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Inside Dentistry
November 2018
Volume 14, Issue 11

Treating a Biologically and Esthetically Deficient Smile

A multidisciplinary approach utilizing periodontal, orthodontic, and restorative modalities

Jack Ringer, DDS

There are many challenges that need to be addressed and overcome when the dentist is confronted with both biologic and esthetic deficiencies. Success or failure can hinge on the communication between the patient and the practitioner, which must be comprehensive and include a discussion of all of the risks and benefits of each treatment option. Cases such as these involve not only what the patient "needs," but also what they "want." Typically, it is easier and more predictable to treat needs as opposed to wants, because this does not require the practitioner to "get into the patient's head." Understanding and providing what the patient wants requires an added dimension in treatment planning, involving expanded communication, smile design, and a complete understanding of the principals of esthetics.

Once the deficiencies have been identified and all possible treatment options have been discussed, a definitive treatment plan can be selected. At this point, it is critical for the clinician to engage in a proper protocol that includes smile design, diagnostic wax-up, thorough and complete coordination with any referring specialists (ie, periodontist, orthodontist, laboratory technicians, etc), conservative tooth preparations, accurate provisional restorations, and proper ceramic cementation and finishing.

Typical esthetic deficiencies include issues involving tooth color, gingival tissue asymmetries, and the proportion and position of the individual teeth. Biologic concerns typically involve dental or periodontal disease, malocclusions, or tempromandibular irregularities. Unfortunately, many patients have had the misfortune of presenting with more then one of these deficiencies in the anterior region of their upper arch. Correcting biologic deficiencies while also achieving a high level of esthetics can be a complex process and may require a multidisciplinary approach. Therefore, it is essential for clinicians to thoroughly review all treatment options with patients in order for them to be able to make an informed decision. In addition, it is essential for general practitioners to know their limitations and when to refer their patients to a specialist.1-4

Presentation and History

A 35-year-old female patient (Figure 1) presented to the office in good general health, and with the exception of the presence of primary tooth D, her historical dental condition was stable and asymptomatic (ie, dentition, periodontal tissues, occlusion). Her chief complaint was with the esthetics of her upper anterior teeth (Figure 2 through Figure 4).

She stated that she was unhappy with the color, symmetry, and shape of her upper front teeth and that she was finally ready "to let go of her baby tooth." Having done her own research about the options for replacing missing teeth, she was adamant that wearing a removable appliance or sacrificing tooth structure to manufacture a fixed partial denture was unacceptable. To achieve her desired esthetic outcome, she preferred to evaluate options that would result in a natural-looking and long-lasting smile utilizing the most conservative approach possible.

Clinical Evaluation

A complete diagnostic workup was performed on the patient, which included a full series of digital radiographs, a muscle and joint evaluation, intra- and extraoral digital photographs (Nikon D700 Camera System, Nikon Inc.), diagnostic study models, a Kois dentofacial analysis, a visual evaluation, and a computer simulation depicting the expected esthetic outcome. A template was designed and this, along with other desired esthetic specifics, were forwarded on to the computer simulator in order to create an accurate digital preview. The complete clinical examination revealed an absence of any general dental, periodontal, or muscle abnormalities; therefore, the focus of the evaluation was shifted to assess the appearance of the upper and lower anterior teeth. The biologic or "needed" aspect of her treatment was confined to the removal of her deciduous lateral, followed by replacement with a biologically healthy and esthetic restoration (ie, implant, abutment, crown). The esthetic or "wanted" aspect of her treatment was to correct the size, shape, and symmetry of the upper anterior teeth in the region of teeth Nos. 7 through 10, along with the general color of her upper and lower anterior dentition.

