Case Presentation: Smile Enhancement Using CAD/CAM Technology

Published Date 01/15/2019
A little can go a long way when performing a smile enhancement. My patient, a healthy young man, presented with a reverse smile curve that caused a poor esthetic smile and reduced his confidence when socializing (Figure 1). I felt that a number of dental disciplines could be employed to improve his smile. Orthodontic clear aligner therapy was planned to level, align, rotate, and correct a crowded, narrow arch form. Additionally, 3 first molar teeth would be replaced using ATLANTIS abutments and the Astra Tech Implant System EV (Dentsply Sirona Implants). The maxillary centrals were previously treated with endodontic therapy and 2 restorations that were nonesthetic.

My case presentation for his smile enhancement included Invisalign (Align Technology), Zoom Whitening (Philips), and 4 CEREC restorations (Dentsply Sirona) for teeth Nos. 7–10. The treatment would make use of a lab-processed wax-up to improve the morphology and lengths of the 4 maxillary incisors. The case required increasing the incisal lengths and widths to provide a natural smile curve that followed the curve of his lower lip.

The wax-up is key to make my restorations follow the provisional mock-up that is created by transferring the esthetic wax-up to the patient’s existing dentition. This becomes the proposal and basis for the definitive CEREC restorations. The CEREC software includes a feature called Biocopy, which gives us the ability to copy either a wax-up or a mock-up of the provisionals and then design the final restorations to replicate the morphology, optimal tooth positions, and esthetics. I selected a square-square incisal shape, and my lab returned a beautiful, highly esthetic wax-up.
Figure 1—Preop smile
Figure 2—Laboratory wax-up for Nos. 7–10
Figure 3—Provisional restorations for Nos. 7–10
Six months of Invisalign therapy provided an improvement in the overall arch form and plane of occlusion. Zoom whitening created a shade change from A3 to B1. A failing endo in the right central was endodontically retreated. The patient was informed that, if the periapical lesion were unresolved, a surgical endodontic procedure would be necessary. A fiber post was bonded into this canal and a new core built up to receive the new restoration. A putty matrix was returned with the wax-up (Figure 2) and used to transfer the new morphology and length to the existing dentition. The 4 maxillary incisors were provisionalized with Luxatemp bis-acryl material (DMG) so that the patient could preview his new smile (Figure 3).
Figure 4—Preparations and margin for Nos. 8 and 9
Figure 5—Grid to aid in design of central incisors
Figure 6—Veneer preparations and margins
The patient was pleased with the shape, size, and esthetic improvement that these 4 restorations provided. It is critical to place the incisal edge position in the most favorable positions for proper speech, lip support, and smile esthetics. The 2 centrals were treated with full-coverage crowns and the laterals received veneers. The results of these provisionals were dramatic, and the patient received compliments about his new smile.

CEREC Restorations
Enter CEREC and the Biocopy imaging of these 4 units, which became the blueprint for the design of the final VITA CAD/CAM restorations. The improved natural and esthetic design was scanned into CEREC. The prepared teeth were optically imaged and this Biocopy proposal was merged and used to design and mill the VITA Mark II restorations. These CAD/CAM blocks are made of highly esthetic feldspathic porcelain and can be milled and polished with smooth well-fitting margins.
Figure 7—Incisal design and proposals for Nos. 7 and 10
Figure 8—The enhanced smile
Figure 9—Postop occlusion with 4 incisors and 3 implants restored
I completed these 4 restorations in 2 visits, with the centrals being bonded in first and the veneers for the laterals during a second visit. The crowns and veneers were etched with 5% hydrofluoric acid gel, silanated with Monobond Plus (Ivoclar Vivadent) and bonded with SpeedCEM Plus (Ivoclar Vivadent) translucent resin cement.
The CEREC workflow—which includes the CEREC (AC, AF, or AI) with Omnicam, milling units such as the CEREC MC XL Practice Lab, and the CEREC SpeedFire—provides faster treatment with no impression tray and no temporary protheses.
CEREC Omnicam is an innovative, ergonomic handpiece that ensures excellent intraoral access to all teeth, including posteriors, with ease and agility. The ColorStreaming feature allows continuous capture of dentition.
Dr. Ramirez specializes in cosmetic smile design and digital implantology in his practice in Brooklyn, NY. In practice since 1983, Dr. Ramirez is a Master of the Academy of General Dentistry, a Diplomate of the International Congress of Oral Implantology, a key opinion leader for Dentsply Sirona, a CEREC Doctors mentor and trainer, and an attending physician at New York Presbyterian Brooklyn Methodist Hospital. Dr. Ramirez utilizes 3D CBCT imaging and CEREC CAD/CAM technologies to promote a fully integrated digital dental practice and to improve quality of life for his patients.
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