere made, and models were mounted using afacebow leveled with the eyes. A diagnosticwaxup of all the proposed changes was made onthe cast (Fig 2). The diagnostic waxup is the mostcritical step for predictability in any type of restora-tive procedure. Not only does it allow visualizationof the final proposed changes, it also revealswhether the desired changes are reasonable and

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able to be achieved. In this case, the facial surfacesof the central incisors were ground down slightlyon the diagnostic cast to make them less rounded,and the distal of the left canine was modified toallow correction of the rotation prior to the waxup.Knowing how much was ground off helps tremen-dously in the preparation step.The incisal edges were waxed first, followed by

the facial contour, and then the tissue heightswere corrected by waxing over the gingival mar-gins where necessary to level the gingival plane.The waxup enabled the future tooth preparationdesign and soft tissue leveling to be visualized.

Soft Tissue Leveling and Contouring

The patient returned for surgical crown lengthen-ing. A modified approach to the technique, as de-scribed by Eriks,9was used. A papilla-preservationflap was elevated, and the bone was contoured tobe at the same level on both the canines and thecentrals, taking into consideration the incisal edgepositions. The bone on the maxillary right lateralincisor was leveled with that of the maxillary leftlateral. As mentioned earlier, a biologic width of2.5 mm was found when sounding to bone. Thismeasurement was used to position the bone ac-cording to the final position of the marginal tissueas determined by the waxup. Care was taken notto create a situation in which the dentin would beexposed. Because of this, the centrals were leftsomewhat shorter than the canines, and the later-als were not leveled perfectly. More aggressivecrown lengthening would have exposed dentin.After 3 months of healing, the smile already re-

vealed a harmonious improvement (Fig 3a). Thebiologic width was evaluated again for maturationby sounding to bone. When the measurementequaled 2.5 mm, it was deemed ready for prepa-ration. It was noted at this time that the tissueheights of the central incisors were not level eventhough the bone had been carefully placed in thecorrect position (Fig 3b). It is possible that someremodeling of the bone around the left central in-cisor occurred.

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Second Diagnostic Waxup

Becausethe soft tissue was surgically corrected, asecond diagnostic waxup was necessary. A newalginate impression of the maxilla was made, andthe cast was mounted against the mandibularmodel.Using silicone indices, the tooth contours of the

original waxup were duplicated on the postopera-tive maxillary cast with the corrected gingival lev-els and contour. Now that the central incisorswere longer, they could be made wider and moredominant. A full-coverage silicone index of thewaxup was made, extending beyond the facialand palatal margins and from second premolar tosecond premolar (see Fig 6a). This would be usedfor fabrication of the provisional restorations. A fa-cial index was also fabricated to be used for verifi-cation of precise reduction of the preparations inthe facial plane (Fig 4).

Tooth Preparation

The patient was given local anesthetic, and thepreparations were begun. Current techniques sug-gest using a depth-defining bur to ensure properreduction, which is 0.3 to 0.7 mm for porcelain ve-neers.'OIf the teeth to be veneered are properlyaligned and no major changes in tooth form arerequired, this type of technique is useful. On theother hand, when changes in tooth form andalignment are required, a more precise techniqueis needed, one that will take into considerationthe final shape and contour of the veneers. In thiscase, a facial silicone index was beneficial in guid-ing the preparation depth and design (see Fig 4).Knowing how much stone was removed from thecast to create the tooth contours was also benefi-cial. All waxups were prepared by the restorativedentist since he was responsible for evaluatingand determining the final changes. Preparationswere begun by removing the existing bondingand then opening the proximal surfacesusing dia-mond disks. The latter technique facilitates prepa-ration of the proximal surfaces, impression mak-

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ing, and laboratory procedures. Because one ofthe objectives was to close the diastema and thecervical embrasures, the preparations needed tobe continued to the palatal aspects of the teethinterproximally aswell as subgingivally to allow fora smooth emergence profile of the veneers. Inter-proximal preparation is also necessary for alter-ation of the position and rotation of a tooth.Once the teeth were disked, Ultrapak 000 cord

(Ultradent, South Jordan, Utah) was placed inter-proximally within the sulcus. The teeth were pre-pared again so that they finished at the level of thetissue facially and at the level of the cord interprox-imally (Fig 5). The facial matrix was used to ensureproper reduction of the facial and interproximal as-pects of the teeth. Cervically, the preparationswere left in enamel. Under normal circumstances,the preparations would be cut to the tissue levelwhen little or no alterations in color are needed. Inthis case, the soft tissue of the left central incisorwas more cervical than that of the right central in-cisor following surgical correction, even thoughbony placement during surgery was carefully mea-sured with a caliper. If the bone was placed in thecorrect position, then the tissue should eventuallymove down to the desired position. Because ofthis, the cervical extent of the preparation on theleft central incisor was made by carefully measur-ing the preparation on the right central incisor sothat the teeth would be the same length, eventhough tooth structure remained cervical to thepreparation. Once the preparations were finished,a laserwas used interproximally to modify the cer-vical contour of the tissue (seeFig 5).

ProvisionaJization

Once the preparations were finished, the full-cov-erage matrix of the waxup was filled with Aliketemporary resin (GC America, Alsip, IL) andplaced in the mouth (Fig 6a). The matrix with theresin inside was gently pumped up and down untilthe resin set (Fig 6b). The provisional restorationswere then finished with burs and disks after evalu-ation in the mouth, and any necessary contour

Predictable Esthetics Using Porcelain Laminate Veneers ••

Fig 1a Initial presentation of lips atrest.

Fig 1b Initial smile. Fig 1c Initial intraoral frontal view.

Fig 1d Closeup of maxillary anterior teeth showing di-astema and discolored composite resin restorations.

Fig 3a Smile after esthetic crown lengthening.

Fig 4 Facial matrix made from the waxup model.

Fig 2 Diagnostic waxup of proposed changes.

Fig 3b Intraoral view of soft tissue after esthetic crownlengthening.

Fig 5 Final tooth preparations.

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changes were made by either addition or subtrac-tion of acrylic resin. At this point, interproximalshape was modified to close the cervical embra-sures and to shape the cervical contour of the tis-sue. Once the final contours were achieved, theprovisionals were removed and measured individ-ually from the cervical extent to the incisal edgeto verify correct reduction. Any areas that werenot reduced enough were corrected by modifyingthe preparation.

With every provisional fabricated from awaxup, some modification is always needed inthe mouth. The waxup is prepared without theface to provide context. The final contours mustbe corrected in the mouth to obtain a true visual-ization. Only after the provisionals are properlycontoured can it be determined if the prepara-tions were made correctly (Figs 7a and 7b).

Once the preparations were deemed com-pleted, a second cord, Ultrapak 00 soaked in a20% aluminum chloride gel (Styptin, Van RDental,Oxnard, CAl, was packed into the sulcusto retractthe tissue for final impressions. Small cords aregenerally used for veneers because, if there areno alterations in the tooth color, a supragingivalmargin, or one made to the tissue level, is ade-quate. As always, the final objective is to have gin-gival health at the periodontal-restorative inter-face. Final impressions were made using apolyvinyl siloxane material (Affinis, Coltene Whale-dent, Mahway, NJ).

Photographs

Color photographs of a shade guide with the origi-nal teeth and the tooth preparations were taken toallow the technician to see the underlying toothcolor. This is essential to inform the technician ifany blockout is needed to achieve the desiredshade (Figs 8a and 8c). A black-and-white photo-graph was also taken to allow evaluation of the de-sired value versusthe shade tab (Fig 8b).

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Provisional Cementation

The provisional veneers were cemented with resinand no bonding agent. There is generally enoughfriction to hold them in place because of the inter-proximal preparation. If friction is limited, spotetching and bonding with a resin can be used toaid in the retention. The initial cord used forpreparation was left in the sulcus until after theprovisionals were cemented.

Alginate Impressions

Once the provisionals were cleaned, alginate im-pressions were made of the provisionals and theopposing arch. Becausethe lingual aspects of theanterior teeth were not altered, no occlusal recordwas needed.

Laboratory Considerations

Three casts were made from the final impressionwith type IV dental stone. The first pour was keptas a solid cast, the second was used for fabrica-tion of a saw-cut working model, and the thirdwas used for final control dies. The DVA (DentalVentures of America, Corona, CAl model systemwas used for the working model. This system pro-vides duplicate molds for single teeth and ex-changeable, heat-resistant, aluminum oxide pinsfor the refractory dies. The dies were sealed with athin-bodied cyanoacrylate, and one layer of diespacer was applied to the surface. The prepareddies were then duplicated using a polyvinyl silox-ane material (Doubletake, Ivoclar Williams,Amherst, NY). Refractory dies were fabricatedfrom this impression.

Once all the casts were ready, the workingmodel and the solid cast were cross-mounted withthe provisional model for reference. From thecross-mounted provisional model, four types of in-dices were made. The first was a full-coverageindex (Fig 9a) cut into vertical segments. This was

used to verify the available space for porcelainlayering, the labial curvature of the provisionals,and the length of the planned restoration. Thenext index fabricated was the labial index (Fig 9b)cut into horizontal segments. This index showedthe labial separations between the teeth, the posi-tion of the line angles, and most importantly, thewidth of the desired final tooth form. A third indexwas made from the palatal (Fig 9c) aspect. Thisindex was used to establish the correct length ofthe dentin body, the placement and position ofthe internal effects, and the final length of therestoration. The fourth index was made by im-printing the incisal edge (Fig 9d). This index wasused as a precautionary measure to ensure properincisal edge position during the buildup process.By opening the pin 1 mm and building up the ce-ramic to the incisal index, the restorations shouldbe either slightly long or perfect in length afterporcelain shrinkage occurs.

After all of the indexes were made, the veneerswere built up on the refractory dies, checked onthe master dies, and adjusted on the solid cast.The internal aspect of the veneers were thenetched with 9.5% hydrofluoric acid for 5 minutesand delivered to the restorative dentist.

Final Cementation

At delivery, the health and beauty of the soft tis-sue form was evident. This was developed by thepreparation design, the precise fit of the provi-sionais, and meticulous oral hygiene by the pa-tient (Fig 10). These elements are essential forfinal cementation of the veneers. The only way toachieve a healthy soft tissue is by atraumatic ma-nipulation of the gingival tissues throughout therestorative phase of treatment (preparation, re-traction, provisionalization, and final cementation).

A local anesthetic was administered followedby removal of the provisionals and scaling of theresin from the teeth. The sulcus was packed withUltrapak 000 cord soaked with the same hemo-static agent used previously. The cord serves

Predictable Esthetics Using Porcelain Laminate Veneers ••

many purposes: it allows retraction of the tissuefrom the preparation margin, aids in moisture con-trol, provides hemostasis, and helps in the finalcleanup of excesscement.

The veneers were tried in first to evaluate theinterproximal contacts. Articulating paper wasused to verify the contacts, and adjustments weremade with a diamond-impregnated wheel whereneeded. The esthetics were then evaluated withthe patient by placing water in the veneers andseating them in the mouth. After the patient ap-proved them, the veneers were re-etched with a9.5% buffered hydrofluoric acid (Ultraetch, Ultra-dent) for 3 minutes and placed in the ultrasoniccleaner for 5 minutes to remove any residue. Theywere then silanated with Scotch Bond ceramicprimer (3M Dental Products, St Paul, MN), and alayer of bonding agent was applied to the surfaceand the excess blown off. The preparations werecleaned with pumice, rinsed, and etched with 32%phosphoric acid (3M). Bonding agent was appliedto the moist tooth surface (Single Bond adhesive,3M), and the veneers were cemented with RelyXveneer luting cement (color BO.5/white, 3M). Ex-cess cement was removed initially with a brushand the contacts cleaned with floss after 3 sec-onds of light curing. Removalof the cord and finalcement cleanup were performed after the veneermargins were covered with Deox, an oxygen-bar-rier solution (Ultradent) and light cured ade-quately.

After 2 weeks of healing, the patient presentedfor final photographs. It was evident that all of thedesired objectives were achieved (Figs 11a to11f). The soft tissue was leveled to create a bal-anced and harmonious gingival plane; tooth ar-rangement and contour were improved, as wasthe occlusal plane; the diastema was closed; theaxial inclinations of the teeth were improved toprovide harmony; and the maxillary left caninewas derotated to create a smooth transition be-tween the anterior and the posterior aspects ofthe arch.

The veneers are biologically, mechanically,functionally, and esthetically sound.

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Fig 8a Color photograph of theteeth at initial presentation with B1shade tab.

Fig 8b Black-and-white photographused for evaluation of the value ofthe teeth relative to the shade tab.

Fig 6a Full-coverage silicone matrixwith acrylic resin prior to placementin the mouth.

Fig 6b Full-coverage silicone matrixafter acrylic resin has set.

Figs 7a and 7b Smile and intraoralview of provisional veneers on thetooth preparations. Note the expo-sure of dentin beyond the margin ofthe provisional of the left central in-cisor.

Fig 8e Photograph of the toothpreparations with B1 shade tab.

9a

Fig 9a Full-coverage index used toevaluate facial reduction.

Fig 9b Labial index used to evalu-ate both the labial separation be-tween the teeth and the width of theproposed veneers.

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Fig ge Palatal index used to estab-lish correct length and internal ef-fects of the porcelain.

Fig 9d Incisal index used to ensureproper incisal edge position duringthe porcelain buildup .

Predictable Esthetics Using Porcelain Laminate Veneers.

Fig 10 Tissue health at delivery of the final restorations,after removal of provisionals.

Fig 11a Final incisal edge position with lips at rest.

Fig 11 b Final smile.

Figs 11 c and 11 d Final intraoral views. Note that the tissue level around the left central incisor is almost level rela-tive to that of the right central incisor.

Fig 11e Right lateral view of veneers. Fig 11 f Left lateral view of veneers.

