Recreation of Aesthetic Smile by Restoring Form, Function and Aesthetics: A Prosthodontic Approach: A Case Report

Introduction

Smile is the cynosure of one's attractiveness and personality.¹ From antiquity to modern times, the face and its expressions have always played a crucial role as they can greatly affect interpersonal relationships. People are concerned about their joyful smile, the way they feel about it, and its effect on others. A smile, when pleasing and attractive to observers, enriches not only the one who smiles, but also those who view it. Dentofacial aesthetics and psychological wellbeing are the two most crucial factors that play a vital role in day-to-day life of an individual. Dental characteristics that widely drift from the normal may have a negative influence on self-concept, thereby hampering an individual’s career development progress.¹

Numerous studies conducted have revealed that, an appealing smile which influences the facial appearance of an individual imparts composure, well-being, and a favourable outcome in the perceiver. Hence, in addition to the functional aspect, patients who approach the dentists should be provided with an outcome that enhances their aesthetic needs, thereby resulting in an involuntary smile. The dental professional, thus can boost the patient’s smile in a remarkable way, transforming both the soft tissue architecture as well as the shape, colour, position and size of the teeth.²

Interdisciplinary dentistry is a team approach of different specialties on diagnosis and treatment planning and treatment of oral health conditions. It includes various treatment modalities like aesthetic dentistry, conservative dentistry, periodontal management, oral surgery, orthodontic treatment and restoration with dental implants.³ An adequate understanding of the relationship between periodontal tissues and restorative dentistry is of prime importance in order to affirm an appropriate form, function, esthetics, and comfort of the dentition. The procedure of Crown Lengthening (CL) prior to prosthetic rehabilitation becomes mandatory in patients with badly mutilated or grossly decayed teeth due to non-availability of sufficient clinical crown height.⁴ It involves surgical increase in the clinical crown in an incisal-apical dimension for either restorative or aesthetic needs or a combination of both.⁵ Different clinical situations which may include either an irregular smile line, gummy smile, mutilated or fractured teeth or worn out teeth by parafunctional habits like bruxism may require the need for crown lengthening to enhance the prosthetic outcome.⁶

Dental treatment should thus aim at providing functional and aesthetic restoration to the patient with minimum complications and longevity.⁷ Long-term survival of prostheses makes it imperative for the periodontium to remain healthy. Also, there should be harmony of the dental prosthesis with the surrounding periodontal tissues, fostering the health of the periodontium rather than causing undue damage. Considering the impact on function and structure of the teeth as well as determining the needful aesthetic modifications, the dentist will be able to use various specialties in dentistry to provide the highest level of dental care to each patient.³

This case report presents an interdisciplinary sequence of treatment of a young adult female patient with compromised maxillary and mandibular anterior dentition involving extraction of teeth with poor prognosis, aesthetic crown lengthening with osseous contouring, intentional endodontic treatment followed by conventional porcelain-fused-to metal fixed prosthesis to improve function, aesthetics, and dental health.

Case Presentation

A 20-year-old female patient reported to the Department of Prosthodontics and Crown & Bridge, with a chief complaint of unesthetic appearance due to few missing teeth in the anterior region of upper and lower jaws for the past one year (Figure 1). The patient was not satisfied with her smile which created a negative effect on patient’s self-esteem. Extra-oral examination included examination of facial symmetry, lymph nodes, temporomandibular joint which were within normal limits. Medical history did not reveal any systemic condition or disease that would contraindicate the dental treatment. Past dental history revealed that patient had undergone extraction of teeth 11, 31, 41 due to caries and periodontal problems. Intra-oral examination revealed unpleasant shape, contour, size and shape of maxillary and mandibular anterior teeth. Supra eruption of maxillary incisors and canine was also noticed clinically. On further clinical and radiographic assessment, root stumps were seen in relation to 14, 22, 24, 43. There was congenital absence of teeth 34, 44 and also rotation in relation to 32, 42 along with an associated carious lesion as noticed in the digital OPG.

Diagnostic impressions were made with irreversible hydrocolloid and poured in dental stone to obtain diagnostic casts. Diagnostic casts were then mounted on a semi adjustable articulator using facebow and centric interocclusal records. With the aid of mounted diagnostic models, along with clinical and radiographic findings, the treatment plan was formulated. Considering the patient’s age and aesthetic zone of rehabilitation, all-ceramic fixed prosthesis was the preferable treatment option; however, patient did not prefer this due to financial reasons. Implant supported fixed prosthesis could have been another choice for treatment in this case but it was not considered owing to the financial issues of the patient and also the patient presented with a reverse smile line where the treatment outcome was unpredictable. Thus, among the different treatment options presented to the patient, anterior maxillary and mandibular conventional porcelain-fused-to metal fixed dental prosthesis (13-23 and 33-43) was opted by the patient. Written consent was taken for the entire treatment procedure to be carried out. The patient was informed about the surgical, periodontal, endodontic and restorative procedures required and all other treatment alternatives including the differences in costs, the required levels of tooth structure reduction, the expected clinical longevity, the time period necessary to complete the treatment, and the possible aesthetic results were explained.

