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426
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
70-6.&t/6.#&3tWINTER 2017
VENEZIANI
427
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
70-6.&t/6.#&3tWINTER 2017
CLINICAL RESEARCH
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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VENEZIANI
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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Case report
Clinical procedures
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of hypersensitivity in the maxillary teeth
and was concerned about gingival re-
cession. She was very motivated and
Fig 1 Initial frontal view of the patient’s face. keen to improve her smile (Fig 1). Clin-
ical examination showed cervical abra-
sions with moderate asymptomatic gin-
gival recessions in the mandibular arch.
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in both arches, and between the ca- inadequate relative dimensions among teeth, non-
carious cervical lesions, wear of incisal margins,
nines and first premolars in the maxil- and flat incisal line with loss of embrasures.
lary arch.
Fig 4 Maxillary occlusal view. Wide diastemas Fig 5 Mandibular occlusal view. Wide diastemas
can be found between the lateral incisors and ca- can be found between the lateral incisors and ca-
nines, and between the canines and first premolars. nines.
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Inadequate relative dimensions of the A second mock-up, with a final check
teeth were found: the central incisors of the treatment plan.
were small and hardly predominant Prosthetic procedure, with teeth prep-
compared to the lateral incisors; all aration driven by a mock-up.
incisors had an improper height/width In the maxillary arch, the creation of
ratio – the recessions on the canines six ceramic laminate veneers from ca-
and premolars had altered the coro- nine to canine, plus two additional ve-
nal proportions. neers on the mesial aspect of the first
The teeth suffered from a loss of buc- premolars. In the mandibular arch,
cal volume and surface texture; their the creation of six ceramic laminate
color was characterized by low value veneers from canine to canine.
and moderate chromaticity. Try-in and adhesive luting of the ve-
The incisal margins were flat due to neers.
wear. The incisal embrasures were
lost, resulting in an inverted smile line Esthetic analysis and DSD
that caused esthetic disharmony.
DSD8 is a recent digital previsualization
The patient’s occlusal situation showed technique that allows the clinician to:
a good molar class I, with proper anterior Efficiently plan the treatment of simple
overjet and overbite. The interproximal or complex esthetic cases.
contacts in the posterior sectors were Improve the communication between
adequate. The curve of Spee was flat the dental team members involved in
and needed no modification. the treatment.
A multidisciplinary treatment plan was Obtain better communication with and
elaborated: increase the patient’s involvement in
A nonsurgical periodontal treatment, the planning of his or her smile, and
with motivation and improvement of achieve better patient motivation and
the homecare routine. understanding of the advantages of
A full set of intraoral photographs, the proposed treatment.
video clips, and study models were Enhance the predictability of the
collected. DSD previsualization would whole treatment thanks to a digital
guide the wax-up and the subsequent project, which guides the actual clin-
clinical previsualization with a direct ical treatment.
mock-up.
Mucogingival surgery to recreate an DSD is based on a clear intra- and ex-
anatomic cementoenamel junction traoral photographic protocol, leading to
(CEJ) and achieve proper root cover- a thorough esthetic analysis of certain
age in the maxillary lateral sectors. elements in a specific sequence:
Orthodontic treatment with transpar- 1. Facial analysis.
ent aligners to optimize space as a 2. Dentofacial analysis.
function of the prosthetic plan (DSD- 3. Dentolabial analysis (incisal edge
driven orthodontics). position, incisal display during smile,
smile line, buccal corridor).
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Facial mid-line
Upper lip
Lower lip
Occlusal
plane
Bipupillary line Horizontal plane
Digital
ruler
Fig 6 DSD: virtual treatment planning with digital previsualization. The design of the new dental profile
is guided by the “facial cross,” by extraoral parameters (bipupillary line, lower and upper lips) and by
the relationship of rectangles. The amount of the required modifications can be measured by means of a
calibrated digital ruler. The obtained measurements will guide the dental technician while performing the
wax-up. The final result can be previewed by superimposing custom dental shapes on both intraoral and
full-face photographs, thus greatly improving communication with the patient.
