|Year : 2014 | Volume
| Issue : 1 | Page : 55-58
Importance of anatomic mock-up for predictable esthetic smile design with ceramic veneers
Manuel S Thomas1, K David2
1 Department of Conservative Dentistry and Endododntics, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India
2 Department of Periodontics, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India
|Date of Web Publication||21-Jun-2014|
Manuel S Thomas
Department of Conservative Dentistry and Endododntics, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Ceramic veneers are considered as an esthetic treatment option for anterior teeth with unusual positions or appearance, as they conserve tooth structure and offer predictable results when planned adequately. Anatomic wax mock-up is an important tool during the phase of treatment planning. It allows the dentist to effectively communicate with the patient regarding the final esthetic result. Esthetic preevaluative temporaries prepared from the anatomic wax mock-up will allow the clinician and the patient to assess the form and contour future restorations to be placed; and its effects on the lip posture, smile line, and function. The mock-up can also help in the fabrication of an index to aid in the conservation of the tooth structure, while veneer tooth preparation and also assist in temporization. The purpose of this case report is to highlight the importance anatomic mock-up for predictable esthetic smile design with ceramic veneers.
Clinical Relevance to Interdisciplinary Dentistry
- The dental and gingival component of the smile can be manipulated to create a beautiful smile.
- A multidisciplinary role between restorative dentist, periodontist, and orthodontist is often required when designing a smile for a patient.
- Anatomic mock-up is an important tool for effective communication between the dentists from various fields, between the dentist and the ceramist, as well as between the dentist and the patient when altering the patients smile.
Keywords: Ceramic veneer, diastema, gingival recontouring, mock-up, smile design
|How to cite this article:|
Thomas MS, David K. Importance of anatomic mock-up for predictable esthetic smile design with ceramic veneers. J Interdiscip Dentistry 2014;4:55-8
|How to cite this URL:|
Thomas MS, David K. Importance of anatomic mock-up for predictable esthetic smile design with ceramic veneers. J Interdiscip Dentistry [serial online] 2014 [cited 2018 Oct 20];4:55-8. Available from: http://www.jidonline.com/text.asp?2014/4/1/55/135014
| Introduction|| |
Abeautiful smile can be a great asset to one's personality. The three main components to a smile include; (1) facial/labial (2) gingival and (3) dental components.  The ease at which these components can be manipulated to design an attractive smile follows a reverse order. The color, shape, proportion, position of the teeth can be worked with to create a pleasing smile.  The gingival architecture can also be modified. A proper white and pink esthetic balance is the key in smile designing.  Three people crucial for accurate smile design include the dentist (usually require the integration of various fields of clinical dentistry), the ceramist/laboratory technician, and the patient itself. A proper communication between these three individuals is vital to success for designing an esthetically pleasing smile. An effective way to communicate about the expected outcome with all the above mentioned characters include the use of anatomic mock-up. 
The restorative materials to modify the dental component of the smile include either dental composite resin or dental ceramics. Ceramics have come a long way after its introduction with respect to its esthetic and physical properties. Pressed lithium disilicate based ceramics have become the choice for many dentists due to its better strength, good marginal fit, and esthetic properties. , Ceramic veneers are preferred in cases where major changes in the color and/or form of the teeth are required as it provides predicable esthetics and is a conservative treatment option.  The case presented in this article demonstrates the importance of anatomic mock-up for designing a functionally effective and esthetically pleasing smile using ceramic veneers.
| Case report|| |
A 24-year-old female patient came with a chief complaint of discolored upper anterior teeth and occasional bleeding from the gums, especially while brushing [Figure 1]a and b. She gave a history of undergoing orthodontic treatment from a private dentist for the correction of diastema and protruded upper front teeth 1 year prior to the current visit. The medical history was noncontributory. The clinical examination revealed discolored composite resin restorations which were placed to close the spaces between upper anterior incisor region and hold the staple pins placed into prepared Class III cavities [Figure 1]c and d. It was assumed that the private dental practitioner had used the composite-staple pin intracoronal splint as a permanent postorthodontic retainer. Radiograph also had revealed a root canal treated right upper lateral incisor. The intraoral examination also showed inflamed marginal gingiva with swollen interdental papilla in the upper anterior region and high frenal attachment.
