Date post: | 16-Nov-2015 |
Category: |
Documents |
Upload: | cesar-augusto |
View: | 18 times |
Download: | 0 times |
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
50THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Smile Esthetics: a Methodology
for Success in a Complex Case
Jean-Christophe Paris, DMDPrivate practice, Aix en Provence, France
Stphanie Ortet, DMD Private practice, Aix en Provence, France
Annick Larmy, DMDPrivate practice, Marseille, France
Jean-Louis Brouillet, DMD, DDSPrivate practice, Marseille, France
Andr-Jean Faucher,DMD,DDS Private practice, Marseille, France
Correspondence to: Dr Jean-Christophe Paris
Academie du Sourire, 12, Cours Sextius, Aix en Provence 13100 France
Tel: 00 336 11226371; e-mail: [email protected]
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
51THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Abstract
The clinical case presented is the dem-
onstration of a multidisciplinary ap-
proach to a complex treatment. A pre-
cise methodology is important to ensure
that the treatment objectives are clear
to all the teams. The aim of the treat-
ment is to restore dentofacial harmony
to a young, 22-year-old, female patient
showing severe attrition of the anterior
teeth. The direct effect of this is an age-
ing of the smile. This type of multidisci-
plinary treatment, which seems compli-
cated at first, is greatly simplified once
time has been spent on the diagnosis
and treatment plan: it thereby becomes
a succession of clinical stages.
(Eur J Esthet Dent 2011;6:5074)
51THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
52THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Introduction
The smile can be a snapshot of the soul,
a weapon of seduction, the primary
means of communication, a reflection of
personality so many definitions, which
underline the essential role of the smile
in expression and communication be-
tween human beings.
The direct relationship between the
beauty of the smile and self-esteem
should also be mentioned, an extremely
important notion regarding the quality of
ones socio-professional life.1-3
These reflections affirm that the es-
thetic restoration of the patients smile
is an essential medical act. It can never
be approached with anything less than
a perfectly codified method, which rules
out failure, even if the success is not
complete.
This method consists of a checklist,
which brings together all esthetic and
functional parameters. It clarifies and
facilitates the work of clinicians, so that
they are able to perform complex es-
thetic rehabilitation by following clear,
step-by-step guidelines. A number of
checklists have been described in the
dental literature, and one of the most ac-
complished is that of Mauro Fradeani in
2004.4
The clinical case described hereaf-
ter reflects this approach and method
of diagnosis, which has been called the
Esthetic Guide.
The first step was to a make a deci-
sion regarding the treatment, either par-
tial, by integrating into an existing smile,
or global, by bringing a new harmony to
the smile.
The Decision-Making Table facilitates
this decision.
Materials and methods
The Decision-Making Table
By referring to the Decision-Making Ta-
ble3, it is possible to analyze a smile in
its entirety and approach a case study in
a precise and methodical way.
Using the guiding principles, which
govern smile esthetics, the Decision-
Making Table (Fig 1) is a therapeutic tool
that allows the clinician to reinforce an
esthetic diagnosis and treatment plan.5
Indeed, this evaluation of esthetic crite-
ria is more than just an analysis of the
dental composition. It also includes the
gingival tissues and the final esthetic
restoration in the framework of the smile
and face, taking into account the pa-
tients personality.
Thus, during an esthetic consultation,
this guide quickly brings to light any lo-
calized problems which will be treated
and assimilated into an initially-harmo-
nious smile, or determines if there is a
global problem, which then requires re-
habilitation of the smile.3
This new diagnostic approach will be
illustrated in the following clinical case.
The Esthetic Guide (EG)
When confronted with complex smile re-
habilitation, it is essential to think about
and elaborate a structured case study.
This is why, during the clinical exam,
the use of the Esthetic Guide (Fig 2) al-
lows for the collection of a great deal of
information relating to the patient (face,
smile, occlusion, and dental and gingi-
val composition).6
The Esthetic Guide is a guide to a clini-
cians therapeutic and esthetic decision,
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
53THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
depending on the results of the patient
examination.
