International Journal of Esthetic Dentistry (EN), 01/2008

Numerous esthetic deficiencies may be present in natural, restored, or orthodontically enhanced smiles. The most frequent defects are transposed anterior teeth following aplasia, existing or remaining diastemas, form abnormalities and discolorations, abrasion, erosion, and dysplasia. Conservative treatment modalities such as enamel recontouring, bleaching, microabrasion, and resin composites have the potential to correct or improve esthetic problems. These treatments deserve more attention because they have tremendously improved in practicability, efficiency, and predictability. The search for a perfect smile should not always lead to invasive solutions such as veneers and crowns, since invasive treatments may have a negative impact on the long-term tooth biomechanical behavior and global treatment cost. This article discusses the treatment rationale for the use of nonrestorative and additive procedures and their respective indications in a comprehensive approach to dental esthetics.

Traditionally, a full-mouth rehabilitation based on full-crown coverage has been the recommended treatment for patients affected by severe dental erosion. Nowadays, thanks to improved adhesive techniques, the indications for crowns have decreased and a more conservative approach may be proposed. Even though adhesive treatments simplify both the clinical and laboratory procedures, restoring such patients still remains a challenge due to the great amount of tooth destruction. To facilitate the clinician's task during the planning and execution of a full-mouth adhesive rehabilitation, an innovative concept has been developed: the three-step technique. Three laboratory steps are alternated with three clinical steps, allowing the clinician and the laboratory technician to constantly interact to achieve the most predictable esthetic and functional outcome. During the first step, an esthetic evaluation is performed to establish the position of the plane of occlusion. In the second step, the patient's posterior quadrants are restored at an increased vertical dimension. Finally, the third step reestablishes the anterior guidance. Using the three-step technique, the clinician can transform a full-mouth rehabilitation into a rehabilitation for individual quadrants. This article illustrates only the first step in detail, explaining all the clinical parameters that should be analyzed before initiating treatment.

The recession of the gingival margin is becoming a more prominent condition in the oral situation of many patients and should be treated at its earliest detection. The multifactorial etiology, decision modality, and current trends in the treatment of gingival recession are discussed in this article. The surgical technique of choice depends on several factors, but among the different surgical protocols available, the clinician should select one that will minimize surgical trauma and achieve predictable esthetic results. All of the approaches described in this article can effectively treat deep and shallow Class I or II buccal recessions. Recently, as an alternative to autogenous gingival grafts in root coverage procedures, enamel matrix derivative (Emdogain) and acellular dermal matrix allograft (AlloDerm) were utilized to correct these gingival defects, negating the morbidity and the requirement for a second palatal surgical procedure. Emdogain or AlloDerm materials used alone or in combination are a predictable treatment for root coverage, are relatively easy to perform (although they are technique sensitive), present low patient morbidity, offer a significant increase in the percentage of root coverage and amount of keratinized tissue, and should be part of the periodontal plastic surgery armamentarium.

There are many options with respect to materials, construction methods, and design concepts for the technical implementation of implant-supported dental prostheses. Different methods of anchorage can be used to attach removable superstructures to implants. Telescopic crowns make it possible to fabricate inexpensive superstructures with precise and passive fit. Computer-aided design/computer-assisted manufacture (CAD/CAM) technology allows copings to be fabricated from materials such as zirconia or titanium. Moreover, CAD/CAM crown copings can serve as a base for fabricating customized ceramic replacement teeth. Different veneering techniques, such as pressed-on ceramics for zirconia cores, ensure a fast and economic work process. With the use of electroforming it is possible to manufacture highly precise secondary structures that ensure passive seating of the prosthesis in a stable position. This article demonstrates a restorative treatment option using current techniques with the aim of rehabilitation with an esthetic and functional implant- supported removable denture.