ABSTRACT

In the modern competitive society, a pleasing appearance often means the difference between success and failure in both personal and professional lives. As the mouth is one of the focal points of the face, the smile plays a major role in how we perceive ourselves. Esthetic or cosmetic dentistry strives to merge function and beauty with the values and individual needs of every patient. In this case report, esthetic rehabilitation has been done to correct an un appealing smile due to improper frenectomy.

KEYWORDS

esthetic, laminate, diastema, ceramic veneer, frenectomy

INTRODUCTION

The philosophy of esthetic dentistry can be defined as the process of providing the most convincing natural dentition possible, while maintaining it to the highest of standards.Owing to the vast  improvements in dental technology, materials and techniques, most of the procedures that were thought to be primarily cosmetic have been found to be quite durable as well. The conservative restoration of unaesthetic anterior teeth has been revolutionized by the introduction of laminate veneers.1,2

Minimally invasive preparation designs and modern ceramic materials make this treatment option increasingly conservative to the natural tooth structures, while providing both predictable and long-lasting aesthetics. All-ceramic veneers guarantee color and translucency close to those of the natural tooth as well as fulfilling the need for adequate retention, while preserving maximum remaining tooth structure.3

CASE REPORT

A 24 year old female presented to us with a desire to improve her unaesthetic facial appearance due to ‘gaps’ present between her front teeth. On clinical examination it was found that the central incisors were in labioversion, presence of a midline diastema with a prominent band of fibrous tissue between 11 and 21, mesial rotation of 23 and a mesioincisal fracture in relation to 21 (Fig. 1). She also gave a history of frenectomy performed during childhood As the patient was unwilling for long term fixed orthodontic therapy, a cosmetic procedure was planned for improvement of her appearance.

PROCEDURE

The treatment plan was divided in three phases to be carried out in three visits.  

1st visit – fabrication of study models

Diagnostic impressions were made( Plastalgin ) and 2 study models were fabricated for a comprehensive treatment planning. As the patient’s chief concern was midline diastema, one set of study models was used for wax up of the central incisors alone (Fig. 2). However, it was noticed that the teeth looked too large in this treatment plan. On the 2nd set of study cast, mock preparations were done in relation to 11, 21, 12, 22 and 23. Diagnostic wax up was done distributing space evenly among all the teeth according to the individual tooth size (Fig. 3).
2nd visit – tooth preparation and temporization

During the patients 2nd visit, the models were presented to the patient who agreed for the 2nd treatment plan. Surgical excision of the fibrous band was carried out to avoid impingement of the veneer over the muscle. Tooth preparations were carried out in relation to 11, 21, 12, 22 for porcelain laminates and 23 for a complete coverage crown. The veneer preparations started with placement of depth cuts. The veneer margins were then established using long, tapered medium grit diamond to prepare definitive chamfer 0.3 to 0.4 mm deep at the gingival margin. Tooth contacts were removed, more from the distal aspect as compared to the mesial aspect, and the entire gingivo-proximal definitive chamfer margins were established. Facial preparation was then done around 1mm for facial enamel. Adequate facial reduction allows for better matching with adjacent crowns and to prevent over contouring the veneer. The incisal edges were reduced 1mm, 30o toward the lingual surfaces in relation to 12, 21 and 22 and 0.5 mm in relation to 11. This lingual angulation prevents porcelain fracture and better finish line to finish the porcelain. After that, the preparations were checked to ensure no undercuts exist or any sharp line angles. (Fig. 4) Endodontic therapy of 23 was done due to the labial rotation of the canine causing inadvertent exposure of the pulp during tooth reduction (Fig. 5). Polyvinyl siloxane impressions ( Aquasil ) were made, shade matching ( Vita ) was done followed by fabrication of temporary crowns ( DPI tooth coloured self cure ) which were cemented using non eugenol temporary cement. Master casts were contructed (Fig. 6) and the patient was recalled after 3 days for final cementation.
3rd visit – final cementation