Radiographic status
The radiographs did not show any endo-
dontic or periodontal conditions.
Photographic status
In esthetics, this collection of perfectly
codified documents is fundamental to
the establishment of the treatment plan,
in the same way as radiographs are for
the endodontist (Figs 3-14).
Fig 2 The Esthetic Guide.
Fig 1 Decision-Making Table.
Decision-Making Table
Balanced smile Disharmonious smile
localized problem global problem
I. FaceI.1 Visual balance between look and smile
II. Smile
II.1 Smile line
too high
too low
irregular
II.2 Esthetic frontal plane
too high
too low
asymmetrical
II.3 Sagittal plane
II.4 Horizontal plane
III. Dental composition
III.1 Dimensions
III.2 Proportions
III.3 Shade
III.4 Shapes
IV. Gingival composition IV.1 Gingival architecture
Integration Rehabilitation
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
54THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 3 Frontal view.
Fig 4 Side view.
Fig 5 Full smile.
Fig 7 Right view.
Fig 6 Four-tooth smile.
Fig 8 Left view.
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
55THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 11 Right view (canine edge-to-edge).
Fig 9 Frontal view (rest position).
Fig 13 Maxillary occlusal view (mirror).
Fig 12 Left view (canine edge-to-edge).
Fig 10 Frontal view (edge-to-edge bite ).
Fig 14 Mandibular occlusal view (mirror).
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
56THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Indeed, they enable the collection of
all the information regarding the initial sit-
uation, and constitute an element of ob-
jective comparison following treatment.
They are also a tremendous means of
communication with the patient and the
ceramist, giving precise indications.
Analysis of study models
Study models constitute a three-dimen-
sional reference of the initial situation
(Fig 15). Set in an articulator, they fa-
cilitate the dynamic appraisal of patient
function and make potential problems
visible.
Clinical case
A 22-year-old woman arrived at the of-
fice, showing severe esthetic problems.
Her smile, which she was embarrassed
about, revealed abraded and highly-dis-
colored teeth. The medical questionnaire
indicated that during her adolescence,
she had two serious orthodontic treat-
ments in order to put the two impacted
maxillary canines into their correct place.
Being perfectly aware of the impact of
this kind of imbalance on her personal-
ity, this young patient shared her wish to
find once again a smile in harmony with
her age.
Fig 15 (a to c) The examination of the study models shows a number of functional anomalies:
indeed, the abrasion of the anterior teeth reveals a
parafunction of the bruxism kind and dysfunctional
lateral movements.
a b
c
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
57THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
The patients esthetic expectations Taking into account this patients es-
thetic requests was a fundamental
step in the clinical success of her
smile.5 Being attentive to patients and
respecting their wishes enables per-
sonalized treatments, while remaining
within the functional possibilities and
morphophysio logical characteristics of
the patient.6-8
Indeed, a standardized esthetic ap-
proach is simply not possible. It is not
just an impersonal analysis of criteria.
Each patient and each smile is unique,
and the practitioner needs to know how
to create a natural harmony in order
for the beauty to be born again.3 In this
particular case, the patient provided
photographs illustrating the smile she
desired.
Esthetic analysisDetails of the Decision-Making Table for
the present case (Fig 16) follow.
Study of the faceA balance between the intensity of the
look and the vitality of the smile is es-
sential to the harmony of the face. It is
therefore the primary parameter to be
determined (Fig 17).
Study of the smileThe smile line is probably the most im-
portant feature of the smile. It is the posi-
tion of the teeth in relation to the soft tis-
sue: lips and gums. The smile line can be
low, medium, or high.9 In this case, the
smile line is low, the patient reveals only
a little of her teeth (Fig 18a). Because of
excessive abrasion of her incisors, the
esthetic frontal plane is flat and does not
correspond to the patients real age.
