Esthetic Rehabilitation of Bilaterally Missing Maxillary Lateral Incisors in a Young Adult: A Step-by-Step Clinical Case Report

Abstract

This case report shows the esthetic rehabilitation of a young female patient with congenitally missing maxillary lateral incisors, a fractured previous fixed prosthesis, and dissatisfaction with her smile. A minimally invasive approach was followed, utilizing digital smile design with ExoCAD (Exocad GmbH, Darmstadt, Germany) digital software to plan and fabricate zirconia bridges following minimal crown preparation. The treatment aimed to restore both function and esthetics, resulting in a natural-looking, harmonious smile. The patient expressed high satisfaction with the outcome, citing improvements in appearance, comfort, and oral function. This case emphasizes the critical role of individualized treatment planning, advanced digital technology, and the use of high-quality restorative materials in achieving successful dental outcomes.

INTRODUCTION

Nowadays, there is a growing interest in esthetic enhancement aimed at improving smiles and overall facial appearance. Correspondingly, the field of dentistry has shown significant advancements in esthetic techniques and materials to meet patient expectations. Notably, the development of ceramic materials, renowned for their natural-looking properties as synthetic replacements for missing teeth, has enabled clinicians to closely mimic the natural appearance of dentition, contributing to highly esthetic and clinically successful outcomes.[1] Patient dissatisfaction may arise from various factors, such as tooth loss, improper alignment, and disproportionate spacing between teeth. Our patient expressed dissatisfaction with her smile and a lack of confidence. Properly restoring the space, both functionally and esthetically, was our primary concern. As many studies affirmed, the success of prosthetic treatment is related to its survival, biocompatibility, and patient satisfaction. By following a comprehensive clinical evaluation and patient consultation, a meticulous treatment plan was formulated.[2]

Case description

A young female patient presented with dissatisfaction regarding her smile following previous dental treatment. Clinical examination revealed previously prepared maxillary canines and a missing cantilever bridge [Figure 1]. A comprehensive diagnostic evaluation, including clinical and radiographic assessments, was performed. Orthodontic treatment and dental implants were initially suggested. However, cone-beam computed tomography (CBCT) was performed for a more detailed view for accurate planning. It revealed significant alveolar bone deficiency in the edentulous site. Given the extent of bone loss, the need for bone augmentation, and the long period of orthodontic treatment, the patient refused the treatment option.

Figure 1.

Pre-operative photographs

An alternative treatment plan was discussed with the patient. After obtaining informed consent, the definitive treatment plan involved esthetic rehabilitation using two separate bridges. The treatment included modification of the existing maxillary canines’ preparations and minimal preparation of the maxillary central incisors. The prosthetic design was guided by esthetic principles to ensure an esthetic and functional outcome. Upon completion, the patient expressed satisfaction with the improved esthetics, speech, and oral function. This case highlights the value of individualized treatment planning and patient-centered care in achieving successful outcomes in esthetic dentistry.

MATERIALS AND METHODS

A comprehensive diagnostic evaluation, including a thorough dental history and clinical examination, was conducted on the patient. Evaluation of the patient’s oral hygiene status, periodontal health, and any existing dental restorations was done. Radiographic analysis was executed through periapical and panoramic radiographs to assess the crown-to-root ratio and ensure the absence of any apical pathosis that may intervene with the treatment.

Alginate impressions for both maxillary and mandibular arches were made to fabricate diagnostic casts, which are needed in occlusal analysis and smile designing.

Digital dental photographs were captured pre-operatively from different angles [Figure 1] to document the patient’s pretreatment condition, aimed at patient education and used as a reference throughout the treatment. Smile design was digitally made following the principles of the golden proportion, which is a useful tool for the evaluation of symmetry, dominance, and proportion in the diagnosis of anterior tooth arrangement. This proportion evaluates the width-to-height ratio of the anterior teeth to ensure balanced and symmetrical anterior final restoration alignment for a harmonious smile. Scaling for the teeth was carried out to get rid of present plaque and calculus deposits to ensure proper gingival healing, and oral hygiene instructions were given.

