Closing the Gap A Team-Based Treatment Plan Yields "You've Changed My Life" Results

What can be more rewarding than a patient telling her dentist, “You’ve changed my life!” It happened in my office, and what a great feeling it was to hear that remark. Cosmetic dentistry is more sought after—and its effects are more influential on patients—than we dental practitioners understand. From newer and better regenerative techniques1-7 and finer restorative materials8-10 to the proactive techniques of altering nature (orthodontics, orthognathic surgery, etc), we have an arsenal of powerful tools and strategies with which to make constructive, powerful changes that affect the entire individual, not just the mouth.

We are continuously learning that the effects of our profession are dramatic and far-reaching. Cosmetic dentistry is beginning to be recognized and appreciated as a major positive influence on the psyche of a patient and not just as a technique to show off a “white, bright smile.” As newer techniques become more practical and predictable, cosmetic enhancement is becoming a reality and is more appreciated and sought after by patients.

Since cosmetic dental restoration has now become an essential component of dentistry, we must explore how to get the best results for the patient. In my experience, a multistep team approach provides the necessary ingredients and best cosmetic results. A team approach involves a restorative dentist, a cosmetic periodontist, and a patient all working together. Combined, they have input, technical abilities, and anticipated and communicated goals. The steps involve planning, execution, and postoperative communication. The team effort might involve a few extra spoonfuls of humility, a dash of cooperation, and a tincture more of patience, but the result will be worth it. The technical abilities of the respective dentists’ and patients’ desires and expectations can all be applied to the same objective, which is to achieve the best results.

The following case presentation demonstrates a “team approach” to cosmetic periodontal surgery in conjunction with restorative dentistry, culminating in a “you changed my life” result.

CASE REPORT

Figure 1a. Presurgical labial view. Note short-appearing square teeth, diastemas, and frenum level. Figure 1b. Presurgical right side labial view showing dark spacing between teeth Nos. 5 and 6, 6 and 7, 7 and 8, and short, square-appearing teeth.
Figure 1c. Presurgical left side labial view showing dark spaces (diastemas) between teeth Nos. 9 and 10, 10 and 11, 11 and 12, and short, square-appearing teeth.

A young woman was referred to my office by her restorative dentist. She relayed a strong desire to “have her smile corrected.” She related being self-conscious of her smile, as evidenced by the immobility and rigidity of her upper lip, not allowing her smile to surface. She complained that she didn’t like the dark spaces between her maxillary anterior teeth (Figures 1a, 1b, and 1c show the diastemas between her central incisors, her left central and lateral incisors, and right lateral incisor and cuspid). She also expressed concern about her short-appearing maxillary teeth (the short, square appearance of her maxillary anterior teeth; gingival-incisal length), and of course, she hated the darker yellowish color of her teeth. Observation and examination revealed that she did have small teeth and a gummy-appearing smile, as she had stated with frustration.

From a periodontal perspective, after periodontal probing, radiographs, and assessing the gingival-tooth relationship as well as her periodontal status, I felt confident that I could help this patient. The restorative dentist, my office, and the patient all worked, scheduled, and planned the desired results before commencing. The commitment of time, finances, and effort was discussed by everyone on the team. The patient was included in every step. The patient definitely wanted the spaces between her teeth closed, but it wasn’t easy for her to make this commitment because years ago she had undergone orthodontic treatment with an unsuccessful result. It had included serial extraction of all 4 of her first bicuspids and required her to wear orthodontic appliances for over 18 months to eliminate spacing problems. She related that she ended up with more spaces and that this was devastating to her. She also related that she was never consulted nor made part of that process.

We decided to proceed, accomplishing the periodontal phase first. Periodontal treatment consisted of nonsurgical periodontal therapy that encompassed scaling, curettage, and encouraging oral physiotherapy. After completion of this treatment, the tissues were reevaluated before the surgical phase commenced, and the team discussed the next phase.

Figure 2. Mucoperiosteal flap (“growing enamel”) keeping interproximal tissue intact; frenectomy.
Figure 3a. Labial view of mucoperiosteal flap sutured at desired level. Figure 3b. Right side labial view of sutured mucoperiosteal flap.
Figure 3c. Left side labial view of sutured mucoperiosteal flap.

A “growing enamel”1,11 cosmetic surgical procedure followed. Careful attention to preserve all of her interproximal tissue was emphasized. The tissues interproximally were carefully excised, making sure no dark triangular areas were created (Figure 2). No interproximal tissue was removed. The epithelial level at the apices of the tissue was left intact. This allows epithelialization from the coronal tissue, as well as predictable healing of the repositioned keratin. The area was sutured at the desired level, repositioning the pink keratinized gingival tissue12,13 (Figures 3a, 3b, and 3c).14

The frenum level was also changed during the repositioning by releasing the frenum and manipulating keratinized tissue to that area. If the frenum had been left in the same position, its color would be cosmetically unacceptable, emphasizing a reddish unkeratinized patch of tissue (frenum) within the healthy pink keratin, and it would be positioned lower toward the “new teeth” and compete with the illusion being created. That level may also interfere with the patient’s hygiene efforts. The profession today recognizes the importance of different shades of tooth colors, and this is also true for the “background” of the healthy smile. It is imperative in this case not to have a peninsula of red (frenum) amidst a sea of healthy pink.

