Case study – same-day smile makeover: a digital workflow

Filipe Amante presents a clinical case that follows a full digital workflow to restore a patient’s upper maxillary incisors.

Cosmetic dental treatments have been in exponential demand in the UK for the last two decades. 

Cosmetic dentistry has become the popular term both within professional and patient domains, and is defined as procedures that are provided predominantly to improve the appearance of the teeth, mouth and face (Alani et al, 2015). 

The patient of the 21st century is increasingly concerned with the appearance and values the importance of the smile as a high-quality asset to face the challenges of professional and private life. 

The increase in popularity of supposedly cosmetic dental procedures, many of which are not benign, not reversible and frequently unnecessarily destructive of sound tooth tissue may, in part, be linked to fashion changes where ultra-white, very even, big teeth are deemed to be a desirable fashion accessory or adornment in some countries and cultures (Theobald et al, 2006; Goldstein, 2007). 

Therefore, it’s essential to have a precise grasp of the patient’s expectations and the required restorative protocols to achieve them to avoid disappointment and undesirable morbidity. 

The technology presently available is helping dentists answer more of the patient’s aesthetic concerns and meet their expectations with more accuracy, confidence and reduced risks (Coachman et al, 2012).

Digital dentistry and same-day fitting of definitive restorations have been true game changers in aesthetic dentistry and smile designing. 

Due to the introduction of a whole range of devices, machines and software, the digital revolution is completely changing the dental profession (Stanley et al, 2018).

The digital systems with computer-aided design/computer-aided manufacturing (CAD/CAM) technology are continuing to develop efficient, predictable workflows for restorative dentistry, which are invaluable in cosmetic treatments. 

This report is a presentation of a clinical case that follows a full digital workflow. 

After a minimally invasive preparation approach, the digital wax-up CAD/CAM monolithic lithium disilicate ceramic crowns were used to restore a female patient’s upper maxillary incisors. 

Case report

A 64-year-old female patient, PS, had been a regular visitor to our practice for many years when, during a routine check-up, she enquired about the possibility of changing the appearance of her upper front teeth. 

She confessed she wasn’t happy with her smile and had been conscious of the appearance of her front teeth for some time. 

She had two porcelain veneers on her upper lateral incisors that had been fitted several years ago (Figure 1) and UL2 had debonded a couple of times recently. 

She was also unhappy with the discrepancy of size and shade of her front teeth. She described them as ‘uneven and unappealing’ (Figure 2). 

PS was an artist and painter, and mentioned she was due to have a very important exhibition in less than two weeks’ time. She was a healthy lady, had no regular prescription drugs, did not smoke and consumed alcohol rarely. 

Prior to this date, she had attended twice a year for routine examinations and regular visits to the hygienist over several years as a faithful patient. 

She presented with a good oral hygiene and a moderately restored dentition with some generalised gum abrasion, which had been stable in the recent years. She had her lower right first molar replaced with an implant three years previously. 

PS confessed she would be incredibly happy if she could have her smile improvement completed before the day of her important art event, as this would definitely boost her confidence. She also mentioned she would be quite worried about having to use temporary crowns for several days as she thought she would constantly be anxious that they could come out in public.

At that time, after discussing different treatment options, we decided to proceed with a quick intraoral diagnostic scan of her dentition using Cerec Omnicam. We agreed to do a virtual mock-up of her maxillary incisors. 

Using a combination of CAD/CAM software (Meshmixer and Exocad), the predicted treatment simulation using four ceramic crowns was created and a digital mock-up was produced and emailed to her within 48 hours (Figures 3 and 4). 

The patient was very happy with the predicted results and booked a double appointment on the same day to prepare and fit her new crowns. 

The virtual mock-up allowed the patient to visualise the minimal reduction needed to perform the preparation and fitting of the ceramic restorations. 

Due to the slight palatal position of her central incisors compared to the lateral incisors and the presence of the old veneers on the UR2 and the UL2 due to be removed, we were able to plan a harmonious result, with a natural shape and a pleasant relation between central and lateral incisors in a minimally invasive fashion. 

  • Figure 1: Preoperative initial smile

Treatment

PS attended on the morning of the day of the procedure to have the preparation done. At this time, we 3D printed the mock-up model so she could visualise the predicted final outcome before the prep (Figure 5). 

The mock-up was placed in mouth and the patient had the chance of contemplating the provisional smile with great joy (Figure 6). 

This was done by using a silicone putty guide on top of the 3D printed mock-up model and using Protemp acrylic resin. 

Another digital impression was performed (biocopy) and the preparation was performed with the mock-up as reference/wear-guide and the intraoral scan of the prepared teeth followed (Figure 7). 

The scanning data was then forwarded to the Wensleydale lab located within the practice and the manufacturing of the crowns followed – shaped using the biocopy of the mock-up and milled on the Sirona Cerec MC XL milling unit from lithium disilicate A3 blocks, followed by glazing and characterisation of the dental anatomy (Figures 5 to 7). 

  • Figure 5: 3D printed mock-up

After less than three hours, they were ready to be fitted and, prior to cementing them, the patient was given the opportunity to contemplate them using a mirror and she couldn’t stop smiling. 

The cementing of the four lithium disilicate crowns was performed using Relyx dual-cure cement, with a careful excess removal and adequate polishing (Figures 8 to 10). 

Lithium disilicate is a material with excellent aesthetics and high strength (500MPa, biaxial flexural strength), that can be used in minimally invasive preparation and adhesive cementation of crowns with a layer thickness of 1mm (Hian, 2017). 

The patient left the practice on the same day she had her teeth prepped with a happy smile on her face, ready to face her art exhibition that was going to take place a few days after. 

She returned a month later for a review appointment and her willingness to smile hadn’t faded away. 

She mentioned her art exhibition had been fantastic and she had not only sold a great number of paintings, but was also complimented on her confidence and her smile.

  • Figure 8: Intraoral scanning design

Conclusion 

The digital workflow and the multitude of possibilities that it enables has taken dentistry by storm. It is causing a paradigm shift worldwide. It’s changing the way we treatment plan, obtain consent and treat our patients. 

It’s also having an impact on the dynamics between clinical and lab work by optimising this important communication channel, making it more fluid and accurate, and, therefore, more efficient – with obvious benefits for both patients and dentist. 

This case report was a simple and routine treatment. However, it turned out to be a rewarding experience as we were able to meet the patient’s expectations and offer a same-day smile makeover option. This made the difference to her.

Thanks to the evolution of technology in dentistry, it is possible to do a full digital case and solve problems more predictably. Nevertheless, more clinical studies are needed to obtain consistent results about the digital workflow compared to the conventional technique and with long-term follow-up to closely monitor the final restorations.  

  • Figure 11: Postoperative intraoral (frontal view, bimaxillary)

Products used

Cerec Omnicam, Sirona Cerec MC XL – Dentsply Sirona

Meshmixer – Autodesk

Exocad – Exocad

Protemp, Relyx – 3M

This article first appeared in Clinical Dentistry magazine. To read more like this, you can sign up to the magazine here.

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