Fig 16 Decision-Making Table of the patient. Fig 17 This frontal view of the face demonstrates a significant contrast between this discreet smile
and the dominant look of the teeth, which the patient
is trying to hide.
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
58THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
The maxillary anterior teeth seem to
be too buccal in comparison with the
maxillary lip. The presence of significant
diastema makes unsightly so-called
black holes visible (d13-14 = 1 mm,
d23-24 = 3 mm) (Fig 18b).
Study of the dental composition Measuring the teeth allows the clinician
to appreciate their proportions within the
smile.
Studying the width/length ratios7,10
enables one to reach the following con-
clusions:
the incisors are too short (Fig 18c)
the central incisors are too narrow
and square
the lateral incisors are too wide in
comparison with the central incisors
b
c d
Fig 18 (a to d) The shape of the teeth did not correlate with the patients face, personality, or age.
a
the canines are not sufficiently
present in the smile (Fig 18b).
The excessively dark color of the teeth
contributes to a recessive smile.
Study of the gingival compositionThe dental composition is highlighted
by the harmony of the gums, which
through their healthy state and harmo-
nious architecture reinforce the unity of
the smile.4,6 It is therefore an element
that should be taken into careful consid-
eration. A significant gingival recession
was located at the maxillary left canine;
when probing, the visibility of the probe
testifies to periodontal fragility.
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
59THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
The EG revealed asymmetrical gingi-
val contours at the maxillary incisors be-
tween the right and the left side (Fig 18d).
SummaryThanks to the Decision-Making Table,
this patients smile analysis showed the
need for a global rehabilitation, which
required an accurate esthetic study us-
ing the Esthetic Guide.4 The red crosses
symbolize abnormalities, and the blue
represent normality.
Treatment plan
Of course, various treatment options are
available, but it should be remembered
that the best solution for the patient is
always the least invasive. Also it should
always be asked if an irreversible prepa-
ration of the teeth could be avoided by
an orthodontic treatment. When this is
not possible, the golden rule is to show
a preference for composite restorations
over veneers, and veneers over crowns,
etc.
By referring to the results of the es-
thetic analysis, it is essential to take a
multidisciplinary approach to the treat-
ment:
1. OcclusionAnalysis
no history of trauma or previous or-
thodontic traction
behavior: clenching and bruxism
skeletal relationship: class III, skel-
etal open-bite
centric relation: incisal midline dis-
placed 2 mm to the right, stable
centric occlusion
mandibular incisors: normal occlu-
sion relationship
Fig 19 (a and b) The orthodontist carries out a functional set-up to reposition the upper incisor-
canine group; in this way, a simulation of the desired
orthodontic treatment can be obtained.
a
b
maxillary incisors: buccal inclination
increased by 5 degrees (class III
compensation), correct sagittal and
vertical position
anterior guidance: lack of canine
guidance and incisal guidance too
steep.
Conclusion
A behavioral rehabilitation, reinforced
by wearing a relaxing night guard, al-
lows for the correction of bruxism and
crispation parafunctions. The occlusal
analysis will determine the prosthodon-
tic reconstruction criteria:
strict preservation of the maximal
inter-incisal opening (good, stable
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
60THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
posterior bite) and the occlusal verti-
cal dimension
preservation of the bite plane and
the Spee curve
rearrangement of the maxillary an-
terior teeth with bilateral equilibra-
tion of the propulsion, with a view
to achieving an effective cuspidal
guidance (Fig 20).
2. Orthodontics After positioning 13 and 23 on the arch,
these teeth will be moved back in order
to fix them in the best position in relation
to the opposing arch.
