Difficult aesthetic challenges frequently present to dental offices. Often, the skills of several dental disciplines are needed to achieve a pleasing cosmetic result. Malposed teeth, high lip lines, and “gummy” smiles are common occurrences and are seen on a daily basis in cosmetic practices. Utilizing an interdisciplinary approach, cases such as these can be routinely managed when following the strategy outlined in this case report.
CASE REPORT
Evaluation and Treatment Plan
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| Figure 1. Patient’s initial presentation, cheeks retracted. | Figure 2. Occlusal view, showing tooth malposition. |
A man in his early 30s presented with numerous aesthetic challenges. A high lip line revealed a “gummy” smile, with teeth Nos. 7 through 10 alternating with a lingual malposition or facial protrusion. Tooth No. 7 had a large resin restoration that had darkened. Tooth No. 8 had an old porcelain/metal crown with exposed margins (Figure 1). Its root was almost black because of an oxidized amalgam buildup that was visible through the inflamed tissue. Both teeth Nos. 8 and 10 had a severe facial prominence. Contrary to the position of teeth Nos. 8 and 10, tooth No. 9 had a pronounced lingual position and inclination (Figure 2). Finally, all the remaining upper and lower teeth had a yellow-grayish hue that the patient wished could be brighter.
The patient’s request is a common one we hear often in a cosmetic dental practice: “I want to show more tooth and less gum. Can I get rid of this “black-rooted” tooth with the ugly crown? Can you make all my teeth straight and even? But I don’t want to wear braces!” While orthodontic therapy is routinely offered as a treatment alternative, patients in high-profile, high-intensity careers often prefer to expedite treatment utilizing restorative options. It seems simple to the ordinary patient but is truly a difficult aesthetic challenge for any dental team.
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| Figure 3. Laboratory aesthetic wax-up. |
To begin the dental cosmetic makeover, the dental laboratory technician was instructed to fabricate an aesthetic wax-up (Figure 3), creating new tooth shape and contour utilizing the “golden rule” proportions.1 In an aesthetic work-up, we consider parameters that have been described by several clinicians.2-4 We prefer a central incisor tooth length between 10 to 11 mm and a width of 8.5 mm. Once the incisal edge position is established in our wax-up, the only way to achieve the desired final tooth length clinically is to extend apically utilizing periodontal crown-lengthening procedures. In addition, the wax-up indicated one tooth (No. 10) would need elective root canal therapy prior to final preparation because of its facial malposition. The final incisal edge position will be determined using phonetics after the delivery of the laboratory-processed temporaries.
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| Figures 4a and 4b. Gingival contour surgical stent, fabricated from aesthetic wax-up. |
Once the patient approved the final aesthetic “look,” the wax-up was then utilized for 2 useful items: (1) fabrication of laboratory-processed acrylic provisionals; and (2) fabrication of a gingival-contour surgical stent (Figures 4a and 4b), to be used by the periodontist during the crown-lengthening procedure to visualize the proposed final gingival contours at surgery.
PERIODONTAL EVALUATION PHASE
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| Figure 5. Gingival contour surgical stent, placed by the periodontist, at the surgical appointment. |
During the periodontal evaluation, tooth position, biologic width, and embrasure size must all be evaluated prior to crown-lengthening procedures. The distance between the osseous crest to the base of the sulcus must be at least 3 mm in length for the insertion of the attachment apparatus.5-7 Biologic width is defined as the sum of the sulcus depth, the junctional epithelial attachment, and the supra-alveolar fiber attachment.8 For predictable final tissue levels, the biologic width is a constant. It must be accounted for when osseous contouring is performed. In this case, the final prosthetic goal was communicated to the periodontist utilizing this surgical guide (Figure 5). Soft tissue and bony contours will then be shaped in order to recreate the desired final aesthetic goal.
SURGICAL PHASE
The first treatment appointment for the patient was with the endodontist. As stated earlier, the patient elected root canal therapy on tooth No. 10 prior to tooth preparation and periodontal surgery. This is a wise choice for most patients as they can avoid unnecessary discomfort and inconvenience if planned in this sequence.
