International Journal of Esthetic Dentistry (EN), 03/2021

Aim: To investigate whether different restoration designs, overlay types, and full crowns in posterior teeth have similarly acceptable marginal sealing and quality. Materials and methods: For Part 1 of the present study (investigation of fracture resistance), 70 extracted molars were divided into five groups (N = 14), prepared with four different posterior indirect adhesive restoration (PIAR) overlay design types, according to the adhesthetics classification. The groups were: 1. Butt Joint; 2. Full Bevel; 3. Shoulder; 4. Full Crown; 5. Sound Tooth. For Part 2 of the study (present article; marginal quality), there was no group 5, and only 56 of the 70 extracted molars were used. Seven expert dentists performed all the preparation and cementation phases with codified protocols. A CAD/CAM workflow was used to realize the 56 monolithic lithium disilicate restorations. The samples were tested with thermomechanical loading (TML) and the marginal quality evaluated. The data relating to fracture resistance are presented in Part 1 of this study (Int J Esthet Dent 2021;16:2–17). Results and conclusions: In terms of marginal quality after TML, within the limitations of the present study, in molar teeth (without endodontic treatments) restored with different monolithic ceramic lithium disilicate PIAR designs, it is possible to present the following conclusions:

The injectable composite resin technique is a minimally invasive and purely additive procedure that uses a transparent silicone index and flowable composite resin to translate the restorative plan from the wax-up to the final restoration. Its minimally invasive nature means that it can preserve tooth structure as it may not require hard tissue reduction. It is also an indirect/direct molding technique that allows the clinician to perform a direct restoration based on a proper analysis and planning. This case report describes a simple case of reshaping the maxillary lateral incisor and maxillary first premolar of a 25-year-old female patient to close the buccal corridor and restore smile symmetry. Digital planning was used to make a biocopy of the contralateral incisor to mimic the restoration. A printed model was prepared based on the design of the digital wax-up, followed by an analog protocol. Shade selection was challenging due to the high translucency of the incisal edges. This article is a step-by-step description of the injectable composite resin technique. It also compares this technique with other treatment options such as ceramic veneers, prefabricated composite veneers, different molding techniques, and freehand bonding. The significant advantages of the injectable composite resin technique include its predictability, repeatability, simplicity, minimal invasiveness, and financial affordability for patients. Recent studies demonstrate significant improvements in physical, mechanical, and optical properties of specific flowable composite resins, which reinforces the justification for implementing them in different restorative procedures.

Patient expectations for rehabilitations of a high esthetic standard as well as the demand for fast but efficient care have provided new work perspectives in dentistry. Dentists also have to choose between conventional and digital workflows. The aim of the present randomized restorative trial was to compare diagnostic waxing (DW) performed conventionally with its digital counterpart and to assess the two approaches from the point of view of both patient and dentist. Twenty patients with esthetic complaints were selected to undergo molding processes to obtain conventional study models on the one hand, and intraoral scanning to obtain virtual models on the other. Both the 2D planning and 3D virtual models were sent to the laboratory for the performance of DW. The restorative trial was evaluated by one evaluator dentist, while patient opinion was determined through customized questionnaires. The results show that although 80% of patients rated the digital method to be more convenient in terms of execution time and comfort and indicated that scanning was the most reliable way to obtain an impression, 65% chose the conventional DW for their esthetic restoration after the mock-up tests were performed and analyzed. The evaluating dentist preferred the conventional DW technique in 50% of cases assessed. The conclusion is that although digital technology has its advantages, the final esthetic result does not always meet the expectations and demands of patients and dentists.

The mock-up technique is a widely used clinical method to achieve successful esthetic and functional treatments. Several methods have been described to fabricate the mock-up, either directly in the mouth or indirectly using a silicone index or CAD/CAM options. The mock-up mainly serves as a guide during the preparation stage, but it is also a useful communication and validation tool. Based on the controlled depth preparation concept, the mock-up ensures a specific restoration thickness sufficient for the ceramic and respectful of the enamel tissue. Any error in fabricating the mock-up may cause debonding complications and have a negative impact on the esthetic result. Currently, most mock-ups are created indirectly using a silicone index injected with a temporary resin that mimics the final esthetic project. The present article reports on the protocol involved in a clinical study conducted to validate the precision of reproducibility of this indirect method. Two different options for creating the silicone index were investigated. Twenty mock-ups were realized on the same subject by the same operator. Each mock-up was 3D scanned to compare its reproducibility using the superimposition of 3D meshes. The results show that the reproducibility of indirect mock-ups is clinically acceptable (~ 100 µm), regardless of the fabrication method used. However, a combination of standard silicone and a rigid tray produces better results than hard silicone alone.