Pressable ceramic (IPS EMPRESS ) individual laminates and crown were fabricated. During the 3rd visit of the patient, the laminates and crowns were treated with silane . The teeth were etched with 40% orthphosphoric acid using a microapplicator tip and the laminates and crown were luted using dual cure luting resin cement (ESPE). Post cementation instructions were given. ( fig. 7 and 8)

DISCUSSION

A diastema is a space seen most often between the maxillary incisors. At some stages of dental development it is normal to have one, but it eventually closes during further development. Campbell et al stated that midline diastema could be transient or created by developmental, pathological or iatrogenic factors.4 In this case, the persistence of the low attached maxillary labial frenum which could be seen as a pendulous attachment was responsible for the the midline diastema. thus, in our case, an attempt was made to remove the etiology followed by a restorative procedure.

Current esthetic treatment modalities for anterior dentition enable the clinician to address specific clinical situations. Laminate bonding is indicated for a combination of mild to moderate anomalies of color, position, and form of the teeth. If the esthetic problem is limited to contour, cosmetic reshaping of the teeth might suffice.

Porcelain laminate veneers (PLVs) have become the alternative to composite restorations ceramic crowns and the traditional porcelain-fused-to-metal.5 Smiles can be transformed painlessly, conservatively and quickly with dramatic, long-lasting results with the successful use of the porcelain laminate veneer. Porcelain veneers are now the restorative choice for esthetics in numerous clinical circumstances that would have resulted in the use of full crowns in the past. Tissue response is excellent, and the finished surface is very similar to the natural tooth. Veneers exhibit natural fluorescence  and absorb, reflect, and transmit light exactly as does the natural tooth structure. Patients are highly enthusiastic about these restorations that represent a conservative treatment that enhances patient self-image.6 The subsequent introduction of special acidetching techniques improved the long-term retention of veneers.7-9 Horn 10 and Simonsen and Calamia,11 increased interest in porcelain veneers. They were influential in demonstrating that the bond strength of hydrofluoric acid-etched and silanated veneer to the luting resin composite is generally greater than the bond strength of the same luting resin to the etched enamel surface.12

The longevity of composites is questionable as they are susceptible to discoloration, marginal fractures and wear. Consequently, any esthetic result requiring long-term durability will be compromised, while porcelain veneers are superior in esthetic quality and longevity. The biocompatibility and nonporous surface of the porcelain that prevents plaque adherence has increased its popularity and usage. Furthermore, the applicability of the supragingival preparation technique, used in most veneer restorations, ensures excellent periodontal health. As a result, the porcelain laminate veneers have an important role as a solution to both functional and esthetic challenges.

Adequate tooth preparation for porcelain veneers is necessary because inadequate preparation results in inferior esthetics. Better colour matching can be achieved by carrying preparation over the incisal edge taking in consideration the crown translucency. Method of cementation and shade selection of the luting resin cement could also have an effect. Medium to high viscosity resin luting agent is highly recommended because this type of cement will provide superior esthetics for light scattering.13 Pressable ceramics were used which had the following advantages – a) safe, b) highly esthetic, c) less work time, d) firm fit, e) long term success, f) large indications.

The field of esthetic dentistry has expanded dramatically in the last two decades. Various restorative materials and application techniques have been developed to achieve optimal aesthetics. The aesthetics of anterior restorations and the health of the surrounding tissues are primary determinants of the successful outcome of a clinical procedure. However, esthetic treatment planning should be based on scientific data to fulfill the obvious ethical requirements.14,15

Figure Legends

Fig 1	Fig 2	Fig 3
Preoperative photograph	Diagnostic wax up involving closure of the diastema	Diagnostic wax up involving anterior 5 teeth

Fig 4	Fig 5	Fig 6	Fig 7 & 8
Correction of the frenectomy and preparation of the teeth	Endodontic therapy done in relation to 23	Fabrication of the master cast	Post insertion photograph

References

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