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b c
Fig 7 DSD-driven wax-up of maxillary (from premolar to premolar) and mandibular (from canine to ca-
nine) anterior groups. Three silicone indices were obtained from the wax-up: (a) a complete index for the
creation of the mock-up and temporary restoration; (b) a palatal index; (c) a buccal index, horizontally
sectioned as a book. The latter two were used as references during the preparation phase.
ruler that allowed for the quantification of tools to guide the different procedures
the amount of the modifications needed for the overall treatment: surgical, ortho-
on every single tooth to obtain an anter- dontic, implant, and preparation guides.
ior sector in harmony with the patient’s In this case, three silicone indices
lips, surrounding tissue, face, and per- were obtained from the wax-up: 1) a
sonality. complete index for the creation of the
Traditional DSD sequences were inte- mock-up and temporary restoration; 2)
grated using ClinCheck software (Align a palatal index; 3) and a buccal index,
Technology), which allowed for a real 3D horizontally sectioned as a book. The
control of movement sequence, and a latter two were used as references dur-
0.1-mm level of precision in movement ing the preparation phase (Fig 7).
and space opening. The next step is to convert the two-
dimensional (2D) digital project into a
Wax-up and clinical previsualiza- 3D mock-up, which may be either direct
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Fig 8 Direct mock-up molding with rigid silicone Fig 9 Clinical previsualization (mock-up) of the
index (95 shore). maxillary anterior teeth after intraoral finishing and
polishing.
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a b
c d
Fig 10 Multiple coronally advanced flap in the maxillary left quadrant. (a) After measuring the depth of
the recession, oblique incisions are cut, converging toward the center of rotation (ie, the canine). (b) After
removing the epithelium on the papillae, a bilaminar graft is taken from the palate and, once the epithelium
is removed, sutured on tooth 23. (c) With proper passivation, the flap is coronally advanced. A 6-0 absorb-
able PLA-PGA suspended suture is performed. (d) After tissue maturation, a complete coverage of gingival
recessions can be observed.
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a b
Fig 11 (a and b) Lateral views showing a stable molar class I, with proper anterior overjet.
In the presented case, after soft tissue any relevant change. The projection of
maturation in the maxillary arch, ortho- the maxillary incisal margin on the nasal
dontic records were collected to evalu- spine was good, so no modification of
ate and visualize the necessary move- the anterior teeth line was necessary.19
ments. The main aspects analyzed were: The planned movements were ob-
Whether or not to improve the inter- tained with transparent aligners (Invis-
cuspation in the lateral sectors. align, Align Technology).20,21 The Clin-
The need for modification of the an- Check software is effective in simulating
terior tooth line. the space opening among maxillary
The movement needed in both arch- and mandibular incisors, starting from
es to proceed to a good finalization. the mesiodistal dimensions previewed
The most effective and efficient with the DSD and the initial wax-up.22
device needed in order to obtain Different options may be analyzed and
such movements, with respect to the virtually tested by means of 3D software.
patient’s esthetic needs. Perfect communication among team
members is ensured by simulations that
The cephalometric analysis and lateral are easily understandable, and by the
views (Fig 11a and b) show a class I possibility of sharing previews via the
occlusion with proper overjet and nor- internet. Once the simulation fulfills the
mal divergence. No temporomandibular clinical objectives, the aligners can be
joint (TMJ) pain was reported. Protrusive manufactured.
and lateral guidance appeared inade- Rectangular vertical attachments were
quate due to the parafunction, leading applied, according to the ClinCheck soft-
to severe wear of the anterior sector. ware, to achieve a better movement of
Nevertheless, muscle excursion in later- the incisors. Treatment lasted 7 months,
al and protrusive movements was within OFFEJOHBMJHOFST 'JH
/PSFGJOJOH
normal range, as was maximum open- phase was necessary. Finally, the patient
ing. Maxillary and mandibular incisor in- was given two removable retainers and
clination was also within normal range, was instructed to wear them for at least
and the interincisal angle did not show 3 months to maintain the result.
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Fig 12 Orthodontic treatment with space redistribution. Teeth movements were planned with the Clin-
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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nine to canine).
a b c
d e
Fig 15 Maxillary teeth: step-by-step tooth preparation driven by the mock-up. Removal of the tooth
structure between the guiding grooves is performed with round-ended, slightly tapered diamond burs.
Preparation is performed both on the facial surface (a) and at the incisal margin (b). Prepared surfaces
are finished with fine grit burs (c), and polished with silicone points (d). The horizontally sectioned silicone
index obtained from the wax-up is used to double check for facial clearance (e).
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Table 3 Mechanical properties of the natural tooth compared with composite and ceramic materials.
