An aesthetic, minimally invasive restoration

Dr Carlo Massimo Saratti

Tue. 9. January 2024

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A 42-year-old male patient presented to our practice hoping to improve his smile. He was conscious of the worn dentition of the maxillary anterior sextant and some posterior teeth. This situation had led to exposure of a significant area of dentine, which had created a high level of sensitivity and negatively affected the aesthetics of his smile in the anterior region (Fig. 1). He also presented with some crowding and a Class III molar relationship that had resulted in some modification to the occlusion, a tendency to a Class III incisor relationship and an edge-to-edge bite (Fig. 2).

The patient had undergone partial restoration at another clinic two to three years before, but treatment of the mandibular molars, mandibular right second premolar and maxillary left first premolar remained incomplete. The patient’s request was to maintain the restorations already delivered if they were still in good condition.

Treatment

The first step was to increase the vertical dimension of occlusion (VDO) by placing occlusal veneers on the abraded and eroded teeth, especially teeth #17–14, 25–27, 34, 35 and 44. A digital impression was taken with the DEXIS IS 3800W intra-oral scanner (Dental Imaging Technologies Corp.) of the increased VDO with the jaws in centric relation and stabilised with a posterior occlusal jig (Fig. 3).

Figs. 2a-e: Initial intra-oral photographs.

Fig. 2b-c.

Fig. 2d.

Fig. 2e.

Fig. 3: Digital impression of the occlusion.

The restorations were designed on exocad software (Fig. 4), and lithium disilicate was chosen for their fabrication (Fig. 5). The restorations were bonded adhesively in the patient’s mouth. After the increasing of the VDO, the patient’s anterior occlusion was ideal for restoration of anterior guidance. It was therefore necessary to provide the patient with orthodontic treatment (Fig. 6). After the orthodontic treatment had been completed, the incisal edges of the mandibular incisors were restored directly with composite (Fig. 7).

Figs. 4a–f: Design in exocad for posterior restoration.

Figs. 4c–d.

Figs. 4e–f.

Fig. 5a &b: Vertical dimension of occlusion augmentation.

Fig. 5b.

Figs. 6a & b: The situation pre- and post-orthodontic treatment.

Fig. 7a-d: Direct composite restoration of the mandibular anterior sextant.

Fig. 7b.

Fig. 7c.

Fig. 7d.

Subsequently, the final aesthetic wax-up of the anterior sextant was completed in order to ultimately validate the aesthetic restoration and to guide the minimally invasive preparation of the maxillary crowns (Fig. 8). The final preparation was guided by the mock-up (Fig. 9) and, for the most part, was limited to the interproximal areas (Fig. 10). After that, we took a final digital impression of the anterior crowns after displacement of the gingiva with retraction cord (Fig. 11).

Figs. 8a & b: Anterior wax-up.

Figs. 8c-e: Anterior mock-up.

Fig. 8d.

Fig. 8e.

Figs. 9a–f: Guiding grooves for preparation.

Figs. 9d–f.

Figs. 10a–c: Situation after preparation.

Figs. 11a & b: Digital impressions of the maxillary anterior crowns.

Fig. 11b.

For the digital design, limited reduction of the inferior half of the buccal surface of the monolithic restorations was performed in order to allow stratification of porcelain for achieving the best possible aesthetic result (Figs. 12 & 13).

Fig. 12: Thickness control.

Fig. 13: Final design (with space for anterior stratification).

Figs. 14a & b: Final restorations.

Fig. 14b.

Figs. 15a & b: Adhesive procedures.

Fig. 15b.

Ultimately, the final restorations (Fig. 14) were bonded adhesively in the mouth under dental dam isolation (Fig. 15). The patient was followed up several weeks after the cementation (Figs. 16 & 17).