cosmetic dentistry_ beauty & science

case report _ smile design and reconstruction I results. The following case report is a clear exam- ple of this kind of management. _Case report A female patient presented to the office wish- ing to improve the health and aesthetics of her maxillary anterior teeth, and had only 15 days in town before returning to her home country. She presented with several defective composite restorations in the maxillary incisors, a slight diastema between the central incisors, with ex- cessive material at the mesial, distal and vestibu- lar surfaces. The patient also wanted her teeth to be whiter. They were greyish, with significant opacity and saturation at the cervical area (Fig. 3). The first appointment entailed determining the patient’s expectations regarding her ante- rior teeth, making study models, capturing photographs (intra- and extra-orally, used for the digital smile design; Fig. 4), and performing a through prophylaxis accompanied by oral hygiene instruction. At the second appointment, we restored the cervical non-carious lesions in the molars and premolars, restored occlusal equilibration to sta- bilise the occlusion, and noted the need to incre- ment the cusps of the maxillary canines, which was originally planned in the digital design. The design was presented to the patient, but she didnotlikethesizeofthecentralincisors,desiring smallerones.Wetookimpressions,andmanufac- tured models and duplicates of the models for fabricating the whitening trays, the digital design of the smile had to be customized. We saw that as in this case the mathematical proportions were not always pleasant to patients. At the third appointment, the teeth were prepared using polyvinyl siloxane rigid patterns to perform as minimal tooth preparation as possible because the teeth were all vital. Use of IPS e.max Press (Ivoclar Vivadent) was indicated using high-translucency ingots in shade BL4 owing to the appropriate colour of the vital preparation of the central incisors, which showed a significant buccal flare (Fig. 5). Based on the distal half of the natural lateral incisors, we chose to use shade 110 (Chromascop) to perform a cut-back and stratification with IPS e.max Ceram (Ivoclar Vivadent) following the marginalsealandtry-in.Wehadtofinishthetooth whitening while fabricating the full-coverage crowns. We took the final impressions and pro- visionalised with bis-acrylic temporary crowns. At the forth appointment, five days later, the whitening was almost complete, the ceramic cop- ings of the pressed crowns were tried in, the mar- ginalsealwasverified,asweretheprimaryanatomy details,andtheapplicationofin-officewhiteningwas continued. Colour selection was performed again and this time we achieved a colour that was more transparent than 110. The teeth showed a definitive greyishaspect,whichwasverychallengingtorepli- cate.Workingcloselywiththelaboratorytechnician was crucial. His coming to the office to meet the patient to assess the details needed to mimic the naturaldentitionwasdecisiveforthefinaloutcome. Following wash preparation cook, IPS e.max Ceram Glaze in shade A1 was applied to saturate the cervical area and lightly applied to the proxi- mal surface. Then the deep dentinal mass struc- tures were powdered with IPS e.max Ceram in shadeA2.Atthestratification,DeepDentinshade A2 was used for the cervical area, shade 110 for the body, transparent blue for the incisal halo, and grey for the incisal edge. Transparent neutral was used to finish it owing to the low value of the teeth, which explains the greyish final aspect. Five days after we had received the glazed crowns, the bleached teeth presented a different surfacelustre,soitwasnecessarytotouchupthat aspect. We were able to both replicate the size the patient had in mind and satisfy the occlusal and anterior guide requirements; however, the di- astemabetweenthecentralincisorsrequiredthat space be redistributed towards the mesial sur- faces of the lateral incisors, where we needed to replace defective composite restorations (Fig. 6). We proceeded with the resin composites in the lateral incisors and canines, all of which should free I 19cosmeticdentistry 2_2013 Fig. 10 Fig. 11 Fig. 8 Fig. 9