This series of articles will review in detail a clinical case that I treated. The patient was my manager Cheryl, who was conscious of her smile. I carried out a comprehensive dental assessment and reviewed all of her treatment options. We elected to do a Smile Makeover (laser gum lift with soft and hard tissue lasers, followed by the provision of ten upper porcelain veneers). It will be clearly apparent the absolute minimal intervention approach in this case (all the preparations and the fitting of the porcelain veneers were done with no local anaesthetic).
The series of five articles will cover the following topics in treating this case:
- Comprehensive dental assessment and treatment planning
- Laser crown lengthening, records for wax ups and mock ups
- Preparation techniques
- Trial smile creation and the review appointment
- Cementation and the celebration
Cheryl was mainly concerned with:
- The small size of her teeth
- The gummy smile
- Narrow buccal corridors (i.e. a “narrow smile”)
Images left-right: pre-op (face), pre-op (smile)
Images left-right: pre-op (retracted), dental panoramic tomograph
She wanted a whiter, fuller, less gummy and natural smile as the end result. Cheryl needed a couple of conventional composite restorations on the posterior teeth as well as routine gum treatment with the Hygienist. She is a motivated patient with good oral hygiene.
The following table illustrates some of the key findings during the comprehensive dental assessment. I firmly believe that the key to success is the ability to be able to understand the patient clearly, and also carry out a detailed dental assessment to reach accurate diagnoses. This allows the dentist to treatment plan well, and offer the ideal treatment solution(s).
|Temporomandibular Joints (TMJ)||Ligament laxity on opening and closing (Right TMJ), and a double click on opening (Left TMJ)||
Despite the clicking, Cheryl was symptom free. Joint Vibration Analysis (JVA) tests showed that there was some disc displacement with reduction (Right TMJ) and also ligament laxity or partial disc displacement with reduction (Left TMJ). Cheryl understood the pre-existing condition of the TMJ and the slight risk of getting TMJ problems in the future
|Manipulation into the Centric Relation (CR)||Moderate difficulty||
If the vertical dimension is to be changed, then it is important to de-programme the muscles with a device such as an NTI Appliance before the accurate CR record is taken. In Cheryl’s case, it was decided to treat her in Centric Occlusion after some occlusal equilibration to remove non-working interferences
|Maximum opening||41 mm, with some deviation of the lower mandible to the right side||The normal range of opening is 50-60 mm|
|Movement of mandible sideways (measure at the centre line)||Right side 11mm, Left side 11mm||Normal range is 8-12mm|
|No pain at TMJ in excursions||Yes||
|Molar relationship||Right=Class II, Left=Class II|
|Canine relationship||Right=Class 11, Left=Class II|
|Lateral excursion contacts||Right Side: UR4, UR5 and UR6
Left Side: UL4, UL5 and UL6
|Aim for canine guidance in the final result, rather than group function|
|Protrusive guidance||UR1, UR2, UL1 and UL2||
Balanced protrusive contacts with the four incisors is ideal
UL6 distopalatal cusp and UL7 palatal cusp on right lateral excursionUR6 distopalatal cusp and UR7 palatal cusp on left lateral excursion
|Important to avoid in the final result. Occlusal equilibration was required for occlusal harmony and a better end result|
|Shimstock hold in Centric Occlusion||At UR4, UR6||
Excellent record to keep for all cases involving laboratory work
|Evidence of grinding||Yes||
A hard mouth guard had been made for Cheryl at the age of 17, but this was not worn. She is aware of clenching her teeth at night time
There was some evidence of erosion on the palatal surfaces of the upper anterior teeth
LR7 had a small occlusal cavity, and the amalgam at UL6 occlusally was not ideal
|Composite fillings were required|
|Hygiene||Generally good (fairly motivated patient). Flosses regularly, and sees the Hygienist too||
A one-hour Hygienist session was advised
After the general assessment, a thorough Smile Analysis was carried out.