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CASE 2

Esthetic Evaluation and Treatment Plan

A 34-year-old man presented with two existing ve-neers. His chief complaint at the time of treatmentwas the difference in the color of the two veneers.He was also unhappy with the embrasure that wasdeveloping between the teeth and the darknessat the junction of the maxillary right veneer andtooth (Figs 12a to 12c).A thorough esthetic evaluation was performed

as described for case 1. The soft tissue profile wasdeemed acceptable. The necessarycorrection waslocalized to the central incisors. As with case 1,predictability even with only two teeth is achievedby determining the objectives for treatment. In thiscase, the objectives were (1)to reshape the maxil-lary central incisors to mimic natural contours andoptical qualities; (2)to close the cervical embrasurebetween the central incisors to create balance inthe soft tissue; and (3) to make the junction be-tween the tooth and veneer invisible.Veneers were clearly the restoration of choice

for improvement of the patient's esthetic concerns.

Waxup

As with case 1, a waxup was prepared to obtainthe desired corrections in contour, size, and tissueform (Fig 13). When waxing to close a cervicalembrasure, facial line angles help define the finalcontour of the teeth. The line angles give the illu-sion that the teeth are tapering even though theactual tooth form may be more square as a resultof the lengthened contact. Embrasure closure isobtained from the palatal aspect of the restora-tion. Indexes were made from the waxup as incase 1.

Preparations

Ultrapak 000 cord was packed into the sulcusafterlocally anesthetizing the area. The teeth were pre-

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pared based on the changes made on the modeland the waxup and with the use of the facialindex. Preparations were extended to the palatalaspect and intrasulcularly to allow room for asmooth emergence and embrasure closure (Fig14). As in case 1, a full silicone index was used tofabricate the provisionals. The provisionals wereremoved and contoured using acrylic burs and avariety of disks. Once the desired contours wereachieved, the smile was evaluated for harmonyand balance by the clinician and the patient (Fig15a). The cervical contact point was carried justabove the papillary level. When soft tissue is ma-nipulated from an intrasulcular position, a smallinterproximal space must remain for coronalmovement of the papilla, which occurs with lateralpressurefrom the provisional.The provisionals were measured for adequate

preparation depth (Fig 16), and any needed ad-justments were made. Preparation was aimed atfinishing in enamel; however, not only does re-moval of old veneers make this difficult, but in thiscase, the preparations were already partly indentin. An explorer was used to determine whenthe existing porcelain and composite had beenremoved.

Final Impressions and Photographs

Once the provisionals were made and the prepa-rations were acceptable, a second cord (0) wasplaced into the sulcus. Final impressions weremade using a polyvinyl siloxane impression mate-rial. Photographs were taken of the preparationsand the adjacent teeth with shade tabs. Thesewere done both in color (for color comparison)and black and white (to compare value).

Provisional Cementation

As in case 1, the first cord was left in the sulcus.The provisional veneers were cemented with resincement with no bonding agent. Because thepreparations were parallel, there was enough fric-

Predictable Esthetics Using Porcelain Laminate Veneers.

Fig 12a Initial smile. Fig 12b Initial intraoral view. Fig 12c Closeup of existing veneerson the central incisors. Note the ex-posed margin on the distal aspect ofthe right central incisor and the cer-vical embrasure.

Fig 13 Waxup of the proposed changes.

Fig 15a Smile with provisionals.

Fig 15b Closeup of provisionals. Note the clo-sure of the cervical embrasure and tissue re-contouring.

Fig 16 Measuring the thickness of acrylic resinto ensure proper reduction of the preparations.

Fig 14 Final preparations for veneers with re-traction cords in place, ready for impression.

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tion to hold the provisionals in place. As an addedprecaution, alginate impressions of the provision-als were made, and a vacuum-formed appliancethat the patient would wear was fabricated to helphold the provisionals in place. The cords were re-moved after the composite was light cured.

Alginate Impressions and LaboratoryConsiderations

Alginate impressions of the provisional model andthe opposing arch were made for cross mounting.No occlusal records were made. The impressionwas treated as in case 1 and was cross-mountedwith the provisional model. All the same indiceswere fabricated to maintain predictability.

Ceramic Buildup

Porcelain layering was carried out using d.SIGN(IPSd.SIGN, Ivoclar Vivadent, Amherst, NY). Thefirst layer was made using d.SIGN margin materialapplied in a thin layer up to the margin. This layerseals the refractory die and provides a securebond between the porcelain and refractory mate-rial. The initial ceramic layer was a modified deepdentin placed on the incisal and interproximalareas to prevent excessive light absorption intothese areas and to help smooth the transitionfrom the incisal edge of the prepared tooth to theporcelain (Fig 17).

Three different types of dentin were used (Fig18). Incisally, a modified dentin was used to en-hancethe brightness and value. Regulardentin wasused in the center of the tooth. A blend of dentinand transparent was used on all areas where thepreparation ended to allow the color of the under-lying tooth to influence the color of the restoration.The length of the ceramic buildup was checkedwith a palatal index prior to cutback forenamel/translucent layering. In contrast to otherceramic materials, the dentin of the d.Sign system

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is so translucent that it is possible to apply internaleffects directly onto the dentin. It is not necessaryto apply those effects on the enamel wall.

The final form was developed in alternating in-crements of various enamels and translucents (Fig19). A second bake is usually necessary to opti-mize form and contours. Quite frequently, inter-dental deficiencies, such as blunted interdentalpapillae, unfavorable tooth morphology, or di-astemata, require an artificial closure of the inter-proximal spaces. In these cases, the interproximalcontacts are overcontoured in the second bake.Once baked, the contact point is modified so itbegins just above the position of the retractedpapilla and ends near the incisal edge. Creatingsuch a long contact area can cause an unnaturalappearance to the tooth form. It is necessary tomaintain the natural tooth form by emphasizingthe triangular line angles and making the proximalcontacts more toward the palatal aspect to givethe illusion of reality.

Final Contouring and Finishing

The final contouring and surface texturing werecarried out using a variety of diamond burs andgreen stones. Final tooth surface contour must beachieved prior to elaborating the surface texture.Use of silver powder applied directly to the sur-face helped to visualize the final contours and sur-face texture (Fig 20). Final surface treatment wascompleted with a quartz-infiltrated nylon wheel(Upofix Austenal, York, PAl and an oven glazingcycle without a vacuum. Mechanical polishing withpumice and a felt wheel is optional.

The dies were removed from the veneers, andthe veneers were cleaned with 30-flm glass beads.The definitive restoration margins were checkedon the master dies. Contours and interproximalcontacts were confirmed and adjusted on a solidcast, both with and without the soft tissue modelmaterial in place (Fig 21).

Predictable Esthetics Using Porcelain Laminate Veneers.

Fig 17 Modified deep dentin layer to smooth the tran-sition between the incisal edge of the preparation andthe porcelain.

Fig 18 Dentin buildup.

Fig 19 Enamel and translucent buildup. Fig 20 Silver powder to help visualize the final con-tours and surface texture.

Fig 21 Definitive restorations on the solid cast.

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Figs 22a and 22b Final smile showing improved esthetics. The black-and-white photograph shows the value of theveneers relative to the adjacent teeth.

Figs 22c and 22d Frontal views of the final restorations.

Fig 22e Closeup of the veneers on the central incisors. Note the unde-tectable margins and closure of the cervical embrasure.

Final Cementation

The teeth and the veneers were treated and ce-

mented as in case 1. One week after final cemen-

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tation, tissue health and soft tissue embrasure clo-

sure from the papillae were evident, and the

restoration margins were clinically undetectable

(Figs 22a to 22e) .

CONCLUSION

Following a step-by-step protocol is crucial toachieve predictability in any restorative case. Onlythrough a meticulous process can successbe con-sistently insured. The clinician's initial evaluation isimperative for success. Clinical cases must beevaluated from structural, biologic, functional, andesthetic standpoints. Not only does the initialevaluation enable the clinician to identify what al-terations must be made, but it also helps in theformulation of the treatment plan needed toachieve the desired result. Treatment planning canonly be verified by using the diagnostic contourscast, and only through this procedure can onetruly tell if the proposed changes are possible.From the development of the proposed contours,reduction templates can be made to aid in correctpreparation depth and design, to guide the sur-geon as to the required soft tissue contours, andto directly fabricate the provisional restorations.The provisional restorations are the only way

for the clinician and patient to visualize the out-come within the natural frame of the face andmouth. When the provisional is correctly con-toured, the soft tissue can be manipulated andshaped appropriately. A final esthetic tooth formand arrangement of the veneers is more consis-tently achieved by correctly cross-mounting a castof the provisional restorations with the castsof theactual tooth preparations and using the informa-tion gathered from the various templates and in-dices. The final shade of the restorations can bepredictable when the clinician supplies pho-tographs of teeth and preparations for both shadeand characterization and when the laboratorytechnician has a thorough understanding of ce-ramic layering. Throughout the treatment process,atraumatic manipulation of the soft tissue duringtooth preparation, adequate provisionalization ofthe teeth, and careful cementation are essential ifa healthy gingival response is to be achieved.

Predictable Esthetics Using Porcelain Laminate Veneers •

REFERENCES

1. Magne P,Douglas WHo Cumulative effect of successiverestorative procedures on anterior crown flexure: Intact vsveneered incisors. Quintessence lnt 2000;31 :5-18.

2. Reeh ES, Douglas WH, Messer HH. Stiffness of endodon-tically treated teeth related to restoration technique. JDent Res 1989;68:1540-1544.

3. Calamia JR. Clinical evaluation of etched porcelain ve-neers. Am J Dent 1989;2:9-15.

4. Kourkouta S, Walsh n, Davis LG. The effect of porcelainlaminate veneers on gingival health and bacterial plaquecharacteristics. J Clin Periodontol 1994;21 :638-640.

5. Chan C, Weber H. Plaque retention on teeth restoredwith full ceramic crowns: A comparative study. J ProsthetDent 1986;56:666-671.

6. Koidis PT,Schroeder K, Johnston W, Campagni W. Colorconsistency, plaque accumulation, and external marginalsurface characteristics of the collarless metal ceramicrestoration. J Prosthet Dent 1991 ;65:391-400.

7. Narcisi EM, Culp L. Diagnosis and treatment planning forceramic restorations. Dent Clin North Am 2001 ;45:127-142.

8. Vig RG, Brundo Gc. The kinetics of anterior tooth display.J Prosthet Dent 1978;39:502-504.

9. Eriks RE.A predictable approach for enhanced aesthetics:A case report. Pract Periodontics Aesthet Dent 1997;9:229-231.

10. Touati B, Miara P,Nathanson D. Esthetic Dentistry andCeramic Restorations. London: Martin Dunitz, 1999.

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I.

Improving Soft Tissue Form Around Implantsvia Forced Eruption

Tal Morr, OM 0, MSO

I.

O ntegration of a single-tooth implant in theesthetic zone can be one of the most diffi-cult treatment options because of the nu-

merous biologic and esthetic requirements. Ofcritical importance is the soft tissue integration ofthe implant-supported restoration relative to therest of the anterior teeth. Failure to mimic the nat-ural gingival form from both the cervical contourand the papillary form can create an estheticdilemma. The need to preserve the gingival formhas led to the trend of immediate implant place-ment. After anterior tooth loss, the normal courseof wound healing will cause the facial bone andsoft tissue to recede both facially and palatally.'-4Without support, this recession may be com-pounded by the loss of the interdental papilla.s

This creates a narrower residual ridge that may im-pede placement of an implant in an ideal, restora-

Private practice, Aventura, Florida, USA.Correspondence to: Dr Tal Morr, 20760 West Dixie Hwy,Aventura, FL33180, USA. Fax: +305 935 6753.E-mail: tmprostho@yahoo.com

_QDT2005

tively driven position without additional surgicalprocedures, even if the soft tissue form looks ac-ceptable.6 Although surgical procedures to rebuildthe residual ridge can be performed with gener-ally good results, rebuilding the papilla to itsproper form can be much more of a challenge.Forced eruption via orthodontics can be a criticaladjunct to regenerating papillae adjacent to animplant, especially when papillary regenerationvia a surgical procedure may not achieve the de-sired result.

CASE 1

A 40-year-old woman was referred to the office byan orthodontist who questioned the integrity of anexisting anterior restoration made 18 years earlier.

At age 18, the patient had had an accident inwhich she lost tooth 6(13) and fractured the re-maining incisors, with a resultant need for en-dodontic treatment. The patient was rehabilitatedwith a fixed partial denture from teeth 3(16)through 8(11) (tooth 5[14] was extracted for or-

Improving Soft Tissue Form Around Implants via Forced Eruption ••

Fig 1 Initial radiographs at presenta-tion.

Fig 2 Lips at rest during initial evalua-tion.

Fig 3 Smile during initial evaluation.Note the papillary levels from right toleft; the papillae on the right side areshorter.

Fig 4 Intraoral frontal at presentation.Note the discrepancy in the level ofthe gingiva, which is higher on theright side.

Fig 5 Initial preparations. Note theshort preparations and form of thepontic area.

thodontic purposes, 6[13] because of trauma),with single units (full-coverage crowns) on teeth9(21) and 10(22).

Implants were not readily available at the timeof the injury, so the patient opted for a fixed partialdenture to replace the missing canine. Radio-graphic evaluation revealed fairly short roots onthe anterior teeth, with good residual height ofbone in the area of tooth 6(13),although there hadbeen both vertical and horizontal bone loss (Fig 1).

Clinical evaluation of the incisal edge at rest po-sition revealed approximately 5 mm of tooth expo-

sure (Fig 2). Assessment during smiling showedmore papilla on the left side than the right (Fig 3).

At the time of examination the patient was al-ready in mandibular orthodontic appliances for thecorrection of crowding (Figs 4 and 5). After intra-oral evaluation, it was determined that the marginalintegrity of the restorations was compromised bywashout of the cement and the resultant decay.

Evaluation of the pontic area 6(13) revealed fairto good remaining soft tissue form, although defi-cient in the horizontal aspect and the papillae(Figs 4 and 5). The soft tissue margin was posi-

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tioned more cervically around tooth 7(12) andmore coronally around tooth 11(23) than aroundthe other remaining anterior teeth. The marginaltissue contours on the central incisors were notsymmetrical or level. The papillary heights werenot level; the papillae on the left side were morecoronal than on the right (see Figs 3 and 4).

