Esthetic demand of patients increases day-by-day, enhancing our daily practice towards smile design and rehabilitation. Treatment modalities vary widely with the progressive development of dental materials, technologies and techniques. Smile design has become one of the widest multidisciplinary procedures in dentistry nowadays [1].

Healthy periodontium is one of the mandatory elements of a pleasant smile. Absence of inflammation, bleeding, swelling, pocketing and other signs of periodontal disease are crucial to obtain the desired esthetic result. However, the amount of gingival display, gingival architecture, clinical crown dimensions and tooth position play an important role in the esthetic value of the cosmetic restoration [2]. Therefore, an interdisciplinary approach is necessary to achieve the optimal result.

Composite resins and ceramics are very popular in this field [3]. Each one has advantages and disadvantages that influence the choice of the used material. Composites are usually the first conservative approach with low cost, acceptable esthetics, minimal preparation needed and can be done chair side [3] [4]. On the other hand; polymerization shrinkage, marginal micro-leakage, plaque retention and shade instability are still big problems that face dentists [3].

Dental ceramics have become one of the promising tooth colored materials with superior optical properties that mimic natural teeth. Also, biocompatibility, wear resistance, high compressive strength and minimal plaque adherence have made ceramics an excellent choice [5]. However, some physical properties can be still a main concern that may affect the long term results. For example, brittleness, poor tensile strength and crack propagation may affect the long-term durability of the restoration. These weaknesses can be overcome by choosing the proper restoration design [3][4][5] [6].

The case report presented here describes the use of two different designs of ceramic restorations accompanied by gingival plastic surgery for maximal esthetic effect.

A 31-year-old male presented to our clinic with multiple complaints regarding the smile. His main concern was to remove old white fillings that were done four years ago as a treatment of mild discoloration in the anterior teeth as he described.

Full medical history was recorded, in which the patient is totally healthy. Clinical extraoral examination was done without any obvious abnormality. Temporomandibular joint (TMJ), regional lymph nodes, face symmetry and muscles of mastication were examined well. Intraoral clinical ( (Figure 1) and radiographic (periapical X-ray) (Figure 2) examination revealed a list of problems:

• Generalized marginal gingivitis (plaque induced).
• Moderate fluorosis, which is a common clinical feature in the area of Gassim, Saudi Arabia.
• Poor composite veneers with leaking discolored and rough margins with some overhangs inter-proximally.
• Multiple carious lesions inter-proximally of some of upper anterior teeth.
• Irregularities in the marginal gingival levels.
• Short clinical crowns of the right and left upper premolars, which was evident upon maximum smile.

Treatment options were discussed with the patient. A decision was made to improve the esthetic appearance of all his upper teeth that show in the smile (including upper second premolars). First, selective crown lengthening would be done to level the gingival margins. Second, metal free crowns for upper anteriors, and veneers for upper premolars would be done.

Improving oral hygiene

Scaling, polishing and oral hygiene instructions were given strictly. Smoothening of the poor over-hanged margins of the composite veneers was done. Chlorhexidine 0.2% mouthwash was prescribed twice daily after brushing and flossing. Appointment was given after one week for periodontal surgery.

Crown lengthening

Periodontal surgery was done for upper premolars and right lateral incisor. Conventional internal bevel incision was done using blade 15c, 2–3 mm away from the free gingival margin. Sulcular incision was done along the sulcus of the relevant teeth. Resected gingiva was removed by sickle scaler .

Periodontal dressing was applied on the selected teeth. Postoperative instructions were given to the patient, with the advice to continue using chlorhexidine 0.2% mouthwash twice daily. A follow-up appointment was given after one week (Figure 3).

Teeth preparation and impressions

After four weeks of surgery, the prosthetic part was started. Teeth were prepared using diamond burs to form an equigingival deep chamfer finish line for the crowns , and light chamfer for the veneers. A butt joint with partial buccal cusp coverage design was done for the premolars . Finishing discs were used to smooth and round the preparation angles (Figure 4).

Moisture control was obtained by cotton rolls and saliva ejectors. Double retraction cords were used. Impressions were done using addition-cured silicon in metal trays, single stage technique (Figure 5). Shade was selected from Vitapan 3D Master shade guide. Provisional crowns were fabricated directly using acrylic resin and cemented temporarily. Consequently, bite registration at centric occlusion position using additional silicone and alginate impression for the lower arch were done.

Disinfection for the impressions was done by immersion in sodium hypochlorite 1% for 10 minutes, and then sent to the ceramist.

Metal free crowns were designed to achieve the desired esthetic goal. IPS e-max ZirCAD copings with IPS e-max Ceram layering were the choice for the crowns, IPS e-max lithium disilicate for the veneers .

Cementation

The patient was recalled. Provisional crowns were removed, try in was done using try in paste. The marginal integrity for each unit was checked individually. Occlusion in maximum intercuspation, lateral excursions, and protrusive movements was examined, in which a group function guidance was designed. No working and non- working interferences were found. The patient was completely satisfied with the shade and shape of the teeth. Therefore, a decision was taken to do permanent cementation.

Moisture control and teeth isolation was well obtained. The whole prepared teeth were treated with 35% phosphoric acid etchant and single bond. The veneers were treated with 10% hydrofluoric acid etchant and silane coupling agent. Cementation was done with dual cured resin cement for the crowns, and light cured one for the veneers (Table 1).

One week after cementation, the health of gingival tissues surrounding restorations were observed, enhancing the integration between ceramics, gingival margin and lips. The esthetic results were very satisfactory (Figure 6). The quality of the prosthesis and the appearance of the gingival margin were maintained after one-year follow-up (Figure 7 Figure 8).