Written by Elliot Mechanic, BSc, DDS Thursday, 31 March 2005 19:00
It is suddenly really “cool” to be a dentist! These are incredible times for dentistry, truly a golden age. Reality television with programming like “Extreme Makeover” and “The Swan” has brought aesthetic dentistry and how it can dramatically change people’s lives to the forefront of public awareness. Due to pioneering work with the media by dentists such as Irwin Smigel, Larry Rosenthal, and Bill Dorfman, dentistry is being profiled on local and national television and in magazines and newspapers throughout the country. The media and public are hungry to learn about and see the results of dentistry.
Aesthetic dentistry can truly alter not only a person’s appearance, but his or her personality as well. Creative smile design through altering the length, form, and position of teeth can instantly reduce years from a person’s appearance. Usually, a dental makeover will lead to other forms of beautification, often beginning with a new hairstyle. Although some patients proceed to have plastic surgeries, most do not care to or need to go to such extremes. Aesthetic dental changes, a new hairstyle, new ways of applying makeup, and a new wardrobe can result in a dramatic boost in self-confidence.
Aesthetic dentistry and the passion of today’s dentist often open the door to incredible results and a level of excitement and “buzz” that significantly raise the public’s awareness of dentistry. When dentists have the right patient, present all the facts and treatment options, and have the patient’s acceptance and trust, often the most complex dental treatments proceed smoothly with spectacular results.1
THE ROLE OF THE PROVISIONAL RESTORATION
The ability to create and easily modify provisional restorations simply and quickly has opened the door to predictable aesthetic dental changes. As opposed to other plastic surgeries, dental temporization can give the patient a chance to preview his or her new smile, live with it for awhile, show it to family and friends, and alter it as necessary.
|Figure 1. Putty template created from diagnostic wax-up.|
A putty template is created from a diagnostic wax-up (Figure 1) or mock-up created directly on the patient’s teeth, which is filled with an injectable bis-acryl material and placed over the patient’s prepared teeth. These provisionals can then be trimmed and glazed to a lifelike realism.
Our material of choice is Luxatemp Fluorescence (Zenith/DMG). It’s patented 10:1 base:catalyst ratio provides the perfect blend of strength, aesthetics, accuracy, and fast set time. It can be easily added to and modified using Luxaflow Fluorescence (Zenith/DMG) or any microfill composite, and then glazed with Luxaglaze (Zenith/DMG), which not only gives it polish but adds to its strength.
A well-made temporary restoration is the key to an aesthetic restoration. It provides the lab with a blueprint for tooth length, width, thickness, arch position, midline cant, and occlusion. Once the patient has approved the temporary, the lab replicates it in porcelain using silicone templates. You cannot go wrong!
The temporary restoration is the first and most dramatic factor in creating a major aesthetic change.2 It normally makes the patient more self-confident and often leads to other physical changes. These changes can dramatically affect how the patient is perceived by others. As dentistry strives to aim “outside the box,” we establish new standards of care and create techniques to alter facial appearance by cosmetic dental changes.
FACIAL CHANGES THROUGH TEMPORIZATION
Dr. Irwin Smigel refers to advanced aesthetic dentistry as “plastic surgery without a scalpel.” Continuing dental education today often includes plastic surgeons describing what types of facial changes they are capable of achieving. They recognize the benefits of aesthetic dentistry. The worlds of plastic surgery and dentistry are converging.
Creative dentistry by mani-pulation of tooth form and position can yield significant alterations to a person’s facial form.
The Round Face
|Figure 2. Initial presentation.|
Our patient had numerous dental problems. She was totally unaware of her long-standing periodontal breakdown and presented to our office for an aesthetic consultation (Figure 2). We educated her as to her dental problems and asked how she felt about the shape of her teeth and the shape of her face. When she expressed that she did not like her small, square teeth and gummy smile and disliked her round-shaped face, it opened the door for us to try to introduce what today’s aesthetic dentistry has to offer.
|Figure 3. Round-shaped face: a wide, circular face can be made to appear narrower by designing a longer upper arch. This will center the viewer’s eyes at the bridge of the nose, minimizing the round facial form.|
It was explained that her short, square teeth with round edges, weak development of the buccal corridors, and flat “shaggy dog” haircut further accentuated her facial features.3 From experience, we know that a wide circular face can be made to appear narrower by designing a longer upper arch. This will center the viewer’s eyes at the bridge of the nose, minimizing the round facial form (Figure 3).
|Figure 4. Computer-generated imaging and diagnostic wax-up.|
Computer-generated imaging was used to illustrate a projected result. The patient was delighted (Figure 4)! A diagnostic wax-up incorporating our new tooth form and arch width was fabricated on articulated study models (Figure 4). The upper arch was prepared and temporized based upon this wax-up. The preparation margins were placed at ideal levels regardless of biologic width and alveolar bone position. The presence of existing periodontal disease with enough root length remaining in bone gave us aesthetic flexibility for our margin placement. A diode laser was used to place the margins exactly where we wanted them regardless of the position of the alveolar bone. Aesthetics was the sole criterion at this point in time, and we sculpted papilla in the gingival tissue, aligned gingival levels, and placed our teeth in harmony with golden proportions.