Treatment Plan

The patient wanted to have single-tooth prosthesesrather than bridgework. To determine if this waspossible, the teeth would be evaluated periodon-tally at the time of provisionalization to determinewhether they could be maintained as single units.Once the determination was made that the teethcould be made into single units from the stand-points of function, mechanics, and biology, themarginal heights of the soft tissue would be cor-rected with crown lengthening along with an im-plant placed in the area of tooth 6(13). The softtissue around tooth 7(12) would be coronally posi-tioned to cover the exposed root and help to levelthe soft tissue. Shortening of the incisal edges andcervical positioning of the soft tissue would main-tain the proportions of the teeth.

The final restorations would be fabricated withProcera crowns (Nobel Biocare, Goteborg, Swe-den) to replace teeth 3(16), 5(14), 7(12), 8(11),9(21), and 10(22), with a porcelain-fused-to-metalcrown and a gold custom abutment replacingtooth 6(13) and a feldspathic veneer tooth replac-ing tooth 11(23).

The patient began treatment as described. Atthe time of provisionalization, it became evidentthat the patient needed crown lengthening, notonly for esthetic reasons but also for form retentionand resistance of the preparations because of theinadequate height (see Fig 5). The mobility of theteeth was negligible; therefore, an implant wasdeemed appropriate for replacement of tooth6(13). Once the functional and esthetic require-ments were fulfilled in the provisional phase (Fig 6),the patient was sent to a periodontist for estheticcrown lengthening and an implant to replace the

IIIIIODT 2005

missing maxillary right canine. The patient wasanesthetized with Xylocaine (AstraZeneca, London,United Kingdom) 1:100,000 epinephrine. A sulcularincision was made around tooth 7(12) and contin-ued into an inverse bevel incision at the newmarginal levels of the remaining maxillary anteriorteeth, sparing the papilla from the mesial of tooth7(12) to the distal of tooth 12(24). In the area ofteeth 3(16) through 5(14), facial and palatal flapswere reflected to enable circumferential ostectomyfor resistance and retention form of the prepara-tions. Vertical incisions were made on the mesial oftooth 5(14) and the distal of tooth 7(12) internal tothe papilla on either side to enable coronal posi-tioning of the soft tissue over the implant site 6(13).In the area of the residual ridge, the flap was ex-tended slightly palatal of the center of the ridge toobtain extra tissue. Upon reflection of the flap, thebone was reshaped on all teeth slightly coronal tothe bony level of tooth 7(12), as it was the limitingfactor because of its bony dehiscence, short root,and minimal bony support. No bone was removedaround tooth 7(12) at all. A narrow-diameter stan-dard neck dental implant (Straumann,Waldenburg,Switzerland) was placed in the area of tooth 6(13)with the head of the implant 3.0 mm cervical to thedesired gingival margin of the future implant crownas dictated by the surgical stent (Figs 7 and 8). Thesoft tissue was sutured in place with the flap overthe implant coronally positioned to gain verticalheight (Fig 9). The soft tissue around tooth 7(12)was also coronally positioned to level the gingivalmargins (Fig 10).

At 5.5 months, the biologic width had re-estab-lished itself, and the patient was ready to begin re-lining of the provisionals and soft tissue manipula-tion in the area of the implant. Verification ofmaturation was made by sounding to bone andcomparing the biologic width in the implant area toareas that were not surgically modified. The massof the papilla on the mesial of the implant (distal of7[12]) was almost negligible, with only the palatalaspect remaining (Figs 11 and 12). The marginalridge remained very flat, with an angular transitionfrom the marginal ridge to the papilla rather than anice scallop (Fig 12). The gingival margin around

Improving Soft Tissue Form Around Implants via Forced Eruption ••

Fig 6 First set of provisionals.

Fig 7 Implant placement from an occlusal view. Notethe reflection of the papilla on the distal of tooth 7(12).

Fig 8 Implant placement from a facial perspectivewith the provisional in place.

Fig 9 Coronal positioning of the flap over the implantand healing abutment.

Fig 10 Facial view of suturing after implant placementin the area of tooth 6(13), crown lengthening of theanteriors (except tooth 7[12]), and coronal positioning'of the soft tissue over tooth 7(12).

tooth 7(12) ended up in a more cervical positionthan the remaining anterior teeth (Fig 11). Theteeth were prepared again to the gingival level, ex-cept for tooth 7(12),which was left slightly coronalto the margin (Fig 11). An octa-abutment wastorqued into the implant, followed by modificationof a titanium temporary abutment with addition ofacrylic resin to create a root form to support and

mold the soft tissue (Figs 13 and 14).The provision-als were relined, and the patient was told to returnin 3 months.After 3 months, the soft tissue form around the

implant was still unacceptable. Not only was the fa-cial half of the papilla almost nonexistent, with onlythe palatal aspect remaining, but the marginalridge form around the implant was too flat and an-

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gular, creating a defect on the mesial of the canine(Fig 15). The marginal ridge height of tooth 7(12)remained more cervical than the remaining teeth.

At the time of the initial evaluation it seemedthat there was adequate soft tissue and bony to-

• QDT 2005

Fig 11 Soft tissue form after full healing and refor-mation of the biologic width. Note the defect aroundthe implant at site 6(13).

Fig 12 Lateral view of the soft tissue around the im-plant at site 6(13).

Fig 13 Placement of an acta-abutment prior to fabri-cation of a temporary abutment.

Fig 14 Temporary abutment in place after beingmodified with a bur and acrylic resin. Note the flatgingival form and deficient papilla on the mesial ofthe implant.

Fig 15 Provisional relined over the temporary abut-ment. Note the short papilla on the mesial of the ca-nine compared to the other teeth.

pography to adequately restore tooth 6(13)with animplant without bone augmentation prior to place-ment. In hindsight, it may have been appropriate inthis caseto augment at least the soft tissue compo-nent in this area. The patient had fairly thin soft tis-

Improving Soft Tissue Form Around Implants via Forced Eruption II

sue, especially in the papillary area distal to tooth7(12) (see Fig 5). Evaluation of the preoperativephotographs reveals that the papillary heights onthe right side of the maxilla were at least 1.5 mmshorter than those on the left side (see Figs 4 and5). Without augmentation, the two sides wouldnever be at the same levels.

At the time of surgery, a vertical incision wasmade through the distal papilla of tooth 7(12) toallow coronal repositioning of the flap over thehealing abutment so that the soft tissue could gainvertical height. Close observation of the surgicalprocedure shows that the incision was placed veryclose to tooth 7(12), leaving very little bulk or massof papilla (see Figs 8 and 9). As a result, the bloodflow to the area was compromised, and the facialaspect of the papilla sloughed over time, leavingonly the palatal aspect. Both a loss in vertical andhorizontal massof the papilla was evident (see Figs11 and 12). A better approach may have been to in-clude the papilla in the flap by making the verticalincision at the distal line angle of the central incisorrather than through the papilla. This would have al-lowed even greater freedom to coronally positionthe flap and possibly get root coverage over thelateral incisor.

Options for Redevelopment of the Papillaand Marginal Tissue

One option for regeneration of the papilla andmesial marginal ridge of the implant was to wait forthe biologic width to regenerate. The dentogingivalcomplex was described in 1961 by Garguilo et all ina study in which they measured the distance fromthe free gingival margin to the underlying bone.This complex comprises the connective tissue at-tachment, the epithelial attachment Qunctionalep-ithelium), and the gingival sulcus. They reportedmeasurements of 2.04 mm for the depth of theconnective tissue and epithelial attachments and0.69 mm for the depth of the sulcus. KoisB de-scribed a similar biologic width of 3 to 4 mm on thefacial aspect of central incisors,with 85%of the sub-jects within the 3-mm range. Interproximally,a mea-

surement of 4.5 mm was observed. This coincideswith the study done by Tarnow and associates inwhich they measured the distance from the cervicalcontact to the underlying bone and evaluated thepresence or absence of a papilla.9 There was com-plete presence of a papilla when the distance waslessthan 5 mm. Both of these studies evaluated thepapilla between two adjacent intact teeth. Betweentwo teeth, the papillary height is actually controlledby the shape and volume of the gingival embra-sure, which is determined by the contours of theadjacent roots and teeth and the level of interseptalbone. When one of the contacts is eliminated viatooth loss, aswas the casewith the missing canine,the papilla will generally collapse to a normal bio-logic dimension of 3 mm. The connective tissue at-tachment and junctional epithelium in the papillaryarea still compose only 2 mm of the total length ofthe papilla, as they do at the free gingival margin.Between a tooth and an implant, bony support ofthe soft tissue papilla comes from the attachmentlevel at the tooth side, not the bone level of the im-plant.lO Waiting for the regeneration of the papillacould take up to 1 year,and there would still remaina vertical and horizontal deficiency in comparisonwith the adjacent papilla. This would also not ad-dress the marginal discrepancy of tooth 7(12). Thesecond option for redeveloping the papilla was tosurgically rebuild the papilla. Several techniqueshave been proposed for rebuilding the papillaaround single-tooth implants,11.12although they aredifficult to perform, predictability hasnot been doc-umented, and there are no data regarding long-term stability. These surgical techniques also relysolely on thickening of the overlying soft tissuewithout augmentation of the underlying supportingbone. The most biologically sound and predictablemethod for altering gingival/eve/s and papillary lev-elswas to forcibly erupt tooth 7(12).

Forced Eruption

Forced eruption is defined as an orthodontic pro-cess whereby a tooth is intentionally moved in acoronal direction through the application of gen-

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tie, continuous force in order to effect changes inthe soft tissue and bone.13.14Because forced erup-tion modifies the gingival and alveolar crest, it hasbeen used to alter gingival discrepancies and os-seous defects of periodontally involved teeth.15-19The fibers of the periodontal ligament are at-tached to the bone by fibers, with formation ofnew bone around the ends of the fibers.20.21Boneis dynamic in nature and hence is constantly beingresorbed and rebuilt. When tension is applied tothe periodontal ligament, periodontal fibers areelongated, and osteoblasts are induced to de-posit new bone in the alveolus, where the attach-ment is.22.23When a tooth is erupted, the bonecomes with it and the height of the fiber attach-ment remains constant.24 If a tooth is forciblyerupted and, following the movement, held in itsnew position for 4 to 6 months, the bone and softtissue should re-establish themselves in this new3-dimensional position.

Technique

The provisional restorations were sectioned, leav-ing the restoration at 7(12)as a single unit. This unitwas cemented with a final cement (RelyXARC, 3MESPE,St Paul, MN) to prevent loosening during theforced eruption. Only three brackets were used forthe eruptive process (Fig 16): one on the maxillaryright canine, one on the maxillary right lateral in-cisor, and one on the maxillary right central incisor.Because the canine was an implant and the rightcentral incisor was splinted to the other central in-cisor and the left lateral incisor medially, there wasno mobility and hence no reason to add morebrackets posteriorly. The bracket on the lateral in-cisor was placed more cervical in relation to thebrackets on the canine and central incisor to createa coronal force on the lateral incisor for eruptivepurposes (Fig 16). Once the brackets were placedand the acrylic resin was set, nickel titanium wirewas placed in the brackets and held with ties. Asmall-diameter 0.016-mm wire was used to create aslow force during eruption to bring down the boneand soft tissue with the maxillary right lateral in-

: GDT 2005

cisor.The forced eruption process in this case tookonly 2 weeks (Fig 17).This was most likely becauseof the limited bony support around the root of thelateral incisor (Fig 19). Once the lateral incisor waserupted to its correct position, it was luted back to-gether with the remaining provisionals and thebrackets were removed. The incisal edge wasshortened to compensate for the eruption. Gener-ally, a 4- to 6-month stabilization period is advo-cated to allow for proper reorganization of the softtissue and bone and for prevention of relapse (in-trusion).25In this case, a 4-month stabilization pe-riod was chosen to allow redevelopment of thepapilla and the gingival margin around the implant.Not only was the gingival margin around the lateralincisor brought more coronal, but the papillaryheight was increased by approximately 1.5 mm(Figs 18 and 20). Although there was good im-provement in the papillary form and the gingivalmargin of both the canine and lateral incisor, thethickness and bulk of the papilla preventedachievement of an ideal form on the mesial aspectof the marginal ridge of the canine (Figs 20 and21). Once the tissue was healthy, final impressionswere taken (Fig 22).

All of the restorations other than the implantcrown and the veneer were fabricated from all-ceramic Procera crowns (Nobel Biocare). For theimplant crown, a castable custom gold abutmentwas fabricated (Fig 23). It was decided to use goldrather than a ceramic abutment because thecrown for the implant was going to be made ofporcelain fused to metal, allowing the same typeof porcelain to be used for the porcelain veneersfor the purpose of color matching. If a Proceracrown had been made for the implant, the porce-lain used for the veneer would have to have beenmade of a different type of porcelain than theoverlay porcelain for the Procera. This in turnwould have been difficult to match.

The final results were good considering theoriginal soft tissue defect following surgery (Figs24 through 26). Radiographs showed that theimplant was well integrated, and the new boneapical to the root of tooth 7(12) filled in nicely(Figs 19 and 27).

Improving Soft Tissue Form Around Implants via Forced Eruption.

Fig 16 Beginning of the eruptive process on tooth7(12) to coronally position the margin and grow thepapilla.

Fig 17 Tooth 7(12) erupted into place after 2 weeksof orthodontics.

Fig 18 Soft tissue form around the mesial of the im-plant improved tremendously, including the marginalconfiguration and the papillary form and height.

Fig 19 Radiograph after eruption of the lateral in- 21cisar. Note the space at the apex of the root.

Fig 20 New provisionals relined over the teeth andthe temporary implant abutment.

Fig 21 Facial view of the provisionals after ortho-dontics, prior to making the final impression. Thepapilla and soft tissue on the mesial of the canine arestill not ideal.

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Fig 22 Final preparations with chord and implant transfer coping on implant 6(13).Note the improved clinical crown length on the teeth.

Fig 23 Final gold abutment on implant 6(13).

Fig 24 Intraoral frontal view of the final case.

Fig 25 Final smile.

Fig 26 Lateral view of final crowns.

Fig 27 Final radiograph of implant 6(13).

