Aesthetics in Prosthodontics – Making the Most of a Difficult Situation

6 Nov 2017 - 19530

In our daily practices, we are facing a wide range of aesthetic issues which we have to provide with prosthodontic restorative treatments in order to solve the different pathologies of our patients.

Out of all our cases, among the most challenging ones are the situations in which we have to treat teeth that have an aesthetic importance, especially the upper frontal group, because of the social and emotional involvement for our patients, and the technical challenge of doing everything 100% in an unforgiving area.

These particular situations become even more demanding in case of retreatment, where from an emotional point of view we have an unsatisfied patient with high expectations, and from a technical point of view we have to treat dental tissues that have been tempered. 

Regardless of the extent of the treatment, it is these cases that we have to treat extra carefully, tune our patients expectations, focus our abilities and use the best tools available in order to achieve the best outcome possible.

Fig. 2

Because of the high gummy smile, we can expect that any small issue of the final result, will be extremely visible and unforgiving.

Fig. 3

Intraoral aspect of the initial situation.

Fig. 4

Before making any plans on the aesthetic outcome, we have to ensure the health of the periodontal tissue, so that we can see the actual central incisors zenith level.

Fig. 5
Fig. 6

The old crowns have been removed carefully to prevent any damage to the dental abutments.

Fig. 7
Fig. 8

The crown removal reveals the over prepared dental abutments.

Fig. 9

After further cleaning of the remaining  cement and the placement of a retraction cord, we can see sub-gingival preparations, with different submerge levels, being much deeper in the proximal areas of the abutments.

Fig. 10

After this initial analysis we can expect a difficult case of preparation, provisionals, impression and luting.

 

Fig. 11

The abutments have been rebuilt using composite, and have been reprepared at the same cervical height as the initial preparations.

Fig. 12

Direct provisionals were made in the same appointment.

Fig. 13

The 1 month recall shows improvement of the gingival health, with reduced inflammation and no bleeding on probing. We now know that it is a good time to proceed with the crown lengthening procedure, in order to bring the 2 centrals at the same gingival level.

Fig. 14

A surgical guide was used for the crown lengthening procedure. The procedure was performed by Dr. Bogdan Baldea.

Fig. 15

In the same meeting, the preparation buccal limit of 2.1 was placed more apically, at the same level as 1.1.

The provisional crowns were remade.

Fig. 16

The 1 month recall shows a good stabilisation of the new gingival level of 21.

Also the medial part of the lateral incisors was reshaped using direct composite by Dr  . Silvana Canjau  in order to better distribute the existing frontal spaces. Although we offered the possibility to close the diastema, the patient felt it was part of her personality and decided to keep it.

Fig. 17

As we know, one of the most important issues we have to take into consideration to obtain a precise impression, is the fluid control and the periodontal status. The periodontal tissue looks healthy and we can start the impression procedure for the final restorations.

Fig. 18

After inserting the first retraction cord, that was impregnated with aluminium chloride, we also performed electrosurgery and applied retraction paste, in the hope that we will have clear finishing lines, and a good control of the fluids.

Fig. 19

But, despite our best efforts, we were unable to obtain the proper conditions for a predictable impression. In cases such as this, the best choice is to postpone the impression, redo or refinish the provisionals, to try to offer the periodontal tissue the best conditions to heal.

Fig. 20

In 2 weeks time, we can clearly see a much better situation, with healthy periodontal tissue.

Fig. 21

But there still are some areas of concern because the deep margin preparation, especially in the proximal areas.

Fig. 22

In order to better expose the deep margin of the preparations, the double cord technique was used. This implies the use of a retraction cord that is placed in the gingival sulcus for vertical retraction of the gingiva and that will remain there. and a second cord that is partially placed in the sulcus for horizontal retraction and is removed right before the impression.

Fig. 23

We can see the difference between margin exposure with one cord.

Fig. 24

And after the removal of the second cord.

Fig. 25

There are many impression techniques that we can use to send the information to the laboratory, but for many reasons, I find the most reliable one is the one step technique, in which you apply both the putty and fluid at the same time.

One of the conditions that must be met, in order to have good results with the one step technique, is that the consistency of the putty material must be as low as possible. this allows the fluid impression material to make a precise registration, without being pushed aside by the putty material.

Another factor that should be taken into consideration when selecting the impression material is the working and setting time. In the one step technique the longer the working time, the better.

One of the best materials I have ever used, that meets these requirements is Honigum from DMG.

It has the most flowable putty that I worked with. Usually, good flowable properties for the putty materials means that it has less dimensional stability. This is not the case with Honigum, because of patented rheologically active matrix from DMG that manages to perfectly balance and overcome these compromises.

Thanks to DMG snap-set technology, Honigum exhibits long working time and fast set time. This makes it easy to use and comfortable for the patient.

Fig. 26

Margin control of the impression shows good registration of the abutments.

Fig. 27
Fig. 28

The impression cord that came out with the impression was cut in the sections were it was loose.

Fig. 29

The laboratory all ceramic lithium disilicate final restorations made by dental technician Adi Gherman.

Fig. 30
Fig. 31

At the try-in, we checked to see if the final restorations met the dimensions and shape that we established with the provisionals, by placing the two restorations next to each other.

Fig. 32

Final restorations try-in.

Fig. 33
Fig. 34

I find LM Arte Fissura instrument most useful at the try-in for margin control and to check the fit of the restorations.

Fig. 35

Isolation for the adhesive procedure. Variolink Esthetic DC from Ivoclar was used for the luting of the final restorations.

Fig. 36

Two weeks recall.

Fig. 37

New emergence profile will ensure long term gingival health.

Fig. 38

Comparison between the initial situation.

Fig. 39

And the final aspect of the smile.

Fig. 40

The smile of a satisfied patient, makes all the effort worthwhile.

 

Conclusions

The upper frontal group of a patient with a gummy smile is an unforgiving area, were we have to put our best skills in use for the best outcome possible.

Thanks to DMGs snap set technology, and long working time, we can take precise impressions, even in the most difficult situations.

A precise impression helps us provide not only a beautiful smile, but a long lasting, reliable result as well, due to a perfect fit of our restorations.

Bibliography

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Huang CSomar MLi KMohadeb JVN. Efficiency of Cordless Versus Cord Techniques of Gingival Retraction: A Systematic Review. J Prosthodont. 2017 Apr;26(3):177-185.

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