As I celebrate my 30th year practicing cosmetic and restorative dentistry, I reflect on the evolution of my clinical approach to complex cosmetic cases. In the beginning, I used a traditional approach to treat these complex cases. For example, for the correction of gummy smiles, I performed traditional periodontal crown lengthening to reduce the gummy look and create a uniform appearance of the gingival architecture. This traditional approach led to extensive surgical procedures, painful healing, and lengthy healing times. Now, with an innovative approach to this type of correction, all of these problematic issues can be avoided, and patients are ecstatic about the more comfortable treatment protocol and outcome.
When using traditional methods in complex cosmetic cases, the treatment can sometimes take 6 to 8 months (or more) to accomplish the desired results. Compared to the past, patients today are not as tolerant about having lengthy treatments. We now live in a time when we have amazing technologies, such as smartphones, that provide us with fast services and instantaneous search results. In the same way, the modern patient expects dentistry to keep up with society and develop treatment methods that solve complex problems on a timelier basis. Therefore, dentistry also needs to evolve to meet the demands of our tech-savvy patients. Having treatment plans extending for many years is now unacceptable. By using innovative thinking, we are able to create new protocols for the complex cosmetic case that will better meet the needs of the modern patient.
CASE REPORT
Diagnosis and Treatment Planning
A 23-year-old female patient, in good health, presented, seeking cosmetic dentistry to correct her congenital dental problems (Figures 1 to 3). Initially, she had consulted with several orthodontists and was told that her best option would involve a cosmetic dental correction.
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| Figure 1. The patient presented with a complex cosmetic case that included congenital peg laterals, a gummy smile, multiple diastemas, and proportionally undersized teeth. | Figure 2. A lack of aesthetics in the patient’s smile reduces the potential for total facial beauty. |
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| Figure 3. The pretreatment retracted view. |
First, a diagnostic work-up was completed, which included a comprehensive oral exam, a periodontal exam, smile analysis, mounted diagnostic models on a semi-adjustable articulator (Denar Combi Articulator [Whip Mix]), a diagnostic photographic series (AACD photo guide to Accreditation [AACD]), and a full-mouth radiographic series. From these records, a 3-D diagnostic wax-up was created to help determine options for an approach to case correction. Creating contours, shapes, and sizes to meet her aesthetic concerns was important to do prior to starting the case.1 In closing up the diastemas, it was determined that working on her teeth alone would not give her the optimal proportion and balance to meet her facial aesthetic needs. When creating a dynamic facial aesthetic result, the teeth proportions must balance well with her facial elements. Therefore, it was determined that gingival surgical correction was important to reduce the gummy smile and to achieve her desired aesthetic outcome.2
Paradigm Shift in Minimally Invasive Surgical Corrections
Over the last 20 years, this author has had experience in a minimally invasive approach to gingival/osseous surgical corrections. The traditional approach to crown lengthening includes an extensive flap procedure, which leads to 3 to 6 months of postsurgical healing, potential postsurgical complications, and potentially painful healing.3 There was a need to develop a more patient-friendly approach to periodontal crown lengthening.
In 1994, a hallmark article was written on altering gingival levels.4 It discussed a new approach to understanding the dental gingival complex (DGC), in which predictable healing of gingival tissue could be attained with a surgical procedure. According to this article, in normal healthy gingival tissue, the position of the osseous crest in the anterior dentition is 3.0 mm from the facial-free gingival margin and 4.0 mm from the interproximal-free gingival margin. Thus, if the total DGC is 3.0 mm along the maxillary anterior, then predictable re-establishment of biologic width will always be attained. Knowing this, the placement of the final restorative margin can be done with confidence at the time of surgery because the DGC will re-establish itself to 3.0 mm along the anterior and 4.0 mm along the interproximal. If the DGC is fewer than 3.0 mm, the restorative margin location would be closer to the osseous crest, violating the biologic width.3-5
By understanding the biologic parameters of healing, we are able to pre-establish restorative margin location at the time of surgery and know that gingival tissue healing will take place predictably to the parameters that are set at that time.3,4 Because of this paradigm shift in altering gingival levels, a minimally invasive surgical approach can be done using a closed-flap approach.
