Galip Gürel applies a direct and indirect mock-up technique to achieve a repeatable and predictable aesthetic outcome in this case study
The demand for aesthetic dentistry is increasing as more and more patients come to desire the perfect smile. Treatment planning in advance, is the key to fulfilling the individual expectations of the patient and to ensure a guided treatment plan with stress-free, repeatable procedures.
A reliable clinical concept should pre-visualise, step-by-step, a final aesthetic outcome that can be shared and discussed with the patient. Before the reconstruction starts, this communication process should produce a definitive aesthetic solution.
Finally, a two-step simulation of form, function and phonetics (using a 90% correct direct and a perfect indirect mock-up) helps to ensure a predictable outcome without time consuming redoing, reshaping or general failure.
All-ceramic restorations are the material of choice to simulate the natural tooth structure. During preparation, the natural tooth, particularly the enamel, should be seen as a precious commodity to avoid harming the patient without any reason.
In addition, being minimally invasive and preparing just the enamel for a restoration raises the success rate of veneers to 99%, because the bond strength to enamel is significantly higher.
The problem starts when the labial enamel gets lost. When the dentine is exposed, the tooth flexes 200% more, transferring stress to the rigid porcelain. As a result, the risk of adhesive failure and fractures is increased dramatically.
This patient, a 50-year-old male, presented to the practice because he did not like the aesthetic appearance of his dentition (Figure 1). In general, he complained about the yellowish colour and irregular position of the teeth in his upper and lower jaws.
Initial photo documentation illustrated several aesthetic problems. The incisal edges of the upper central incisors were at different levels (Figure 2). Due to that, the upper left central incisor was elongated and presented obvious signs of abrasion. The canines were also worn, leading to a loss of physiological guidance.
Due to the position of the upper lip, the smile line showed a harmonious gingival margin and a correct midline on the upper jaw, whereas the lower teeth presented severe overcrowding (Figure 3). Multiple gingival recessions presented generally in the aesthetic zone, except for the left upper incisors.
The central incisors – UR1, UL1 and UL2 – were rotated out of the dental arch. The overcrowded incisors in the lower jaw were generally over-erupted and exhibited tipping and migration. The patient had no functional problems. There was no divergence between the centric condylar position and the habitual intercuspation.
However, the lower teeth definitely needed orthodontic treatment. Functionally, the attrition on the incisal tips of the canines needed to be restored in order to recreate the natural canine guidance.
Figure 1: The patient's smile before treatment started
Figure 2: Close up of maxillary teeth — note the difference in incisal levels
Figure 3: Close up of both maxillary and mandibular teeth — note overcrowding lowers
Direct aesthetic simulation
A very important step in identifying the expectations of the patient and proving the clinical feasibility, is to simulate the aesthetic outcome directly in the mouth. In this case, Ecusphere Shape (DMG) was used, without any bonding procedure, to sculpt the first idea of an optimised aesthetic result.
The consistency of this composite material enables very fast modelling with the fingertip and a spatula.
First, the labial facade was contoured to visualise the aesthetic smile design. After light-curing, the functional incisor-palatal area was simulated with the imprint of the static and mobile occlusion.