Treatment planning and material selection

After checking all the clinical records, a personalized treatment plan was developed. Alginate impressions were taken for studying cast fabrication for clinical purposes and documentation. Material selection was thought to achieve the desired esthetic outcomes at a proper cost. According to the reported studies, the type of restoration material is a critical factor that influences biological behavior. It was found that the soft tissues’ behavior adjacent to ceramic crowns was significantly better than with ceramic fused to metal crowns. Moreover, less material thickness is required for zirconia restorations, making dental preparation minimally invasive and more conservative to the sound tooth structure.[2] In the presented work, zirconium dioxide was the material of choice due to its high esthetic and functional properties and fair cost. Shade selection was achieved using Ivoclar Vivadent Dental Shade Guide. The chosen shade and digital photographs were sent to the dental laboratory to ensure that the perfect color matches the patient’s natural teeth. Final cementation was done by self-cured glass ionomer, which shows excellent marginal integrity and chemical bonding strength.

Temporization phase

At the initial appointment and before tooth preparation, elastomeric impression material was used to record the upper arch. The impression was sent to the dental laboratory for the fabrication of a diagnostic mock-up and silicone index. The mock-up serves as a guide for the provisional restorations following tooth preparation, aiding in the stabilization of gingival tissues, minimizing post-operative sensitivity, and temporarily restoring the patient’s esthetics and function.

Tooth preparation

Under local anesthesia, central incisors were prepared, and canines were modified. Chamfer finish line was performed [Figure 2], and great care was taken to round all line angles to reduce stress concentration points that could lead to restoration fracture.

Figure 2.

Chamfer finish line for marginal adaptation

Impression taking

The retraction cord was applied. Impressions were taken using the two-step technique with polyvinyl siloxane (PVS) material. The first stage involved heavy body material to create a base, followed by a light body material to record fine details of the preparation.

Laboratory procedures

The impressions were sent to a certified dental laboratory specializing in esthetic restorations. The bridge design was created using ExoCad software (Exocad GmbH, Darmstadt, Germany). Proper distribution of the spaces for pontics and alignment of the restoration was checked on the software [Figure 3]. A provisional polymethyl methacrylate (PMMA) try-in was fabricated to evaluate the marginal adaptation, check for any occlusal interferences, and ensure the design met the patient’s expectations [Figure 4]. After approval, the laboratory proceeded to the final restoration phase, employing a layered fabrication technique. This involved using a zirconium dioxide core for strength and durability, topped with a layer of porcelain to achieve natural translucency and color depth. This combination successfully replicated the appearance of natural teeth while ensuring long-term functionality.[1]

Figure 3.

Bridges were designed using ExoCad software

Figure 4.

PMMA try-in inserted in the patient’s mouth. PMMA = polymethyl methacrylate

Cementation procedure

The bridge was cemented using self-cured glass ionomer (GI) cement [Figure 5]. Research has shown that zirconia restorations cemented with GI cement exhibit no fractures or secondary caries, along with minimal marginal staining and a low risk of loss of retention.[3] Proper isolation and cementation protocols were followed, and excess cement was carefully removed. Occlusion was checked with the patient, and heavy contacts were adjusted as necessary.

Figure 5.

Bridge’s delivery immediately post-cementation

Post-operative care

The patient received comprehensive post-operative instructions, which included recommendations for maintaining oral hygiene and avoiding heavily biting anteriorly and hard foods that might damage the new anterior restorations. Follow-up visits were scheduled for 1 week, 1 month, 3 months, and 6 months to assess the condition of the bridges and ensure the health of the surrounding gingival tissues.

Outcome evaluation

Patient satisfaction was evaluated through a subjective assessment, during which the patient expressed an increased confidence in a smile and a high level of satisfaction with both the esthetic appearance and functional results. Clinical examinations during follow-up visits confirmed optimal marginal integrity, with no evidence of bridge loss of retention or discoloration. An ongoing long-term follow-up is planned to monitor the durability of the restorations.

DISCUSSION

A successful esthetic rehabilitation of a patient’s smile requires proper treatment planning, understanding of dental esthetics, meticulous execution, and understanding of the patient’s needs. The goal was to reach a balanced esthetic and functional outcome to ensure a perfect smile that complements the patient’s facial features and restores her confidence. One of the principal challenges in this case was the distribution of spaces for pontics, but it was carefully designed by ExoCad software. Zirconia layered restoration was the material of choice due to its multiple properties. The patient showed high satisfaction with the new smile.

CONCLUSION

Fixed prosthesis is a transformative line of treatment that restores function, esthetics, and significantly enhances a patient’s quality of life. By providing long-term stability, comfort, and confidence, it serves as a life-changing solution for individuals with missing or damaged teeth.

Declaration of patient consent

The authors confirm that all necessary patient consent forms have been obtained. In these forms, the patient provided consent for the use of their images and clinical information in this publication. They have been informed that while their names and initials will not be disclosed, and all reasonable measures will be taken to protect their identity, complete anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.