|Figure 5. Provisional restoration 10 days after placement.|
Periodontal surgery was performed immediately after temporization, with the periodontist having the benefit of our ideally placed temporaries to serve as a template to recreate biologic width, repair boney defects, and align gingival levels according to the projected aesthetic result.4 If the periodontal surgery were to be performed before temporization, we may have been left with a lack of interdental papilla, black triangles, and irregular gingival architecture. Ten days later when the patient returned for suture removal, her smile was radiating, and she appeared with a changed hairstyle (Figure 5). She expressed that she felt “brand new.”
We congratulated her on her new look, and not wanting to criticize or discourage her, expressed our fascination with the idea that a more elevated hairstyle may further deaccentuate her round facial features. We gave her the name of a hairstylist that we knew and told her that he was “avant-garde” and performed wonders with many of our patients. Not everyone has the same view of aesthetics, so we discretely directed her to a hairstylist with our vision! She was more than open to this and excited by our suggestion.
|Figure 6. Provisional restoration No. 1.|
Three months later, as the periodontal surgery continued to mature (Figure 6), our patient returned with a new hairstyle based upon our referral. Her face did not appear to be round at all. She was truly feeling good about herself. When asked if she desired sexier teeth to give her a sharper, more “animalistic” look, her eyes lit up with excitement. We were pushing the right button.
|Figure 7. Provisional restoration No. 2.|
We added Matrix microfill composite resin (Discus Dental) to lengthen the anterior teeth, square off the edges, and give the teeth a bit of irregularity, a term this author refers to as “asymmetric symmetry.” This gave the teeth a more “in your face” look. She absolutely adored this exciting new look and approved it as the tooth form that she desired for the permanent restoration (Figure 7). Photographs and impressions of this provisional were taken so that templates could be made, allowing the porcelain restoration to approximate the provisional. The temporaries were removed, the preparations refined, and final impressions taken. The case was mounted to the existing lower model and sent to the technician.
|Figure 8. Final case.|
IPS Empress porcelain (Ivoclar Vivadent) restorations were then fabricated using a multilayering technique. A TC1 ingot was chosen as the basic shade, as the patient’s teeth were in the Vita A range. Some neutral and clear porcelain was fired around the margins to make them appear invisible (Figure 8).
The Narrow Face With Asymmetric Features
|Figure 9. Initial presentation.|
|Figure 10. Narrow-shaped face: If we design a flatter smile line, a narrow face will appear wider. If the teeth are made very symmetric, then the face will appear to be more balanced.|
Our patient presented with upper anterior teeth that were crowded and heavily filled with composite restorations (Figure 9). She actually desired a referral to an oral surgeon, as her chief complaint was that she disliked her long, narrow chin, which appeared to angle off to one side. If we design a flatter smile line, a narrow face will appear wider. If the teeth are made very symmetric, then the face will also appear to be more symmetric (Figure 10).
|Figure 11. Computer-generated imaging.|
Computer-generated imaging was created to give us an idea of what kind of result could be achieved without any surgical intervention (Figure 11). The results spoke for themselves, and it was agreed that we would redesign and restore the smile before undertaking any form of mandibular surgery.
|Figure 12. Diagnostic wax-up.|
|Figure 13. Provisional restoration.|
Orthodontics was out of the question for this patient. She made this point very clear. A diagnostic wax-up was fabricated in order to establish what could be achieved by dental restoration (Figure 12). Preparation of the 6 maxillary anterior teeth, gingival alignment with a diode laser, and temporization with Luxatemp Fluorescence resulted in an extremely pleasing result (Figure 13).
|Figure 14. Porcelain restoration.|
The final IPS Empress restoration reflected what had been created in the temporary. Layering of the porcelain and texturing the labial anatomy gave the teeth a vibrant realism (Figure 14). Designing a flatter, more symmetric smile line made the face appear wider and more symmetric. After viewing the final result, mandibular surgery was no longer a consideration.
The Gummy Smile
When a person smiles, his or her upper lip moves to expose the anterior teeth. It is desirable for the lip to align with the gingival margins of the central incisors to expose 1 to 2 mm of gingiva. Sometimes, when more than 2 mm of gingiva shows, the patient finds it unaesthetic. There are several potential causes for a gummy smile:
• short upper lip
• hypermobile lip
•vertical maxillary ex-cess
• anterior overeruption
• wear and compensatory eruption
• altered active eruption
• altered passive eruption.
