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Inside Dentistry
April 2024
Volume 20, Issue 4
Peer-Reviewed

Conservative Treatment to Improve Function and Esthetics

Pre-restorative orthodontics and soft-tissue management enable placement of virtually no-prep veneers

Amanda Seay, DDS

Patients turn to us for professional advice regarding treatment that aligns with their best interests. As clinicians, our role is to offer patients solutions that meet their esthetic goals while ensuring that the treatment provided does not pose additional risks. Challenges can arise when patients are hesitant to undergo recommended treatments, forcing us to decide whether or not to accommodate their wishes in another manner, even if it involves removing more tooth structure, compromising tooth integrity, altering the bonding substrate, or impacting the long-term predictability of the results.

The patient in this case report expressed concerns about the thinning and wearing down of her anterior teeth as well as erosive lesions on the cervical necks, which had previously been bonded with composites. Her desire was to prevent the occurrence of further wear while enhancing her smile through restorative dentistry. Because she had an edge-to-edge bite, retroclined maxillary teeth, and collapsed buccal corridors, addressing this case without orthodontics would necessitate opening the vertical dimension, which would lead to the treatment of more teeth and involve preparation designs to wrap porcelain over occlusal surfaces and functioning cusps, resulting in further reduction of tooth structure.

The patient agreed to undergo pre-restorative orthodontics with clear aligner therapy to establish the correct functional position and allow for veneers with virtually no preparation. The orthodontic plan took the desired thickness of the restorative material into consideration, ensuring an additive approach. After uprighting the teeth and managing their spacing in accordance with the intended smile design, the patient underwent a 3-month retention period, during which records were acquired, a smile wax-up was completed, and she whitened her teeth.

Although restoration primarily focuses on white esthetics, or those of the teeth, it is crucial to consider pink esthetics and address the gingiva and the lips framing the smile. The patient in this case had generally pleasing gingival heights; however, slight crown lengthening was required for the premolars, and the gingival scallops of the maxillary anterior teeth were opened to alleviate the narrowness of their cervical necks. The soft- tissue alteration was performed on the same day, and the bone alteration was completed after placement of the provisional restorations.

Following an evaluation of the patient's tissue health and approval of the smile design, records were sent to the laboratory for the fabrication of the final porcelain veneers. The final restorations, which were seated two at a time under rubber dam isolation, met the patient's expectations and improved her function while respectfully conserving her tooth structure.

About the Author

Amanda Seay, DDS
Fellow
American Academy of Cosmetic Dentistry
Clinical Instructor
Kois Center
Private Practice
Charleston, South Carolina

(1.) Pretreatment full face patient portrait.

Figure 1

(2.) Pretreatment full smile photograph displaying retroclined maxillary teeth and collapsed buccal corridors.

Figure 2

(3. AND 4.) Pretreatment right and left lateral smile photographs showing the tight anterior relationship.

Figure 3

(3. AND 4.) Pretreatment right and left lateral smile photographs showing the tight anterior relationship.

Figure 4

(5.) Full face patient portrait acquired after the completion of clear aligner treatment (Invisalign®, Align Technology) but before the restorative treatment was performed.

Figure 5

(6.) Full smile photograph acquired after the completion of clear aligner treatment but before the restorative treatment demonstrating how the teeth have been uprighted, the buccal corridors are fuller, and there is now room in the anterior to lengthen the teeth.

Figure 6

(7.) Analog wax-up of the smile design of teeth Nos. 4 through 13 (designed by Myung Joo Shin at Synergy Ceramics).

Figure 7

(8.) Retracted maxillary view showing how spaces were created not only to allow room for proper function but also to achieve better width/length proportions with the restorations.

Figure 8

(9.) Tissue recontouring and crown lengthening were performed to achieve ideal gingival scalloping and heights, and the teeth were barely prepared, which resulted in an all-enamel substrate and bright color.

Figure 9

(10.) Provisional restorations (Luxatemp [Bleach Light], DMG America) were placed to permit assessment of the new tooth and tissue alterations in the smile.

Figure 10

(11. AND 12) Right and left lateral smile photographs of the provisional restorations.

Figure 11

(11. AND 12) Right and left lateral smile photographs of the provisional restorations.

Figure 12

(13.) Retracted maxillary view of the provisional restorations. The tissue health as well as the papilla heights, gingival scallop, and gingival zeniths were carefully assessed.

Figure 13

(14.) Full face patient portrait of the provisional restorations to evaluate dentofacial esthetics.

Figure 14

(15.) The final restorations (GC Initial® LiSi, GC America) were delivered two teeth at a time under rubber dam isolation (Dental Dam [heavy gauge], Nic Tone; Brinker Clamps, Coltene).

Figure 15

(16.) Posttreatment full smile photograph demonstrating a longer, fuller smile with proper function.

Figure 16

(17. AND 18.) Posttreatment right and left lateral smile photographs.

Figure 17

(17. AND 18.) Posttreatment right and left lateral smile photographs.

Figure 18

(19.) Posttreatment retracted maxillary view.

Figure 19

(20.) Posttreatment full face patient portrait.

Figure 20

Amanda Seay, DDS

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