|Figure 1: (a) Pretreatment image of the patient showing discolored composite restorations in the upper incisors (b) intraoral view showing discolored tooth with infl amed gingiva (c) Intra-oral periapical radiograph (IOPA) showing intracoranal permanent retainer using staple pin placed by a private dentist after inadequate closure of the anterior teeth diastema (d) anterior teeth splinted together with intracoronal staple pins and composite|
Click here to view
Initially, all the composite resin restorations along with the staple pins were removed. The Class III defects between the upper incisors were then restored with composite resin restorations. Oral prophylaxis was performed and proper oral hygiene instructions were given. Once the gingival inflammation had subsided, upper, and lower impressions were taken to prepared diagnostic cast. On the diagnostic cast, anatomic wax mock-up was prepared. As the crown height to width proportion was not adequate, crown-lengthening along with gingival recontouring and frenectomy was performed in the upper anterior region using a soft-tissue diode laser (810 nm, Picasso AMD Lasers) in contact mode with a power setting of 1W [Figure 2]a. After 5 days, an upper impression was again taken to prepare a new anatomic wax mock-up [Figure 2]b. Ceramic veneers were planned for the all the six upper anterior teeth to proportionally redistribute the space. With the help of putty impression (Dentsply Caulk, Milford, DE) the anatomic wax mock-up was transferred into the patients' oral cavity using provisional temporaries (Protemp™ 4; 3M -ESPE, St Paul, MN) [Figure 2]c. These preevaluation temporaries were used to evaluate the esthetics, incisal length, occlusion and phonetics. Once the adjustments were made an impression was made as a reference for the ceramist for fabricating the ceramic veneers. Depth cuts were then placed with the anatomic temporaries in place to achieve minimally invasive and accurate tooth reduction [Figure 2]d. Incisal reduction of approximately 2 mm, followed by the labial reduction after the removal of the temporaries was performed using round end tapered diamond point to achieve a uniform veneer thickness of 0.6 mm labially [Figure 2]e and f. The final rubber base impression was then taken. Temporaries (Protemp™ 4; 3M -ESPE, St Paul, MN) were then placed with the help of the index made from the anatomic wax mock-up.
The shade details, adjusted mock-up, and final impressions were sent to the ceramist for the fabrication of pressed lithium disilicate glass ceramic (IPS e.max, Ivoclar Vivadent). Once the veneers were delivered from the laboratory, they were tried in and evaluated. Once found satisfactory, they were etched (20 s with, 10% hydrofluoric acid gel; Angelus, Londrina, Brazil), rinsed, dried, and silanated (Monobond-S; Ivoclar Vivadent, Schaan, Liechtenstein). The veneers were bonded using the etch-n-rinse technique with the use of a single bond (3M -ESPE, St Paul, MN) and light cured resin cement (translucent shade of Rely X veneer cement; 3M-ESPE, St Paul, MN). The excess cement was initially removed after tack curing and later removed with the help of finishing and polishing burs after final curing. The result was a very pleasing smile with a balanced dental and gingival component [Figure 3]a and b.
|Figure 2: (a) Immediately after gingival recontouring and frenectomy (b) anatomic wax-up (c) preevaluative temporaries prepared from the anatomic wax mock-up (d) placement of depth cuts on the anatomic temporary veneers (e and f) conservative tooth preparation|
Click here to view
|Figure 3: (a) Posttreatment image immediately after cementing the veneers (b) 3 months recall image showing good esthetic outcome and healthy gingival response|
Click here to view
| Discussion|| |
Correction of dental esthetic inconsistencies needs careful evaluation, planning and multidisciplinary approach. Anatomic wax mock-up is one of the most important tools when planning to alter the patient's smile. The various benefits of an anatomic mock-up for smile designing are as follows:
- Diagnostic mock-up allows the clinician to visualize the alterations needed to achieve a pleasing smile and assist him/her in treatment planning 
- The diagnostic wax mock-up can be transferred into the patient's mouth with the help of silicon index and provisional material to fabricate preevaluation temporaries. This will allow the clinician to communicate with the patient regarding the final esthetic result 
- With the preevaluation temporaries in place, the esthetics, the phonetics and even the occlusion can be evaluated and necessary corrections be made 
- Once the size, shape and proportion of the veneers have been finalized by the patient and the dentist, an impression is taken with the preevaluation temporaries in position. This can act as a guide for the ceramist in the fabrication of the ceramic veneers.  This will also aid in the ceramic build-up of incisal edge using the cut-back technique 
- Anatomic wax-up can also be used in the fabrication of a gingival-contour surgical stent, which is used during the crown-lengthening procedure to visualize the proposed final gingival contours at surgery 
- These anatomic temporaries will act as a tooth preparation guide for preservation of tooth structure as in the present case ,
- Lastly, after tooth preparation, the silicon index can be used for the fabrication of temporaries until the final cementation of the veneers.
