Fig.1
This young male patient, 27 years old, is looking for a smile makeover. His smile line is strongly affected by a wear process (mainly erosion and abrasion).

Fig.2
The cervical line is also asymmetric due to the disposition of his teeth. The more palatal is the position of a central incisor, the lower is the cervical margin.

Fig.3
The first issue discussed was orthodontic treatment, which the patient refused. At this step of treatment planning, it is important to leave an open door for an interdisciplinary approach, including orthodontics as it is difficult to anticipate the final outcome with this option. This is why it was decided to proceed to a full mock-up from this initial situation and see if proportions and esthetic compromises were acceptable without undergoing orthodontic treatment. That’s the beauty of the mock up which is stressless on both sides.

Fig.4
The visible erosion process is attributed to soft drinks that were a habit to the patient.

Fig.5
In the lower jaw, wear process on the occlusal surface has eliminated almost all the enamel causing dentin exposure.

Fig.6
Once we tried the mock up (DMG Luxatemp Star) both the dentist and patient were satisfied with the result, especially with the thickness of teeth 21 and 22.

The correlation between the new smile line and this wear process will offer freedom for creating a new smile line thanks to the increase in vertical dimension.

Treatment planning was the following:

Increasing vertical dimension from:

– Buccal and palatal veneers from 13 to 23 for the upper arch

– Occlusal veneers from 34 to 37 and 44 to 47

– Crown on 42

Redesigning of the pink line with gingivectomy for 21 and 22 which are tilted towards the palate

Fig.7
Once the full mock up was validated, we used it as a preparation guide in the anterior area to control the depth of the cut following Gurel’s technique.

Fig.8
For the lower arch we prepared as well through the mock up. For the occlusal veneers a minimum thickness of 0,5 mm was ensured while keeping the marginal ridge, following my own technique.

Fig.9
Preparations were minimal and were made to follow the new gingival line, corrected to maintain the gum in the ideal position with temporaries and final restorations.

Fig.10
Temporaries were fabricated with the same material used for the mock up (DMG Luxatemp Star) and with the same silicone index. A spot of adhesive is applied on the buccal surface of the preparation and is light cured. Then just a little excess material is removed with burs to create a clean margin. You can note that teeth 11 and 21 don’t have the same color because of different thickness of the temporaries.

Fig.11
Luxatemp resin is a chemical cure material syringeable available in two versions: Fluorescence and Star.
The trick is to leave the setting time beyond 4 min when temporaries are made in order to have a super nice texture avoiding a sticky effect.

Fig.12
Palatal veneers, made with composite block (DMG LuxaCam block), and buccal veneers, made with Emax LT B1, are simultaneously bonded using Optrasculpt PAD (Ivoclar Vivadent).

Fig.13
Restorations are bonded one by one. You can see the important difference between the initial situation and the final outcome in terms of volume both on the palatal and occlusal sides.

Fig.14
Occlusal veneers are bonded following the same protocol.

Fig.15
View of the final restoration for the lower arch.

Fig.16
Note the good esthetic integration of the palatal veneers (DMG LuxaCam composite).
Thanks to the increase in vertical dimension, the lost enamel is replaced without touching the palatal structure following a no prep approach.

Fig.17
Integration of the buccal veneers and the new bite. The global appearance is well integrated even if symmetry is not ideal. This is a good example to define beauty: you can’t define it but you can recognize it.

Fig.18
Natural smile with a very good integration of the buccal veneers.
Thank you CDT Gerald Ubassy (ceramist) for this masterpiece.

Conclusions

In such a case, in which many clinical parameters have to be redefined, the use of a predictable tool like the full mock up is really the GPS able to drive you through the treatment and offer confidence from the first appointment to the final result.
Calibration of the preparation is the key to be minimally invasive and guarantee the required thickness for the occlusal and buccal veneer.
Dentistry has to be simple, guided and, of course, esthetic!

Bibliography

Abduo J. Safety of increasing vertical dimension of occlusion: a systematic review. Quintessence Int. 2012 May;43(5):369-80.
Abduo J, Lyons K. Clinical considerations for increasing occlusal vertical dimension: a review. Aust Dent J. 2012 Mar;57(1):2-10.
P. Margossian G. Laborde S. Koubi G. Couderc P. Mariani. Use of the Ditramax System to Communicate Aesthetic Specifications to the Laboratory. Eur journal of esth dent Volume 6 • n°2 • Summer 2011
Vailati F, Belser U. Classification and treatment of anterior maxillary dentition affected by dental erosion: the ACE classification. Int J Periodontics Restorative Dent. 2010 Dec;30(6):559-71.
S Koubi, G Gurel ,P Margossian, R Massihi, H Tassery. A simplified approach for restoration of worn dentition using the full mock-up concept: clinical case report. Int J Periodontics Restorative Dent. 2018 Mar/Apr;38(2):189-197
Gurel G, Bichacho N. Permanent diagnostic provisional restorations for predictable results when redesigning the smile. Pract Proced Aesthet Dent. 2006 Jun;18(5):281-6
Koubi S, Gurel G, Margossian P, Massihi R, Tassery H. Nouvelles perspectives dans le traitement de l’usure : les “Table Tops”. Réalités Cliniques 2013. Vol. 24, n°4 : pp. 319-330
Koubi S, Gürel G, Margossian P, Massihi R, Tassery H. Traitement de l’usure: rôle fondamental du projet esthétique et fonctionnel. Inf Dent 2014; 96 (31): 66-80.
Koubi S, Gürel G, Margossian P, Massihi R, Tassery H. Préparations postérieures a minima guidées par le mock up dans les traitements de l’usure. Rev Odont Stomat 2014; 43 (3) : 231-249.
Koubi S, Gürel G, Margossian P, Massihi R, Tassery H. Aspects cliniques et biomécaniques des restaurations partielles collées dans le traitement de l’usure: Les table top. Réal Clin 2014 ; 25 (4): 327-336.
Koubi S, Gürel G, Margossian P, Massihi R, Tassery H. Le projet esthétique et fonctionnel: nouveau “GPS” de la dentisterie moderne. Rev Int de Proth Dent 2014, n°4: 257-272.
Gurel G, Bichacho N. Permanent diagnostic provisional restorations for predictable results when redesigning the smile. Pract Proced Aesthet Dent. 2006 Jun;18(5):281-6