International Journal of Esthetic Dentistry (EN), 02/2019

This third article in this series (Part III) aims to present new clinical results and long-term follow-up of resin composite inlays and onlays using the modern clinical concepts presented in the Part I and Part II articles. These revised protocols have contributed to eliminating the most frequent difficulties related to the preparation, isolation, impression taking, and cementation of tooth-colored inlays and onlays. This clinical report presents a series of 25 cases of indirect or semidirect inlays and onlays (intra- and extraoral techniques) made of microhybrid and nanohybrid composites with 6- to 21-year follow-ups. The restoration performance was assessed through clinical examination, intraoral radiographs, and clinical photographs. The overall clinical assessment aimed to confirm the absence (success) or presence (failure) of decay or restoration fracture, while the restoration quality was judged on intraoral photographs. The restoration status with regard to margins, anatomy, and color was assessed using three quality scores (A = ideal, B = satisfactory, C = insufficient). Descriptive statistics were used to evaluate the possible impact of composite structure (microhybrid or nanohybrid) or observation time on restoration quality. Over this medium- to long-term observation period, no clinical failure was reported. Only a few restorations (mainly those made of conventional inhomogeneous nanohybrid) presented discrete marginal discoloration (n = 4) or occlusal anatomy change due to wear (n = 7). This first clinical survey with long-term follow-up supports the application of the aforementioned clinical concepts, which thus far have only been validated by in vitro studies.

Cosmetic recontouring based on the enameloplasty of natural teeth is a treatment with esthetic benefits that can be considered both economical and safe. Not only does the clinician need to restore the harmony of the smile, but treatment planning must also take the functional aspects of the restoration into consideration. One way to recontour is through an additive technique with direct composite resin that improves the esthetic outcome of the final treatment. Of the various types of treatment that can be offered in the dental clinic, cosmetic recontouring is a conservative one with low biological and financial cost that obtains good functional and esthetic results. This article describes a clinical case including enameloplasty and the addition of direct composite resin to improve the balance and harmony of the smile and dentition.

It is very common for a dentist to detect white discolorations (WDs) of the teeth. The most common causes for this condition are fluorosis, early caries demineralization, molar incisor hypomineralization (MIH), and trauma or infection of the corresponding primary tooth. In cases of severe enamel discoloration, invasive approaches such as resin composite restorations, ceramic veneers or even crowns are generally chosen. This clinical report describes a combined minimally invasive treatment of a teenager's maxillary teeth affected by fluorosis. Dental bleaching, microabrasion, and resin infiltration were performed. The satisfactory clinical result has made it possible to avoid more invasive and expensive treatments.

Historically, preparations for ceramic veneers have varied from extremely aggressive to a minimal reduction or a lack of preparation. Today, we are moving toward minimally invasive dentistry with the philosophy that less is more. Less tooth reduction means more adhesion and clinical longevity. What must be considered when performing minimally invasive preparations is that in a significant number of cases the dental element will receive a veneer that will modify its final contour. This is quite common in cases of conoid teeth, diastemas or loss of dental structure by abrasion, erosion or attrition. The aim of this article is to present a step-by-step protocol to achieve conservative preparations for ceramic veneers, called the mock-up driven technique. This technique takes into account the final contour desired for the veneer, and results in considerably less invasive dental preparations.

Changing the occlusal vertical dimension (OVD) has been one of the most controversial issues of restorative dentistry. The modification of the OVD may be indicated whenever it is necessary to harmonize dentofacial esthetics, provide space for planned restorations, and improve occlusal relationships. The OVD should not be considered an immutable reference, but rather a dynamic dimension within a zone of physiological tolerance that can be altered as long as the dentist respects the envelope of function. However, vertical changes in the relationship between the maxilla and mandible may have some biological, biomechanical, esthetic, and three-dimensional (3D) functional implications because the initial references of maximum intercuspation and anterior tooth relationships must be reconstructed and adjusted in a new dimension of space. This article aims to present a critical review of the relevant OVD literature and provide the clinical objectives and subjective parameters necessary to guide the clinician and laboratory technician during treatment involving OVD alterations.

Purpose: It can be extremely challenging to replace a hopeless tooth in the maxillary central incisor area with an implant restoration, especially when the bony housing of the tooth is severely damaged. This condition is frequently found in teeth that have been severely traumatized in childhood. To avoid their extraction, these teeth might have been exposed to multiple compromised treatments and repeated traumatic injuries. When skeletal changes cease and implant therapy becomes an option, the surgeon may often find only remnants of the socket walls. This imposes difficulty when regenerating the missing tissues required for long-term functional and esthetic implant restoration. This article describes the unique anatomical, biological, and surgical considerations in the treatment of such a case. Materials and methods: In the reconstruction of a safe bony housing around the implant, obliteration of the incisive canal was followed by the use of bovine bone mineral (BBM) and titanium mesh (Ti-mesh) layered with a crosslinked collagen membrane. The soft tissue was augmented with a xenogeneic soft tissue matrix and further enhanced by a novel technique, the 'radial cuts technique.' Results: Functional and esthetic implant restoration was successfully achieved. Follow-up of the patient took place for 2 years post-implant loading and 3 years post-ridge augmentation, after which the stability of the implant and surrounding tissue was demonstrated. Conclusion: Enhanced functional and esthetic results may be achieved when BBM and Ti-mesh layered with a soft collagen membrane are utilized as augmentation materials in the esthetic zone. The key factors for success in this case were combining the advantages of the different materials with a carefully considered sequence of procedures.

Background: In the maxillary esthetic zone, gingival tissue characteristics play an important role in designing and achieving a beautiful smile. The gingival line, gingival angle (GA), and gingival zenith angle (GZA) can provide an insight into the dimensional soft tissue requisites in procedures involving reconstruction of the papillae and gingival margins. The hypothesis of the present study was that these parameters could be influenced by an individual's gender and age. Purpose: The present study aimed to evaluate the GA, GZA, and gingival thickness (GT) in the maxillary anterior teeth and to correlate these findings with the age and gender of the study patients. Materials and methods: In 160 periodontally healthy patients equally divided into two groups (Group I: 21 to 40 years; Group II: 41 to 60 years) with equitable gender distribution were evaluated for the parameters of GA, GZA, and GT in the maxillary anterior teeth. Results: The mean values of GA and GZA were consistently lower for female patients in both the age groups for the three tooth types - central incisor (CI), lateral incisor (LI), and canine (CA). The mean GT values for females and males in Group I was 1.15 ± 0.21 and 2.56 ± 0.26 mm, while for Group II it was 1.13 ± 0.21 and 2.54 ± 0.27 mm, respectively, indicating the presence of a thick gingival biotype in males. Conclusion: The results of the present study reveal that GA and GZA are greater in males than in females, irrespective of age. A significantly higher GT was observed in males than in females. However, there was no evident direct correlation between GA and GZA or between GZA and GT.

The digital technology can be a GPS in designing a multidisciplinary treatment that involves orthodontics and restorative dentistry. A proper hierarchy of decisions and responsibilities need to be defined. Form is everything but position and size. For this reason the orthodontist first needs to set up the proper occlusion deciding the position and the available size that will be necessary for the restorative dentist to obtain the proper form with a minimally invasive preparation. This case report illustrates with a step-by-step approach all the clinical issues of the treatment, from diagnosis to orthodontic guided position of Tads, materials of choice and laminate veneers realization passing through all the interactions between the dental team members explaining who does what and when and proposing a clear hierarchy of decision. A review of digital and classical possibilities for the realization of laminate veneers is proposed with its pros and cons.