However, the class III tendency of this
patient implies a progressive increase in
the initial buccal position of the incisors,
in tandem with the closing of the diaste-
ma. This is why, in accordance with future
prosthetic rehabilitation, it is essential to
find the right compromise between an
excessively pronounced buccal version
and oversized diastema. It is here that
the notion of esthetic corridor is most im-
portant (Fig 21).
b
Fig 20 (a and b) Using this setup, a functional waxup of the palatine surfaces indicates by how much it is possible to extend the free edges while respecting functionality, and to reconstruct a correct anterior
guidance (according to the instructions of the occlusal analysis). Finally, a minimally invasive treatment
was chosen for this patient, with veneers instead of crowns, using orthodontic treatment to recreate the
anterior functions.
a
3. PeriodonticsTaking account of the gingival biotype
of 13 and 23, a gingival thickening (by
means of a subepithelial connective tis-
sue graft) will be necessary beforehand,
as well as a lengthening of the crowns at
the 12-11 level, with the aim of harmoniz-
ing the general situation of the gingival
margins. Finally, gingival palatine thin-
ning will be required in order to free the
incisor cingulums.
4. BleachingThe choice of an ambulatory technique
seemed most appropriate.
5. Prosthetic reconstructionWithin the framework of an esthetic and
harmonious restoration of the smile, por-
celain veneers were the obvious choice
thanks to their optical quality and the re-
spect shown to the tissue during prepa-
rations.
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
61THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Previsualization of the smile
There can be some difference between
the patients mental image, the words
used to express this, and how they are
understood. It is therefore essential to
give the patient a material idea of the
treatment, and this is why a previsualiza-
tion of the smile is recommended.11 This
therapeutic strategy makes it possible to
demonstrate the future treatment, and to
assess the proposition in a concrete and
life-sized way prior to preparing the teeth.
It not only clarifies the practitioners
reasoning, but also gives the patient the
possibility to express his/her approval
or reservations in an enlightened man-
ner throughout the various prosthetic
sequences.
Prior to any kind of treatment, and tak-
ing the importance of anomalies into ac-
count, a precise occlusal study is nec-
essary.
Initial conditionsThe occlusodontist and orthodontist
combined their requirements in order to
design a setup, which was both func-
tional and esthetic.
Diagnostic waxupUsing the dental model, a waxup was
made, prefiguring the ideal morphol-
ogy.12 It is the first materialization of the
esthetic project, since it informs the cli-
nician of the esthetic changes possible
in terms of future shapes and propor-
tions, taking account of the phonetic and
Fig 21 (a to c) These pictures show the intraoral orthodontic appliances, the distribution of the di-
astema and the compromise between the function
and esthetics. Such a treatment cannot be finalized
by orthodontic treatment alone.
a b
c
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
62THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 22 (a and b) Taking account of the patients wishes, these waxups demonstrate the appearance of a convex and symmetrical esthetic plan, an increase in the length of the teeth, and a reduction in the width
of the lateral incisors, hidden by a mesial inclination in relation to the initial situation.
Fig 23 (a to c) Initial situation.
a
a
c
b
b
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
63THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 24 (a to c) Esthetic setting: using the ortho-dontic setup and the functional waxup, the gingi-
val level is redesigned and the buccal surfaces are
remodeled in accordance with the ideal morphol-
ogy and the dimensions determined by the Esthetic
Guide.
b
c
a
occlusal data. In the case of this young
patient, the objective of the treatment
was to give her a powerful smile, by re-
inforcing the dominance of the central
incisors within a more feminine dental
composition (Fig 22).
Esthetic project Computerized previsualization
A virtual elaboration of the treatment de-
sired allows patients to visualize the re-
sult, which is motivating and reassures
them in their choice.13
This computerized approach, rein-
forced with a laboratory procedure (Figs
23 and 24), thereby strengthens com-
munication between the medical team,
the patient, and the laboratory techni-
cian (Fig 25).
Esthetic Project (EP)
Using the esthetic study, all data is col-
lected in order to develop a coherent EP.
Favoring realization in the mouth of
the diagnosis and treatment plan, the
EP constitutes an essential step in the
prosthetic rehabilitation.
