PMC6077168_01
Patient reporting dissatisfaction with her smile, due to the size of her teeth and the amount of gingiva exposed when smiling.
gr1.jpg
PMC6077168_01_gr1.jpg
fig0005
A 23-year-old female attended the Esthetic Dentistry Clinic of our institue, reporting dissatisfaction with her smile, due to the size of her teeth and the amount of gingiva exposed when smiling (Fig. 1).
a, b, e, c - Initial Photographic protocol: Maximum smile. Front, left and right side views. d, e, e - Initial Photographic protocol: Lip sealing and incisal exposure Analysis. f - Initial Photographic protocol: Gingival exposure analysis at maximum smile. g, e, h - Initial Photographic protocol: Right and left half profile view. i - Initial photographic protocol: Maximum habitual intercuspation. j - Initial photographic protocol: Close-up of the anterior dentition, with contrast mirror, to evaluate shape, anatomical characteristics and arrangement of dental elements in the arch. k, e, l - Initial photographic protocol: Close-up of anterior dentition of left and right half-profile, with contrast mirror.
gr2.jpg
PMC6077168_01_gr2.jpg
fig0010
The face, smile, gingival contour and teeth of the patient were analyzed both clinically and photographically (Fig. 2a-l).
a - Mini-Jig Aesthetic and Functional device to determining the ideal dimensions of the incisor to be rehabilitated on the upper central incisor. b - Mini-Jig Aesthetic and Functional device positioned and need for clinical crown lengthening evaluation.
gr3.jpg
PMC6077168_01_gr3.jpg
fig0015
This device is used to evaluate the following: the correct proportion of the dimensions of the central incisor to be rehabilitated, involving its height and width, as well as its ideal spatial positioning in the arch; to predict the need for surgical intervention to lengthen the clinical crown and to provide an effective communication between the dental surgeon and the dental laboratory technician, guiding the diagnostic wax-up from the anatomical references obtained. (Fig. 3a and b).
a, e, b - Impressions for study models were taken using addition silicone.
gr4.jpg
PMC6077168_01_gr4.jpg
fig0020
Impressions for study models were taken using addition silicone (Virtual, Ivoclar Vivadent AG, Liechtenstein) (Fig. 4a and b).
a, e, b - Diagnostic wax-up based on the anatomical references provided by the device.
gr5.jpg
PMC6077168_01_gr5.jpg
fig0025
The esthetic and functional device positioned in the model aided the technician in building a diagnostic wax-up based on the anatomical references provided by the device (Fig. 5a and b).
Silicone dam was used to obtain a guide for the diagnostic restorative test (mock-up).
gr6.jpg
PMC6077168_01_gr6.jpg
fig0030
This silicone dam was used to obtain a guide for the diagnostic restorative test (mock-up) (Fig. 6).
Mock-up to patient approval.
gr7.jpg
PMC6077168_01_gr7.jpg
fig0035
Once the mock-up was tried in, the need for clinical crown lengthening was established aiming to reestablish the height and width proportions of the upper anterior teeth (Fig. 7).
Clinical crown lengthening Incisions guided.
gr8.jpg
PMC6077168_01_gr8.jpg
fig0040
Incisions were made using an internal bevel blade #15 from the mesial aspect of the first right upper molar to the mesial aspect of the first upper left molar, accompanying the cervical margin of the mock-up, which corresponded to the future margins of the prosthetic rehabilitation (Fig. 8).
Incisions from 15 to 25 to remove the gingival margin collar.
gr9.jpg
PMC6077168_01_gr9.jpg
fig0045
Subsequently, intra-sulcular incisions were made from 15 to 25 to remove the gingival margin collar (Fig. 9).
a, e, b - Full thickness flap and Osteotomy and osteoplasty guided by the transparent guide.
gr10.jpg
PMC6077168_01_gr10.jpg
fig0050
A Molt 2-4 instrument was used to raise a full thickness flap and expose the entire frontal region of the maxilla, granting access to the subnasal depression and the anterior nasal spine (Fig. 10a). Excess bone tissue was removed to a distance of 3 mm between the bony crest and the new gingival margin, to safeguard the biological width, as recommended by Gargiulo et al. (Fig. 10b).
PMMA prosthesis was fixed by screw between teeth 11 and 12 and the other between teeth 21 and 22.
gr11.jpg
PMC6077168_01_gr11.jpg
fig0055
One screw was fixed between teeth 11 and 12 and the other between teeth 21 and 22 (Fig. 11).
Simple 6-0 nylon suture Sutura.
gr12.jpg
PMC6077168_01_gr12.jpg
fig0060
At the end of the surgical procedure, the gingival flap was repositioned and a simple 6-0 nylon suture was placed (Fig. 12).
a, e, b - At the 16-day follow-up of the surgical procedure, the patient was reassessed and the sutures removed, revealing a more harmonious smile than before, with reduction of the exposed gingiva, secondary to an increased clinical crown length and new support and repositioning of the upper lip.
gr13.jpg
PMC6077168_01_gr13.jpg
fig0065
At the 16-day follow-up of the surgical procedure, the patient was reassessed and the sutures removed, revealing a more harmonious smile than before, with reduction of the exposed gingiva, secondary to an increased clinical crown length and new support and repositioning of the upper lip (Fig. 13a and b).
a-g - The smile aesthetic rehabilitation was complemented using 10 lithium disilicate-based ceramic veneers.
gr14.jpg
PMC6077168_01_gr14.jpg
fig0070
The smile aesthetic rehabilitation was complemented using 10 lithium disilicate-based ceramic veneers (IPS Emax, Ivoclar Vivadent AG, Liechtenstein) (Fig. 14a-g).
Twenty months follow-up, on which occasion the esthetic results and periodontal health were reported to be maintained.
gr15.jpg
PMC6077168_01_gr15.jpg
fig0075
Twenty months after treatment completion, a new clinical evaluation was performed, on which occasion the esthetic results and periodontal health were reported to be maintained (Fig. 15).