The comprehensive examination revealed that tooth No. 7 was congenitally missing. Her deciduous tooth D was occupying the site, and its clinical crown was significantly smaller than a typical permanent lateral incisor. In the visible smile zone (ie, teeth Nos. 5 through 12), the gingival architecture was normal in appearance and health with the exception of the asymmetry associated with tooth D and teeth Nos. 8 and 9 (although one could also argue that there was a slight buccal corridor deficiency). Radiographically, there were no abnormalities present among the dental or periodontal structures except for the excessive root resorption and class II mobility associated with tooth D (Figure 5). It was also noted that, due do to the discrepancy in the dimensions of the upper anterior teeth, a slight malposition had resulted with diastemas between teeth Nos. 5 through 12 (Figure 6). Lastly, it was noted that the upper and lower teeth exhibited a general, yellow stained appearance as a result of normally absorbed stains (Figure 7). The patient stated that she was not a current or former smoker and that her diet did not consist of staining foods (eg, blueberries, excessive coffee or tea).

Smile Design

Engaging in any esthetic dental therapy requires a "blueprint." Therefore, after compiling and evaluating all of the gathered diagnostic information, a 2-dimensional template design (Figure 8) and computer simulation (Figure 9) were created to develop a "preview" of the proposed smile to be discussed with the patient. The template design is created with a simplistic program that allows one to draw out the shape and position of the proposed teeth. Once the template design is finalized, a realistic computer simulation can then be created. There are various methods available to create a simulation, but the most accurate way involves manipulating the digital preoperative photograph's pixels using a program such as Adobe Photoshop. If the clinician is skilled in this area, he or she can do this personally; however, this task is more commonly outsourced to computer simulation companies (eg, Virtual Smiles®). The accepted 2D design was then forwarded to the laboratory technician, who used it to manufacture a 3-dimensional design (ie, diagnostic wax-up) based on the patient's esthetic desires and clinical condition (Figure 10). Because it is totally noninvasive and relatively inexpensive, the creation of a digital blueprint in comprehensive esthetic cases results in a "no harm, no foul" scenario. The blueprint can be continuously modified until the patient accepts the design. In order to accurately identify any esthetic deficiencies and to be successful in creating these smile design blueprints, it is necessary that the dentist possess excellent communication skills and be well versed in all of the elements of smile esthetics (ie, tooth form, position, color; gingival architecture; etc).1-3,5,6

Treatment Plan

After reviewing the proposed smile design with the patient, all potential treatment options were discussed and a definitive treatment plan was formulated. The patient stated that she was happy with the proposed smile design, but desired one minor modification. She requested that the gingival tissue associated with her upper laterals be positioned slightly more coronally in order to retain what she felt was a more natural appearance. Although this position was not ideal in terms of soft- and hard-tissue relationships, it is the dentist's responsibility to deliver what the patient wants, provided that the patient's desires will not inhibit biologic function or result in other oral health consequences.

Following the acceptance of the proposed treatment plan, the dentist, orthodontist, periodontist, and laboratory ceramist engaged in thorough communication in order to ensure that the treatment would be predictable and consistent throughout every phase.

First, the patient would be referred to an orthodontist to align teeth Nos. 6 through 11 in order to equalize the root emergence, minimize the gingival asymmetry, and balance the interdental spaces. Although a very slight buccal corridor deficiency existed, the patient, did not want to address it; she was quite happy with the arrangement of her teeth except for the upper anterior segment.

Upon completion of the orthodontic treatment, the patient would be referred to a periodontist for extraction of her deciduous lateral (ie, tooth D), followed by the placement of an endosseous implant in the tooth No. 7 site. To optimize the symmetry of the gingival architecture, any necessary residual gingival recontouring would be performed simultaneously.

