CLINICAL SCIENCES

A review of esthetic alternatives for the restoration of anterior teeth

Ant oni o Bello, DDS, a and Ronald H. larvis, DDS, MSD b
Uni versi dad Naci ona[ Aut onoma de Mexi co, Lomas de Chapu]tec, Mexi co,
and State Uni versi t y of NewYor k at Buffalo, Buffalo, N.Y.
Pur pose. This article describes different options for the esthetic treatment of anterior teeth, starting with
minimally invasive procedures, such as facial surface bleaching and bonding with composites.
Methods. The importance of metal ceramic restorations, porcelain shoulder techniques, and metal free
ceramics are also emphasized. The options are carefully demonstrated to identify advantages and limita-
tions of each technique. (J Prosthet Dent 1997;78:437-40.)
I n the restoration of anterior teeth, there are many
factors t o be considered that depend on the patient' s
expectations and the expertise of the dental practitio-
ner. The purpose of this article is to provide a checklist
of esthetic systems for the restoration of anterior t eet h
and to cover i mport ant factors to consider before choos-
ing a specific treatment.
MI NI MALLY I NVASI VE PROCEDURES
Bleaching
Patients frequently desire i mprovement in their smiles
because fashion magazines emphasize innovative met h-
ods t o improve esthetics. However, potential patients
are unaware of t reat ment options, so it is the responsi-
bility of the dentist to suggest the most conservative,
desirable treatment. When patients complain of "ugl y
t eet h, " the dentist must det ermi ne whet her the t erm
uglyis the result of color or shape of the dentition. There-
fore the following questions are appropriate: (1) Are you
comfort abl e with the shape of your t eet h and (2) do
you approve of the color of your teeth?
I f the answer t o question one is affirmative and color
is the main concern, bleaching the t eet h is a reasonable
choi ce? However, the patients should underst and that
this procedure is only considered a t emporary measure.
Fur t her mor e, whiter t eet h are merely an interim mea-
sure if smoking or excessive drinking of liquids that stain
are continued.
Resin bonding
When a patient wishes to improve their smile because
of dark spaces between the t eet h (Fig. 1), esthetic bond-
ing may be the resolution. I f the configuration of the
t eet h is modified, the patient can achieve satisfaction. I f
the patient does not smoke or drink dark-colored liq-
uids that can alter the color of the teeth, esthetic bond-
Fig 1. Patient with diastemata between central and lateral in-
cisors.
Fig. 2. Diastemata were closed with composites, following
natural outline of teeth.
Presented before the American Prosthodontic Society, Chicago, Illi-
nois, February 1996.
aAssociate Clinical Professor, Department of Prosthodontics,
Universidad Nacional Autonoma de Mexico.
%ssociate Clinical Professor, Department of Prosthodontics, School
of Dental Medicine, State University of New York at Buffalo.
ing with composites is the most conservative approach
for several reasons; namely, (1) sound t oot h structure
will not be removed, (2) anesthetics are infrequent, (3)
one appoi nt ment is common, and (4) the professional
fee is usually inexpensive.
NOVEMBER 1997 THE JOURNAL OF PROSTHETIC DENTISTRY 437
THE JOURNAL OF PROSTHETIC DENTISTRY BELLO AND JARVIS
Fig. 3. Bonding on central and lateral incisors. Fig. 5. Porcelain fused to metal crowns on central and lateral
incisors are defi ci ent in length, color, and margins.
Fig. 4. Porcelain veneers to replace bonding on central and
lateral incisors.
Fig. 6. New porcelain fused to metal crowns on central and
lateral incisors blend wi th natural dentition.
I f the natural outline of the patient' s t oot h is followed,
an esthetic result can be ensured (Fig. 2).
I RREVERSI BLE PROCEDURES
Por cel ai n l ami nat e veneers
Porcelain vencers were described in dental literature
in the early 1980s 2 and i nt roduced a conservative op-
tion for esthetics. The esthetics and life expectancy of
these restorations surpass composi t e esthetic bondi ng.
The pat i ent in Figure 3 had composi t e bondi ng placed
on the maxillary incisor t eet h 4 years previously. How-
ever, pat i ent decided to have new restorations with a
mor e natural appearance. Porcelain laminate veneers
were placed with use of the translucent ceramics on the
maxillary incisors and maxillary right canine for a mor e
natural appearance (Fig. 4). 3'4
This met hod of adhcr i ng porcelain to t oot h structure
was also used for artificial crowns, inlays, and onlays.
The restorations were made on refract ory dies, but un-
fort unat el y were met with limited success.
Me t a l / c e r a mi c r est or at i ons
Porcelain fused t o met al (PFM) crowns are selected
for most clinical situations for several reasons: (1) PFM
crowns arc st ronger t han ot her ceramic restorations; (2)
they possess mor e durability; (3) they are esthetic in the
presence of thick gingival tissue; (4) fabrication is a fa-
miliar procedure to dental laboratories; (5) PFM crowns
are selected for anterior and post eri or teeth; (6) they are
suitable for fixed partial dentures (FPDs); (7) they are
indicated for i mpl ant prosthesis; and (8) PFM crowns
are acceptable for extremely dark teeth.
