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16 Dental Tribune Middle East & Africa Edition | November-December 2014Aesthetics Dr. Kostis Giannakopoulos DDS, PhD Assistant Professor, AEGD Program Director European University College Dubai Health Care City Ibn Sina Building, No. 27 Block D, 3rd Floor, Office 302 P.O. Box 53382, Dubai – UAE Email: Kostis.g@euc.ac.ae Contact Information Figure 15 - 17: The smile of the patient after completion of the treatment appears significantly improved esthetically. Figure 18 - 21: Retracted and palatal view of the case completed. Figure 10: After removal of the orthodontic devices the spaces are properly distributed. Note the gingival asymmetries. Figure 13: After ZOOM whiten- ing the smile appears signifi- cantly brighter. Figure 11: Immediately after the periodontal surgery the gin- gival improvement is apparent. Figure 14: An e.max press crown and an e.max press Maryland type all ceramic bridge with wings are fabricated. Figure 12: CBCT radiograph verifies that there is not ad- equate bone to place an implant and a GBR procedure would be needed. < Page 13 make it easier to distinguish and completely remove it after the orthodontics was completed. Af- ter treatment, the goals set were accomplished (Figures 7-9). Surgical phase As stated previously, the dental team decided to align the in- cisal edges of #11 and 21 and not intrude further #11 to align the gingival zeniths. This deci- sion was based on the fact that the teeth showed no signs of wear, in which case the worn tooth would be intruded more to be back in its original pre- wear position and then would be treated restoratively. The goals of the periodontal surgery were: 1. align the gingival zeniths of teeth #11 and 21, 2. gingivec- tomy with osseous reduction on #12 to reduce as much as possi- ble the gingival display without compromising the long term prognosis of the tooth due to loss of periodontal support, 3. gingi- vectomy in mostly all the upper teeth to bring the gingival dis- play to a more pleasing appear- ance. After surgery, a healing period of 8 weeks was recom- mended by the periodontist be- fore the restorative procedures start (Figures 10, 11). The option of a single implant placement for the missing lateral incisor #22 was rejected before surgery, as an additional bone grafting procedure would be required and this was not accepted by the patient (Figure 12). Aesthetic/Restorative phase Six weeks after the periodontal surgery, in office whitening was performed so the patient’s desire for brighter teeth is met (Philips Zoom, Philips Oral Healthcare, Stamford, USA). The shade of the teeth 10 days after the whit- ening was completed was A1 for the upper centrals and A2 for the canines (Figure 13). After proper healing of the peri- odontal tissues was confirmed with the periodontist, tooth #12 was prepared for an all ceramic lithium disilicate crown and teeth #21 and 23 were prepared for an all ceramic lithium disili- cate Maryland type bridge with wings (e.max, Ivoclar Vivadent, Schaan, Lichtenstein). The latter was selected because of the con- servative approach and the min- imal preparation required only on the palatal surfaces of the abutment teeth, as the occlusion was favorable and the patient had no parafunctional habits. This type of restoration appears to be a viable solution in select- ed cases, as it does not have the problems of the conventional Maryland bridge with frequent debondings and the metal show- ing through thin and translucent central incisors. After gingival retraction with a retraction paste (Astringent Retraction Paste, 3M ESPE, Seefeld, Germany), a final impression was taken with poly- ether heavy and light body im- pression material (Permadyne, 3M ESPE, Seefeld, Germany) on a full arch metal tray. The bite registration was recorded and an alginate impression was taken of the opposing dentition. Temporization was performed conventionally for #12 with an adjusted and relined prefabri- cated acrylic crown and for the abutment teeth #11 and 23, with spot etching in the middle of the preparations and clear from the margins and pink composite so it could be distinguished easily when removed before try-in so it did not affect the sit of the resto- ration. A temporary for #22 was added in the Essix orthodontic retainer after a denture tooth was fitted on the model and glued in the retainer. After the restorations were fabri- cated (Figure 14) and the tempo- raries were removed, they were tried in and the fit and contacts were verified. Another try in was performed with a glycerin based paste (KY Jelly) so that the shade, contour and surface texture were assessed and ap- proved by the dentist and the pa- tient. At the same appointment the restorations were bonded after the porcelain was etched with 9% hydrofluoric acid and silanated (Ultradent Products Inc, South Jordan, UT, USA), and the teeth cleaned with pumice. A 3 step etch and rinse adhe- sive (All Bond 2, Bisco, Schaum- burgh, IL, USA) and a dual cure resin luting cement (Duolink, Bisco, Schaumburgh, IL, USA) were used. Spot curing was per- formed and excess cement was removed and after light curing for 60 sec each surface, the ce- ment was left for 5 additional minutes to complete the chemi- cal cure mode as well. Final finishing, adjustments of occlu- sion and polishing were per- formed with finishing diamonds (KOMET, Lemgo, Germany), rubber points (Astropol, Ivoclar Vivadent, Schaan, Lichtenstein) and finishing strips (Soflex, 3M ESPE, Seefeld, Germany). Fi- nally, a diamond polishing paste was used (Ultradent Products Inc, South Jordan, UT, USA) on a Flexibuff (Cosmedent, Chicago, IL, USA). An alginate impres- sion was taken to fabricate a new Essix orthodontic retainer in the in-house lab within 1 hour. Oral hygiene and mainte- nance instructions were given to the patient and a follow up ap- pointment was scheduled after 4 weeks (Figures 15-21). A multidisciplinary approach in treatment planning and per- formance, as well as the use of contemporary restorative mate- rials and techniques allow for a conservative, yet very aesthetic final result. References 1. Managing congenitally miss- ing lateral incisors. Part I: Ca- nine substitution. Kokich VO Jr, Kinzer GA, J Esthet Restor Dent 2005;17(1):5-10 2. Prevalence of peg-shaped maxillary permanent lateral in- cisors: A meta-analysis. Hua F et al. Am J Orthod Dentofacial Or- thop. 2013;144(1):97-109 The Author would like to thank the Orthodontist, Dr. Evita Ia- kovidi and the Periodontist, Dr. Alexis Bakopoulos for their con- tribution to the treatment of this case.