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| Figure 4. Marking a new free gingival margin location. | Figure 5. Analyzing the impact of the new gingival free margins in the patient’s smile line. |
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| Figure 6. Verifying periodontal measurement through osseous sounding. | Figure 7. Using the Okuda Closed-Flap method to re-establish new free gingival margins. |
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| Figure 8. Temporary prototypes were created to meet the aesthetic needs of the patient and support the gingival tissues for calculated healing. | Figure 9. The temporary prototypes were artistically hand sculpted to match the patient’s personality and to accentuate her unique facial features. |
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| Figure 10. Using the latest materials for state-of-the-art porcelain veneer bonding. | Figure 11. A #12 surgical blade is used for initial luting resin removal. |
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| Figure 12. The beautiful 2-week postoperative healing with new porcelain veneers. | Figure 13. With the minimally invasive Okuda Closed-Flap Surgical Technique, predictable margin placement can be achieved. |
Clinical Protocol
Prior to the start of the procedure, periodontal measurements were retaken by probing the sulcus on teeth Nos. 5 to 12. Then osseous sounding was recorded to determine the crestal height position of each tooth.5 This was done to determine which teeth would only need gingivectomies and which teeth would need osseous crestal removal. Upon evaluation, it was determined that all teeth, except the right canine (tooth No. 6), could be treated with laser-sculpted gingivectomies. Because of the high-crestal nature of the right canine, this was the only tooth that needed osseous crestal removal along the facial aspect to move the free gingival margin without creating a biologic width violation.3-5 Using a black Sharpie marker, the gingival tissue was marked to where the new ideal position of the free gingival margin would be from an aesthetic point-of-view (Figures 4 to 6). The smile was then analyzed from all directions prior to performing the minimally invasive surgical procedure.2,6,7
Using a diode laser (NV Microlaser [DenMat]), laser-assisted gingivectomies were done on all the involved teeth to establish the new free marginal position. Then, along the right canine, the Okuda Closed-Flap Surgical Technique was performed to carefully remove crestal bone along the facial aspect (Figure 7). This was done using a micro-prep bur (838M-007 [Komet USA]) (in the sulcus along the facial gingival tissue until a measurement of 3.0 mm was attained from the new free gingival margin to the anterior crestal bone.3,4
After aesthetically altering the gingival levels, minimally invasive porcelain veneer preparations were done using a diamond prep bur (#6844 [Komet USA]) from teeth Nos. 5 to 12. Since the teeth were already smaller in proportion, very little tooth structure needed to be removed. Whenever possible with porcelain veneers, it is always good to leave enamel intact for optimal porcelain-to-tooth bonding to increase the long-term success of the restorations. The prep margins were done so that it was right at the new free gingival margin. Since we were able to predict where the tissue would heal prior to the actual healing process, final impressions (Impregum [3M]) were taken on the same day as the gingival surgical procedure.4 In addition, a facebow measurement (Denar Slidematic Facebow [Whip Mix]), bite records (Blu-Mousse [Parkell]), and internal shades were also taken.
Based on the diagnostic wax-up, hand-sculpted temporary prototype veneers were created (Turbo Temp 3 [Zest Dental Solutions]) to support the healing gingival tissue and to meet the individual aesthetic needs of the patient (Figure 8).8 In comparison to using computer software to determine aesthetic contours, time was spent directly with the patient to artistically create unique contours that would aesthetically fit her personality, accentuate her lip curvature, and match proportions to blend with her unique facial features (Figure 9).9
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| Figure 14. The pretreatment view of the smile shows excessive gumminess and a lack of good proportion in the patient’s smile. | Figure 15. The post-treatment view shows a profound change in the patient’s smile. |
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| Figure 16. Proper aesthetic correction, using a same day closed-flap surgical technique and porcelain veneers, can lead to predictable results. | Figure 17. Dynamic results were attained by balancing the patient’s smile with her facial features. |
Optimal colors were selected to accentuate the patient’s facial skin tone. This was conveyed to the ceramic artist through a customized color map, texture map, and digital images. Then, for an ultimate high-end aesthetic outcome for our patient, the ceramist artistically created hand-layered feldspathic porcelain veneers.