According to the treatment plan, treatment was initiated with oral prophylaxis of the patient. Extraction of root stumps was done in relation to 14, 22, 24, 43 as per radiographic examination followed by intentional endodontic treatment of 12, 13, 21, 23, 32, 33, 42 due to supra eruption of maxillary incisors, canine and rotation of mandibular anterior teeth which would compromise the prosthetic rehabilitation. Maxillary crown lengthening in anterior region was done with osseous contouring due to the bony prominence of premaxilla which would interfere with prosthetic rehabilitation. In mandibular arch, crown lengthening in anterior region was completed with laser rather than scalpel. The advantage of using a diode laser was that it caused minimal damage to the periosteum and bone under the gingiva being treated, and it has the unique property of being able to remove a thin layer of epithelium cleanly.

After two weeks of healing, maxillary and mandibular anterior teeth were prepared following the standard protocol of tooth preparation for porcelain-fused-tometal fixed dental prosthesis (Figure 2). Temporary crowns were fabricated for both the arches with the help of tooth moulding powder from the diagnostic wax up model and were cemented in place with temporary cement. Patient was kept under observation for few days and since the patient did not report any discomfort and was quite satisfied with aesthetics and function at the recall appointment, the procedures for final prosthesis were carried out.

Temporary crowns in both maxillary and mandibular arches were removed, gingival retraction was done using chemical retraction method and final impressions were made in vinyl polysiloxane impression material. Impressions were poured in die stone to obtain working casts. Facebow record was made and transferred to the semi adjustable articulator followed by jaw relation with centric interocclusal record. Final wax-up was done prior to fabrication of final prosthesis. Copings were fabricated and checked intraorally for marginal accuracy and fit of the final prosthesis. Porcelain layering was done and Porcelain-fused-to-metal (PFM) prosthesis was completed. Bisque trail was done and after minor adjustments, the final PFM prosthesis was glazed and cemented using GIC (Figures 3 and 4).

Postoperative instructions were given to the patient. Follow up was done at an interval of one month. At recall visit, soft tissues were found to be healthy and restorations were in satisfactory function without any complications and the patient was satisfied with the treatment outcome. 

Discussion

The peculiar features of a dentition along with a harmonious soft tissue architecture determines the aesthetics of a smile.² Dental treatment aims to restore oral health, function, and aesthetics with minimal complications and long-term success. In the present clinical scenario, successful oral rehabilitation would not be accomplished only with prosthetic treatment. Therefore, an interdisciplinary treatment approach involving a combination of endodontic treatment, surgical crown lengthening and prosthetic management was required to enhance the treatment outcome.³ Currently various materials and methods for restorative procedures are available and have made it both exciting and confusing for dental practitioners. It should be understood that, limitations exist, and the application of techniques are not universal.⁸

Congenitally or traumatically missing anterior tooth may result in impairment of aesthetics, speech and function. Various treatment modalities are available for replacing anterior tooth which includes implant supported prosthesis, conventional FPD, Resin bonded FPD (RBFPD) or RPD.^9,10 So far various materials have been used for the replacement of missing tooth in the anterior region like zirconia, lithium disilicate, leucite reinforced, alumina and others. PFM crowns can be colour matched to the teeth and are the most common type of crowns used. These crowns are very strong, have a good appearance, and are very reasonably priced. All types of alloys are used. Porcelain can be fused to a standard alloy base which can be comprised of metals such as nickel or chromium, or they can be fused to precious metals such as platinum, silver, or gold. The precious metals cost more than standard alloys. However, in full natural light, the metal base can show through as a shadow in the tooth, especially for front teeth. Also over time, if the gums recede from the crown, the metal base can be seen as a dark line that will show where the crown meets the gingiva.¹¹

On the other hand, full porcelain or full ceramic crowns provide the best natural appearance and are also an excellent choice for patients who have metal allergies. They are most commonly used for anterior teeth, as they have an excellent natural appearance. However, they have poor strength as compared to PFM crowns, are more expensive, and can be prone to chipping or cracking. Thus, in the present clinical scenario, keeping these factors in mind and considering the approval of patient, PFM crowns were fabricated in contrast to full ceramic crowns for anterior aesthetic rehabilitation.¹¹

Nevertheless, to use metal-ceramic systems, the clinicians are quite adequately informed necessitating minimal additional knowledge for their routine use, whereas to use all-ceramic systems successfully, the clinician must have a high level of knowledge both to maximize the aesthetic result and to choose materials appropriately for structural longevity.¹¹ Successful anterior rehabilitation can thus be accomplished with a comprehensive treatment planning taking into consideration the aesthetic and functional parameters.¹²

Happiness is a state of mind. It is brought about by a feeling of well-being, security and confidence in one’s self. The dentist should restore the confidence of the patient by providing the best possible treatment modalities. Thus, the emergence of a pleasant smile is mainly dependent on the skills and knowledge of the dentist.

This clinical report therefore gives an insight into the interdisciplinary approach required for an extensive treatment planning for aesthetic and functional rehabilitation of maxillary and mandibular anterior teeth. A profound knowledge of interrelationship between restorative dentistry and periodontal therapy is thus critical for ensuring harmonization of orofacial musculature.

Conflict of Interest

All authors declare that they have no conflict of interest directly or indirectly in the information or products listed in the paper.