It was only after the periodontal surgery had healed for about 2 months after the cosmetic surgery, allowing for keratinization to mature, that the patient could visualize the goal to be achieved and that she truly started “to believe.” We were very encouraged by this, since a positive mental state is a great benefit to good healing.

Figure 4. Labial view after healing. Note large symmetrical background of pinkish keratinized tissue and larger-appearing teeth with a symmetrical CEJ level.
Figure 5a. Temporary laminates and gingivoplasty. Figure 5b. Temporary laminates and healing gingivoplasty.

After healing and returning to good oral hygiene (Figure 4), the patient underwent phase 2 of the agreed upon team plan. This involved placing temporary provisional laminates on the soon-to-be restored teeth (Figures 5a and 5b).7 Visualizing with provisionals what the final shape of the teeth would look like, the restorative dentist (Dr. S. Lantner) requested aesthetic gingival sculpting to match her new provisional laminates. The team approved this procedure. We performed a gingivoplasty using a blade in conjunction with a laser (Figure 5a). When healed, the new background color was symmetrical, keratinized pink tissue (Figure 5b). It was a canvas upon which we could now paint, and the “wrong” color of the background tissue had been eliminated.

Figure 6a. Final restored anterior teeth, labial view with laminates. Note harmony of periodontal background, allowing for hygiene maintenance; no frenum pull or different tissue color; symmetry of CEJ line. Figure 6b. Final appearance, right labial view.
Figure 6c. Final appearance, left labial view. Note length of teeth; color of teeth; healthy, proper coloring; symmetrical periodontium; no dark spaces between teeth.

The final restorations of laminates and laminate onlays (Figures 6a, 6b, and 6c) turned out wonderfully. The spaces between her maxillary anterior teeth were gone, and the teeth appeared to be natural. The symmetrical gingival CEJ line blended with her new, youthful color. The incisal levels were not lengthened, yet the gummy appearance was corrected with a symmetrical background, allowing for a natural longer tooth appearance. Her new appearance caused her (with moistened eyes and a huge glowing smile) to comment, “You’ve changed my life.”

CONCLUSION

As dentists, we are pledged to promote good health, but we often do not realize the psychological and physical effects that dentistry can have on individual patients. When her treatment was completed, this patient “glowed” not only with a physically bright smile, but with an energy and confidence that comes with physical rejuvenation. To accomplish this cosmetic transformation, an aesthetic team approach was vital. The team consisted of a restorative dentist, a cosmetic periodontist, and the patient, and involved multistage communication. Input from all 3 led to a blend of techniques, desired goals, and great results.


Acknowledgment

The author would like to thank J. Zeizel and E. Burger for their assistance in the writing of this article.


References

1. Hoexter DL. Surgical techniques for a winning smile. Dent Today. 1994;13:46-49.

2. Pini Prato G. G.T.R. Nonresorbable membranes used in root coverage. J Periodontol. 1992;63:554-560. 

3. Nelson S. The subpedicle connective tissue graft: a bilaminar reconstruction for the coverage of denuded root surfaces. J Periodontol. 1987;68:96.

4. Hoexter DL. Preprosthetic cosmetic periodontal surgery, part 1. Dent Today. 1999;18(10):100-105.

5. Hoexter DL. Cosmetic periodontal surgery, part 2: using variations of gingival graft techniques. Dent Today. 1999;18(11):110-115.

6. Hoexter DL. Periodontal aesthetics to enhance a smile. Dent Today. 1999;18:78-81. 

7. Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Dent. 1980;1:205-213.

8. Garber DA, Goldstein RE, Feinman RA. Porcelain Laminate Veneers. Chicago, Ill: Quintessence Publishing Co, Inc; 1988.

9. Goldstein RE, Belinfante L, Nahai F. Change Your Smile. 3rd ed. Chicago, Ill: Quintessence Publishing Co, Inc; 1997:6.

10. Smigel I. Dental Health, Dental Beauty. New York, NY: M Evans & Co; 1979.

11. Hoexter DL. The background of a smile. Alpha Omegan. 1995;88:16-19.

12. Nabors CL. Repositioning the attached gingiva. J Periodontol. 1954;5:38-39. 

13. Bahat O, Handelsman M. Periodontal reconstructive flaps: classification and surgical considerations. Int J Periodontics Restorative Dent. 1991;11:480-487.

14. Hoexter DL. A team approach to a brighter smile. Dent Today. 1997;16:46-50.



Dr. Hoexter is director of the international Academy of Dental Facial Esthetics and is a clinical professor of periodontics at the University of Pittsburgh. He received his degree from Tufts University, where he was also an adjunct professor of periodontics. He is a diplomate (implantology) of the ICOI, the American Society of Osseonitegration, and the American Board of Esthetic Dentistry. Dr. Hoexter has lectured and published nationally/internationally and has been awarded 11 fellowships. He is in a private practice limited to periodontics, implants, and aesthetics in New York City.He can be reached at (212) 355-0004.

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