Internally beveled scalloped incisions were initially performed with the stent in place. Care was taken to preserve the interproximal papillae. It was determined that the patient’s smile extended beyond his canine teeth, so the incisions were extended to include the first bicuspids bilaterally. The stent was then removed and the surgical flap was refined and elevated. In this case, it was not necessary to reflect the flap past the mucogingival junction because of the abundance of attached gingivae. If patients present with minimal attached gingivae, crown lengthening is then achieved by moving the entire dentogingival complex apically by reflecting beyond the mucogingival junction.
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| Figure 6. Osseous recontouring completed by the periodontist. |
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| Figure 7. Gingival contours at the completion of periodontal surgery. |
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| Figure 8. Two weeks post surgery, showing the newly developed tissue contours. |
The location of the bone was then measured using a periodontal probe. The distance from the alveolar bone height to the newly created free gingival margin was determined. In this case, the distance varied from 1 to 2 mm. Ostectomy was performed with hand and rotary instruments to recreate an osseous profile, following contours 3 mm apical to the free gingival margin (Figure 6). The flap was then sutured with 4-0 silk and a surgical dressing was placed. Healing was uneventful and the sutures were removed one week postsurgically (Figure 7). A minimum of 6 to 8 weeks of healing time prior to impression taking is recommended for maturation of the dentogingival tissues (Figure 8).
RESTORATIVE PHASE
After a healing period of 8 weeks, the laboratory-processed provisionals (Biotemp, Glidewell Laboratories) were delivered. During healing, the more obvious “black root” became the patient’s chief cosmetic concern. To mask the root until adequate tissue healing and maturation were achieved, a composite opaque and tooth shade (Esthet-X MicroMatrix, DENTSPLY Caulk) was bonded until the provisionals were delivered.
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| Figure 9. Facial view of laboratory-processed provisional restorations. | Figure 10. Placement of laboratory-processed temporary, showing relationship to malpositioned teeth. |
At the appointment for delivery of the lab-processed provisionals, the patient had his first glimpse of the final cosmetic change we were able to achieve (Figure 9). Because of the patient’s initial aesthetic demands for the final case, teeth Nos. 7 and 9 were prepared to receive porcelain laminates, while teeth Nos. 8 and 10 were prepared for full porcelain crowns (Figure 10). While we waited for tissue healing and maturation, the patient elected to brighten his teeth employing an in-office whitening technique utilizing 35% hydrogen peroxide gel (QuasarBrite, Spectrum Dental) and a plasma arc light. The final porcelain shade would be based on the newly achieved tooth color. After 2 sessions of in-office whitening, the patient achieved a final tooth shade 4 shades brighter than his starting shade (from A4 to A1).
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| Figure 11. Double cord impression technique. |
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| Figure 12a. Silicone incisal index of final tooth position, fabricated from provisionals. |
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| Figure 12b. Index is used to position the final restorations. |
After waiting 8 weeks to stabilize the final tissue contours and crown margins, final impressions were taken utilizing a double-cord retraction technique (Figure 11) and polyvinyl siloxane impression material. This technique delivers clean, error-free final impressions. The prosthodontist preferred the putty viscosity for compression and the light-bodied syringe material for increased accuracy and tear strength (Aquasil Smart Wetting, DENTSPLY Caulk). Because of the patient’s input on tooth length, functional requirements, and final smile line, the temporary was altered during the transitional period. These final dimensions were captured with an alginate impression of the acrylic provisionals in the mouth. A silicone index (Figure 12a) was fabricated for use by our ceramist, indicating incisal width, tooth position, midline, and lingual contour. The final tooth contours and shape developed in the provisionals could now be conveniently communicated to the laboratory technician and transferred to the completed case (Figure 12b).
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| Figure 13. Final all-porcelain restorations. |
Two porcelain laminates and 2 porcelain crowns (Divine Dental Laboratory) were delivered 1 week after final impressions (Figure 13). Braided retraction cords (No. 00 Ultrapak, Ultradent Products) were placed before tooth conditioning. The conditioned enamel and dentin were then wet and disinfected with Tubulicid Red (Global Dental Products) prior to wetting with bonding agent (Prime and Bond NT, DENTSPLY Caulk). The porcelain restorations were silanated and then luted with modified-resin cement (Calibra, DENTSPLY Caulk). The excess cement was removed utilizing scalers and a No. 12 scalpel blade. Final polish was completed after occlusal adjustment using rubber cups and points (Flexicups and Flexipoints, CosmeDent).
