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 clinicans 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 authors 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 exisitng canines and bicuspids which as is being suggested should be in relatively good aesthetic postion, the treatment of chioce should be bleaching. It is also to be understood that in nature the incisors have a higher valuse 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 elliminates 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 Desgin in Dubai who fabricated all these restorations.
Img. 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
Img. 2 – Before: Right view
Img. 3 – Before: Left view
Img. 4 – Before: Frontal view
Img. 5 – Minimal preparations were done throught the Mock Up in order to preserve tooth tissue. They were smoothened and no sharp lines were present
Img. 6 – Double cord retraction to manage soft tissues
Img. 7 – 2 weeks after: bleaching and 4 veneers
Img. 8 – Good hard tissue integration
Img. 9 – Good integration of Indirect Restorations and the existing dentition
Img. 10 – After: Right view
Img. 11 – After: Left view
Img. 12 – Smile make over with 4 indirect restorations
Img. 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
Img. 14 – Before: Right view
Img. 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 felspathic ceramic using a refractory die techinique
Img. 16 – Before: Anterior View
Img. 17 – Smooth prepatation and tissue managment as suggested in the 1st Case
Img. 18 – After: 2 weeks post-cementation view
Img. 19 – Right view after cementation
Img. 20 – Left view after cementation
Img. 21 – Final smile: frontal view
Img. 22 – CASE 3: a 45 year old lady wanted her smile to be enhanced. She had an old PFM crown on 21. Some disatemas, reverse smile line relatively large teeth.
Img. 23 – Before: Right view
Img. 24 – Before: Left view
Img. 25 – A quick direct mock-up to check for relative esthetics when the changes will be made.
Img. 26 – Mock Up: Right view of the smile
Img. 27 – Mock Up: Left view of the smile
Img. 28 – Intra-oral view: Preoperative. One can see the mismatched PFM crown that was encroching on the biological width and also had a discoloured 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.
Img. 29 – Healthy tissues and no discolouration of the gingiva. Preparation and tissue managment
Img. 30 – One Emax/Lithium disilicate crown on 21 and 3 feldspathic veneers on 11,12, 22
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