Creation of a new smile

An indirect smile makeover requires thorough treatment planning, the right technique, and the selection of the correct materials, including temporization, impression and cement. A 26-year old female patient came to our practice complaining about shape and shade of her teeth and seeking for an aesthetic improvement. As an indirect approach was chosen based on the clinical findings, an impression was taken with an A-silicone (DMG A-silicon Honigum) to fabricate a provisional restoration in order to let the soft tissues heal (after gingivectomy).

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styleitaliano style italiano intial situation of patient unsatisfied with her esthetics

Fig.1
Initial situation of the patient with the un-accepted shape and shade of the teeth and multiple carious lesions.

styleitaliano style italiano intraoral view with decayed tissue

Fig.2
Initial intraoral situation.

styleitaliano style italiano close up of upper arch decay

Fig.3
Close – up view of the teeth, the far-from-ideal width to length proportion was the main reason for crown lengthening.

styleitaliano style italiano gingivectomy before veneer restoration

Fig.4
A gingivectomy and crown lengthening without bone reduction (only soft tissue) was enough to increase the length of the teeth.

styleitaliano style italiano initial veneer preparation

Fig.5
A 0.5-mm depth-cutting bur was used during the initial preparation by following the curvature of the labial surface.

styleitaliano style italiano marking grooves for precise veneer preparation

Fig.6
A pencil was used to mark the depth created by the guide groove bur.

styleitaliano style italiano buccal veneer preparation

Fig.7
A coarse diamond bur was then used across the whole facial surface and after the thickness and the depth reduction, the dentist should focus on the preparation design and follow some basic rules:
– Respect buccal convexity
– Cervical margin located 0.5 with the level of the gum.

styleitaliano style italiano finishing preparation with soflex disc

Fig.8
Due the low amount of enamel on the labial surface, the proximal spaces were opened to expose more enamel. A Soflex disc was used at low speed to round the sharp angles to avoid stress concentration at these areas.

styleitaliano style italiano preparation margin check

Fig.9
Final preparation for veneers, and its finish line was then evaluated from the incisal before final impression.

styleitaliano style italiano putty and light impression material by dmg

Fig.10
The impression was taken with a single step technique using DMG Honigum Putty Soft Fast and Honigum Pro Light Fast.

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styleitaliano style italiano mixing putty paste

Fig.11
Mixing the material with the longitudinal method to get perfect mixing.

styleitaliano style italiano injection of impression material on tray

Fig.12
The light body material is very flowable and able to fill all the space created by the second retraction cord, with the double mix technique it is also necessary to inject the material (light body) around the prepared teeth.

styleitaliano style italiano bite registration material

Fig.13
O-Bite for bite registration is a superior new bite registration material that provides you with exceptional accuracy, predictability and speed, specifically developed to yield more stable and precise bite registrations.

styleitaliano style italiano precise bite registration silicone

Fig.14
Long working time, short setting time and highest final hardness of the bite is very important for both dentist and lab.

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styleitaliano style italiano cutting impression to fabricate index

Fig.15
The impression was cut with a surgical blade to fabricate an upper arch index.

styleitaliano style italiano injecting provisional restoration material in silicone index

Fig.16
The first impression was then filled with a self-curing resin material (DMG Luxatemp Star) in order to create a temporary restoration for the prepared tooth. DMG Luxatemp Star A2 resin was applied inside the silicone index. When doing so, the mixing tip should be not removed from the silicone index until all the teeth are filled, in order to prevent internal voids.

styleitaliano style italiano index fabrication of provisional restorations

Fig.17
After placing the index in the mouth, we should wait for the gel phase before removing the excess material. Then keep the index in the mouth for two more minutes before removing it for polishing procedures.

styleitaliano style italiano provisional restorations before polishing

Fig.18
After removing the index from the patient’s mouth, some finishing and polishing is required to remove the excess and sharp edges especially from the gingival embrasure area to create space for the papilla to heal and to fill the embrasure.

styleitaliano style italiano smile with provisional restorations

Fig.19
Two weeks later, with the provisional restorations.

styleitaliano style italiano lithium disilicate veneers

Fig.20
Lithium disilicate (e-max) ceramic veneers were fabricated by the dental lab.

styleitaliano style italiano resin cement for veneers

Fig.21
Vitique is a premium cementing system for complicated veneer work. The light-curing, composite-based cements are available in a wide range of shades. Perfectly matched try-in pastes for each shade allow a reliable preview of the final result.

styleitaliano style italiano veneers before cementation

Fig.22
Before cementation, the veneers fit was checked inside the patient’s mouth. An aesthetic resin cement (DMG Vitique White) was be used for cementation, with the air of an Optragate latex-free lip and cheek retractor.

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styleitaliano style italiano try in of veneers

Fig.23
Try-in stage before the final cementation, the gingiva looks very white due to local anesthesia and the effect of the retraction cord. The purpose of the retraction cord (size 1 cord mostly used) at this stage is to achieve enough vertical displacement of the gum to expose the finish line, in order to evaluate the relationship between the finish line and the margin of veneers, and to be able to safely remove all composite excess.

styleitaliano style italiano retraction of soft tissues during veneer try in

Fig.24
Evaluate the integration between margin and finish line, note the blue retraction cord under the gingiva for vertical displacement. It’s important to remove the cord as quickly as possible after finishing the cementation procedure to avoid the permanent damage of junctional epithelium.

styleitaliano style italiano cemented veneers

Fig.25
Final intraoral situation of the patient.

styleitaliano style italiano texture and marginal fit of lithium disilicate veneers

Fig.26
Side view of fit and texture.

styleitaliano style italiano before and after veneer rehabilitation

Fig.27
Before and after.

styleitaliano style italiano after veneer treatment

Fig.28
Final intraoral situation.

styleitaliano style italiano smile after veneer treatment

Fig.29
Final smile.

Conclusions

Bis-acryl resin materials such as DMG Luxatemp Star, are an aesthetic, fast and easy solution to fabricate a temporary restorations in the dental office.

The choice of materials is very important, In this case was used the resin cement (DMG Vitique) that available in wide range of shades to suit every case and his special veneers tip allows for easy and controlled application of the cement in addition to a try-in paste with a matching color is available and can be used to check the color match in difficult cases before the veneers are finally cemented.

Bibliography

1.Galip G. The science and art of Porcelain Laminate Veneers, London, Quintessence, 2003.

2.Koubi S. Laminate veneers. 2020 Quintessence.

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