Once the osseointegration was complete, the esthetic restorative therapy would be delivered. This would involve, first, bleaching the upper and lower dentition, followed by the fabrication and placement of an all-ceramic crown on the previously placed implant for tooth No. 7 and porcelain laminate veneers on teeth Nos. 8 through 10, whose esthetics would be made to be harmonious with the surrounding dentition and consistent with the accepted smile design.2,7-9

Treatment Description

Prior to beginning orthodontic treatment, the patient completed an at-home bleaching regimen (Opalescence, Ultradent Products, Inc.). She had a baseline shade in the Vita 3D-MASTER2m2 range, and upon completion of bleaching treatment, she achieved a result in the Vita 3D-MASTER 1M1.5 range. Following a consultation with the orthodontist to convey the treatment plan and all compiled diagnostic information, therapy was initiated to align the patient's upper anterior teeth and balance the interdental spaces associated with teeth Nos. 7 and 10. Because her overall occlusion was well within normal limits, the orthodontist felt that the therapy required to align her upper anterior segment would be minimal. The orthodontist placed a fixed arch wire and predicted that adequate repositioning of the teeth could be achieved in approximately 90 days. After three months of the orthodontic therapy, the patient's upper anterior dentition was properly aligned, her interdental spaces were balanced, and she was cleared to proceed with the periodontal phase of treatment.

Prior to starting the periodontal therapy, the periodontist was consulted and a surgical stent to assist in the placement of the implant and the gingival recontouring was designed from the approved diagnostic wax-up, manufactured by the laboratory, and delivered. The patient underwent extraction for tooth D, ridge augmentation, and placement of a 3.5 mm implant (Astra Tech Implant System, Dentsply Sirona). During the procedure, the desired gingival architecture was developed utilizing the surgical stent. A prefabricated, esthetically acceptable acrylic flipper was provided to replace tooth No. 7 while the implant went through its integration and healing process. After 14 weeks, the periodontist exposed the implant in order to place an abutment and a custom manufactured, screw-retained resin provisional crown. This step was necessary to allow the gingival tissue around the provisional to remodel, establishing a normal emergence profile.8,9

Following a 6-week healing period, the gingival tissue had remodeled sufficiently to exhibit a normal emergence profile with the provisional, and it was stable enough to proceed with the final restorative phase. The upper anterior segment was anesthetized (The Wand®, Milestone Scientific, Inc.), and teeth Nos. 8 through 10 were prepared for very conservative porcelain laminate veneers. A final impression (Impregum, 3M ESPE) was taken of the prepared teeth and the implant using an analog implant impression coping. Taking a digital impression is also an option when doing this type of therapy, but it will require a scan body to be used in place of the analog impression coping in order to capture a digital image (or a healing cap for implant systems that utilize "encoding"). Custom resin provisional veneers (Protemp® 3 Garant®, 3M ESPE) were placed on teeth Nos. 8 through 10, and the previously fabricated provisional abutment and crown were screwed into position. The impression, bite registration, and shade selection information, as well as photographs of the prepared teeth, stump shade, and the accepted provisional, were sent to the laboratory along with a model of the accepted provisional teeth and length of the proposed central teeth (Figure 11). The patient was scheduled to return once the ceramic fabrication was completed.

Because all of the restorations were to be placed in the esthetic zone, material selection needed to be based not only on what would be most predictable biologically with a good long-term prognosis, but also on what would achieve a superb esthetic outcome. Feldspathic porcelain (Super Porcelain EX-3, Kuraray Noritake Dental Inc.) was selected for the outermost layer of all of the restorations because its properties allow for the creation of lifelike esthetics. However, feldspathic porcelain has a low flexural strength (ie, approximately 100 MPa) and should not be allowed to extend more then 2 mm from the natural tooth surface if unsupported.