Improving Soft Tissue Form Around Implants via Forced Eruption II

CASE 2

A 55-year-old man presented with a porcelain-fused-to-metal crown on tooth 7(12) in his hand.The crown had come loose the previous day (Fig28); the post had remained within the crown. Thisis a classicexample of the failure associated with alack of ferrule in which the cement seal breaks, thecement washes out, and the post comes out withthe crown, leaving decay in the canal and a bro-ken-down tooth.26 There was approximately 0.5mm of remaining tooth structure above the gingi-val line with decay into the canal space (Fig 28).For long-term predictability, there needs to be atleast 1.5 mm of tooth structure beyond the coreto create a "ferrule effect."26

Evaluation of the gingival levels revealed anideal gingival margin location, and the patient de-sired an ideal esthetic result. The patient wasgiven three options, although there were only twooptions (options 1 and 2) for treatment that wouldmaintain the same gingival levels:

• Option 1: Forced eruption of tooth 7(12) alongwith supracrestal fiberotomy

• Option 2: Extraction of the tooth and immediateimplant placement

• Option 3: Crown lengthening, which would cre-ate a "long tooth" relative to the adjacent teethand disturb the esthetic balance

The patient refused to wear braces due to van-ity reasonsand therefore chose option 2. Alginateswere taken, and a removable provisional was fabri-cated to replace tooth 7(12). The patient was re-ferred to an oral surgeon for extraction of thetooth and immediate implant placement. Peri-otomes were used to extract tooth 7(12) with notrauma to the surrounding bone and soft tissue. A4.1 X 3.8-mm implant (Straumann)was placed inthe extraction socket with the head of the implantplaced 3 mm apical to the desired marginal ridge(Fig 29). An implant design that decreases in diam-eter apically (ie, a tapered implant) is ideal to pre-vent perforation or stress to the thin labial plate.The surgeon modified a plastic healing abutment

to create the proper anatomical emergence form(Figs 30 and 31). The healing abutment was leftabove the gingival margin to allow full support forthe papilla. The removable provisional was in-serted as a temporary prosthesis (Fig 31).

After 6 months of healing, the patient was readyfor restoration. A titanium temporary abutment wasmodified with acrylic resin to create the properemergence profile (Fig 32). The acrylic resin wasapplied with a salt-and-pepper technique directlyinto the sulcus form created by the healing abut-ment. Once set, the temporary abutment was pre-pared directly in the mouth. The provisional was re-lined over the abutment, and the tissue wasallowed to heal for 1 month prior to the final im-pression (Fig 33). Even with meticulous surgicaltechnique, there was slight recession on the distalaspect of the central incisor papilla.

At the time of the final impression, acrylic resinwas added to the transfer coping to register theemergence profile to the final model. A polyvinylsiloxane impressionwas taken and poured in stone.

A custom abutment was fabricated using acastable abutment. Porcelain was baked on theabutment to create the emergence form and tocover the metal of the abutment so that an all-ceramic crown could be used (Fig 34). An Inceramcrown (Vita, Bad Sackingen, Germany) was fabri-cated to match the existing porcelain Dicor crowns(Dentsply, York, PAl (Fig 35). After torquing theabutment and cementing the final crown, the pa-tient was told to return in 1 week for photographs.

Emergency Visit

Six days after delivery of the implant crown, tooth8(11) had fractured down to the gingival line. Thepatient again presented to the office with a crownin his hand, although this time, the preparationwas broken within the crown (Fig 36).

Intraoral evaluation revealed that the gingivalmargin of tooth 8(11)was in the ideal position. Thetooth had fractured to the gum line with no remain-ing ferrule effect, but radiographically, there wasenough root length to restore the tooth if the

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Fig 28 Tooth fracture down to thegum line.

Fig 29 Implant placed immedi-ately at the site of tooth 7(12).

Fig 30 Healing abutment support-ing the soft tissue around the im-p/ant.

Fig 31 Flipper in place with softtissue, supported by the healingabutm\"nt.,

Fig 32 Temporary abutmentprepped and modified with acrylicresin to create the proper emer-gence form.

Fig 33 Placement of the provi-sional.

Fig 34 Final porcelain-fused-to-metal abutment. Porcelain wasbaked on the abutment to coverthe metal and create a tooth-colored margin and post.

Fig 35 Final crown at try-in.

Improving Soft Tissue Form Around Implants via Forced Eruption.

Fig 36 Tooth8(11) fractlJredto the gumline 1 weekafter deliveryof an implant-supportedcrownat site 7(12).

Fig 37 Radiographof the fracturedtooth. Note the angularpeaksof bone aroundthe root.

crown was lengthened or the tooth erupted (Fig37). The root taper was fairly significant, so a nar-rower marginal diameter would be created if thetooth was crown lengthened or erupted. The inter-proximal bone surrounding the root of tooth 8(11)

was angular, not horizontal, with the peaks morecoronal than the adjacent bone. The root was actu-ally supporting the two peaks of interseptal bone.Taking the aforementioned into consideration,

the patient was given two options for treatment.Only option 1 would ensure an ideal gingivalmarginal relationship; however, option 2 was moresound biomechanically:

• Option 1: Forced eruption with supracrestalfiberotomy and restoration with a crown

• Option 2: Implant placement immediately post-extraction and restoration with a single crown

Even though it would take much longer toforcibly erupt tooth 8(11}, and even with thebiomechanical compromise of maintaining thetooth versus placing an implant, the patient chose

to maintain his tooth for esthetic reasons and felthe could always have an implant placed if thetooth failed over time.There were many reasonswhy forcibly erupting

the central would create a more esthetic result. Ra-diographically, it was evident that the root of tooth8(11) was supporting the angular interproximalpeaksof bone surrounding the root (Fig 36). Extrac-tion of the root, even with immediate implantplacement, would inevitably have resulted in theloss of the interseptal bony peaks. After extractionand immediate implant placement, there is gener-ally up to 1 mm of apical migration of the free gin-gival margin.27.28Interproximally, the ideal bonewidth is approximately 1.5 mm at the crest to mini-mize lateral resorption of the osseouscrest and bio-logic width violation after implant placement withresultant bone loss.29The bone on the distal of theroot of tooth 8(11) adjacent to the implant was thin(lessthan 1.5 mm), especially in the coronal portion(Fig 37). Becausethe interproximal bone was angu-lar, in order to maintain the peaks of bone, the im-plant would need to have been placed more coro-

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nal than the adjacent implant and tooth 9(21).Thiswould have created a very short distance from theimplant head to the free gingival margin, whichwould have made creating a smooth emergenceprofile very difficult. Placementof the implant in thecorrect depth for creation of a smooth emergenceprofile would have necessitated obliteration of theangular peaks of interseptal bone. The last disad-vantage of placing an implant adjacent to anotherimplant is that when 2 adjacent implants areplaced, the biologic width around flat implantsdoes not support the papilla interproximally.30Infact, only 3 to 4 mm of interproximal soft tissueheight is routinely possible, even with a 3-mm dis-tance between implants, as advocated by Tarnowet al.29Becausethe biologic width is apical to thecrest of interproximal bone between implants, theconnective tissue attachment and the epithelial at-tachment will not support the papilla. Findings byTarnow et al31indicated that the height of the softtissue covering the inter-implant bony crest is 2 to4 mm as compared to the 5 mm found aroundteeth. Kois and Kan32also found comparable mea-surements of 3 to 4 mm of peri-implant mucosaforanterior single implants.

Taking the aforementioned into consideration,placement of an implant in the area of tooth 8(11)would most likely have created an esthetic night-mare due to loss of papilla, especially betweenthe two implants, as compared to forced eruptionwith a supracrestal fiberotomy of the remainingroot of tooth 8(11). Again, the patient chose tomaintain his natural root.

Forced Eruption with SupracrestalFiberotomy

It is advantageous to erupt a tooth for the purposeof crown lengthening when there is need forsound tooth structure and the gingival height andcontour is ideal. Given that surgery would createan imbalance in the marginal levels and increasethe crown-to-root ratio, orthodontic eruption witha fiberotomy is the treatment of choice. Kozlovskyet al33used forced eruption combined with an inci-

. QDT 2005

sion of the supracrestal gingival attachment. Theintrasulcular incisions were performed in conjunc-tion with root-surface curettage at 2-week inter-vals. This technique prevented coronal displace-ment of the attachment apparatus, eliminating theneed for surgery. Pontoriero et al34indicated thatthe fiberotomy eliminated tensile stress on thealveolar bone and allowed more rapid toothmovement. Bone and soft tissue were left behind,although they recommended weekly fiberotomies.

Technique

The patient was sent to an endodontist for rootcanal treatment of the maxillary right central in-cisor. Once week later, a GC post pattern (GCDental, Tokyo, Japan) was fabricated and cast intype III gold alloy. After cementation with zincphosphate cement, the preparation was refinedwith a diamond bur, and an acrylic resin provi-sional was fabricated. The provisional was ce-mented with RelyXARC cement to ensure reten-tion during the eruption process.

Five brackets were placed; one on the implantcrown at site 7(12), one on the provisional, andthree on the contralateral central incisor, lateral in-cisor,and canine for anchorage (Fig 38).

The bracket on tooth 8(11) was placed 2.5 mmcervical to the remaining brackets to create acoronal force after wire placement. Prior to plac-ing the wire, the patient was anesthetized on boththe facial and palatal aspects of the soft tissue sur-rounding tooth 8(11).A no. 15C blade was placeddirectly into the sulcus until contact with bone oc-curred. The blade was pulled against the root sur-face and moved around the full circumference ofthe root to ensure severing of the supracrestalgingival fibers. The root was planed to the level ofthe bony crest as described by Kozlovsky et al.33

A 0.018 nickel titanium round wire was used torapidly extrude the right central incisor. Eventhough the tooth reached its final position afteronly 2 weeks, the patient returned for a fibero-tomy every week for 5 weeks to ensure that thefibers would not reattach. The brackets remained

Improving Soft Tissue Form Around Implants via Forced Eruption •

Fig 38 Orthodontic forcederuptionof tooth 8(11)after a supracrestalfiberotomy.

Fig 39 Finalpositioningof tooth 8(11) after forcederuption.

Fig 40 Radiographicviewof tooth 8(11) in its finalpositionfollowing forcederuption.

•

in place for 4 months to allow reformation of thebiologic width and for bone deposition apical tothe root (Figs 39 and 40). At this point, there wasno movement of the gingival margin.

Choosing Orthodontic Brackets

There are two main types of orthodontic tech-niques, the standard edgewise technique and thestraight-wire technique. The standard edgewiseincorporates a brace with no torque and noangulation. The clinician must introduce torque

and angulation by means of bending a stainlesssteel wire. For the general practitioner who doesnot understand angulation and torque, this can beconfusing. A more popular technique is the easier-to-use straight wire system. This involves using abrace that has a predetermined angulation andtorque. The brace itself controls the root torqueand angulation of the tooth. The torque and an-gulation are determined by a prescription, de-pending on which method is used. The mostpopular prescription is the Roth technique. Thiswas the technique used by the author.

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Choosing a Wire

There are round and rectangular wires. When around wire is used, only angulation can be al-tered; the torque of the brace is not expressed.The torque and angulation of the root can only becontrolled using a rectangular wire. Torque controlbecomes very important when the premaxilla isthin, and it is imperative to avoid moving the rootfacially and possibly creating a dehiscence. Mostof the time, a round wire is appropriate. The typeof wire used by the author was a round, heat-sen-sitive, superelastic nickel titanium wire. For a slow,controlled eruption aimed at bringing the boneand soft tissue down with the tooth, a 0.014- or0.016-size wire can be used. For fast eruption,one can use 0.018-size wire or a rectangular wire.

Provisional and Final Restoration

During the healing process, redoing the res-toration on tooth 9(21) was discussed with the pa-tient. The objective was to modify the papillaryform between the centrals to close the cervicalembrasure. The only way to do this was to restoreboth of the centrals and change the interproximalshape of the crowns. Redoing the maxillary leftcentral crown would make matching to the maxil-lary right central much more predictable. Oncethe bone filled in apical to the root, as verified bya periapical radiograph (see Fig 40), the provi-sional was removed along with the old crown onthe maxillary left central incisor (Fig 41). There wasvery little remaining tooth structure on the prepa-ration (Fig 41); this may be why tooth 8(11) frac-tured. Care was taken not to touch the existingpreparation. Provisionals were fabricated from awaxup of the proposed new restorations (Fig 42).Because the preparations were narrow at themargin, especially the right central incisor, a morehorizontal emergence form on the interproximalhad to be developed to mold and shape thepapilla as well as to close the cervical embrasure(Fig 43). After 2 weeks, the papillary form wasdeveloped and final impressions were taken

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(Fig 44). Individual porcelain-fused-to-metalcrowns were fabricated to help mask the color ofthe gold post of the maxillary right central incisor(Fig 45). The final crowns were cemented withRelyX ARC cement. A harmonious gingival bal-ance and a healthy soft tissue response wasachieved via forced eruption (Figs 45 and 46).

DISCUSSION

Soft tissue integration of a single-tooth implant isthe most difficult and the most important estheticaspect in creating an implant prosthesis that ap-pears natural. Not only is the marginal level im-portant, but the papillary form and height are criti-cal. When the soft tissue outcome followingimplant placement is not as desired, a proceduresuch as orthodontic eruption can be a tremen-dous tool in your armamentarium to assistthe ma-nipulation of the soft tissue form around an im-plant or on a tooth adjacent to an implant.Surgically rebuilding the soft tissue can be quiteunpredictable and very technique-sensitive, andno long-term data are available on the stability ofrebuilt soft tissue. With orthodontics, not only canthe marginal tissue of an adjacent tooth be coro-nally moved, but the papilla can be brought downas well. What makes this even more valuable as aprocedure is the long-term predictability of mov-ing the biologic complex 3-dimensionally to anew position rather than rebuilding one aspect ofthe biologic component (the soft tissue) withoutsupport by the other (the bone). Orthodonticsmay make it possible to save and restore teeththat previously may have been deemed hopelessbecause of lack of tooth structure, especiallyadjacent to an implant restoration. This can becritical when the soft tissue form is ideal and asoft tissue defect will be assured following extrac-tion and placement of one implant adjacent toanother.

l

Improving Soft Tissue Form Around Implants via Forced Eruption ••

•

Fig 41 Preparations after removingold crown 9(21) and temporarycrown 8(11). Note the excess softtissue on the mesial of tooth 8(11)from the orthodontic procedure.Also note the previous overprepa-ration of tooth 9(21).

