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State of the ArtState of the Art

Excellence in Dental Esthetics: A Multidisciplinary Challenge

QDT 2012 3

Today, esthetic restorative dentistry can offer smile reha-bilitations using a conservative approach with minimal re-moval of sound dental structures. The aim of this article is

to demonstrate a multidisciplinary, ultraconservative method of restoring the harmony of the smile.

CASE REPORTThe patient was extremely embarrassed of her smile, resulting in shyness and minimal social interaction. The initial clinical exam revealed diastema, congenitally missing maxillary lateral incisors with the canines located in the lateral incisor positions, and the primary maxillary canines still located in their original positions

also malocclusion.1 Therefore, a multidisciplinary treatment was suggested to restore both esthetics and function.2

Victor Grover Rene Clavijo, DDS, MS, PhD 1

Paulo Fernando Mesquita de Carvalho, DDS, MS 2

Robert Carvalho da Silva, DDS, MS, PhD 2

Julio Cesar Joly, DDS, MS, PhD 2

Luis Alves Ferreira, CDTVictor Humberto Orbegoso Flores, DDS, MS, PhD 4

1 Professor, Advanced Program in Implantology and Restorative Dentistry, ImplantePerio Institute, São Paulo, Brazil.

2 Director, Advanced Program in Implantology, ImplantePerio Institute, São Paulo, Brazil.

4 Associate Professor, Restorative Dentistry, Preventive, and Fixed Prosthodontics, Federal University of Alfenas School of Dentistry, Alfenas, Minas Gerais, Brazil.

Correspondence to: Dr Victor Clavijo, Rua Cerqueira Cesar, 1078 Indaiatuba, São Paulo, Brazil 13330-005. Email: [email protected]

Achieving Excellence in Smile Rehabilitation Using Ultraconservative Esthetic Treatment:

A Multidisciplinary Vision

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Figs 1a to 1e Preoperative situation showing esthetic deficiencies due to diastema, canine location, and presence of pri-mary teeth. Note the discrepancy in the position of the gingival margin.

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Achieving Excellence in smile Rehabilitation Using Ultraconservative Esthetic treatment

Phase 1: Planning

All dental professionals involved in the treatment (or-thodontist, periodontist, master ceramist, and opera-tive dentist) evaluated the clinical case individually to decide which noninvasive procedures were indicated. Next, the four professionals discussed the prognosis and limitations of the case. The master ceramist per-formed a diagnostic wax-up to provide a model of the multidisciplinary treatment. After patient approval, the conservative treatment was then split into three restorative phases: orthodontic, surgical, and restor-ative.

Phase 2: Orthodontics (Figs 2 to 6)

The orthodontic phase began with the analysis of craniofacial growth, radiographs, and study casts. Pri-mary maxillary canines were extracted, and a fixed orthodontic appliance was used to close the diastema between the maxillary central incisors and redistribute the interdental spaces for esthetic rehabilitation. The orthodontic treatment used the following parameters for evaluation: sagittal relationship between the den-tal arches; posterior occlusion; location, shape, and size of the canines; amount of remaining interdental space; and profile and facial skeletal pattern of the pa-tient.3 After orthodontic treatment was finalized, the orthodontic brackets were removed and a removable appliance was used to replace the missing maxillary lateral incisors.

Phase 3: Surgical (Fig 7)

The surgical phase was initiated with esthetic flap sur-gery to reposition the zenith of the maxillary canines and central incisors. On the same day, open full-flap envelope surgery allowed the placement of two im-plants to replace the congenitally missing maxillary lateral incisors (3.3 × 14 mm, Straumann Bone Level Narrow CrossFit, Straumann, Basel, Switzerland). After implant placement, conjunctive grafts were performed to increase the gingival volume, and healing caps were placed. These procedures were necessary to restore the harmony of the pink (gingival) and white (dental) architecture.

Phase 4: Restorative (Figs 8 to 36)

After a period of healing and osseointegration, uncov-ering surgery was performed. The transfer copings were then positioned, and a polyvinyl siloxane (PVS) impres-sion was made to fabricate the working cast. Zirconia abutments and provisional crowns were fabricated to shape the gingival margins to the desired contour.

After the gingival tissues were remodeled and con-toured, acrylic resin impression copings (Duralay, Reli-ance Dental, Worth, Illinois, USA) were fabricated for the implant abutments before the final pickup impres-sion was taken using PVS. Before the impressions pro-cedures, an interocclusal bite registration was taken and the shade was selected.

Two lithium disilicate all-ceramic crowns (IPS e.max Ceram, Ivoclar Vivadent, Schaan, Liechtenstein) were made for the implants, and two feldspathic ceramic fragments (IPS d.Sign, Ivoclar Vivadent) were fabri-cated using the refractory die technique to close the diastema between the maxillary central incisors.