The following table illustrates the key features to look for and the findings in this particular case:
|Patient concerns (upper teeth)||
It is important to note exactly what is concerning the patient
|Patient concerns (lower teeth)||
|Facial profile (lateral view)||Normal|
|Lips||Thinner upper lip, normal sized lower lip; slightly asymmetrical||Lips play an important part in a person’s smile|
|Teeth showing on smiling||Upper ten teeth||
Ask the patient to have a look in a large mirror, say “E” and smile fully – record the number of teeth that show on each side
|Buccal fullness||Improved fullness was required for UR3, UR4, UR5, UL3, UL4 and UL5||A fuller smile at the sides looks much better|
|Gingival display on smiling||Moderate||
Correction of the gummy smile was an important goal for Cheryl
|Laser use||Soft tissue and hard tissue lasers were required||
I carried out gingival and osseous crown lengthening with lasers, i.e. no flaps were raised
|At rest (tooth amount showing)||
|It was decided to keep the incisal edge position the same as UR1|
|CEJ-CEJ measurement||11.75 (between UR2 and LR2)||
Important measurement when assessing how much to open up the vertical dimension (VD) - if this is being changed
|Profile of central incisors||Deflective||
Better aesthetic result will be achieved if teeth are reflective compared to deflective (i.e. retroclined). We therefore wanted to bring out the incisal half of the central incisors with the porcelain restorations…this is important in this case
|Size of central incisors||
UR1: 7.94mm wide, 7.94mm highUL1: 7.84mm wide, 8.27mm high
|Important to understand the width: height ratio (ideally 8:10). Digital calipers were used to take these measurements|
|F & V sounds||On the wet part of the lips||
Ideal position on the vermillion border i.e. in this case the edges of the upper centrals were retroclined. A better cosmetic outcome would be achieved if the edges were brought forwards
|J sounds||4mm at mesio-buccal cusp of upper 1st molar||
If there is more than 2mm between upper and lower teeth (when the patient keeps saying “J”), then good prognosis to open up the vertical dimension (if this is actually required)
|Incisal edges of upper teeth parallel to interpupillary and commissural lines||No|
|Midline||In the middle of the face and vertical||
Ideally the centre line should be vertical (and not canted), and can be up to 2mm either side of the patient’s facial midline
|Pre-op shade||1M1 and 1M2 neck (see Fig 1.5)||
It is important to carefully select the pre-operative colours with the patient, and also get a staff member’s opinion too
|Desired colour||Between 1M1 and 0M3||
Patient wanted a natural look
Fig 1.5: pre-op shade recording
The following diagnoses were made after the assessment:
- Decay (mild)
- Erosion (mild)
- Periodontal problems (mild)
- Cosmetic concerns
- Gummy smile
- TMJ (dormant problem)
Because the incisal edge position was correct, it was immediately apparent that crown lengthening was required to create a less gummy smile as well as correctly proportioned teeth.
Occlusal equilibration with T Scan and articulating papers would be required – this was mainly to remove the non-working interferences posteriorly.
A Versawave all-tissue laser was to be used to carry out gingival contouring, as well as bone removal without raising a flap (as is required in conventional crown lengthening with a periodontist).
Our Hygienist saw Cheryl to carry out a thorough periodontal prophylaxis and to reinforce ideal oral hygiene techniques. Composite fillings were done as necessary.
Lower cosmetic contouring, lower ZOOM teeth whitening (home whitening), and ten upper porcelain veneers were the ideal cosmetic treatment plan. Cheryl was then planning to have some facial aesthetics treatments as well as slight use of muscle relaxing injections to reduce the gummy smile further.
The use of digital photographs, study models, appropriate radiographs and a clinical assessment help to communicate and diagnose accurately. In the next article, I will be covering the various records and materials that are used to carry out diagnostic mock-ups, and also explain about the various records that are required to be sent to the ceramist technician so that accurate aesthetic and functional wax ups are created in readiness for the preparation appointment.
Ashish B Parmar (Ash) is a private dentist and has a unique state-of-the-art practice in Chigwell, Essex called Smile Design By Ash (www.smiledesignbyash.co.uk). Ash is a national and international lecturer and was one of the main dentists on the three series of Extreme Makeover UK. He offers an outstanding 8-day Course which includes training on leadership, vision creation, goal setting, step by step techniques in doing Smile Makeovers, treating advanced cases (e.g. wear cases), lasers, fibre-reinforced composite dentistry, photography, communication, case presentation skills, team development, occlusion, etc. Ash has written numerous clinical articles in dental journals and is well recognised for his passion in cosmetic dentistry – using both composite and porcelain techniques.
For lots of FREE information, clinical videos and articles and to find out more about the unique training Course run by The Academy By Ash, visit www.theacademybyash.co.uk, or send an email to firstname.lastname@example.org.
Alternatively, you may phone Ash personally on his mobile number 07971 291180.