Using resin mock-ups fixed to the un-
prepared teeth, the EP allows the patient
and laboratory technician to objectify
the anticipated effect of the future res-
toration.12
It represents a sketchbook, allowing
the practitioner to test the esthetic prop-
osition and validate it with the patient be-
fore any irreversible clinical steps have
been taken, hence its importance. Using
the esthetic and functional waxup, there
are two ways of realizing this project that
follow below.
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
64THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 26 (a to d) Direct esthetic project: using a transparent silicone splint moulded on to the corrected dental model, this procedure uses an automolding technique and, as its name suggests, is performed
directly in the mouth.
a b
Fig 25 (a to d) Computer simulation: using this wax previsualization, and thanks to the photographs made to the same scale, this tool facilitates insertion of the modified teeth under the patients lips. The
patient can see in advance the real result of the project.
a
c
b
d
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
65THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 26 (a to d) continued.
Fig 27 (a to d) Modifying the shape of the central incisors allows them to play a major role within the framework of the smile. The axis of the lateral incisors in relation to the canines has been modified, thereby
reinforcing the esthetic value of the central incisors.
d
a b
c d
c
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
66THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 28 (a to d) Indirect esthetic project: Using this waxup and following the indications given in the esthetic analysis, the laboratory prepares eight fine shells made of stratified composite resin, measuring
0.2 to 0.3 mm. These mock-ups are then transferred to the unprepared teeth.
a
c
b
d
Direct esthetic project Based on a waxup, this project is real-
ized directly in the mouth, following a
classic automolding technique. How-
ever, using a resin whose surface ap-
pearance is relatively crude runs the risk
of disappointing demanding patients
(Figs 26 and 27).
Indirect esthetic projectUsing a more sophisticated material,
which resembles the final ceramic more
closely, the mock-ups offer a more natu-
ral result. The illustration presented to
the patient will therefore be closer to re-
ality (Fig 28).
The final esthetic project on eight
teeth responds perfectly to the expec-
tations voiced by the patient during the
clinical examination (Fig 29).
Preparation of teeth impression stage
This stage is delicate in technical terms,
and demands great meticulousness.
Indeed, over-preparation leads to a
pointless mutilation, which can only be
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
67THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 29 (a to d) Note the more feminine cut, softer around the free edges.
c
a
d
b
offset by a thick layer of ceramic, giv-
ing the final restoration an artificial ap-
pearance.14 In the case of under-prep-
aration, it is difficult to correct any poor
positioning.
Reduction keys are therefore a precon-
dition to any preparation. Consequently,
these guides allow the operator to esti-
mate and check reduction volumes, in
order to make homothetic preparations
in the volume pertaining to the final res-
toration, rather than to the initial dental
volume. This allows for maximum con-
servation of tissue14 (Figs 30 and 31).
Contour shapes Preparations without a palatine inva-
sion are carried out. Using the silicone
guide, which allows visualization of the
shape and position desired, reduction
is performed according to the principle
of controlled penetration. Indeed, the
preparation, guided by grooves whose
depth is obtained using a calibrated bur,
must not exceed the contact points on
the proximal surfaces, and finish with a
very fine butt margin at the level of the
incisal edge.
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
68THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
ImpressionSince the preparation limits are most
often supra- or juxta-gingival, making
the impression is not a serious chal-
lenge.16 Taking account of the esthetic
impact in this region, the method used
must be the least traumatic possible,
hence the choice of a double-mix im-
pression technique, used together with
a thin retraction cord.
Temporary veneers using mock-ups
The aim of this procedure is to conserve
the reconstruction criteria established
beforehand during the esthetic project,
and to combine it with the advantages of
elaboration using the indirect method, in
order to easily obtain quality temporary
elements (Figs 3238).