All restorations were checked for fit, marginal adap-tation, and interproximal contacts. The final shade was evaluated using glycerin-based try-in paste (Variolink Try-in, Ivoclar Vivadent), which resulted in the selection of clear translucent resin cement. All restorations were adhesively cemented. The fragments were etched with hydrofluoric acid for 90 seconds, rinsed, and dried. To remove any ceramic debris, additional etching was carried out with 35% phosphoric acid for 30 seconds. All fragments were silanated (Monobond, Ivoclar Viva-dent). The lithium disilicate crowns were also processed as described above, except that the hydrofluoric acid etching was performed for only 20 seconds.

The ceramic fragments were simultaneously bond-ed to etched enamel using light-polymerized dental adhesive (Excite, Ivoclar Vivadent) and a clear translu-cent light-polymerized resin cement (Variolink II, Ivo-clar Vivadent). Facial and palatal ceramic overcontour-ing was removed with a high-speed fine diamond bur, followed by polishing with intraoral ceramic finishing and polishing points. After cementation of the ceramic fragments, the lithium disilicate ceramic crowns were adhesively cemented to the zirconia implant abut-ment. The zirconia abutments were silanated (Mono-bond Plus), and dual-cured resin cement was used for bonding (Variolink II). Occlusion was checked, and the patient was dismissed.

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Fig 2a Orthodontic appliance in place.

Fig 2b After 24 months, note the recov-ery of space required for prosthetic reha-bilitation of the maxillary lateral incisors.

Figs 3 Facial view after completion of orthodontic treatment.

Figs 4a to 4d Extraoral views of the smile after orthodontic treatment.


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Figs 6a to 6c Incisal views of the maxillary anterior teeth.

Figs 5a to 5e Intraoral views of the maxillary anterior teeth after orthodontic treatment. Note the asymmetry of the gingival margins and the diastema between the central incisors.

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Figs 9a and 9b Placement of the transfer guides.

Figs 8a and 8b A minimally invasive surgical procedure was performed to expose the implants.

Figs 8c to 8e Placement of the transfer copings.

Figs 7a and 7b Clinical appearance 2 months after implant placement at the maxillary lateral incisor sites.

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Figs 10a to 10d PVS impression procedure.

Fig 12a Machined pillar and prefabri-cated zirconia abutment [Au: “pillar” = implant?].

Fig 12b Phosphoric acid applied for 60 seconds.

Figs 12c and 12d Application of Metal-Zirconia Primer (Ivoclar Vivadent).

Fig 12e Application of the adhesive (Multilink, Ivoclar Vivadent) into the zirconia abutment.

Fig 11a Transfer copings and analogs. Fig 11c Placement of the transfers and analogs on transfer guides captured by the mold.

Fig 11b Insertion of the transfers into the analogs.


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Fig 13a Cementation of the abutment (Multilink).

Fig 13b Removal of excess cement.

Fig 13c Finishing of the bonded inter-face.

Fig 13d Abutments after cementation (Luiz Alves Ferreira, CDT).

Figs 14a to 14c Provisional restora-tions and abutments.

Fig 14d Abutments on the cast.

Fig 14e Acrylic resin guide for abut-ment placement.

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Fig 15a Removal of the healing cap.

Figs 15b to 15e Guided insertion of the abutment.

Fig 16a Soft composite resin sealing of the screw access hole.

Fig 16b Light polymerization.

Fig 16c PVS impression of the abut-ment.

Figs 17a to 17c Provisional restorations 3 months after placement.

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Figs 19a to 19d Shade selection: (a) VITA Classical Shade Guide (VITA Zahnfabrik, Bad Säckingen, Germany) with different hues, chromas, and values; (b) same image in grayscale; (c) detail view of the central incisors; (d) detail view of the central incisors with increased saturation.

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Fig 18a After healing, note the condition of the soft tissue prior to final impression procedures.

Figs 18b to 18d Impression copings.


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Fig 20a Clinical try-in of the ceramic fragments (Luiz Alves Ferreira, CDT).

Figs 20b and 20c Interproximal contact verification.

Fig 20d Positioning of the ceramic fragments.

Fig 20e The try-in procedure (Variolink II) resulted in the selection of translucent resin cement.

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Fig 21a Ceramic fragments prior to bonding.

Fig 21b Hydrofluoric acid etching for 90 seconds.

Fig 21c Intaglio aspect after hydroflu-oric acid etching.


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Fig 22a Application of phosphoric acid for 30 seconds to remove etched ceramic debris.

Fig 22b Ceramic fragments after phos-phoric acid cleaning.

Fig 23a Application of silane for 60 seconds (Monobond).

Fig 23b Application of bonding agent (Excite).

Fig 24a Prophylaxis of enamel surfaces before bonding with pumice slurry.

Fig 24b Enamel etching for 30 seconds.