When appropriately const ruct ed, PFM crowns can
reverse an esthetic (Fig. 5) pr obl em with naturally ap-
pcaring crowns on the maxillary incisors (Fig. 6). The
PFM crowns were selected for the pat i ent in Figure 6
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BELLO AND JARVIS THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 7. Porcelain fused to metal crown on natural tooth struc-
ture displays gray appearance at gingival margin.
Fig. 8. Grayish appearance at margin is avoided because of
porcelain facial margin.
because the gingival tissue S allowed the disguise of the
margins of these restorations.
Por cel ai n mar gi n f or met al / cer ami c cr owns
There are certain clinical situations in which PFM
crowns do not meet the expectations of either the den-
tist or the patient. This is commonl y seen because of
extremely delicate gingival tissue, with a grayish color
evident in the cervical third (Fig. 7). One met hod of
verifying this clinical condi t i on is the placement of a
periodontal probe in the gingival crevice. I f the tip of
the peri odont al probe is observed t hr ough the gingival
margin, a conventional PFM crown should be avoided
and a porcelain gingival margin substituted. The gray
shadow in a conventional PFM crown will disappear
when the facial margin is const ruct ed in porcelain (Fig.
8).
The porcelain margin for PFM crowns was first intro-
duced in the 1960s. 6 It was later popularized by differ-
ent researchers in the 1970s7-9 and in the 1980s the tech-
nique was i mproved with i nt roduct i on of shoulder por-
celain. This new porcelain made it easier to fabricate the
gingival margin and increased its popularity. This type
of modified PFM crown can be selected for most clini-
cal situations, and when indicated, possibly including a
short span FPD.
ALL CERAMI C RESTORATI ONS
Por cel ai n j acket crowns
The porcelain jacket crown (PJC) was i nt roduced over
five decades ago. The porcelain available t hen was high
fusing and not resistant to fracture. Later, alumina ox-
ides were added t o the composi t i on of porcelain, 1 cre-
ating aluminous porcelain. This innovation in metal-free
ceramics provi ded a stronger and more durable restora-
tion. This aluminous t echni que is still used with the ap-
plication of opaques during fabrication, but occasion-
Fig. 9. Three-unit FPD replacing maxillary right central incisor,
with In-Ceram ceramic prosthesis.
ally restricts adequate translucency in t eet h where mini-
mal t oot h reduct i on is allowed. I f adequate t oot h re-
duct i on is possible, an aluminous PJC is an excellent
selection. However, it is considered the weakest ( RH
Jarvis and R Tallents oral communi cat i on, 1995) and
most susceptible restoration to fracture in the metal-
free ceramics cat egory of esthetic restorations.
I n- Cer am cerami c r est or at i ons
In-Ceram ceramic is anot her all ceramic system (In-
Ceram ceramic, Vita Zahnfabrik, Bad Sackingen, Ger-
many) that will provide a satisfactory alternative for es-
thetics. ~ It is considered the strongest of metal-free ce-
ramic systems currently available. ~2 It is the only system
used in a short span FPD 13 (Figs. 9 and 10), replacing
the maxillary right central incisor. When appropriately
used, it provides an acceptable margin, but adequate
t oot h reduct i on is requi red for esthctics.
NOVEMBER 1997 439
THE JOURNAL OF PROSTHETIC DENTISTRY BELLO AND JARVIS
Fig. 10. Occlusal view of three-unit FPD in In-Ceram ceramic.
Fig. 11. Fractured maxillary left central incisor in 18-year-old man.
Empress ceramic system
Al t hough the first reports were available in 1987, this
heat-pressed ceramic system was introduced in 1990.14
Empress ceramic restorations are indicated for anterior
crowns, posterior inlays, and onlays with impressive es-
thetic results. The advantages of this system are (1) suit-
able marginal fit, (2) minimal abrasion, I~ (3) acceptable
esthctics, and (4) conservative t oot h preparation.
When a qualified ceramist is engaged, the dentist can
achieve desirable results, even in critical clinical situa-
tions, including the crown on a fractured maxillary left
central incisor (Fig. 11), and the final result with an Em-
press ceramic crown (Fig. 12).
CONCLUSI ONS
Selection of a restoration shoul d depend partly on
preservation of natural t oot h structure, with the least
trauma. Nevertheless, it is important to be aware of the
limitations of specific techniques, such as avoiding por-
celain veneers in extremely dark teeth. The sophistica-
ti on of all ceramic systems shoul d be limited to those
Fig. 12. Maxillary left central incisor has been restored with
Empress ceramic crown.
clinical situations when gingival tissues compromise the
esthetics of conventional PFM restorations.
We acknowledge the ceramic work done by Thomas Graber and
Marco Reyna.
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