Ceramic has a stiffness similar to enamel, so it is the best material (more biomimetic) with which to restore
the enamel itself
o
(70–96
Ceramic feldspath- 8–13.5 0.0025 150
ic, lithium
disilicate)
To obtain biomimetic restorations that type of solution provides the highest es-
emulate the biomechanical and opti- thetic result, yet it does not allow any
cal properties of the natural tooth (Ta- change once removed from the refrac-
ble 3), ceramics should be the material tory. For this reason, the diagnostic path
of choice (feldspathic ceramic baked is of critical importance for the treatment
on refractory, layered computer-aided strategy, as it allows a precise definition
design/computer-aided manufacture of the shape and volume of the restor-
[CAD/CAM] or pressed lithium disili- ations before their manufacture.
cate). In the mandibular arch, restorations
In the maxillary arch, veneers were were made in layered pressed lithium
made in feldspathic ceramic, layered disilicate (IPS e.max Press, Ivoclar Vi-
and baked on refractory (Fig 19). This vadent), since their manufacture is
Fig 19 Feldspathic ceramic laminate veneers Fig 20 Pressed and layered lithium disilicate ve-
baked on refractory (maxillary teeth). neers (mandibular teeth).
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After
9% hydrofluoric acid
Silane
Etch-and-rinse 3-step technique Heated Insertion Removal Light curing
composite of the excess oNJO
Fig 21 Adhesive luting procedure of the ceramic veneers on the dental substrate.
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Fig 22 Frontal view of the final result after cemen- Fig 23 Frontal view of the final result after cemen-
tation of the maxillary laminate veneers. tation of the mandibular laminate veneers.
a b
Fig 24 (a) Initial frontal view, before treatment. (b) Frontal view of the final result, at 2-month recall.
Optimal morphologic, functional, and esthetic integration can be observed, as well as excellent periodontal
response.
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Fig 25 Rest position with ideal exposure of the Fig 26 Full smile with a harmonious smile line.
central incisors.
Conclusions
The final photographs show optimal
morphologic, functional, and esthetic in-
tegration, with excellent periodontal re-
sponse (Figs 22 and 23). The functional
and esthetic improvement can be ap-
preciated by comparing the before and
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and b). The smile line is harmonious,
and the teeth provide ideal lip support
(Figs 25 and 26). The patient was ex-
tremely satisfied with the result. Psycho-
logical improvements were also seen,
as there was an increase in the patient’s
self-confidence (Fig 27).
The scheduling of each treatment
phase – also thanks to new, useful virtual
tools such as DSD (Fig 28) – represents
an effective means for clinician–patient
communication, and may provide reli-
able help for the whole dental team.
The diagnostic and therapeutic pro-
tocol described in the present clinical
case showed how, by combining dif-
ferent fields of dentistry (hygienic and
periodontal therapy, restorative, mucog-
ingival surgery, orthodontic, and pros- Fig 27 Frontal view of the face, showing an ideal
thetic therapies), an excellent final result relationship between the teeth and the face.
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a b c d
Fig 28 Full-face photographs at different treatment stages: preoperative (a), digital preview (b), clinical
preview (mock-up) (c), and final result (d).
Acknowledgment
I am proud to thank all my esthetic team:
Dr Fabio Federici Canova for the ortho-
Fig 29 Lateral view of the smile, with an ideal
dentolabial relationship. dontic treatment and for his invaluable
assistance in the drafting of this article,
and the dental technicians, F. Pozzi and
A. Quintavalla (PR Italy), for their excel-
lent work. Thanks also to Dr L. Madini
#4
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28. Magne P, Versluis A, Douglas 33. Magne P, Kim TH, Cascione 37. Schmidt KK, Chiayabutr Y,
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shape: experimental-numer- ate dentin sealing improves ence of preparation design
ical analysis. J Prosthet Dent bond strength of indirect and existing condition of
o restorations. J Prosthet Dent tooth structure on load to
29. Lin CP, Douglas WH. o failure of ceramic laminate
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and crack resistance at the porcelain laminate veneers o
bovine dentin-enamel junc- with special reference 38. Messing MG, Sher JH. A clin-
UJPO+%FOU3FT to the effect of prepar- ical technique for temporiza-
1072–1078. ation in dentin: a literature tion of teeth to receive porce-
#FSUTDIJOHFS$
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review. J Esthet Restor Dent lain laminate veneers. J N J
-àUIZ)
4DIÊSFS1%VBM o %FOU"TTPDo
application of dentin bond- .BHOF1
,XPO,3
#FMTFS 39. Mitrani R, Phillips K, Escude-
ing agents: effect on bond UC, Hodges JS, Douglas ro F. Provisional restoration of
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5BOJHVDIJ5
dentin. J Esthet Restor Dent WH. Effect of luting compos- A multidie technique for
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-PICBVFS6
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