Fig 24c Application of a two-step etch-and-rinse adhesive (Excite).

Fig 24d Evaporation of the solvent and thinning of the bonding agent.

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Fig 25a Ceramic fragments bonded with transparent resin cement (Variolink II) before light polymerization.

Figs 25b to 25d Removal of excess resin cement with (b) an artist brush, (c) cot-ton pellets, and (d) dental floss.

Fig 25e Bonded ceramic fragments were light polymerized for 60 seconds per surface.

Fig 26a Demarcation of the line angles and margins.

Figs 26b and 26c The ceramic/enamel margins were finished with a fine dia-mond bur to remove ceramic overcontouring.

Fig 26d Intraoral ceramic polishing cups were used to polish the margins.

Fig 26e Clinical appearance immediately after cementation, finishing, and pol-ishing of the ceramic fragments.

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Figs 27a to 27c Lithium disilicate all-ceramic crowns for the maxillary lateral incisors (Luiz Alves Ferreira, CDT).

Figs 28a and 28b Intaglio etching with hydrofluoric acid for 20 seconds, fol-lowed by cleaning with phosphoric acid for 30 seconds and silane application.

Fig 28c Application of the bonding agent (Excite) before adhesive cemen-tation with dual-cured transparent resin cement (Variolink II).

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Fig 29a Intraoral view after cementation.

Fig 29b Transillumination of the crowns and ceramic fragments.

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Figs 30a and 30b Close-up views of the maxillary lateral incisors showing adequate gingival contours and emergence profile around the implants.


QDT 2012 17Fig 32a and 32b Proper balance of shade, contour, form, and occlusion was obtained.

Figs 31a to 31c Clinical follow-up after 16 months.31c

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QDT 2011 18 Figs 33 to 36 Final result.

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Achieving Excellence in smile Rehabilitation Using Ultraconservative Esthetic treatment

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CLAVIJO ET AL

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DisCUssionAlthough alternative treatment options were available for this clinical case, the chosen technique guaran-teed the preservation of sound dentition. Orthodontic mesialization of the teeth with intrusion and extrusion could also have been performed; however, the final esthetic outcome would not be the most desirable.4 Conversely, a mesiodistal and facial-palatal alignment of the maxillary canines is completely different from that of the maxillary lateral incisors, which hinders smile esthetics and may contribute to bite overload during chewing.3 Correct positioning of teeth and maxillary bone allows for better lip support and smile esthet-ics.2 The distalization of the maxillary canines ensured restoration of anterior guidance and occlusal function along with the esthetic rehabilitation.4,5

Treatment planning is the key to treatment success. Using a combination of three different treatment phas-es, no reduction or preparation was necessary, and the dental structures remained intact. The diastema was closed using an additive approach via the adhesive ce-mentation of ceramic fragments.6,7 Recent advances in bonding techniques for both teeth and ceramic guar-antee the clinical success of this type of restoration.

After adhesive cementation of the ceramic frag-ments, minimal facial or palatal overcontouring was observed. This overcontouring must be removed by finishing and polishing at the ceramic-enamel inter-face. High-speed fine diamond burs under copious water-cooling can be used to adjust the ceramic inter-face. Next, intraoral ceramic polishing rubber points were used to minimize roughness and restore smooth-ness until achieving a surface analogous to the glazed ceramic.6 Ceramic fragments bonded to unprepared enamel present very few disadvantages; nonetheless, communication between the clinician and technician is fundamental to obtain an acceptable result.6

ConClUsionThis article presented the successful multidisciplinary treatment of a patient with severe esthetic and func-tional deficiencies. Multidisciplinary treatment plan-ning can provide patients with high-quality noninva-sive treatment that results in superior esthetics.

ACknowlEDgMEntsThe authors thank Luis Alves Ferreira, CDT, and Dudu Medeiros for the facial photography of the patient.

REfEREnCEs1. Kokich OV Jr. Congenitally missing teeth: Orthodontic manage-

ment in the adolescent patient. Am J Orthod Dentofacial Or-thop 2002;121:594–595.

2. Davis NC. Smile design. Dent Clin North Am 2007;51:299–318.3. Rosa M, Zachrisson BU. Integrating esthetic dentistry and space

closure in patients with missing maxillary lateral incisors. J Clin Orthod 2001;34:221–233.

4. Oquendo A, Brea L, David S. Diastema: Correction of excessive spaces in the esthetic zone. Dent Clin North Am 2011;55:265–281.

5. Okeson JP. Management of Temporomandibular Disorders and Occlusion, ed 5. St Louis: Mosby, 2003.

6. Rads MG. Minimum thickness anterior porcelain restorations. Dent Clin North Am 2011;55:353–370.

7. de Andrade OS, Kina S, Hirata R. Concepts for an ultraconser-vative approach to indirect anterior restorations. Quintessence Dent Technol 2011;34:103–119.

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