International Journal of Esthetic Dentistry (EN), 03/2007

The purpose of this article is to review biomechanical and occlusal principles that could help optimize the conservative treatment of severely eroded and worn anterior dentition using adhesive restorations. It appears that enamel and dentin bonding, through the combined use of resin composites (on the palatal surface) and indirect porcelain veneers (on the facial/incisal surfaces) can lead to an optimal result from both esthetic and functional/biomechanical aspects. Cases of deep bite combined with palatal erosion and wear can be particularly challenging. A simplified approach is proposed through the use of an occlusal therapy combining centric relation and the Dahl principle to create anterior interocclusal space to reduce the need for more invasive palatal reduction. This approach allows the ultraconservative treatment of localized anterior tooth erosion and wear.

In recent years, implant dentistry has undergone a profound shift in emphasis. The focus evolved first from a surgically driven approach to a prosthetically driven approach and now to a more biologically driven approach with the goal of optimizing and maintaining esthetics. While traditional implant protocols are well established for management of implants placed in healed edentulous sites, the data available offer little clarity on the factors and procedures for long-term esthetic success, particularly in terms of maintained stable soft tissue outcomes around implant restorations in the esthetic zone. Unfortunately, the 90%+ success rates indicated in most studies of dental implant systems today do not represent the success of the esthetic outcome. This has created a demand-certainly among clinicians in private practice focused on the ongoing maintenance of esthetic outcomes- for clear treatment protocols to achieve esthetic results that are not only predictable and consistent but that can withstand the test of time.

Implant-supported single crowns have become a valid alternative to conventional fixed dental prostheses due to their excellent clinical long-term results. However, along with good survival rates, esthetic factors are important for success in anterior regions. Today, several kinds of implant abutments are offered by implant manufacturers. A choice must be made between standardized and customized abutments; further, different abutment materials such as titanium or various ceramics (alumina, zirconia) are available. Finally, the reconstruction can be cemented on the abutment or screw-retained directly on the implant. When choosing an abutment for an anterior single-unit case, several factors should be considered: visibility of the region (eg, high vs low smile line); biotype of the gingiva; color of the neighboring teeth; and finally, esthetic expectations of the patient. In esthetically demanding situations, customized ceramic abutments are indicated. In patient situations with thin peri-implant soft tissues, zirconia abutments and all-ceramic crowns should be used in combination. In cases with thick mucosa, titanium can be used as the abutment material, combined with metal-ceramic crowns. In order to avoid difficulties removing excess cement, screw-retained reconstructions may be preferred; however, the screw access hole should be positioned palatal to the incisal edge.

Traumatic tooth fractures, dental caries, and overzealous tooth preparations can lead to the loss of coronal tooth structure, thus complicating the definitive prosthetic plan. Although exposure of additional clinical tooth structure by surgical crown lengthening is often recommended, such an approach is usually discouraged because of the possible adverse periodontal changes to the adjacent teeth and compromised esthetics, especially in the presence of an otherwise intact arch. This article discusses the application of orthodontic extrusion to conservatively restore a single tooth with minimal coronal tooth structure in the esthetic zone. A detailed description of the prosthetic approach used before, during, and after orthodontic therapy is presented.

This two-part treatment series discusses the prosthodontic rehabilitation of a female patient with a severe preexisting periodontal condition. In Part 1, the diagnostic and treatment planning strategies were presented. In Part 2, the selected treatment will be revealed and discussed in detail using evidence from the literature. The treatment procedures will be presented in terms of three challenging locations: the anterior maxilla, posterior maxilla, and anterior mandible. At the end of the article, the final outcome is presented and compared with the initial situation.