Fig 30 (a and b) The book-page key, sectioned horizontally, allows the entire preparation to be visual-ized from the incisal edge to the neck.15
a b
Fig 31 (a and b) Individual guides allow for production of the quantity of buccal tissue eliminated inside the mouth and on the occlusal surface.
a b
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
69THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 32 This method of making a temporary veneer is straight-forward, consisting of adding three elements: the diagnostic
mock-up, prepared during the EP, whose esthetic criteria have
been validated, and the mock-up, combined with a rebasing
material, is held in the correct position by means of a silicone
key. In this case, the choice of a photopolymerizable resin fa-
cilitates time management, since the operator can control the
final polymerization.
Fig 33 (a to d) This key is indispensable, because it creates a partial buccal support in which the masks can be bonded, and a broad palatine support that acts as a general stabilizer and avoids an overflow of
resin in this direction.
a
c
b
d
repositioning keyrebasing resin
mask
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
70THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 35 Using an ordinary spatula, the elasticity of the resin allows for easy removal of buccal ex-
cesses.
Fig 36 Potential interproximal excesses are cut out to allow for reinsertion.
c
b
Fig 34 (a to c) The prepared surfaces are coat-ed with a film of glycerine. Rebasing of mock-ups
is performed by injection of resin directly onto the
dental surfaces and in the sandblasted interior of
the models. Controlled application is accomplished
thanks to the repositioning key.
a
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
71THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 39 (a and b) In this way, one can obtain replicas, which are true to the future restoration and a new smile, which is then submitted for the patients approval.
Fig 40 Thanks to this method (individual rubber dam), the practitioner is able to resolve problems of
insulation and contamination.
Fig 37 Final photopolymerization. Fig 38 Disinsertion: it is advisable to remove the entire block in such a way as to allow mechanical
locking during its sealing.
ba
This method of converting the masks
into temporary veneers requires the
making of an occlusal repositioning key,
which will guide the reinsertion of the
mock-ups in the correct position at the
rebasing stage.
Transitional restorations are not to be
neglected: by allowing both the patient
and practitioner to validate the EP in
concrete terms,3 they play a major role
in the prefiguration of the definitive res-
toration16,17 (Fig 39).
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
72THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Fig 43 (a and b) In accordance with the guiding esthetic principles, the smile line fits harmoniously with the curve of the lower lip even if the correction of the dental midline had not orthodontically been possible.
b
a b
Fig 41 (a and b) The diastemata of the upper jaw have been rearranged and significantly reduced.
Fig 42 (a and b) These photographs highlight a feminine and youthful dental composition.
a
a
b
Copyright
byN
otfor
Qu
intessence
Not for Publication
PARIS ET AL
73THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Prosthetic fitting
The eight biscuits are tested. At this
stage, it is possible to analyze any po-
tential corrections to be made, and to
convey these modifications to the lab-
oratory.11 The veneers were made of
feldspathic ceramic at the laboratory in
order to obtain the most esthetic result.
Verification criteria at the clinical-
fitting stage:
accuracy of marginal adaptation
inspection of contact points
adherence to esthetic project: vali-
dation of shape, color, proportions,
transition lines, macro- and micro-
geography, and shape of the incisor
edges.
Bonding
Using an individual rubber dam11 greatly
facilitates the clinical stage of the bond-
ing procedure (Fig 40). The bonding
procedure follows a standard protocol
consisting of three stages:
preparation of the veneer: etching,
silanization, adhesive
preparation of the tooth: sandblast-
ing, etching, primer, then adhesive
bonding: because of the implemen-
tation of the individual rubber dam,
excesses are easily removed, and
there is zero risk of overflow onto the
neighboring teeth.
Clinical results
Since the photographic protocol used
before and after operating is identical,
the similarity of the final porcelain crea-
tions to the images of the transitional ve-
neers is apparent.