Fig 42 Provisionals 8(11) and9(21)-manipulating the papillaryform to close the embrasure.

Fig 43 Cervical view of provision-als. Note the cervical contour ofthe provisional compared to themargin of the preparation. Amesial cantilever was made to ma-nipulate the soft tissue.

Fig 44 Soft tissue after manipula-tion of the soft tissue with provi-sionals.

Fig 45 Final crowns 7(12) through9(21).

Fig 46 Lateral view of final crowns7(12) through 9(21).

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ACKNOWLEDGMENTS

Special thanks to Dr Isaac Garazi for his surgical work in case 1and to Dr Stephen Rimer for his surgical work in case 2. Specialthanks also to Mr Harald Heindl for the beautiful porcelain incase 1 and to Emanuele di Piazzera for the beautiful porcelainin case 2.

REFERENCES

1. Abrams H, Kopczyk RA, Kaplan AL. Incidence of anteriorridge deformities in partially edentulous patients. J Pros-thet Dent 1987;57:191-194.

2. Abrams L.Augmentation of the deformed residual eden-tulous ridge for fixed prosthesis. Com pend Contin EducDent 1980;1 :205-213.

3. Tarnow DP, Eskow RN. Considerations for single-unit es-thetic implant restorations. Com pend Contin Educ Dent1995;16:778-788.

4. Jansen CE, Weisgold A. Presurgical treatment planningfor the anterior single-tooth implant restoration. Com-pend Con tin Educ Dent 1995;16:746-761.

5. Weisgold AS, Amoux JP, Lu J. Single-tooth anterior im-plant: A word of caution. Part I. J Esthet Dent 1997;9:225-233.

6. Garber DA. The esthetic dental implant: Letting restora-tion be the guide. J Am Dent Assoc 1995;126:319-325.

7. Garguilo AW,Wentz FM, Orban B. Dimensions and rela-tions of the dentogingival junction in humans. J Periodon-toI1961;32:261-267.

8. Kois Jc. Altering gingival levels: The restorative connec-tion. Part I: Biologic variables. J Esthet Dent 1994;6:3-9.

9. Tarnow DP, Magner AW, Fletcher P.The effect of the dis-tance from the contact point to the crest of bone on thepresence or absence of the interproximal dental papilla.J Periodontol 1992;63:995-996.

10. Salama H, Salama MA, Garber D, Adar P.The interproxi-mal height of bone: A guidepost to predictable aestheticstrategies and soft tissue contours in anterior tooth re-placement. Pract Periodont Aesthet Dent 1998; 10:1131-1141.

11. Jemt 1. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent1997;17:326-333.

12. Azzi R, Etienne D, Takei H, Fenech P.Surgical thickeningof the existing gingiva and reconstruction of interdentalpapillae around implant-supported restorations. Int JPeriodontics Restorative Dent 2002;22:71-77.

13. Ingber JS. Forced eruption: Part I. A method of treatingone and two wall infrabony osseous defects-Rationaleand case report. J PeriodontoI1974;45:199-206.

14. Ingber JS. Forced eruption: Part II.A method of treatingnonrestorable teeth-Periodontal and restorative consid-erations. J Periodontol 1976;47:203-216.

15. Ingber JS. Forced eruption: Alteration of soft tissuedeformities. lnt J Periodontics Restorative Dent 1989;9:416-425.

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16. Potash nick SR, Rosenberg ES. Forced eruption: Principlesin periodontics and restorative dentistry. J Prosthet Dent1982;48:141-148.

17. Van Venrooy JR, Yukna RA.Orthodontic extrusion of sin-gle-rooted teeth affected with advanced periodontal dis-ease. Am J Orthod 1985;87:67-74.

18. Brown IS. The effect of orthodontic therapy on certaintypes of periodontal defects. I. Clinical findings. J Peri-odontol 1973;44:742-745.

19. Levine RA. Forced eruption, part 1: Periodontal andorthodontic considerations for treatment of an isolatedperiodontal angular infrabony defect. Compendium1988;9:10-19.

20. Reitan K.Tissue behavior during orthodontic tooth move-ment. Am J Orthod 1960;46:881-900.

21. Reitan K. Clinical and histologic observations on toothmovement during and after orthodontic movement. Am JOrthod 1967;53:721-745.

22. Stern N, Becker A. Forced eruption: Biological and clinicalconsiderations. J Oral Rehabil 1980;7:395-402.

23. Berglundh T, Lindhe J, Ericsson I, Marinello CP, LiljenbergB, Thomsen P.The soft tissue barrier at implants andteeth. Clin Oral Implants Res 1991 ;2:81-90.

24. Wise RJ, Kramer GM. Predetermination of osseouschanges associated with uprighting tipped molars byprobing. Int J Periodontics Restorative Dent 1983;3:68-81.

25. Mantzikos T, Shamus I. Case report: Forced eruption andimplant site development. Angle Orthod 1998:68(2):179-186.

26. Libman WJ, Nicholls JI. Load fatigue of teeth restoredwith cast posts and cores and complete crowns. Int JProsthodont 1995;8:155-161.

27. Kois Jc. Esthetic extraction site development: The bio-logic variables. Contemp Esthet Restorative Pract1998;2:10-18.

28. Sadoun A, LeGall M, Touati B. Selection and ideal tridi-mensional implant position for soft tissue aesthetics. PractPeriodontics Aesthet Dent 1999;11:1063-1072.

29. Tarnow DP,Cho SC, Wallace SS. The effect of inter-im-plant distance on the height of inter-implant bone crest.J Periodontol 2000;71 :546-549.

30. Elian N, Jalbout ZN, Cho S, Froum S, Tarnow DP. Realitiesand limitations in the management of the interdentalpapilla between implants: Three case reports. PractProced Aesthet Dent 2003;15:737-744.

31. Tarnow D, Elian N, Fletcher P, et al. Vertical distance fromthe crest of bone to the height of the interproximalpapilla between adjacent implants. J Periodontol2003;7 4: 1785-1788.

32. Kois JC, Kan JY. Predictable peri-implant gingival aesthet-ics: Surgical and prosthodontic rationales. Pract ProcedAesthet Dent 2001 ;13:691-698.

33. Kozlovsky A, Tal H, Lieberman M. Forced eruption com-bined with gingival fiberotomy. A technique for clinicalcrown lengthening. J Clin Periodontol 1988; 15:534-538.

34. Pontoriero R, Celenza F Jr, Ricci G, Carnevale G. Rapidextrusion with fiber resection: A combined orthodontic-periodontic treatment modality. Int J PeriodonticsRestorative Dent 1987;7(5):30-43.

(i)

TRANSFER OF INFORMATIONFOR ESTHETIC ANDFUNCTIONAL PREDICTABiliTYIN SEVERE WEAR CASES

Tal Morr, DMD, MSDl

P rosthodontists are often called upon to re-construct the occlusion in patients with se-vere wear. There may be a multitude of is-

sues to address in such cases, including attrition,abrasion, and erosion, all of which contribute touneven wear and compensatory eruption through-out the arches. There may also be incisal wearand/or interproximal wear, and as a result, the oc-clusal plane may need leveling and lengtheningfor enhanced esthetics and to allow correctionand control of the occlusal relationship.Treating the edentulous patient requires the

fabrication of occlusion rims to allow evaluation ofcritical esthetic and functional information, mount-ing of the final casts, and fabrication of estheticand functional complete dentures.'-8The estheticand functional information includes determination

'Private practice, Aventura, Florida, USA.

Correspondence to: Dr Tal Morr, 20760 West Dixie Hwy,Aventura, FL 33019, USA. E-mail: tmprostho@yahoo.com

of the incisal edge position at rest, the occlusalplane, midline and angulation of the midline, lipsupport, facial plane of the incisors, arch form,and buccal corridors. In addition, the clinician canevaluate the vertical dimension of occlusion,check phonetics, and take a centric record.

CRITICAL ESTHETICoETERM INANTSAll comprehensive treatment planning shouldbegin with an esthetic evaluation. Evaluation ofthe face is essential in determining the ideal es-thetic orientation of the teeth from a horizontalperspective. The horizontal reference planes willhelp the clinician align the occlusal plane and thesoft tissue levels along with other related estheticdeterminants. The horizontal reference planesshould be evaluated from two perspectives: thefrontal and the sagittal. The frontal perspective isassessedby having the patient look out into thehorizon and choosing the ideally leveled plane.The most commonly used horizontal reference

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~~,,wI.,.::;:--=:;;:-: :'b- -:..::;:::::-1

., \....,'~ I~';'r"

.&Fig 1 Horizontal reference planes:ophriac, interpupillary, and commisuralplanes respectively,

Fig 3 Sample incisal plane,

planes include the ophriac line, interpupillary line,and commissural line (Fig 1).5,9-10 Most people areslightly asymmetric in these planes, and in thesecases,the floor is used as the horizontal referenceplane. From a lateral (sagittal) perspective, thepatient holds his or her head erect, again lookingout to the horizon. From the saggital perspective,the horizontal reference plane should again beleveled with the floor. Once the horizontal refer-ence plane is established, the critical esthetic de-terminants are established in relationship to thehorizontal reference plane.

The incisal edge position, incisal plane, and oc-clusal plane are the three most important estheticdeterminants in the development of the treatmentplan. These determinants enable the clinician totransfer information throughout the treatment,and are related in specific ways to other estheticcriteria. The first step in determining the positionof the teeth is evaluation of the incisal edge posi-tion at rest (Fig 2). Tooth exposure is consideredto be esthetic in the 1- to 5-mm range.a-" To

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Fig 2 Sample incisal edge at rest.

Fig 4 Sample occlusal plane,

achieve this range, tooth proportions can be ad-justed by either shortening or lengthening the an-terior teeth. For example, if crown lengthening isindicated on teeth that were previously ideallyproportioned, the incisal edge length can be re-duced. Maintaining a minimum of 1 mm of toothexposure at rest should be the goal. Once thefinal incisal edge position is determined, the in-cisal plane (a line from canine to canine in the an-terior portion of the occlusal plane) is evaluated(Fig 3). The incisal plane should be leveled to thechosen horizontal reference plane (the floor, inter-pupillary line, etc), and evaluated from the frontalperspective while the patient is smiling. The nextstep is to evaluate the occlusal plane from a sagit-tal view of the patient's smile. The occlusal planeshould be flat from the incisal edge of the centralincisor back to approximately the mesial of thefirst molar (Fig 4). The illusion of a radial relation-ship of the smile line to the lower lip derives fromthe cant of the maxilla in the frontal perspective(see Fig 3).

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Fig 5 Casts mounted using the occlusalplane guide.

Fig 7 Evaluation of the incisal edge atrest with the occlusal plane guide.

The original occlusal planeguide technique

As with the edentulous patient, a method of trans-ferring critical esthetic and functional information isneeded to allow the technician to predictablyachieve the ideal esthetic orientation and occlusalrelationship of the teeth in the waxup. The originalocclusal plane guide technique'2 employed a vacu-form machine and acrylic resin to evaluate theideal esthetic determinants in the patient's mouth.The maxillary cast was mounted to the articulatorwith the occlusal plane guide using a facebow, anearbow, or a dentofacial analyzer.The mandibularcast was mounted at the evaluated vertical dimen-sion using the occlusal plane guide (Fig 5). Themandibular cast was removed, and a flat mountingplate was placed against the acrylic resin andmounted to the lower member of the articulator(Fig 6). When the occlusal plane guide was re-moved, the space between the original cast andthe flat plane indicated the exact amount the teethneeded to be lengthened. Unfortunately, therewere problems with delamination of the acrylic

Fig 6 Mounting plate mounted againstthe occlusal plane guide.

Fig 8 Evaluation of the occlusal planeusing the occlusal plane guide with thepatient smiling.

resin from the vacuform material, and the acrylicresinwas difficult to trim and shape.Wax is a moresuitable material for this technique due to its easeof trimming and shaping, and its ability to take acentric record at the appropriate vertical dimen-sion (Figs 7 and 8). The centric record should betaken at the appropriate vertical dimension withboth the ideal overjet and overbite relationship.This will minimize the negative effect of the arc ofclosure if the casts are not mounted in a direct re-lationship to the hinge axis of the articulator andthe vertical dimension is modified.

Diagnostic waxup fabrication

Step 1: Develop the occlusal planeMount the casts on the articulator at the correctvertical dimension and relative to the mountingplate, and remove the maxillary wax occlusalplane guide. The resulting space indicates theamount of wax to be added to reach the ideal oc-clusal plane (Fig 9). First, add wax to the incisaledges of the anterior teeth and the buccal cusp

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Fig 9 Maxillarycastwithout the oc-clusalplaneguide.

Fig 11 Evaluationof verticaldimensionwith the caststogether.

tips of the posterior teeth (Fig 10). If wax is addedto fill the space from the mounting plate distal tothe mesial cusp of the first molar, it will be impos-sible to close the casts together in the posteriorarea due to the axis of closure of the hinge.Therefore, the length of the wax distal to the firstmolar should be short of the mounting plate, butequal in distance from the flat plane on bothsides.

Step 2: Alter the vertical dimension of occlusion (ifneeded)Ideally, the casts should be mounted at or close tothe correct vertical dimension of occlusion basedon the restorative space needed to develop theideal anterior relationship, including the anteriorguidance and room for the envelope of function.If the casts are mounted at the ideal vertical di-mension of occlusion, the effect of the arc of rota-tion will be insignificant. If the casts are notmounted at the ideal vertical dimension, open orclose the articulator pin to develop the idealspace needed for the restorative material (Fig 11).If the casts do not close to the ideal position, ei-

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Fig 10 Waxisaddedto incisaledgesof anteriorteeth andbuccalcusptipsof posteriorteeth.

Fig 12 Lingualviewof waxupcreatinganteriorguidance.

ther shorten the maxillary posterior teeth, movethe maxillary buccal cusps facially, or move themandibular buccal cusps lingually. This is a purelysubjective process and can be refined during thenext step.