Aim: 3D face impression techniques have been defined to eliminate the disadvantages of conventional impression methods. The aim of the present study was to evaluate and compare the accuracy of a digital technique using a novel 3D camera in relation to a conventional impression technique. Materials and methods: Ten prefabricated polystyrene head molds each containing 10 predetermined anatomical landmarks were used. The 3D data of each head mold included in the study were generated through the use of the Intel RealSense D415 camera. Ten stone casts of head molds were also fabricated using conventional silicone impressions through a putty-wash impression technique. The reliability of the 3D data (Group 1) was directly compared with that of the stone casts (Group 2) and prefabricated polystyrene head molds (Group 3) by measuring the distances between 10 anatomical landmarks, including 45 distance measurements. Differences and consistencies were determined using the intraclass correlation coefficient (ICC). Results: Significant consistencies were found among the groups in terms of the overall mean values of the 45 distance measurements (ICC = 0.978, P = 0.001). Paired comparisons indicated significant correlations between Groups 1 and 2 (ICC = 0.970, P = 0.001), Groups 1 and 3 (ICC = 0.967, P = 0.001), and Groups 2 and 3 (ICC = 0.998, P = 0.001). Conclusion: The distance measurement accuracy of the 3D camera was consistent with the reference values. Digital impressions obtained with 3D cameras can be an effective alternative to conventional impressions for craniofacial defects or deficiencies.

The treatment of multiple gingival recessions (GRs) is often challenging for clinicians, mainly due to a larger avascular surface, limited blood supply, differences in recession depth, and residual keratinized tissue. Considering these factors, it may be prudent to take advantage of one surgical technique and overcome its limitations by combining it with another technique in certain clinical situations. The present clinical report describes the treatment of multiple GRs of different depths with a combination of the tunnel technique (TUN) and pedicle flap (PED) – double papilla flap (DPF) or coronally positioned flap (CPF) – in conjunction with deepithelialized connective tissue grafts in two patients. The TUN was considered as it allows faster wound healing and improved esthetics due to the avoidance of visible incisions on the surface. However, to achieve complete coverage of the exposed root surface in the deep recession of the terminal tooth, the DPF or CPF were performed. Healing was uneventful, and no postoperative complications were observed. Complete root coverage was achieved in the treated teeth of both patients at the 12-month follow-up. The combination techniques described in this article can be utilized when there is a deep recession on one of the terminal teeth and the remaining teeth exhibit shallow to moderate recession depths. Clinicians should consider the amalgamation of surgical techniques to achieve the goals of complete root coverage in order to meet patients’ esthetic and functional demands while at the same time minimizing postsurgical morbidity.

A smile is a symbol of beauty and wellbeing in our modern society, human facial expression transcending language, culture, race, gender, time, and socioeconomic differences. An esthetic smile consists of three main components: the teeth, the lip framework, and the gingival scaffold. In some patients, the altered relationship between the teeth, the alveolar bone, and the soft tissue may result in the clinical condition known as gummy smile. A single factor or a combination of factors may be present in patients with this clinical condition, including altered passive eruption (APE), vertical maxillary excess, and a short or hyperactive upper lip. The present article reports on a 31-year-old female patient who presented for a consultation. The patient, who was in good general health with no significant medical history, was dissatisfied with her tooth esthetics. She had symmetric facial features with a long face appearance, retruded chin, protruded maxillary incisors, and excessive gingival display that indicated evident APE. In particular, the present case report aims to describe a multidisciplinary treatment involving a phase of orthodontics associated with maxillofacial surgery, and the periodontal surgical sequence of esthetic crown lengthening for the treatment of APE.

Aim: The aim of this randomized control clinical trial was to compare the soft tissue response to mechanical root instrumentation procedures performed using periodontal curettes with different-sized working parts. Materials and methods: Twenty patients affected by Stage 3 Grade B periodontitis – a total of 109 teeth – were treated with either Mini-Five Gracey Curettes (MFC) or Conventional Gracey Curettes (CGC). Measurements were performed by a blinded examiner at baseline and at 6 weeks. Outcome measurements included pocket depth (PD), recession depth (RD), and difference in RD (∆RD). Results: The use of MFC significantly reduced soft tissue shrinkage (1.5 ± 1 vs 2.4 ± 1.3; difference: -0.9 mm; P < 0.001). Patients in the MFC (test) group experienced lower gingival recession (GR), especially in both thin (2 ± 0.4 mm vs 3.1 ± 0.5 mm; difference: -1.1; P < 0.001) and medium (1.6 ± 0.5 mm vs 2.6 ± 0.6; difference: -1 mm; P = 0.010) periodontal phenotypes. Severe periodontal pockets (PD ≥ 7 mm) of patients in the MFC group experienced significantly lower soft tissue shrinkage than those in the CGC (control) group, regardless of periodontal phenotype. Conclusion: The use of MFC resulted in a greater PD reduction and lower rate of GR in the short term. Nonsurgical periodontal treatment performed with CGC led to more soft tissue shrinkage, particularly when performed in patients with a thin periodontal phenotype.