Strength and esthetics were required for all of the restorations; therefore, the abutment for tooth No. 7 was cast in gold and layered with ceramic to closely match the dentin color of a prepared tooth in this position (Figure 12). This would help optically connect the crown with the abutment. The full coverage crown was manufactured from a pressed leucite-reinforced ceramic (Authentic®, Microstar Dental, LLC.), which, due to its physical properties, has sufficient strength (ie, approximately 170 to 250 MPa) to withstand the functional forces generated in the anterior segment. Lithium disilicate ceramics (eg, IPS e.max®, Ivoclar Vivadent), which possess strengths ranging from approximately 450 to 500 MPa, could also be used in this restoration. To maximize the esthetic outcome, the pressed leucite-reinforced ceramic was cut back (ie, approximately 0.3 mm to 0.5 mm facially and approximately 1.0 mm incisally) and layered with conventional feldspathic porcelain in shade A1++. The restoration for tooth No. 10 was also manufactured with pressed leucite-reinforced ceramic and then cut back and layered with feldspathic porcelain in shade A+. This was done because orthodontically balancing the interdental spaces resulted in the presence of large diastemas (ie, greater then 2 mm) around tooth No. 10, and it was decided that it would be more predictable to have a strengthened ceramic supporting the outer layer of feldspathic porcelain. Teeth Nos. 8 and 9 would only require a minimal (ie, 0.3 mm to 0.5mm) amount of reduction during preparation, so these teeth would be definitively restored using only feldspathic veneers (Figure 13 through Figure 15). Due to the minimal preparation, the restorations would be bonded exclusively to enamel; therefore, there would be no need for an underlying strengthened ceramic to support the feldspathic porcelain.4,10-12

Once the final restorations were delivered to the practice, the provisional restorations were removed, and the prepared teeth were thoroughly cleaned using pumice and water to remove any residual debris or resin. The custom abutment was placed on the implant and torqued till appropriately stable. The crown was tried in, and a radiograph was taken (Figure 16) to confirm the fit. With the implant crown in place, the porcelain laminate veneers were then tried in and wet with water to confirm their fit, contacts, and optical connection with the surrounding dentition and the implant crown. When color adjustments are necessary, it is always easier and more predictable to make those modifications to the crown then the veneers. No modifications were necessary in this case, so the crown for the implant was then luted using a resin-modified, dual-cure cement (RelyX Unicem, 3M ESPE). Next, the three veneers were bonded into place using a bonding protocol for conservative preparations. Because the preparations were extremely conservative and remained entirely in the enamel, the teeth were etched with a 37% phosphoric acid for approximately 30 seconds, then thoroughly rinsed and air-dried. Following this, a thin layer of resin adhesive (Single Bond Universal, 3M ESPE) was applied to the teeth as well as the intaglio surfaces of the porcelain laminate veneers and air-dried. To complete the protocol, a translucent, light-cure resin cement (RelyX Veneer Cement, 3M ESPE) was applied to the intaglio surfaces of the veneers and then they were placed on the teeth and cured for 1 minute each using an LED curing light (Elipar FreeLight, 3M ESPE). The excess cement was removed using tungsten carbide carvers and a No. 12 scalpel and any necessary occlusal adjustments were made. After the final radiographs and preliminary final photographs were taken, the patient was dismissed. Approximately 3 weeks later, the patient returned for a postoperative evaluation and to receive any necessary adjustments or polishing. At this time, the tissue appeared normal and healthy and no issues were detected that required intervention. After another 4 weeks of healing, the patient returned for final photographs (Figure 17 through Figure 22).4,7,10-14


When treating patients who present with multiple deficiencies in their esthetic zones, such as gingival asymmetry, malpositioned teeth, deficient tooth size, color and shape issues, and missing dentition, dentists are presented with many challenges and obstacles. However, a natural-looking, predictable, and long-lasting result can be achieved by following a proper protocol involving codiagnosis with the patient, smile design, diagnostic wax-up, custom provisional restorations, and thorough communication with the laboratory and any other specialists involved. In this case, the patient stated that she was ecstatic with the outcome of the therapy. Her surgical and restorative experiences were without incident, and she felt quite comfortable and satisfied during the healing and provisional period. With the current advancements in dental materials, techniques, and technology, dentists have a plethora of options to treat patients who want and need a beautiful and biologically sound smile.


The author would like to thank Erik Haupt, for his incredible ceramic manufacturing skills; Michael Arzouman, DDS, for his exceptional periodontal therapy; and Evelyn Maruko, DMD, MS, for the beautiful orthodontic result.

About the Author

Jack Ringer, DDS
Private Practice
Anaheim Hills, California
American Academy of Cosmetic Dentistry
International Academy forDental-Facial Esthetics


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