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Smile Makeover: Article one

9 August 2013

Smile Makeover: Article one

Introduction

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:

  1. Comprehensive dental assessment and treatment planning
  2. Laser crown lengthening, records for wax ups and mock ups
  3. Preparation techniques
  4. Trial smile creation and the review appointment
  5. Cementation and the celebration

Case History

Cheryl was mainly concerned with:

  1. The small size of her teeth
  2. The gummy smile
  3. Narrow buccal corridors (i.e. a “narrow smile”)

Pre-opPre-op smile   

Images left-right: pre-op (face), pre-op (smile)

 Pre-op (retracted)     Dental panoramic tomograph

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.

Clinical Examination

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).

 

Feature Observation  Comments/Signicance
Muscles

 

No tenderness

 

All OK
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

 

All OK

 

     

 

 Occlusion  Observation Comments/Significance 
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

 

Non-working interferences 

UL6 distopalatal cusp and UL7 palatal cusp on right lateral excursion

UR6 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

 

Wear pattern Erosion

 

There was some evidence of erosion on the palatal surfaces of the upper anterior teeth

 

Restorations

 

LR7 had a small occlusal cavity, and the amalgam at UL6 occlusally was not ideal

 

Composite fillings were required

 

 Periodontal  Observation  Comments/Significance
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:

 Cosmetic  Observation  Comments/Significance
Patient concerns (upper teeth)
  • Smaller teeth
  • Gummy smile
  • Narrow smile
  • Darker colour of teeth
  • Crooked UR2
  • Pointed canines

 

 

It is important to note exactly what is concerning the patient

 

Patient concerns (lower teeth)
  • Slight chipping of the edges of the lower teeth
  • Darker teeth

 

 

 

 

 

Nose OK  
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)

UR1=6.5mm 

UL1=6.0mm

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 high

UL1: 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

 

 

 Pre-op shade recording

Fig 1.5: pre-op shade recording

Diagnoses

The following diagnoses were made after the assessment:

  • Decay (mild)
  • Erosion (mild)
  • Periodontal problems (mild)
  • Cosmetic concerns
  • Gummy smile
  • TMJ (dormant problem)

Treatment Planning

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.

Summary

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.

Ash Parmar   Academy logo

 

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 training@theacademybyash.co.uk.

Alternatively, you may phone Ash personally on his mobile number 07971 291180.

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