Step 3: Develop the anterior guidanceIf the mandibular anterior incisal plane is irregularand the treatment plan calls for restoration of themandibular anterior teeth, level the mandibular in-cisal plane with wax, followed by the lingual as-pect of the maxillary anterior teeth, to developthe correct anterior guidance relationship. If onlyone arch will be restored, add wax to the appro-priate teeth (Fig 12).

Step 4: Level the mandibular posterior planeIf the mandibular occlusal plane requires leveling,add wax to the mandibular occlusal surfaces tolevel the mandibular arch (Fig 13). It may not bepossible to level the mandibular posterior planewith the mandibular anterior plane because thismay require opening the vertical dimension toomuch. If this is the case, level as much as possible.

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Fig 13 Evaluationof spaceto waxthe mandibularocclusalsurfaces.

Fig 14 Evaluationof spaceto waxthe maxillaryocclusalsurfaces.

Fig 15 Finalwaxup.

The level of the lower posterior plane can be eval-uated by opening the pin slightly and assessingthe space between the maxillary and mandibularposterior cusp tips. There should be equal spaceon either side of the arch.

Step 5: Add wax to the maxillary occlusal surfacesto develop the occlusal contactsOnce the mandibular teeth are ideal, add wax tothe maxillary posterior occlusal surfaces to fit intothe mandibular occlusal surfaces in the correct re-lationship (Fig 14).

Step 6: Refine the occlusion and perfect thecontoursAdd to or modify the occlusal surfaces to perfectthe occlusal relationship and to idealize the es-thetic contours (Fig 15). The final contours of thecentral incisors should be determined first, fol-lowed by the lateral incisors and canines, sincethe symmetry of these teeth is not as critical asthe central incisors.

Relationships to the critical estheticdeterminantsThere are certain relationships that can be devel-oped regarding the critical esthetic determinants.It has been established that the midline position isnot as critical as the midline verticality.13If the in-cisal plane has been idealized in the waxup, themidline should be perfectly perpendicular to theincisal plane. Ideally, the facial plane of the in-

cisors should be perpendicular or slightly acuterelative to the occlusal plane from a sagittal per-spective. The gingival plane should be parallel tothe incisal plane.

CASE PRESENTATIONAn 82-year-old man presented to the office inneed of a complex rehabilitation. He had noticedrapid wear on his anterior mandibular teeth in thelast couple of years, and that his maxillary andmandibular anterior teeth were "on top of eachother." Considering the severe occlusal wear andClass III malocclusion, a thorough esthetic evalua-tion was done to formulate a treatment plan. Theincisal edge position at rest was evaluated first.The patient showed approximately 2 to 3 mm oftooth structure with the lips in repose (Fig 16).Ac-cording to esthetic principles, this fell within thedesired range. When the patient smiled, the in-cisal plane also seemed adequate; however, a dis-tinct step between the anterior and posteriorplanes existed, indicating an esthetic need tolengthen the maxillary posterior teeth (Fig 17).Opening the vertical dimension of occlusionwould be beneficial in this case because this pa-tient was in need of a dramatic leveling of themaxillary occlusal plane and the mandibular incisaland occlusal planes to create room for develop-ment of a better functional relationship of the an-terior teeth (Figs 18 to 20).

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Fig 16 Initial incisal edge at rest.Note the good position of incisaledges and incisal plane.

Fig 17 Initial smile. Note the dis-crepancy in the posterior occlusalplane.

Fig 18 Initial right lateral view. Note the discrepancy between the anterior and posterior occlusal planes.

Fig 19 Initial intraoral view. Note the discrepancy of the mandibular anterior incisal plane.

Fig 20 Initial left lateral view. Note the discrepancy between the anterior and posterior occlusal planes.

Modified occlusal planeguide technique

In this case, the anterior occlusal plane was

deemed adequate at the esthetic evaluation, so

the wax was added to the posterior occlusal

plane. This occlusal plane guide was tried in the

mouth and shaped to the correct length corre-

sponding to the ideal esthetic plane. A centric

record was taken at the anticipated vertical di-

mension to aid in creating a better relationship in

the anterior region, as well as room to level both

the maxillary and mandibular occlusal planes.

Mounting the casts

Once the wax of the occlusal plane guide was ide-

alized, the maxillary cast with the occlusal plane

guide was mounted on the Kois dentofacial ana-

lyzer mounting plate (Panadent, Grand Terrace,

DDT 2007

CA, USA) by aligning the facial aspect of the in-

cisors with the line drawn on the platform (Fig 21).

The midline on the maxillary diagnostic cast was

aligned with the midline drawn on the platform.

The Panadent system mounting platform was de-

veloped using scientific data (unpublished re-

search, 2006), so there is no need to use the

dentofacial analyzer or an earbow leveled to the

horizontal plane with this technique (Figs 22 and

23). The incisal edge position on the mounting

platform that was used to align the cast is based

on a 100-mm measurement from the hinge axis of

the articulator (Fig 24). According to Kois and Kois

and others,'4-18this measurement is the average in

the population from the hinge axis to the incisal

edge position, with 80% of the population falling

within 1 standard deviation of the mean. The max-

illary cast was mounted relative to the hinge axis

using the mounting plate. By using the wax to

mount the cast, there was an ideal esthetic rela-

tionship of the cast to the mounting plate. Once

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Hinge Axis to Maxillary Central Incisor Edge Distribution

36

30

>, 24UcQJ

6- 18

~LL

12

85 90 95 100 105 110 115

Distance (mm)*Mean = 100.21 mm

Fig 21 Diagnostic cast mounted Fig 22 Diagram of findings in research conducted by Kois and Kois.14

on the dentofacial analyzer mount-ing platform using the occlusalplane guide.

Fig 23 Illustration of measurementin research conducted by Kois andKois.'4

Fig 24 Articulator with dentofacialanalyzer mounting platform.

Fig 25 Maxillary waxup on thedentofacial analyzer mountingplatform.

Fig 26 Final waxup. Note the per-pendicular relationship of the in-cisal plane to the interincisalangle.

Fig 27 Lateral view of final waxup.Note the perpendicular relation-ship of the facial plane of the in-cisors to the occlusal plane.

the maxillary cast was mounted, the mountingplate was removed and the mandibular cast wasmounted using the occlusal plane guide at the ap-propriate vertical dimension. The wax occlusalplane guide was removed and the diagnosticwaxup was fabricated as previously described, al-though the maxillary cast was waxed against the

dentofacial analyzer mounting plate rather than astandard mounting plate (Fig 25). Both archeswere leveled and aligned to the horizontal refer-ence plane, and other relationships, such as theinterincisal angle and the facial plane of the in-cisors, were also incorporated in the waxup (Figs26 and 27).

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Fig 28 Frontal view of the provi-sional prostheses.

Fig 29 Intraoral view of the provi-sional prostheses.

Fig 30 Maxillary preparations.

Fig 31 Mandibular preparations.

Figs 32 and 33 A different caserequiring crown lengthening. (left)Provisional prostheses prior tocrown lengthening. Note themeasurements given to the sur-geon prior to crown lengthening.(right) Provisional prostheses aftercrown lengthening. Note that thesoft tissue level is parallel to in-cisal plane.

Making the provisional prostheses

Once the waxup was complete, a provisional shell

was made by fabricating a matrix and painting in

both incisal- and dentin-colored cold-cure acrylic

resin. These prostheses were filled with acrylic

resin, relined in the mouth, trimmed, and equili-

brated slightly. It was difficult to visualize the es-

thetic aspect of the provisional prostheses while

the patient was anesthetized, so he was allowed

to leave and return 1 week later for further refine-

ment.There will almost always be a need to

slightly recontour the provisional prostheses to

achieve the desired esthetic outcome, but modifi-

cation of the incisal edge position and occlusal

plane is rarely needed when this technique is used

(Figs 28 and 29).

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Crown lengthening

This patient refused crown lengthening, but after

preparation there was enough tooth structure for

retention of the final restorations (Figs 30 and 31).

In a complex wear case, a surgical procedure is

often needed to level the soft tissue for esthetic

and/or structural reasons. Because the ideal incisal

edge position and incisal plane are developed in

the provisional stage based on the horizontal ref-

erence plane, it is easy to develop ideal soft tissue

levels. If the clinician has determined the proper

esthetic and structural length for the teeth, he or

she can ask the surgeon to measure from the in-

cisal edge up to the desired soft tissue height and

add 2.5 to 3.0 mm of length for the biologic width

to achieve the new bone level (Fig 32). Once the

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Fig 34 Centric record of the maxillary provisional prosthesis to the mandibular preparations.

Fig 35 Centric record of the maxillary preparations to the mandibular provisional prosthesis.

Fig 36 Centric record of the maxillary preparations to the mandibular preparations.

bone level is idealized, the soft tissue is posi-tioned and sutured 2 to 3 mm more coronal thanthe bone. If the ideal tooth width has been devel-oped in the provisional prosthesis, the surgeonalso has the information necessary to scallop thebone so the gingival zenith will be in the correctposition (the height of the contour of the soft tis-sue, distal to the center of the tooth) (Fig 33).

Centric record and cross-mounting

Once the biologic width is redeveloped and theprovisional prostheses are relined, a final impres-sion is taken of at least one arch. This is thenmounted on the articulator using the dentofacialanalyzer to develop the correct relationship withthe face. The various centric records allow thetechnician to mount the casts of the provisionalprostheses and the preparations in identical 3-di-mensional positions. Four critical relationships(centric records) need to be taken if both archesare to be fabricated at the same time. The first is aprovisional prosthesis-to-provisional prosthesisrelationship (see Fig 29). There is no need to takean occlusion rim for this relationship if there is anideally generated occlusal relationship that showsbilateral simultaneous contacts in centric occlu-sion. The second and third centric records are

those of the preparations against the opposingprovisional prostheses in both arches (Figs 34 and35). The final relationship needed is the centricrecord of the preparations to preparations (Fig 36).If only one arch is undergoing restoration, the

provisional-to-provisional and provisional-to-preparation relationships need to be taken onlyfor that arch. These 3-dimensional relationships ofthe preparation casts to the provisional casts areessential in allowing the technician to duplicateboth the esthetic and functional relationships thatwere developed in the provisional prostheses.

Transferring informationin the laboratory

Once the castsare mounted and have become in-terchangeable, the technician must use the infor-mation from the provisional prostheses. One suchtransfer of information is the incisal guide table(Fig 37). This is fabricated by placing acrylic resin(GC America, Alsip, IL, USA)within the table thathouses the pin. When the acrylic resin is in thedoughy stage, the upper member of the articula-tor with the provisional cast is moved against theopposing cast in all directions to replicate theguidance. This movement creates a troughthrough the acrylic resin. After the acrylic resin

QOT 2007

MORR

Fig 37 Incisalguide table.

Fig 38 Maxillaryprovisionalcastwith incisalmatrix.

Fig 39 Porcelainbuildup usingthe incisalmatrix.

Fig 40 Finalrestorationsagainstthe incisalmatrix.

hardens, the trough will guide the lingual contoursof the restorations on the preparation cast tomatch the provisional cast.

The next transfer of critical information in thelaboratory is the fabrication of matrices. The mainmatrices used in the laboratory are the facial ma-trix, the lingual matrix, and the incisal matrix. Thefirst two allow verification or reduction of eitherthe waxup or framework, as well as comparison ofthe final prosthesis to the provisional prosthesisfrom a facial and lingual contour perspective. Thissaves time because the technician does not haveto remake the waxup. Because the provisionalprosthesis is the pattern for the final prosthesis, allthe esthetic and functional information is present.The next step is to open the pin by 1 mm and fab-ricate a matrix against the incisal edges and cusptips of the maxillary provisional cast (Fig 38).When the provisional cast is replaced with thepreparation cast, the laboratory technician knowsexactly how much material to add incisally in theframe to support the ceramics and for the finallength of the ceramics. This matrix can be used tofabricate the ideal porcelain buildup. If the techni-cian knows how much shrinkage will result, the pincan be opened by that amount, and after the first

OOT 2007

bake, the incisal edge will be nearly in the perfectposition (Figs 39 and 40). The final prosthesesshould fit intimately to the incisal matrix.

CONCLUSIONIt is evident that the transfer of information through-out the rehabilitation process is critical. Althoughit may take a bit more time in the diagnosticphase of treatment, accurate means of transfer-ring information throughout the rehabilitation pro-cess is paramount to predictability. In severe wearcases where the teeth are too short and need tobe lengthened, the incisal plane guide is an indis-pensable tool. By transferring the critical estheticdeterminants to the articulator, the process ofwaxing becomes easier and more predictable. Ifthe patient needs crown lengthening, all the infor-mation necessaryfor esthetic successis already in-corporated in the provisional prosthesis becausethe critical esthetic determinants were used forfabrication. Once the provisional prosthesis is ide-alized and the correct occlusal relationships aretaken to allow cross-mounting the casts, fabrica-

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Fig 41 Final incisal edge atrest.

Fig 42 Final smile. Note thelevel maxillary occlusal plane.

Fig 43 Final intraoral frontalview. Note the level maxillaryand mandibular occlusal planes.

tion of the incisal guide table and matrices fromthese casts will guide the laboratory technician toensure esthetic and functional predictability in thefinal restorations (Figs41 to 43).

ACKNOWLEDGMENTSA special thanks to Drs John Kois and Dean Kois for the useof their diagrams and research findings. Also, a special thanksto Harald Heindle (Aesthetic Dental Creations, Mill Creek,Washington) for the beautiful ceramic work.

REFERENCES1. Frush F, Fisher R. How dentogenics interprets the sex fac-

tor. J Prosthet Dent 1956;6: 160-172.2. Frush F, Fisher R. How dentogenics interprets the person-

ality factor. J Prosthet Dent 1956;6:441-449.3. Frush F, Fisher R.The Age Factor in Dentogenics. J Pros-

thet Dent 1957;7:5-13.4. Frush F, Fisher R.The dynesthetic interpretation of the

dentogenic concept. J Prosthet Dent 1965;8:558-581.5. Lombardi RE.The principles of visual perception and their

clinical application to denture esthetics. J Prosthet Dent1973;29:358-382.

