What the Author Did in This Case
This clinical case required orthodontic treatment prior to aesthetic rehabilitation.
Orthodontic Treatment Options:
- Bracket system
- Aligners
Following the diagnostic phase, aligner treatment was chosen due to high aesthetic demands. Treatment duration – 18 months.
Upon completion of orthodontic treatment, fixed retainers were placed on upper and lower teeth.
On molars and premolars, replacement of existing Class I and II composite restorations was necessary.
The final treatment phase included aesthetic rehabilitation using ceramic veneers: 10 veneers on upper teeth and 10 veneers on lower teeth.
Following photo-video analysis of the patient’s face and smile, the following was determined:
- Medium smile line
- Upper tooth visibility – 80%, lower tooth visibility – 30%
- Visibility of two central incisors at rest – 3.5 mm
- Smile width – 10–12 teeth
- Buccal corridors within normal range
Based on this data, the dental laboratory created a Wax-Up (wax model of future teeth).
When planning the future smile design, attention was given to zenith correction to maintain proper tooth proportions. The dental laboratory fabricated a soft tissue correction template for teeth 11, 12, 21, and 22.
The zeniths in this template matched the new design of future teeth. Soft tissue correction was performed within 1–1.5 mm using a plasma knife without flap elevation and osteotomy.
Orthodontic treatment with aligners
Orthodontic treatment of the lower and upper arches was completed
Gingival correction using a template
Gingival appearance immediately following correction
Gingival condition after 4 weeks
Following zenith correction on teeth 11, 12, 21, 22, time is needed for soft tissue stabilization and new biologic width formation.
After 4 weeks, we proceeded to the next phase: using A-silicone, we duplicated the Wax-Up from printed models, creating a silicone key for transferring data to upper and lower dental arches.
Due to minor rotation of teeth 12 and 22, as well as the position of teeth 41, 42, and 32, it was not possible to correctly position the silicone key in the oral cavity without deformation. Before transferring the Mock-Up, preliminary selective grinding of teeth 12, 22, 41, 42, 32 within enamel limits was required. Under infiltration anesthesia, guided by the design, selective grinding was performed.
Selective grinding of teeth 12, 22
Selective grinding of teeth 12, 22, 41, 42, 32
Next, using self-curing bis-acryl composite and a silicone key, we transferred the mock-up of future teeth (Mock-Up) to the upper and lower dental arches.
Mock-Up transfer on upper and lower arches
Using a marking bur (Komet 868B 314018), we performed facial marking of preparation depth, as well as incisal edge reduction. Incisal edge reduction of 1 mm allows the dental technician to create optical effects and conceal the tooth-to-ceramic transition margin.
Mock-Up marking
Next, we removed the Mock-Up – horizontal marks colored with pencil remained on the teeth. Coloring the facial surface of the tooth with pencil enhances contrast between prepared and unprepared areas.
Mock-Up marking
Horizontal grooves remain colored until the desired preparation depth is achieved.
BL3 permanent restorations were planned, so preparation was performed with a 000 retraction cord (Sure Cord) in the gingival sulcus. This allowed more apical displacement of soft tissues and avoided an abrupt brightness transition between the ceramic restoration and the tooth. Teeth were prepared within enamel limits as window veneers with incisal edge reduction.
Retraction with one 000 cord
Before scanning, a second impregnated cord, Sure-Cord 0 was placed (5-minute exposure). This provided horizontal retraction and easy access to preparation margins during scanning.
Retraction with 0 cord (second cord)
The temporary restoration cementation method depends on the final preparation design.
When preserving contact points, achieving proper interproximal retention is challenging.
Before placing the silicone key with self-curing bis-acryl composite, it is necessary to prepare the facial surface of the prepared teeth.
We etched enamel for 15 seconds (2–3 mm) and applied adhesive (without air-thinning or polymerization), then transferred the mock-up of future teeth (Mock-Up), creating temporary restorations by direct method. Excess material was removed after 45–60 seconds, and we waited for complete polymerization.
After removing the silicone template and correcting the gingival area with a scalpel, each tooth was light-cured for 20 seconds.
Enamel etching
Adhesive preparation
Temporary restorations
Ceramic veneers on models
Final Visit – Ceramic Veneer Cementation. The first step was removing temporary constructions and polishing adhesive and bis-acryl residue using Enhance.
After ensuring accurate fit of ceramic constructions and obtaining patient consent, we proceeded with adhesive cementation.
Adhesive Preparation of Ceramic
Ceramic restoration cleaning was accomplished using the air-abrasion technique – 27 μm aluminum oxide powder (Kavo Rondoflex). This is an effective approach for surface cleaning following intraoral try-in.
Tooth appearance following temporary veneer removal
Veneer try-in
Dynamic etching of veneers on refractor with 4.5% hydrofluoric acid for 60 seconds. Exposure for 30 seconds in 96% ethyl alcohol to remove hydrofluoric acid residue.
Ceramic surface silanization to establish internal bonding between restoration and luting material.
ClearFil SE Bond 2 (Kuraray) adhesive system was applied to the silanized ceramic surface, 20-second exposure, followed by air removal of excess. Application of Variolink Esthetic LC luting composite.
To prevent composite cement premature hardening, restorations were stored in an orange light-protective box.
During ceramic restoration cementation, the operative field was isolated using the split dam technique.
Following isolation, air-abrasion tooth preparation was completed with 27 μm aluminum oxide powder (Kavo Rondoflex). Surrounding soft tissues were protected with the LM Gingiva instrument.
Air-abrasion tooth preparation
Tooth appearance following air-abrasion preparation
Adjacent teeth were isolated with Teflon tape to prevent etching gel and adhesive system contact.
Adjacent tooth protection with Teflon
Dynamic enamel etching for 30 seconds. Adhesive preparation was completed using ClearFil SE Bond 2 (Kuraray) system. Spot polymerization of veneers on teeth was performed for 3 seconds, followed by excess material removal with a brush, and in proximal contacts – with floss.
Final polymerization was completed using Air-Block to prevent staining of the tooth-ceramic margin.
Adhesive and luting cement residue was removed with a scalpel, and final polishing of the composite interface was accomplished using air-abrasion technique with glycine Prophyflex Perio Powder (Kavo).
Appearance immediately following cementation completion
Using a multidisciplinary approach (orthodontic treatment), we successfully established a foundation for further prosthodontic treatment.
Occlusion correction provides even distribution of masticatory load, which prevents tooth overload and extends the longevity of prosthodontic restorations.
Final appearance
Smile photos before and after
Photos before and after treatment
Photos before and after treatment
Photos before and after treatment
Conclusion
By enhancing functionality and establishing proper tooth position, we prevent aggressive prosthodontic treatment (preparation) and achieve a natural appearance of future ceramic restorations.
In each clinical case, decisions should be thoughtfully made with involvement of relevant specialists to achieve optimal treatment outcomes. Comprehensive rehabilitations require a multidisciplinary approach.
Involvement of an orthodontist and other specialized professionals in the team is essential for achieving functional, aesthetic, and long-lasting results.
Orthodontic treatment not only addresses structural and functional concerns but also establishes ideal conditions for subsequent treatment (surgical, prosthodontic), ensuring smile harmony and patient health.
