The Power Of 4: Preserving dental tissue

Nowadays, even after the advent of new materials, and the simplification on how to achieve good esthetics, it is often seen and suggested by clinicians to do restorations for all the teeth in the visible area. If a case is being planned for indirect restorations, it is suggested more so. The effort that goes into matching the restorations to the existing dentition is always an issue. It surely requires skills of a master technician to achieve high esthetics and preserve tooth tissue by not having to prepare teeth that are healthy and are in a reasonably acceptable position to achieve optimum esthetics.

The significance and role of the canines and more so if they are present in Class 1 is well established. If a clinical situation allows the canines not to be restored and a mutually protected occlusion to exist, then it is the author’s suggestion that one should try to plan 4 restorations that involve the incisors only in the upper arch.

The teeth might not be in golden proportion, but an attempt should be made to achieve a harmony and balance in dental and facial esthetics.

In order for the existing canines and bicuspids which as is being suggested should be in relatively good aesthetic position, the treatment of choice should be bleaching. It is also to be understood that in nature the incisors have a higher value compared to the canines and therefore even if the 4 anteriors were planned one shade lighter, the restorations integrate in the smile of the individual.

This makes the teeth have a lower value and in most cases eliminates the need for having restorations on them to achieve harmony.

There are three cases to show how only indirect bonded restorations can enhance aesthetics. The author acknowledges the craftsmanship of MDT Lamberto Villani of Oral Design in Dubai who fabricated all these restorations.

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Fig.1
CASE 1
A patient came after endodontic treatment desiring better aesthetics for her teeth that had undergone physical trauma in the past. This is a preoperative frontal view

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Fig.2
Before, right view.

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Fig.3
Before, left view.

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Fig.4
Before, frontal view.

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Fig.5
Minimal preparations were done through the mock-up in order to preserve tooth tissue. They were smoothened and no sharp lines were present.

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Fig.6
Double cord retraction to manage soft tissues.

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Fig.7
2 weeks later, bleaching and 4 veneers.

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Fig.8
Good hard tissue integration.

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Fig.9
Good integration of indirect restorations and the existing dentition.

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Fig.10
After, right view.

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Fig.11
After, left view.

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Fig.12
Smile make over with 4 indirect restorations.

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Fig.13
CASE 2
A 64 year old female patient came in to have her smile improved. There was chipping, some old bonding, different shades of teeth, reverse smile line and also some open embrasures in between tooth number 12 and 11.

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Fig.14
Before, right view.

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Fig.15
Before, left view. It is seen that the canines are very well preserved, and visibility of the posterior dentition is as would have been desired. 2 weeks of home bleaching was carried out and the the indirect restorations were fabricated with feldspathic ceramic using a refractory die technique.

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Fig.16
Before, anterior view.

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Fig.17
Smooth preparation and tissue management as suggested in the 1st case.

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Fig.18
After, 2 weeks post-cementation view.

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Fig.19
Right view after cementation.

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Fig.20
Left view after cementation.

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Fig.21
Final smile, frontal view.

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Fig.22
CASE 3
A 45 year old lady wanted her smile to be enhanced. She had an old PFM crown on 21. Some diastemas, reverse smile line relatively large teeth.

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Fig.23
Before, right view

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Fig.24
Before, left view.

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Fig.25
A quick direct mock-up to check for relative esthetics when the changes will be made.

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Fig.26
Mock-up, right view of the smile.

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Fig.27
Mock-up, left view of the smile.

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Fig.28
Intra-oral view: Preoperative. One can see the mismatched PFM crown that was encroaching on the biological width and also had a discolored margin because of the metal shining through. The old crown was removed. The pocket was cleaned with a soft tissue laser and a well fitting temporary crown was given for 4 weeks. The patient, in the meantime, was suggested to bleach for 2 weeks at home.

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Fig.29
Healthy tissues and no discoloration of the gingiva. Preparation and tissue management.

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Fig.30
One Emax/Lithium disilicate crown on 21 and 3 feldspathic veneers on 11, 12, 22.

Conclusions

It is hereby concluded that:
1) An attempt should be made to minimize and involve the teeth that have the greatest impact on the smile.
2) Use of layered ceramics provide very high quality esthetics.
3) Have very smooth preparations and try to restrict your preparations as much as is possible in enamel.
4) There is a power in 4…think less and not more.

Bibliography

Gürel G (2003) Predictable, precise, and re-peatable tooth preparation for porcelain laminate veneers. Pract Proced Aesthet Dent 15:17-24
Gürel G (2007) Porcelain laminate veneers: Minimal tooth preparation by design. Dent Clin North Am 51: 419-431
McNamara L, McNamara JA, Jr, Ackerman MB, Baccetti T. Hard- and soft-tissue contributions to the esthetics of the posed smile in growing patients seeking orthodontic treatment. Am J Orthod Dentofacial Orthop. 2008;133:491–9.
Snow SR. Esthetic smile analysis of maxillary anterior tooth width: The golden percentage. J Esthet Dent. 1999;11:177–84.

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