6. Lombardi RE.A method for the classification of errors indental esthetics. J Prosthet Dent 1974;32:501-513.

7. Tjan AH, Miller GD, The JG. Some esthetic factors in asmile. J Prosthet Dent 1984;51 :24-28.

8. Vig RG, Brundo Gc. The kinetics of anterior tooth display.J Prosthet Dent 1978;39:502-504.

9. Rufenacht CR. Fundamentals of Esthetics. Chicago:Quintessence, 1990:67-134.

10. Chiche GJ, Pinault A. Esthetics of Anterior FixedProsthodontics. Chicago: Quintessence, 1994:13-32.

11. Arnett GW, Bergman RT.Facial keys to orthodontic diag-nosis and treatment planning. Part I. Am J Orthod Dento-facial Orthop 1993;103:299-312.

12. Phillips K, Morgan R.The acrylic occlusal plane guide: Atool for esthetic occlusal reconstruction. Com pend ContinEduc Dent 2001 ;22;302-306.

13. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the per-ception of dentists and lay people to altered dental es-thetics. J Esthet Dent 1999;11 :311-324.

14. Kois JC, Kois D. Simplified facebow rationale and tech-nique. In press.

15. Bonwill WGA. The scientific articulation of the humanteeth as founded on geometrical, mathematical, and me-chanicallaws. Dent Items of Interest 1899:617-643.

16. Weinberg LA. An evaluation of basic articulators and theirconcepts. Part I: Basic concepts. J Prosthet Dent1963;13:622-644.

17. Weinberg LA. An evaluation of basic articulators and theirconcepts. Part II: Arbitrary, positional, semiadjustablearticulators. J Prosthet Dent 1963;13:645-663.

18. Monson GS. Occlusion as applied to crown and bridgework. JADA 1920;7:399-413.

QOT 2007

ZIRCONIUM OXIDE CAD/CAM-GENERATED RESTORATIONS: AN

ESSENTIAL OPTION IN CONTEMPORARYRESTORATIVE DENTISTRY

Ricardo Mitrani, DDS, MSD1Roberto Duran, DDS2

Eduardo Nicolayevsky, DDS3Joel Lopez, MDT3

Two of the most important characteristics ofmodern restorative dentistry are:

1. The ability to integrate an interdisciplinarytreatment plan

2. A full understanding of current restorative ma-terials and technology

'Affiliate Assistant Professor, Graduate Prosthodontics, Uni-versity of Washington, Seattle, Washington, USA; VisitingProfessor, Universidad Nacional Autonoma de Mexico; pri-vate practice, Mexico City, Mexico.

'Director, Nogales Implant Center, Nogales Sonora, Mexico;private practice, Nogales Sonora and Mexico City, Mexico.

'Private practice, Mexico City, Mexico.

Correspondence to: Dr Ricardo Mitrani, Paseo de losLaureles #458-302B, Bosques de las Lomas, Mexico City05120, Mexico. E-mail: ricardomitrani@hotmail.com

QOT 2007

The treatment planning phase unquestionablyrepresents the foundation of contemporary den-tistry.' Whether dealing with the restoration of asingle tooth, an implant, or a full-mouth reconstruc-tion, it is through this planning phase that thedental team must set the road map for therapy.While the final outcome may be reached througha variety of pathways, close communication be-tween specialistsis essentialto choose the ultimateroute of treatment.Indeed, there is no better investment than the

time spent during treatment planning. The inter-disciplinary team should not overlook even theslightest detail regarding the treatment options.The starting point for any therapy should be a

full understanding of the patient's needs, desires,and complaints. Clinicians should explore the pa-tient's mind before diagnosing his or her mouth,and devote as much time as necessary during

rESTHETIC SUCCESS

Understanding theEsthetic Evaluation

for SuccessTal Morr, DMD, MSD

ABSTRACT

With any restorative procedure, a thorough

evaluation, diagnosis, and treatment plan is

essential for a positive outcome. When

dealing with esthetic dilemmas, the same

holds true. Without a sequential esthetic

evaluation, diagnosis, treatment plan, and

execution, an acceptable outcome is diffi-

cult to predict. The treating clinician should

be able to visualize the esthetic problem, vi-

sualize the proposed changes, and devise

a way to achieve the result while still main-

taining mechanically, functionally, and bio-

logically sound principles.

Esthetic EvaluationThe following method of evaluation

, for esthetics is the author's expressedopinion. Esthetics is subjective andhence there are many concepts thatwork well.

Incisal Edge Position of the Centralshe first objective for eval-uation is to envision thefuture positions of thefinal restorations. Inorder to facilitate this, theclinician should find astarting point in the eval-uation process. A good

starting point is the incisal edge posi-tion of the upper central incisors at rest.The patient is seated and asked to saythe letter "m" followed by relaxation ofthe lips (Figure 1). The amount of cen-tral incisor showing is evaluated andmeasured. According to Vig et al,l theaverage amount of tooth exposure withthe lips at rest in men was less thanwomen. As the age of the patients in-creased, the amount of incisal edge dis-play decreased, and short upper lipsgenerally displayed more maxillarytooth structure than long lips. The fu-ture incisal edge position may be relatedto the sex, lip length and age althoughmore importantly, how youthful the pa-tient wants to appear, and the patientsoverall self image, and personality. Theless tooth exposure, the older appearingis the smile. Generally, the author's ob-jective is to make his patients look more

youthful. If this is the case, there shouldbe some tooth exposure evident at rest,the more, the more youthful appearing.

Occlllsal PlaneThe next step in this evaluation

process is the occlusal plane. This isdone by having the patient smile(Figure 2). The occlusal plane allowsevaluation of the whole arch relative tothe chosen incisal edge position. The oc-clusal plane is actually a flat plane de-rived from the incisal edges of the cen-trals, bisecting the cusp tips of the ca-nines and continuing posteriorly (Figure4). What gives the illusion that it is radi-al in relationship to the lower lip (fol-lows the curvature of the lower lip) isthe cant of the maxilla in a sagittalplane (anterior to posterior) (Figure 2).

Generally, the occlusal plane is ob-tained by paralleling (canine to canine)to the interpupillary line assuming noasymmetries in the eyes (Figure 3). Thisreference plane is used even if there areinherent irregularities of the lips. Theonly time the interpupillary plane isnot used as a reference is if the eyes arenot level. If this is the case, the occlusalplane should be paralleled to the floorby mounting the diagnostic modelsusing an earbow leveled with the floor.

Author / Tal Morr, DMD, MSD, isin private practice limited toprosthodontics in Miami, Fla.

FEBRUARY.2004. VOL.32.NO.2.CDA.JOURNAL 153

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ESTHETIC SUCCESS

Figure 1. The incisal edge position at rest isthe first critical step in the esthetic evaluation.

Figure 2. Having the patient smile allows vi-sualization of the.occlusal plane relationship to thelower lip.

Figure 3. The occlusal plane is achieved byparalleling a line bisecting the cusp tips of the ca-nines and a line bisecting the corners of the eyes.

Figure 4. A line drawn from the incisaledges of the centrals should bisect the cusp tips ofthe posteriors to create a harmonious occlusalplane. A line perpendicular to the occlusal planewill help establish the facial plane of the incisors.

Another reference for the occlusalplane is the curvature of the lower lip.The incisal edge positions of the upperteeth should follow the curvature ofthe lower lip if the objective is to makethe patient appear more youthful, as-suming no irregularities in the smile. Ifthe objective is to make the teeth ap-pear more age appropriate, it is not un-common due to wear of teeth for theocclusal plane to be flattened out rela-tive to the lower lip. If this is the case,the plane should parallel the in ter-pupillary line with the incisal edgesand cusps equidistant from the lowerlip (if the lip is symmetrical).

Facial Plane of the IncisorsA line drawn on the midfacial plane

of the incisors should bisect a linedrawn on the occlusal plane perpendicu-

154 CDA. JOURNAL. VOL.32.NO.2.FEBRUARY.2004

Figure 5. The midline should be perpendicu-lar to the occlusal plane.

larly (Figure 4). Evaluating the facialplane gives an idea if the facial contoursof the proposed restorations need to bemodified to create the appearance ofbeing perpendicular to the occlusalplane. This can be done by making thecervical contour slightly more pro-nounced or by tapering the incisal edgeslingually (if the teeth are proclined) orby bringing the incisal edges outward (ifthe teeth are retroclined). Any modifica-tions to the incisal edges of the centralsin a facial-palatal direction should beevaluated functionally and phoneticallyas well as esthetically (whether the lipsupport will be adversely affected).

MidlineIn an ideal esthetic setting, the

maxillary midline should coincidewith the midline of the face. In reali-

Figure 6. The gingival zenith is the mostapical point of the free gingival margin.

ty, the verticality of the midline ap-pears to be much more critical thanthe mediolateral position.2 As long asthe midline is perpendicular to the oc-clusal plane and hence the interpupil-lary plane, the smile can appear bal-anced (Figure 5). If the midline devi-ates in verticality from being perpen-dicular, this can create lack of flowand symmetry to the smile. Generally,the midline is made to line up withthe middle of the face and thephiltrum of the lip. If a severe medio-lateral abnormality exists, orthodonticor orthognathic treatment may benecessary.

Gingival Health and BalanceSuccessful treatment of the anteri-

or dentition requires both a harmo-nious integration of hard and soft tis-

Figure 7. The axial inclinations of the teethshould be toward the mesial from an apical-incisaldirection. The posterior teeth should flow with theaxial inclination of the cuspid to create a smoothtransition from anterior to posterior.

sue.3 When evaluating the soft tissue,health and harmonious gingival con-tours are essential for esthetics. In ahealthy situation, the gingival tissuefollows the cervical contours of theteeth with the apical extent of the freegingival margin (gingival zenith)lying distal to the center of the tooth(Figure 6). On the mesial and distalaspects of the teeth (interproximally)the cervical embrasures between theteeth are filled by the scalloping ofthe tissue forming the papillae. Forthe appearance of health and beauty,the papillae should fill the cervicalembrasures. Balance is achieved withthe tissue heights of the centrals andcanines at the same level and the tis-sue heights of the lateral incisorslightly more coronal.

There are subtle variations of thispattern that are acceptable as long asthe cervical margin of the contralateralcentrals are at the same level, the con-tralateral canines on either side areclose to being at the same level, andthe lateral incisors are not cervical tothe centrals and canines.

In the esthetic evaluation, finalposition of the soft tissue will be dic-tated by the incisal edge position cho-sen for the occlusal plane. By usingthe average measurements of 10.4-

ESTHETIC SUCCESS

11.2 mm for the central incisors4-6

and measuring cervi cally, the new softtissue levels can be visualized. If theydiffer from the present soft tissue lev-els, the possibility of performing ei-ther orthodontics, soft tissue grafting,gingival reshaping, or esthetic crownlengthening for the purposes of level-ing the tissues becomes evident. Thisdecision process is based on whetherthere is a need for root coverage ortooth exposure.

If veneers are being considered,and the tissue needs to be raised cervi-cally to create a harmonious gingivalcontour, exposure of dentin may indi-cate the need for a different type ofrestoration. Ideally for long-term pre-dictability of ceramic veneers, thepreparation should remain in enameldue to the documented strong bondto enamel vs. the variability of bond-ing to dentin.

ArrangementFrom clinical experience, when pa-

tients present for esthetic changes,they are usually seeking correction ofirregularities or mal-alignments. Innature, there is no such thing as per-fect symmetry. Although more pa-tients are seeking correction of mal-alignments of their teeth by doing or-thodontics, there is still no such thingas perfectly aligned teeth. If our goalis to please our patients yet still makeour restorations appear life-like, creat-ing symmetry of the central incisorsand making any slight rotations or ir-regularities in alignment on the later-als or canines can create a pleasingand natural esthetic appearance to ourrestorations.

Any obvious irregularities in align-ment or rotation that create imbal-ance should be noted by the clinicianin the evaluation. If there exists anycrowding or mal-alignment that wiIlcreate a lack of space after alignment

of the teeth, the patient should be in-formed of the limitations of veneersor crowns to align the teeth or thatoverlapping may be necessary. If over-lapping is not an option, orthodonticsmay be the best option. Again, only inthe diagnostic wax-up phase can theoverall arrangement to be assessed asto whether it will create the estheticgoal that the patient and the dentistare trying to achieve. .

Another important criteria for es-thetic success in arrangement are theposition of canines. The canines areimportant in transitioning the anteri-or aspect of the arch to the posterior.The more visible the distal aspect ofthe canine, the wider the anterior seg-ment of the arch will appear, creatinga squarer shape to the arch with a lossof a smooth transition from anteriorto posterior. Only the mesial half ofthe canine should be visualized froman anterior perspective (Figure 6).Although the golden proportion is amathematical concept that does nottake into consideration dominance,symmetry, and overall subjective cre-ativity, it does emphasize the fact thatthe canine, viewed from a facial per-spective can be seen only from themesial aspect. The facial aspect of thecanine ideally should be made to flowwith the posterior facial aspects tocreate a smooth transition from ante-rior of the arch to the posterior(Figure 7).

Ideally, the heights of contour of allthe upper anterior teeth should followthe gingival zenith (distal to the middleof the tooth) with the axial inclina-tion (Figure 7) from a cervical-incisaldirection toward the mesial.

Tooth Dimension and ProportionDominance and relative symmetry

of the centrals are two of the funda-mental parameters for esthetic success?(Figure 8). The centrals are the focal

FEBRUARY.2004. VOL.32.NO.2.CDA.jOURNAL 155

Figure B. The central incisors should bedominant relative to the other anterior teeth. Theincisal embrasures help to define the tooth formand to create individuality to the teeth. The inter-nal characterization and translucency is critical inmimicking nature.

point of the smile and should appearappropriate in size and relatively sym-metric. In terms of the overall size andproportion of the teeth, there are stud-ies of average measurements that tendto be useful as guidelines for the di-mension of the future restorations.S-1ONot only are there many studies thatshow the average length and width ofteeth, but Sterret et ai, II found that thewidth/length ratios of unworn incisorsand canines both fall within 77-85 per-cent. Centrals and canines have similarcrown length with an average of 1-1.5mm longer than lateral incisors.

