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Dental TribuneAsia Pacific Edition | 3/2016 12 TRENDS&APPLICATIONS Diagnostic wax-up Inordertopreviewtheexpected outcomeandguidethetreatment, adiagnosticwax-upwasprepared. On the model, the incisal edges of both central incisors were located on the palatal side of the red line (wet–dry border) of the lower lip; hence, the position of the incisal edgeswastobeshifted2mmtothe labial side. Furthermore, in order to improve the patient’s deep overbite and large overjet, we de- cided to shift the incisal edges of the maxillary central incisors by 2 mm in the vertical direction, where the lip–teeth relationship could still tolerate changes pa- latally. According to the varied gingivalsulculardepth,inorderto protecttheconnectiveepithelium of the gingival sulcus, the top of the gingival line of the maxillary right lateral incisor, maxillary rightcentralincisorandmaxillary left central incisor would be shifted in the apical direction by 2.5 mm, 0.7 mm and 2.5 mm, re- spectively. The entire restoration wouldbeinclinedtothelabialside by 1.5 to 2 mm so that the palatally inclined roots would not inter- fere with the aesthetic outcome (Figs.9–14). According to the diagnostic wax-up, two silicone indices were fabricated. One of the indices was cut in the labiolingual direction to guide the preparation of the abutment teeth. The margin of the prostheses was designed to be placed 0.5 mm subgingivally (Figs. 15–17). The provisional re- storations would be fabricated ac- cording to the other silicone index, in which the improvement of the aesthetic outcome could be ob- served clearly. However, the shape of the provisional restorations was not designed to emulate the erupted natural teeth, but for the cervical part of the restorations to coverthelabialgingiva.Afteralong period of remodelling and reshap- ing, the form of erupted natural teeth would be established (Figs.22 & 23).The impressions for the post and cores were taken at the same time. Because the restorations were labially inclined, a gold alloy post and cores was chosen. Shaping the gingival contour The patient attended a follow- up two weeks after placement of the provisional restorations. At that time, the intra-oral examina- tion showed recession of the gin- giva and exposure of the shoul- ders on the labial side of both tooth #21 and tooth #12 (Fig. 24). The margins of tooth #11 could also be observed and the gingiva was healthy. At this appointment, the post and cores were placed andfurthertoothpreparationwas carried out to shift the margins in the apical direction. The new pro- visional restorations were fabri- cated to increase the convexity of the cervical part in order to enhance the effect of the gingival contour shaping. In accordance with the patient’s wishes, the in- cisal edges of the crowns were extended slightly by about 1 mm (Figs.25–27). After another two weeks, the patient returned to our clinic and examinationfoundthatthegingi- val contour had changed notice- ably and the reconstruction of the transmucosal gingival contour was almost complete. The gingiva around the restorations was healthy (Fig.28). The transgingival parts of the restorations were modified and the incisal edges were shortened in keeping with the patient’s wishes. Two weeks after the new pro- visional crowns had been placed, the patient returned to our clinic forfurthertreatment.Atthattime, the patient expressed her satis- faction with both the gingival contour and the position of the incisal edges (Fig. 29). Once the provisional crowns had been removed, the gingival contour around the abutment teeth was similar to the soft-tissue collar around dental implants. The final impression was taken in order to fabricate the master model, which would replicate the gingival con- tour accurately (Figs. 30–32). The finalall-ceramicrestorationswere fabricatedaccordingtothemaster model. Completing the final restorations Once the final restorations had been completed, the clear trans- gingival contours of the crowns could be seen and were consistent with the shape of the gingival col- lars around the abutment teeth on the master model (Figs. 33–35). During the try-in procedure, the marginal fit, the shape and the contact points, the consistency of the transgingival contours of the restorations and gingival collars around the abutment teeth were examined carefully. The transgin- gival contours of the restorations should maintain the shape of the gingiva, but not increase the pressure, allowing the gingiva to remain healthy and maintaining the contour in the long term (Figs.36–39). Revisits The one-week follow-up after placement of the final restora- tions found that the gingiva was healthy and stable around the crowns. When compared with the preoperative intra-oral photo- graphs, the aesthetic outcome was a significant improvement (Figs.1,3,40–43). The patient unfortunately did not attend the remainder of the follow-ups until seven years after placementofthefinalrestoration. At this appointment, the exami- nation revealed an undesirable oral health status, with a Debirs Index (+) and Dental Calculus Index (++). The gingiva was mildly reddened and swollen. However, the health of the gingiva around teeth #21, 11 and 12 was better than around any other teeth. Around teeth #21 and 12, the gingiva was healthy and the gingival contour was stable without noticeable gin- gival recession. Around tooth #11, slight gingival recession was 45 46 47a 47b Fig.25: Gold alloy cast post and core.—Figs.26 & 27:The second provisional restorations with advanced gingival contour remodelling.—Fig.28:Two weeks after placement of the second provisional restorations with advanced modification.—Fig.28: Four weeks after placement of the second provisional restorations.The gingival contour and the shape of the crowns were satisfactory.—Fig. 30: Once the second provisional restorations had been removed, the ideal gingival contour could be observed.—Fig. 31: The gingival collars of the abutment teeth.—Fig.32: Regular shoulders did not form around teeth #12 and 11.—Fig.33:The restorations showing remarkable transgingival convexity.—Fig.34:The transgingival contour of the restoration was closely matched to the gingival collars on the model.—Fig.35: Restoration showing remarkable trans- gingival convexity.—Fig. 36: The transgingival contour of the restoration was closely matched to the gingival collars on the model.—Fig. 37: The final restoration seated on the maxillary anterior dental arch.—Fig.38: Left lateral view of the patient’s smile after placement of the restoration.—Fig.39: Right lateral view of the patient’s smile after placement of the restoration.—Fig.40: One-week post-op photograph of the maxillary anterior teeth.—Fig.41: Frontal view of the patient’s smile after treatment.— Fig. 42: One-week post-op photograph of the left lateral view of the patient’s smile.—Fig. 43: One-week post-op photograph of the right lateral view of the patient’s smile.—Fig. 44: The gingiva around teeth #21, 11 and 12 was healthier than the gingiva around any other teeth.The photograph was taken seven years after restorative treatment.—Figs.45&46: Theseven-yearfollow-upshowed that thegingivaof theanteriormaxillary teethwashealthy.—Figs.47a&b: Whencomparing theseven-year post-op photograph (left) to the immediate post-op photograph (right),the gingival contour and position around teeth #21 and 12 were evidently stable. 41 42 43 44 37 38 39 40 33 34 35 36 29 30 31 32 25 26 27 28 Tooth preparation and provisional restoration DTAP0316_10-13_Liu 04.03.16 11:58 Seite 2 4546 47a 47b 41424344 37383940 33343536 29303132 25262728 DTAP0316_10-13_Liu 04.03.1611:58 Seite 2