Fig 44 (a to c) When changing a smile, one must never underestimate the impact.
a
b
c
Copyright
byN
otfor
Qu
intessence
Not for Publication
CLINICAL APPLICATION
74THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
Conclusion
This account of a clinical case, which can
be considered exemplary, is intended to
show the need for a rational approach to
all esthetic smile-restoration projects.
By resorting first to the Decision-Mak-ing Table and later to the Esthetic Guide in order to establish the diagnosis and
treatment plan, it is possible to success-
fully perform all of the stages, which lead
to the result shown in the photographs
above (Figs 4144).
The patients expression shows that
her requests regarding an esthetic,
functional, and, most of all, personalized
rehabilitation have been respected.
Each individual represents a specific
case, and it would not be possible to
perform a standard restoration without
insulting the patients personality and ex-
pectations. Reconstructing a pretty smile
gives patients more than just a healthy
and attractive appearance; it also pro-
vides a mental boost, which has a posi-
tive effect on how they see themselves.
Additional resources
The Esthetic Guide featured in the
present clinical case is available in pdf
format by request to richter@quintes-
senz.de.
Acknowledgements
Pierre Andrieu (dental laboratory, MOF); Profes-
sor Francis Louise (periodontics); Professor Jean-
Daniel Orthlieb (occlusodontics); Dr Jean-Stphane
Simon (orthodontics).
Operator: Professor Andr-Jean Faucher.
References
1. Graber LW, Lucker GW. Dental esthetics self evalu-ation and satisfaction. Am J Orthod 1980;77:163-178.
2. Terry RL, Davis JS. Com-ponents of facial attractive-ness. Percept Mot Skills 1978;42:918-919.
3. Paris JC, Faucher AJ, Makar-ian MH. Smile Aesthetics: Integration or Rehabilitation? Ral Clin 2003;14:367-378.
4. Fradeani M. Esthetic Reha-bilitation in Fixed Prostho-dontics: Esthetic Analysis. Chicago: Quintessence Publishing, 2004.
5. Talarico G, Morgante E. Psychology of dental esthet-ics: dental creation and the harmony of the whole. Eur J Esthet Dent 2006;4:303-312.
6. Paris JC, Faucher AJ. Le Guide Esthtique. Paris: Quintessence International, 2004
7. Chiche GJ, Pinault A. Esthet-ics of anterior fixed prostho-dontics. Chicago: Quintes-sence Publishing, 1994.
8. Fradeani M. Evaluation of dentolabial parameters as part of a comprehensive esthetic analysis. Eur J Esthet Dent 2006;1:62-69.
9. Rufenacht CR. Fundamen-tals of Esthetics. Chicago: Quintessence Publishing, 1990.
10. Duarte S, Lorezon AP, Sch-nider P. The Importance of width/length ratios of maxil-lary anterior permanent teeth in esthetic rehabilitation. Eur J Esthet Dent 2008;3:224- 234.
11. Magne P, Magne M, Belser U. The diagnostic template: a key element to the compre-hensive esthetic treatment concept. Int J Periodontics Restorative Dent 1996;16: 560-569.
12. Faucher AJ, Magneville B, Watine F, Koubi G, Brouillet
JL. Provisional facets and Aesthetic Project. Ral Clin 1994;5:25-33.
13. Goldstein CE, Goldstein RE, Garber DA. Imaging in esthetic dentistry. Chicago: Quintessence Publishing, 1988.
14. Grel G. The Science and Art of Porcelain Laminate Veneers. Chicago: Quintes-sence Publishing, 2003.
15. Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomi-metic Approach. Chicago: Quintessence Publishing, 2003.
16. Derrien G. Provisional restorations with compound prosthetics. CdP 1991;73:67-74.
17. Rieder CE. Use of provisional restorations to develop and achieve esthetic expecta-tions. Int J Periodontics Restorative Dent 1989;9:122-139.
Copyright of European Journal of Esthetic Dentistry is the property of Quintessence Publishing Company Inc.
and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for individual use.