Dentists should have a full understanding and diagnostic skill for the etiology to know if and how easily the smile could be modified.5,6
|Figure 15. Pretreatment.|
|Figure 16. Computer-generated imaging.|
|Figure 17. Diagnostic wax-up.|
Our patient presented for consultation with a chief complaint of a gummy smile (Figure 15). The placement of the gingival margins in the posterior sextants and lack of gummy smile in these areas ruled out vertical maxillary excess and the need for maxillofacial surgery. Periodontal probing of the 4 anterior teeth demonstrated altered passive eruption, with nearly 3 mm of gingiva present until the level of the attachment was reached. Radiographs of the anterior region showed significant root length, leading us to the conclusion that if we repositioned the gingival level and altered the level of alveolar bone to maintain biologic width, then we would create the desired aesthetic result while maintaining periodontal health. Computer-generated imaging (Figure 16) and mounted study models (Figure 17) were taken for the creation of a diagnostic wax-up of the projected new look of the 4 anterior teeth.
|Figure 18. Laser gumline modification and temporization.|
Tooth preparation of the 4 anterior maxillary teeth was performed with the objective of placing the margins of the Luxatemp provisionals at the ideal tissue level regardless of gingival or bone position. A diode laser was used for margin placement, to recreate papillary form, and to ensure ideal gingival levels (Figure 18). Our tooth preparations followed the objectives dictated by our temporaries, even if preparation into the alveolar bone was required. Periodontal surgery was immediately performed, with the periodontist having the benefit of the position of the provisionals to establish biologic width and to align gingival levels.
|Figure 19. Provisional restoration.|
Ten days later, when returning to remove the remaining sutures, our patient appeared happy and vibrant and was wearing a new hairstyle and new clothes (Figure 19). Dent-istry had truly made her feel better about herself, and in expressing her excitement, she referred to us as “the eighth wonder of the world.” The point of temporization is the greatest minute of shock, drama, and excitement for the patient. This is the point in time where dentists create what Ken Blanchard describes as “raving fans.”
|Figure 20. Final porcelain restorations.|
Three months of periodontal maturation and healing was followed by photos and impressions of the provisonals, the removal of the provisionals, refinement of the preparations, photos and choice of stump color for IPS Empress restorations, and choice of our final tooth color. The final restorations (Figure 20) delivered the realistic look the patient desired without a trace of a gummy smile.
When I attended dental school in the 1970s, there was no such thing as aesthetic dentistry. We were taught to draw teeth in their “ideal” form, and if our tooth form varied only slightly from “textbook,” then we failed. I remember placing a set of uniformly white Chiclets-style teeth into a patient’s mouth and getting an A. What a great result. (I would fail today). In my earliest years of dental practice, we simply took an impression, sent it off to a lab technician, and hoped for the best.
However, by the 1980s, not everyone was content with Austin Powers teeth. They actually wanted nice-looking teeth! I was treating a number of popular musicians in 1983 and was asked the following: Can you make my teeth look better? Can you make them look straighter? Can you change their color? (Performing musicians did not have the time for orthodontics and lengthy treatments.) My answer to them was, “Of course I can.” (In reality, I didn’t have a clue.) Fortunately for me, though, other dentists throughout the world were being asked the same questions by patients who no longer wanted “store bought” teeth. New materials and techniques began to appear. Today, the worlds of dentistry and plastic surgery are merging, leading to better patient care and coordinating aesthetic treatment planning. I have performed hundreds of aesthetic dental cases and have found that usually, changing a patient’s teeth leads to a new hairstyle.
Dr. Mechanic wishes to thank his friend and partner in smiles, Camille Halaby (CRH Oral Design, Montreal, Quebec), for his creative lab work.
1. Mechanic E, Hallaby C. The “magic” combination: dentist, technician, and patient. J Cosmet Dent. 2003;19:63-68.
2. Blanchard K, Bowles S. Raving Fans: A Revolutionary Approach to Customer Service. New York, NY: William Morrow; 1993.
3. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51:24-28.
4. Kois JC. Altering gingival levels: the restorative connection, part I: biologic variables. J Esthet Dent. 1994;6:3-9.
5. Kokich VG. Esthetics: the orthodontic-periodontic restorative connection. Semin Orthod. 1996;2:21-30.
6. Chiche G, Kokich V, Caudill R. Diagnosis and treatment planning of esthetic problems. In: Chiche G, Pinault A, eds. Esthetics of Anterior Fixed Prosthodontics. Chicago, Ill: Quintessence Publishing Co; 1994:33-52.
Dr. Mechanic practices aesthetic dentistry in Montreal, Canada. He received his bachelor of science (1975) and doctor of dental surgery (1979) degrees from McGill University. He is a contributing consultant on cosmetic dentistry to Oral Health and is on the advisory board of Spectrum Dental Journal. He maintains memberships in numerous professional organizations, including the American Academy of Cosmetic Dentistry. His work has been profiled in magazines and on television and the radio. He can be reached at (514) 769-3939 or drmechanic.com.
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