Case report

Open Access

The esthetic rehabilitation of misplaced dental arch afterfracture of anterior maxillae: a case reportSuha Turkaslan* and Çagri Turna

Address: Department of Prosthodontics, Faculty of Dentistry, Suleyman Demirel University, Isparta, 32200, Turkey

Email: ST* - suhaturkaslan@yahoo.com; ÇT - turna_cagri@yahoo.com

*Corresponding author

Received: 21 July 2009 Accepted: 19 August 2009 Published: 25 August 2009

Cases Journal 2009, 2:8723 doi: 10.4076/1757-1626-2-8723

This article is available from: http://casesjournal.com/casesjournal/article/view/8723

© 2009 Turkaslan and Turna; licensee Cases Network Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction: In cases where the patient experiences trauma, the teeth may be fractured or a bonesegment could be fractured causing misplaced teeth. Ceramic veneer restorations may be a solutionfor re-establishing the ideal position. The treatment of misplaced dental arch segment is presentedand treatment options are discussed.

Case presentation: A 30-years-old female Turkish patient had a history of a dentoalveolar traumaand a surgical operation. Her main complaints were about the unpleasant appearance of her anteriorteeth. The maxillary anterior teeth were positioned labially and had irregularities in vertical positioninharmonious with each other and the horizontal plane. The misplaced sector treated with minimallyinvasive dentin bonded porcelain laminate veneers.

Conclusion: Ceramic veneers can be a solution for patients with malpositioned anterior teeth eventhe situation is severe and excessive tooth reduction is needed.

IntroductionDental trauma and injuries due to various causes are notuncommon in society. The most common injuries in thepermanent dentition are due to falls, followed by trafficinjuries, acts of violence and sports [1]. Maxillary incisorsare the teeth with the greatest visibility during commonfunctions and are the most susceptible to fractures bydirect trauma, especially in children and teenagers,because of their size and position [1,2]. Injury can leadto displacement, rotation and intrusion of permanentanterior teeth [3].

Dental trauma requires adequate treatment, specific toeach fracture in order to preserve the remaining teeth and

their position [4]. Reestablishment of proper esthetics andfunction in the anterior region is quite important for thepatient. The relentless pace of innovation and develop-ment in restorative materials culminates in offeringclinicians a whole plethora of esthetic materials withdifferent techniques. All-ceramic veneers provide precisecolour match and translucency to the natural tooth andfulfil the need for adequate retention [5]. Porcelainlaminate veneers are very suitable for young adults whohave large pulp chambers and pulp horns close to the teethenamel surface. For these types of restorations, thepreparation does not cause the reduction of axial walls.This results in preservation of tooth structure and thesurrounding hard and soft tissue architecture [6]. Clinical

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performance of porcelain laminate veneers is foundreliable. A ten year clinical follow up revealed high successrates (92%) for five years and moderately high successrates (64%) for another five years [7]. Similar results havefound by other researchers [8].

Fractures involving enamel and dentin can be restored bysimple composite or porcelain laminate veneer restora-tions. Some degree of anterior teeth displacement androtation can also be rehabilitated using ceramic veneerrestorations [2,4,9].

This case report presents an esthetic rehabilitation ofanterior teeth due to misplacement. The indication is nota “classic” congenital misplacement but occurred due tomalpractice during surgical operation.

Case presentationA 30-years-old female Turkish patient referred to our clinicwith compliant of unpleasant appearance of her anteriorteeth. Patient has a history of a dentoalveolar trauma and asurgical operation before being referred to a dentist. Sheindicated that her smile has changed following the surgicaloperation which applied after the traffic accident in theyear 2004. After the healing period she directed hercomplaints to the plastic surgeon but the doctor persuadeher that the problem was related with her teeth only.Therefore the patient appealed to our clinic. The clinicaland radiographic examinations revealed that all of themaxillary incisors were vestibulary positioned. The max-illary right canine along the maxillary incisors had obliquefractures involving enamel. The maxillary left lateralincisor had not fractured and was intact. The position ofmaxillary segment between the right premolar and leftcanine was approximately 3 mm lower than its idealposition (Figure 1). Observing that the inferiority of rightcanine and lateral incisor is higher than the others, there is

a probability that the segment not only placed 3 mmbelow its ideal position but also placed a few degreesdeviation off the vertical axis (Figure 2). The misplacementof the segment is explained to the patient and segmentalosteotomy is suggested. The patient rejected the suggestionindicating that she is tired of serial surgical operations,thus the malpractice played a negative effect on herpsychology as well.

A conservative treatment was taken into consideration.The indication was porcelain laminate veneers for themaxillary incisors and right canine, all ceramic crown formaxillary right first premolar because of excessive hardtissue loss and ametal-ceramic fixed partial denture for theanterior mandible due to economic reasons.

Before the prosthetic treatment the maxillary right centralincisor and first premolar was endodontically treated asthey were found to be non vital during the vitality test.During preparation for ceramic veneers, the facial surfaceswere reduced by 1.5-2 mm which resulted finishing thepreparation on dentin and the incisal edges were reducedby 3-4 mm. All the incisors and canine were prepared witha chamfered finishing line with rounded internal lineangles. Smooth margins were created to prevent stressconcentration zones. Once the preparation was com-pleted, impressions were made using polyvinylsiloxaneimpression material (Elite H-D, Zhermack, Germany), andcast in vacuum-mixed Type IV dental die stone (Fujirock,GC Corp, Tokya, Japan) according to the manufacturerrecommendations. Stone dies were carefully separatedfrom the impressions and two coats of die spacer (Spacer-Tray, Kerr) were applied 0.5 mm short of the finish line ofthe preparations. The veneers were waxed up to dies andthey were fabricated from lithium disilicate-reinforced

Figure 1. The radiographic examination indicates thesuperior position of the maxillary anterior segment to theocclusal plane.