DISCUSSION
Although all patients with malposed teeth are offered orthodontic therapy as a treatment option, few select that alternative. In the New York tristate area, young adults with a busy, hectic lifestyle prefer a “quick” solution to correct their aesthetic concerns. With cases similar to the one reviewed in this article, the final treatment plan would likely include in-office tooth whitening as well as periodontal crown lengthening and porcelain restorations. The only additional treatment was the election of endodontic therapy for the labially malposed lateral incisor.
A crown-lengthening procedure utilizing internally beveled incisions and flap reflection are necessary in cases where ostectomy is required to achieve adequate crown length. If the distance from the bone crest to the free gingival margin is in excess of the required 3 mm necessary for biologic width, and if there is adequate attached masticatory mucosa, then a gingivectomy can be performed for crown lengthening. Some practitioners incorrectly remove tissue utilizing lasers or scalpels to recontour the gingivae without regard to evaluating bone height. This routinely develops into chronically inflamed tissue and/or periodontal pocketing occurring at sites of biologic width invasion.
As illustrated in Figure 5, the surgical stent clearly directs the surgeon to the final location of the free gingival margin in the restorations. A surgeon must have a clear picture of where the final gingival contours are to be placed and then use biologic guidelines along with surgical measurements to achieve that goal. The use of a prosthetically engineered surgical stent is an invaluable tool to achieve excellent anterior aesthetics. Too often, a restorative dentist will request the periodontist to perform a crown-lengthening procedure with no guidelines advised. It is then up to the periodontist to “imagine” where the finish line will be. With the patient outlined in this case report, it would be very difficult to predict this finish line because of the extreme malposition of the teeth. With the utilization of the prosthetically engineered surgical stent, the guesswork has been eliminated because final tooth form, emergence profile, and gingival contours are determined at the outset of treatment.
CONCLUSION
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| Figures 14 and 15. Pretreatment smile and the final aesthetic outcome. |
Complex cosmetic cases are routinely seen at our restorative practices. Utilizing techniques outlined here such as laboratory wax-ups, gingival contour surgical stents, laboratory-processed provisionals, crown-lengthening procedures, and incisal silicone indexes, we can routinely achieve favorable aesthetic outcomes (Figures 14 and 15). When employed in an overall treatment plan, the difficult aesthetic case can be managed effectively and offer our patients a realistic, predictable final outcome.
References
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2. Moskowitz ME, Nayyar A. Determinants of dental esthetics: a rational for smile analysis and treatment. Compend Contin Educ Dent. 1995;16(12):1164-1166.
3. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132(1):39-45.
4. Morley J. Smile design: specific considerations. J Calif Dent Assoc. 1997;25(9):633-637.
5. Ingber JS, Rose LF, Coslet JG. The “biologic width”: a concept in periodontics and restorative dentistry. Alpha Omegan. 1977;70(3):62-65.
6. Block PL. Restorative margins and periodontal health: a new look at an old perspective. J Prosthet Dent. 1987;57(6):683-689.
7. Becker W, Ochsenbein C, Becker BE. Crown lengthening: the periodontal-restorative connection. Compend Contin Educ Dent. 1998;19(3):239-246.
8. Sadan A, Adar P. Esthetic proportions versus biologic width considerations: a clinical dilemma. J Esthet Dent. 1998;10(4):175-181.
Dr. Doundoulakis maintains a private practice in cosmetic dental rehabilitation and implant tooth replacement in New York, NY. He is attending and clinical assistant professor at New York Hospital”“Weill/Cornell Medical Center and co-director of implant dentistry at Mt Sinai Medical Center. He can be reached at (212) 517-3365 or visit cosmeticdentalny.com.
Disclosure: Dr. Doundoulakis performs product evaluations for DENTSPLY Caulk.
Dr. Melnick maintains a private practice in periodontics and implant surgery in New York, NY. He can be reached at (212) 355-1266 or visit fifthaveperio.com.