Evaluation should include a subjec-tive evaluation of the existing dimen-sion and proportion of the existingteeth and any planned changes. Any se-vere discrepancies should be noted inthe clinical examination. Alteration ofthe length of the teeth via estheticcrown lengthening or soft tissue graft-ing will alter overall dimensions andproportions of the final tooth form.Future tooth proportion and dimensioncan only be determined during the di-agnostic wax-up phase of treatment be-cause in reality, the arch form and oc-clusal relationship will dictate thewidth of the teeth. Any changes in thelength of the teeth as dictated by the

156 CDA. JOURNAL. VOL. 32. NO.2. FEBRUARY. 2004

ESTHETIC SUCCESS

evaluation should be incorporated intothe diagnostic wax up. Waxing over thetissue on the diagnostic model tochange the crowns length is necessaryto visualized if the proposed changes intooth dimension and contour will beacceptable with a change in the soft tis-sue contours.

Tooth Contour and IncisalEmbrasures

There are three basic shapes ofteeth: square, ovoid, and triangular.Although there are three natural toothforms, all anterior teeth are formed bythree facial lobes and one palatal lobe.The conjunction of the three faciallobes create the mamelons. As a result,all incisal edges are rounded in youth.As we age, the teeth wear at varying de-grees. This in turn creates a squarer ap-pearance to the incisal edges of the cen-trals, and flattening of the cusps on thecanines. If the objective is to create amore youthful smile and delicate smile,rounder incisal edges and more pointedcusp tips on the canines are necessaryand vice-versa.12

The incisal embrasures (Figure 8)are formed by the interrelationships ofthe incisal edges of the anterior teethand the cusp tips of the canines andposteriors. They are important in creat-ing a life-like appearance to any restora-tion. The interaction of the incisal em-brasures with the space between thelower teeth or lower lip and the incisaledges of the upper teeth when laughing(negative space) helps to outline andgive individuality to the teeth. Inyouth, with less wear, the incisal em-brasures are quite large with the small-est between the central incisors andprogressively getting larger as youmove in the arch posteriorly (Figure 8).If there has been some wear due tofunction or parafunction, not only dothe teeth wear but the incisal embra-

sures get smaller. If a youthful appear-ance is the objective, larger incisal em-brasures are essential.

Color and CharacterIn the evaluation step, it is impor-

tant to determine what types of colorchanges are necessary for the finalrestorations. If the color of the finalrestorations is not going to be changedrelative to the existing color of the teethor only slight modifications in color arerequired, veneers may be the ideal typeof restoration due to their inherenttranslucency. If a moderate colorchange is required, it may still be possi-ble with veneers although the techni-cian should be given slides of the prepa-rations and of shade tabs to be able tovisualize the areas to be blocked out inthe porcelain. If severe color changesare required, either bleaching prior topreparation or choosing a different typeof final restoration may be indicated.

Characterization of the teeth suchas translucencies, crack lines, etc. on re-maining natural teeth should be notedif the veneers are to match them(Figure 8).

Diagnostic Wax upThe diagnostic wax-up phase of

treatment is one of the most essentialaspects in all of the treatment. It is onlythrough the wax up that all of the al-terations that were planned as a resultof the esthetic evaluation can be tested.All of the criteria for esthetic successshould be implemented in the wax up.If any of the changes are not possible,this is where it will be discovered, andnot after preparing the teeth.

Tissue RecontouringOnce the wax up is complete, visual-

ization of the proposed soft tissue alter-ations are possible. The soft tissue levelsmay be waxed up on the model so that

ESTHETIC SUCCESS

Figure 9. A facial matrix made off the waxup model helps to ensure proper reduction of thefacial and interproximal aspect of the preparations.

the proportion and dimension of theteeth can be evaluated. If even more ac-curacy is required than just visualiza-tion, a surgical stent can be made froma model of the wax up by making a vac-cuform cut to the desired soft tissue lev-els. By use of the wax up, the modifica-tions can be made intraorally to idealizethe soft tissue form whether through es-thetic crown lengthening or connectivetissue grafting.

Provisionalization and FinalImpressions

Using a facial matrix made off ofthe diagnostic wax-up model to checkpreparation depth both facially and in-terproximally, proper reduction of thepreparations can be ensured (Fil,'llre 9).A palatal matrix helps to achieve prop-er incisal edge preparation (Figure 10),and a full contour matrix of the diag-nostic wax up helps to fabricate theprovisionals. By loading the matrixwith acrylic and seating the matrix onthe preparations, the contours of thewax up will be formed in acrylic(Figure 11). Only by virtue of the pro-visionals can the esthetic alterations bevisualized and checked. The wax upmay look great on the model but onlyby visualizing the provisionals in themouth can a true evaluation be made.

Any final contour changes shouldbe made to the provisionals intraorally

Figure 10. A palatal matrix made off thewax up model helps to ensure proper incisal edgereduction.

so that they are as close as possible tothe desired width, length, contour, andarrangement of the final restorations.Once the contours are idealized, theprovisionals should be measured to ver-ify adequate preparation and only onceideal, the final impression is taken.Once the provisionals are cemented, al-ginate impressions are taken to producestone casts of the provisionals in themouth.

laboratory ConsiderationsAll of the models are cross mounted

so that the provisional model is trans-ferable with the preparation model.Indexes made off of the provisionalmodel help transfer the informationfrom the provisionals to the finalrestorations.

The final color, character, and tex-ture are all defined in the final restora-tions. Photos are made of the prepara-tions and shade tabs so the laboratorytechnician can determine if any blockout any necessary areas to achieve thedesired color. Internal characterizationis paramount to success of any restora-tion. Teeth have varying amounts oftranslucency and internal characteriza-tion. In the older patient, crack lines area very common occurrence. All of theseminor characterizations help to lend anatural appearance to the final restora-tions. Surface texture is also important.

Figure 11. A full matrix of the wax up allowsfabrication of the provisional restorations.

Teeth erupt into the mouth with a verycomplex surface morphology of hori-zontal lines (lines of retzius) and verti-cal grooves (between the lobes). Thissurface texture reflects and deflects lightand hence makes the teeth appearbrighter. Due to erosion and abrasionover time, the surfaces of older teethtend to display less surface texture. Thisallows more light to be absorbed andhence lower value to the teeth. Surfacecharacterization is based on matchingadjacent teeth or the by overall objec-tive of youthfulness or aging.

Case PresentationA 45-year-old patient presented to

the office for a consult regarding heroral condition (Figure 12). She had ahistory of numerous restorative proce-dures (crowns and large composite fill-ings) in all of the teeth except the uppercentral incisors. She expressed unhappi-ness with the way her mouth lookedand wanted a long-term, natural appear-ing esthetic solution that would makeher appear more youthful. Upon evalua-tion, it was determined she had decayon almost all of her teeth and under herold restorations, necessitating a full-mouth rehabilitation. The patient wasexamined thoroughly from an extraoral,intraoral, and radiographic aspect. Theobjectives of treatment were to create afunctionally, mechanically, and biologi-

FEBRUARY.2004. VOL.32.NO.2.CDA.)OURNAL 157

ESTHETIC SUCCESS

Figure 12. A facial view of the patient atpresentation.

Figure 15. From an intraoral view, the gin-gival imbalance due to recession was visible. Thearch form was V-shaped due to the lingual posi-tion of the canines. The canines were short relativeto the occlusal plane. All of the teeth except thecentral incisors were stained and dark due to previ-ous restorations.

cally sound rehabilitation while makingthe patient look better and more youth-ful. All ceramic Procera crowns wereplanned for the posterior teeth andporcelain veneers for the incisors.

The esthetic evaluation revealedthe following:

Incisal edge positionAt rest, the patient showed approxi-

mately 5mm of tooth structure withwear on the distals of the centrals(Figure 13). This created a V-shaped in-cisal edge relationship between the cen-tral incisors that the patient did notlike. The distal aspects of the centralswere subjectively determined to be thecorrect length for the future incisaledge position because the centrals wereactually a bit long relative to the width.

158 COAl JOURNAL. VOL.32. NO.2. FEBRUARY. 2004

Figure 13. With the lips at rest, the patientshowed 5 mm of tooth structure.

Figure 16. Although the teeth were propor-tional relative to each other, the recession andwear created a lack of proportion of the teeth indi-vidually, necessitating gingival correction andlengthening of the worn teeth.

Occlllsal PlaneWhen the patient was asked to

smile, the occlusal plane was evaluated(Figure 14). Although the posterior as-pect of the occlusal plane was fairly ad-equate, both canines were short relativeto the occlusal plane (Figure 15).

Facial Plane of the IncisorsThe facial plane was nearly perpen-

dicular relative to the occlusal plane.

MidlineThe upper midline was vertical and

hence adequate in positioning (Figure12).

Gingival Health and BalanceFrom an intraoral view, it was evi-

dent that the patient had generalized

Figure 14. The smile revealed a disharmonyin the arch form and the occlusal plane.

moderate amounts of gingival recession(Figure 15). Because the teeth werelong already and because the caninesneeded to be lengthened to level theocclusal plane, the need for a root cov-erage procedure was indicated to createproportional width/length ratios.Another indication for root coveragewas that the centrals and laterals weregoing to be restored with veneers. Inorder to create a finish line in enamel,root coverage was essential.

ArrangementThe arch form in the cuspid area

did not flow with the posteriors aspectof the arch because both canines weretipped palatally on both sides while thefirst bicuspids were slightly buccal(Figure 15). This gave the illusion of aV-shaped arch rather than the desiredV-shaped arch.

Tooth Dimension and ProportionThe distance from the distal aspect

of the incisal edge of the central in-cisors up to the eEl's created a propor-tionate dimension and dominance tothe central incisors. Both lateral in-cisors were worn and although theupper left lateral was an appropriatelength it was not appropriately shaped.The upper right lateral incisor was tooshort relative to the left. The caninesneeded to be lengthened to correct theocclusal plane (Figure 16).

ESTHETIC SUCCESS

Figure 17. Intraoral evaluation of the provi-sionals revealed a more harmonious tissue con-tour, tooth contour, dimension, occlusal plane,and arrangement.

Figure 18. An evaluation of the provisionalswith a smile revealed a more harmonious archform and symmetry.

Figure 19. The length of the final restora-tions at rest were appropriate for the patient.

Figure 20. The occlusal plane was madelevel to the eyes.

Tooth Contour and Incisal EmbrasuresBecause the teeth were worn, the in-

cisal edges were flat, creating an olderappearance to the teeth. (Figure 16). Asa result of wear, the embrasures weresmall as well. The objective was to cre-ate a more youthful smile and therefore,rounder incisal edges and larger incisalembrasures would be appropriate.

Color and CharacterAll of the teeth other than the two

centrals were dark in color due to previ-ous restorations and decay (Figure IS).Due to the severity of the decay, theposterior teeth needed crowns. The lat-eral incisors and the centrals were restor-able via the use of porcelain veneers.

From the esthetic evaluation, a waxup with all of the proposed changeswas made. The patient went to see the

Figure 21. The occlusal plane was radial inrelationship to the lower lip.

periodontist for connective tissue graft-ing of the upper and lower arches(wherever needed) along with a coro-nally positioned flap to cover the ex-posed root surfaces. After three monthsof healing, a wax up was completed ona new diagnostic model reflecting theimproved tissue relationship. The pro-visionals were made using the matrixmade from the diagnostic model andevaluated functionally and esthetically(Figures 17 and 18). With the patient'sapproval, the final impressions weretaken and the case was finished.

From the final photographs, onecan see the esthetic objectives wereachieved to create a harmonious andbalanced smile:

• At rest, the patient showed anadequate amount of tooth structurecreating a youthful look (Figure 19).

Figure 22. The facial plane of the incisorswas perpendicular to the occlusal plane. The in-cisal edge configuration along with the incisal em-brasures gave a feeling of youthfulness.

• When smiling, the occlusal planewas made level to the eyes with a radialrelationship to the lower lip (Figures20 and 21).

• The facial plane of the incisorswas maintained perpendicular to theocclusal plane (Figure 22).

• There was a healthy, pleasing,and balanced symmetry to the soft tis-sue creating teeth of the same length oneither side of the midline (Figure 23).

• The arch form was widened in theanterior segment. The canines werebrought out facially and the bicuspidslingually to create a smooth transitionfrom the anterior segment to the posteri-or segment of the upper arch (Figure 21).

• The teeth were made propor-tional with a pleasing symmetry(Figure 21).

• The incisal edges of the centrals

FEBRUARY.2004. VOL.32.NO.2.CDA.JOURNAL 159

Figure 23. A facial view of the soft tissue re-vealed a healthy, balanced, and harmonious gingi-val contours along with a pleasing symmetry inarrangement. The teeth were made brighter whilestill maintaining a realistic appearance by incorpo-rating internal effects and translucency in theporcelain.

and lateral incisors were made rounder,hence more youthful and delicate(Figures 23 and 24).

• The Incisal embrasures wereopened to create individuality and asense of reality to the restorations(Figure 22).

• The teeth were made whiter,brighter and hence more youthful(Figure 23).

• Translucency and crack lineswere incorporated in to the restora-tions to create an illusion of reality(Figure 23).

ConclusionEsthetic predictability in any

restorative procedure can make our den-tal careers much more enjoyable and re-warding. It would be nice to be able topredictably fabricate beautiful restora-tions. By consistently following a step-by-step protocol, the chances of successare greatly enhanced. Skipping an im-portant step such as the wax up andprovisionalization will ultimately leadto failure. Of critical importance is thatknowledge, ability, and artistic flair ofthe laboratory technician. Not onlyshould he or she know how to transferall of the vital information obtainedfrom the mouth (provisionals) via in-

160 COAl JOURNAL. VOL.32.NO.2.FEBRUARY.2004

ESTHETIC SUCCESS

Figure 24. Lateral view of the final smile.

dexes, but be able to create a life-likereplica in the ceramics. It goes withoutsaying that long-term success demandsthat the esthetic alterations should fallwithin the function, mechanical, andbiologic principles. DB

Acknowledgment / Many thanks for the laborato-ry aspect of treatment to Mr. Harald Heindl.Without his exquisite artistic abilities and under-standing of functional and mechanical principles,the case presented would never be the same .

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To request a printed copy of this article, pleasecontact / Tal Morr, DMD, MSD, 20760 West DixieHighway, Aventura, Fla., 33180.