The simple smile makeover

March 21, 2012

When our patients look to make changes in their smiles, it does not always need to be a full mouth rehab. In certain cases, depending on the lip dynamics, four to six teeth may be ideal for a major change in a patient’s appearance. The key to making a change is always about tooth position, shape and color. And each one of these plays a different role in the makeover process.

When our patients look to make changes in their smiles, it does not always need to be a full mouth rehab. In certain cases, depending on the lip dynamics, four to six teeth may be ideal for a major change in a patient’s appearance. The key to making a change is always about tooth position, shape and color. And each one of these plays a different role in the makeover process.

If color is the main concern, we may need to consider a larger amount of restorative work, again depending on the patient’s lip dynamic. But almost always, the starting point needs to be at least 8 to 10 restorations.

When tooth position is the challenge, it is first recommended to use orthodontic opportunities rather than restorative solutions, with the second option being a combination of orthodontic and restorative. The last option when dealing with tooth position is restorative solutions on their own. This option is undertaken with the realization that we will need to make the movements by tooth reduction and replacement material selection.

Case study
In a case such as this one, the patient is unhappy with his smile (Fig. A). As we examine the lip dynamics we can see that even with a large smile our focus becomes the anterior four only (Fig. B). So in this scenario, just the positional change of the anterior four will complete the change.

As always in a case like this, orthodontic treatment was suggested, but it was not accepted by the patient. For us to proceed without orthodontics, we need to be certain the patient understands more tooth reduction will be required to complete the change.

We need to clearly explain that with an orthodontic treatment this could possibly be only a two- to four-unit veneer case, which would mean much less reduction of the natural tooth and much more opportunity for current success and future ability to revisit this with more options in future years.

Let’s be clear, our job is as much about saving tooth structure as it is restoring it. This again needs to be clearly understood by patients, and when it is, it usually convinces them that orthodontically they will have a much better long-term result.

Still with all of this explained, the patient’s decision is for just restorative treatment. With that information in hand, it helps us and our partner clinician to choose the best material options to complete the esthetic tooth position. In this case, because of the reduction necessary, porcelain fused to metal will give us the safest option. The thought process here is that while all ceramic seems to be an optimal restoration in the anterior zone, the amount of reduction and repositioning of the teeth will give us very little support.

In this case, with ceramic to metal, we can and should design the metal substructure to be supportive of the final restoration (Fig. C). As with all esthetic/functional cases, a diagnostic wax up and possible intraoral mock up is a good starting point (Fig. D). This allows us to evaluate our tooth position concept and to adjust our first plan if necessary (Fig. E). Once all this preliminary work is complete, this becomes a simple smile makeover and our focus now shifts to the esthetics.

With the understanding of the amount of reduction needed to be done and our choice of porcelain to metal for support, the case control now switches to the technician’s understanding of contour and color matching (Fig. F). Ceramic margins are used as always when trying to achieve optimal esthetics, and our case is built on a solid tissue cast to help guide the esthetic contours (Fig. G). Our ceramic is built with a standard layering system as read with the photographic information and fitted back to the tissue cast for esthetic evaluation (Figs. H, I). It is useful and interesting at this point to evaluate the light transmission of the porcelain to metal to verify the ceramics’ ability to blend in the oral environment (Figs. J, K).

When and if possible, a try in at this stage is useful, but not always necessary depending on the previous control system. The “Bisque Bake” concept seems silly to me as the previous guideline has not been set. From the technician’s point of view, this try in is about fine tuning and not any major change, especially to the incisal position where our translucencies and effects have already been applied. A major adjustment would basically mean the diagnostics have not been accomplished.

The ceramic restorations are tried in and evaluated for contour and color (Figs. L, M). With this photographic information, we can evaluate and make any slight changes necessary. At this point the final glaze and polish is completed and verified back on the solid cast (Figs. N, O). The final restorations are cemented with a translucent adhesive to allow the ceramic marginal materials to bring light into the supporting root, and our simple smile makeover is complete. Obviously, there is no such thing as a simple restorative case, but with a diagnostic approach and communication, we can simplify to provide a successful esthetic result (Figs. P, Q, R).