Diastema or spaces between the anterior teeth is a common occurrence. In adult dentition this could distort an individual's pleasing smile. Orthodontic correction or restorative correction or a combination of both can be used to correct the problem of diastema. The final target to be achieved while correcting the diastema is to achieve good esthetics with harmonious interdental relationship and tooth form, with concomitant emphasis on excellent gingival health and functional occlusion.  In the present case, as orthodontic treatment was once attempted by a private practitioner with disastrous outcome, the patient was reluctant to under a similar modality of treatment. Hence, the treatment option left with was the restorative modality, either with the use of composite or ceramic. Ceramic veneers were considered for the present case as it preserves the tooth tissue and side by side allows the clinician to have maximum control in establishing the color, contour, proportion. In addition, the glazed ceramic surface is said to be kind to the adjacent periodontium.  Pressed ceramic veneers where opted for this case as there was excessive space between the incisors and since extreme characterization was not required. 
The closure of the diastema with veneers can result in mesiodistal enlargement of the teeth. Therefore careful planning with the aid of anatomic mock-up is required to maintain the intra-dental proportion (width to length ratio) and inter-dental proportion (ratio of width of individual teeth in the esthetic zone).  In the present case, as the position of the smile line was satisfactory and since the patient had increased overbite, increasing the tooth length to obtain the ideal width to length ratio of 75-80% for the central incisor was possible only in an apical direction with periodontal procedure.  Crown-lengthening procedure along with gingival recontouring to establish the proper gingival architecture was done using soft tissue diode laser. Frenctomy also was performed as there was an aberrant frenal attachment which could have been a contribution to the midline diastema and hindrance for the patient in proper oral hygiene maintenance.  To attain the ideal interdental proportion (i.e., the golden proportion) by redistributing the spaces between all the upper anteriors, six ceramic veneers from upper canine to canine were given. Thus, with the aid of anatomic mock-up, the esthetics and function as desired by the patient was achieved.
| Conclusion|| |
Ceramic veneers can be considered as a conservative and esthetic treatment option when modifying a patient's smile. This case demonstrated the importance of anatomic wax mock-up in achieving the overall success of smile designing from planning to the final stage.
| References|| |
|1.||Paris JC, Ortet S, Larmy A, Brouillet JL, Faucher AJ. Smile esthetics: A methodology for success in a complex case. Eur J Esthet Dent 2011;6:50-74. |
|2.||Bhuvaneswaran M. Principles of smile design. J Conserv Dent 2010;13:225-32. |
|3.||Bitter RN. The periodontal factor in esthetic smile design - Altering gingival display. Gen Dent 2007;55:616-22. |
|4.||Gürel G. Discovering the artist inside: A three-step approach to predictable aesthetic smile designs, Part I. Dent Today 2013;32:74, 76-8. |
|5.||Gürel G. Discovering the artist inside: A three-step approach to predictable aesthetic smile designs, part 2. Dent Today 2013;32:126, 128-31. |
|6.||Shenoy A, Shenoy N. Dental ceramics: An update. J Conserv Dent 2010;13:195-203. |
|7.||Soares PV, Spini PH, Carvalho VF, Souza PG, Gonzaga RC, Tolentino AB, et al. Esthetic rehabilitation with laminated ceramic veneers reinforced by lithium disilicate. Quintessence Int 2014;45:129-33. |
|8.||Doundoulakis JH, Melnick CS. A strategy for correcting poor anterior aesthetics. A case study. Dent Today 2004;23:96-9. |
|9.||Magne P, Magne M. Use of additive waxup and direct intraoral mock-up for enamel preservation with porcelain laminate veneers. Eur J Esthet Dent 2006;1:10-9. |
|10.||10 Oquendo A, Brea L, David S. Diastema: Correction of excessive spaces in the esthetic zone. Dent Clin North Am 2011;55:265-81, viii. |
|11.||Kosyfaki P, del Pilar Pinilla Martín M, Strub JR. Relationship between crowns and the periodontium: A literature update. Quintessence Int 2010;41:109-26. |
|12.||Haupt J. Pressed ceramics versus layered feldspathic veneers: A rationale for modality selection. J Cosmet Dent 2005;21:110-6. |
|13.||Devishree, Gujjari SK, Shubhashini PV. Frenectomy: A review with the reports of surgical techniques. J Clin Diagn Res 2012;6:1587-92. |
[Figure 1], [Figure 2], [Figure 3]