International Journal of Esthetic Dentistry (EN), 03/2022

Digital guides (also known as stents) have become commonly used in daily dental practice. CBCT, digital impressions, and stereolithographic models are considered extremely helpful to create guides for the planning and resolution of surgical cases. In recent years, in periodontal surgery and in particular for the treatment of altered passive eruption (APE), there has been an increasing use of digitally designed guides to improve esthetic outcomes and achieve more predictable results. Digital custom-made guides can be used to improve safety and precision in crown lengthening procedures in patients with APE who have high esthetic expectations. Although most approaches described in the literature show guides used for primary flap or gingivectomy design, the precision of bone recontouring and ostectomy plays a key role in soft tissue rebound and in the final esthetic outcome. The present article describes a new approach using two different guides for soft tissue design in patients with APE.

Digital technology enhances predictability and reli­a­bility in restorative dentistry procedures, especially in cases where precision is crucial in the transfer of information. In this article, several procedures are described for the implementation of a restorative workflow, especially in direct composite anterior and posterior restorations, representing an evolution of the direct stratification techniques described thus far in the dental literature. The clinician’s digital skills are important for accurately managing the workflows to avoid errors and distortions, so that not only the operat­ive phases but the patients themselves become ‘digital entities.’ A comprehensive digital 3D project requires a very ­precise diagnosis and treatment plan.

To potentially overcome current challenges in bone augmentation techniques and the limitations of bone graft materials, extracted tooth roots with periodontal ligament (TRPs) were strategically utilized to assist guided bone regeneration (GBR). This strategy sought to take advantage of the autologous and shapable nature of TRPs, along with their space-making and shielding ability, and the tissue conductivity/inductivity of the preserved periodontal ligament (PDL). The present article reports on three cases of TRP-assisted GBR as part of immediate and staged approaches to implant therapy. The first case involves immediate implant placement into the extraction socket of a maxillary central incisor, where a TRP veneer, shaped from the extracted central incisor, was used during simultaneous lateral augmentation. The second case describes a staged approach to lateral bone augmentation for a severe buccal bony defect at the maxillary lateral incisor site, where sectioned blocks/pieces of an extracted third molar TRP were used with other bone graft materials. The third case describes aggressive vertical and horizontal bone augmentation for staged implant placement, where an extracted third molar was sectioned and placed on the native alveolar bone as a buccal and lingual bracket, then filled with bone graft materials. All three cases received final restoration and were shown to be stable and functional at the 3-year follow-up. Osseointegration has been well maintained, and the transplanted TRPs seem to be integrated with the native or regenerated bone or remodeled and replaced by the native bone. Longer-term follow-up studies are required.

Through the use of the application of a mathematical proportion and a digital golden ratio compass associated with computer software, Digital Smile Planning (DSP) can assist clinicians to achieve the fundamentals of esthetic treatment. The present clinical report describes the application of this technique to propose an alternative and more conservative treatment for a patient who refused the option of orthognathic surgery. To address the diagnosis of a gingival smile with vertical maxillary excess, the alternative treatment comprised crown lengthening surgery, ceramic veneers on the maxillary teeth, and the application of botulinum toxin to reduce lip hyperactivity. Considering the successful resolution of the patient’s situation from the perspective of both the dentist and the patient, the application of DSP was considered to be useful to achieve predictable harmony between the face and the dental structures.

Morphologic anterior tooth alterations and diastemata between the anterior teeth are often considered a major esthetic problem. In most cases, the treatment of these conditions involves a multidisciplinary approach. Orthodontic treatment together with direct composite resin veneers are a viable option to close diastemata and alter tooth shape. The extent and etiology of the diastemata must be considered and properly evaluated for the treatment. The present article is a case report of a patient with multiple diastemata in the maxillary anterior teeth, dental crowding, and peg-shaped lateral incisors corrected with orthodontic treatment and direct composite resin veneers. Digital planning was the tool used to decide the tooth proportions before orthodontic treatment and to guide the diagnostic wax-up. An etch-and-rinse adhesive system was applied after etching. A polychromatic layering technique under rubber dam isolation was used for the composite resin veneer construction. Finishing and polishing procedures were achieved using polishing discs and abrasive materials. Direct composite resin is an alternative that allows predictability, esthetics, and the possibility of adjustments, resulting in patient satisfaction.

The adhesive bonding technique together with tooth-colored ceramic material in fabricating veneers is considered one of the greatest achievements in modern prosthodontics. There is a wide range of indications for veneers, but they are most commonly used to establish adequate function and mask tooth discolorations and inappropriate tooth shape, size or position. A large variety of all-ceramic materials with excellent properties is available on the market today. It is challenging to select the material that will provide the best esthetics and function. The present article explains the principles of a modern, individual treatment approach for a young adult patient with multiple diastemata and shade disharmonies in the maxillary anterior teeth. The treatment plan was based on the selection of the appropriate ceramic material and technical procedures to achieve the best esthetic results using veneers. This included analyzing the specific case; defining the treatment goal; determining the precise shade; and selecting the most suitable and appropriate ceramic material, preparation design, fabrication technique, and adhesive concept. It was decided to use the new VITA zirconia-reinforced lithium disilicate press ceramic system and leucite-reinforced glass-ceramic veneering system to fabricate indirect ceramic veneers for all the maxillary anterior teeth. The size, shape, position, and shade of the natural teeth were changed and the diastemata were closed to achieve a more proportional dental relationship. The esthetic and functional goals were achieved and the patient was extremely satisfied with the final outcome.

The management of cracked teeth represents a difficulty because their diagnosis is complex and there is no consensus concerning their treatment. The present article explains this pathology within enamel and dentin and also focuses on the clinical consequences of crack development in dental tissue. As cracks have both biologic and mechanical implications, a complete review of the literature on the subject has enabled the development of a comprehensive diagnostic approach to identify cracked teeth and optimize their management. The elements of diagnosis are the bite test, transillumination, the pulp sensitivity test, the periodontal test, radiologic examinations, removal of existing restorations, and the use of quantitative light-induced fluorescence. Finally, the management of biologic and mechanical imperatives relating to the treatment of cracked teeth has allowed the proposal of a reliable and reproducible therapeutic strategy based on two pillars: the arrest of bacterial infiltration using immediate dentin sealing, and the limitation of crack propagation using relative cuspal coverage. In this article, the proposed clinical protocol is explained through the use of a decision map and is illustrated by a clinical case example.