Figure 2. Traumatized and fractured anterior teeth, the rightcanine and lateral are more inclined than the centrals.

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glass ceramic material, IPS Empress 2, using the heat presstechnique according to the manufacturer recommenda-tions. After divestment the veneers were finished andglazed.

The inner surface of indirect veneers were treated withair-particle abrasion using 50 μm Al2O (Korox, Bego,Germany) with a chairside air-abrasion device (CoJet,3M-ESPE, Germany) from a distance of 10 mm at apressure of 250 kPa bar for 10 s. Then each surfacetreatment was followed by acid etching with 9% hydro-fluoric acid (Pulpdent Corporation, USA) prior tosilanization (Figure 3). A silane coupling agent (PulpdentCorporation, USA) was applied to the internal veneersurface for 60 s and air-dried.

During the cementation process each tooth was etched for15 s using a 37% phosphoric acid etch-gel (Alpha-Etch 37,Dental Technologies, USA). Subsequently, the toothsurface was rinsed thoroughly and air-dried gently. Dentinprimer and adhesive were applied as the preparationreached dentin structure, according to the manufacturerinstructions (Clearfil, Kuraray). Following the bondingapplication a thin layer of light polymerizing compositeresin luting cement was applied at the intaglio surface ofthe veneers, placed onto the prepared teeth and light-polymerized for 40 s (Elipar Free Light, 3M ESPE) frompalatal, buccal and incisal sides.

Excess luting cement was removed and the marginal areawas finished and polished with abrasive discs. The metal-ceramic fixed partial denture on the anterior mandibulaand the full coverage all ceramic crown for maxillary rightfirst premolar are constructed with conventional proce-dures and cemented (Figures 4, 5). Restorations werechecked to avoid any occlusal interference.

The patient was satisfied with her new smile line andexcellent view of the anterior teeth (Figures 6, 7). She wasrecalled in 2 days and encouraged for better dental flossingand also recalled every 6 months for periodical controls.No complication was observed during 3 years clinicservice.

DiscussionThe conservative restoration of unaesthetic anterior teethhas been revolutionized by the introduction of laminateveneers. Today, ceramic veneers have become the majormodality of treatment when conservative aesthetic resto-ration of anterior teeth is needed [10,11].

Minimally invasive preparation designs and modernceramic materials make this treatment option increasinglyconservative to the natural tooth structures, while provid-ing both predictable and long-lasting aesthetics. It can be

Figure 3. The intaglio surface of porcelain veneers which areready for cementation.

Figure 4. Restorations finished and cemented onto theabutment teeth.

Figure 5. Panoramic radiograph after the restorationscemented.

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concluded that the bonding systems and proceduresused offer reasonable strength and sealing both on theporcelain site and on dentin and enamel [12]. All-ceramicveneers guarantee color and translucency close to those ofthe natural tooth as well as fulfiling the need for adequateretention, while preserving maximum remaining toothstructure [10,11,13].

Treating large morphological and structural defectsdemands more than a labial and incisal covering ofresidual tooth structure. Ceramic veneers involving theincisal edge, proximal areas and larger parts of the palatalsurface have been recognized as an alternative to fullcrowns in the anterior dentition [11,14]. Since full crownpreparations require removal of extensive tooth structure,

in this case report full coverage restoration of misplacedincisors may cause vitality problems or root canaltreatment. Besides the severe reduction in vestibule side,reducing the palatal enamel and some dentin may causethe need of endodontic post applications prior to fullcrowns.

Today, advancement in dentin adhesives, combined withthe highly esthetic resin and ceramic materials in estheticdentistry give the clinicians a chance to mimic the naturaltooth structure. Recently all-ceramic restorations havegained popularity and more frequently preferred indentistry. The versatility of veneers allows them to beused with a variety of preparation forms, from simplefacial veneers to more complex restorations that involvethe replacement of more tooth structure [12,14]. Ceramicveneers are one of the most conservative and aesthetictechniques that can be applied when restoring the dentalarch for improved aesthetics. The use of ceramic facets tosolve esthetic and/or functional problems in the anteriorsection has been shown to be a convincing option. Years ofexperience with both the technique and the materialsemployed offer satisfactory, predictable and lasting results[9,10]. In this case, reducing the anterior teeth to deepdentin layer allowed us to reposition them and correct thevestibule contours while using dentin as bonding surface.Reducing the tooth hard tissues to dentin for porcelainveneer is still a minimally invasive approach to give us anadvantage of avoiding any root-canal treatment. It is foundthat there is a higher risk of failure of veneers on non-vitalteeth compared to vital teeth [15].

Porcelain veneers restore the mechanical behavior andmicrostructure of the intact tooth in vitro even when theyare bonded to an extensive dentin surface using anoptimized application mode of dentine adhesives [12].In the current case report the serious reduction wasobligatory in order to draw the teeth to their idealposition. Reliable dentin bonding systems enabled therehabilitation of the case with dentin bonded ceramicveneers.

ConclusionCeramic veneers can be a solution for patients withmalpositioned anterior teeth even the situation is severeand excessive tooth reduction is needed.

ConsentWritten informed consent was obtained from the patientfor publication of this case report and accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.

Competing interestsThe authors declare that they have no competing interests.

Figure 7. Lateral aspect of the patient. Position, color andform of the teeth are in accordance with the horizontal planeand her smile.

Figure 6. An aesthetic outcome is achieved with restorationsin both dental arches. Patient was satisfied with her excellentview of anterior teeth.

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Authors’ contributionsST accomplished the clinical steps of ceramic veneers andrestored the anterior teeth of the patient and reviewed themanuscript. ST and ÇT prepared draft manuscript. Allauthors read and approved the final manuscript.

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