After receiving the porcelain restorations back from the ceramic laboratory (Recreations Dental Studios, Marina del Rey, Calif), they were evaluated for correct color, contour, and characteristics. Using try-in pastes from the porcelain veneer cementation kit (Choice 2 [BISCO Dental Products]), the porcelain veneers were evaluated for fit, color, and margination. Prior to seating veneer restorations, it is important to properly prepare the porcelain for optimal bonding. The porcelain was etched with a ceramic etch, then a silane coupling agent (Porcelain Primer/Bis-Silane [BISCO Dental Products]), and a porcelain bonding resin (Porcelain Bonding Resin [BISCO Dental Products]) was placed in the intaglio surfaces to optimize the bond strength. The temporary restorations were then removed. Optimal gingival tissue healing as a result of using the minimally invasive Okuda Closed-Flap Surgical Technique was observed. The gingival tissue was isolated via tissue packing to reduce gingival crevicular fluid contamination. Plain flour pumice and a brush (ICB Brush [Ultradent Products]) were used to clean the surfaces of the preparations. Next, chlorhexidine gluconate (Cavity Cleanser [BISCO Dental Products]) was used to clean all the prepared tooth surfaces. Phosphoric acid (Select Etch HV [BISCO Dental Products]) was placed for 30 seconds on the enamel and 10 to 15 seconds on dentin surfaces, then rinsed thoroughly with water. A desentisizer (MicroPrime G [Zest Dental Solutions]) was placed for 20 seconds prior to placing a dental adhesive (ALL-BOND UNIVERSAL [BISCO Dental Products]). After brushing on several layers of adhesive, it was light-cured (Sapphire Plus Plasma Arc Curing Light [DenMat]) along all surfaces.10 The porcelain veneers were then carefully placed and bonded with a light-cured resin cement (Choice 2) using a rapid seat method (Figure 10). After the final light curing of all sides, the margins of the porcelain veneers were initially finished using a curved scalpel blade (#12 Bard Parker [Aspen Surgical]) (Figure 11). Then fine diamond finishing burs (H50A.FG.010 and H246.FG.009 [Komet USA]) were used to finalize all margins. Finally, the diamond ceramic polishing kit (4533C.RA [Komet USA]) and polishing paste (micro-diamond polishing paste [Ultradent Products]) were used to create the final, beautiful luster (Figures 12 and 13). One week later, a postoperative check was done (Figures 14 and 15). During this appointment, the occlusion was re-evaluated and adjusted as needed, and the gingival tissues were checked for proper healing. Particular attention was given to evaluating the gingival tissue health of the areas where minimally invasive gingival surgical correction had been done to reduce her gummy smile (Figures 16 and 17).
CLOSING COMMENTS
In this day and age, it is important for dentistry to keep up with patients who are changing with every passing year. Being able to use knowledge in creative ways to create new modalities of treatment can lead to paradigm shifts. For example, by being able to perform minimally invasive procedures (such as the Okuda Closed-Flap Surgical Technique), we are able to save patients from extensive surgical procedures, long healing times, and potential unnecessary post-op pain. With the progress of knowledge, techniques, and material science, we are able to offer more simple and comfortable solutions to these complex dental problems.
Acknowledgment:
The author wishes to express his appreciation for the Recreations Dental Studios dental laboratory team in Marina del Rey, Calif, for the ceramic artistry clearly demonstrated in the beautiful aesthetic outcome for his patient.
References
- Okuda W. Smile design 2.0: evolving from our past to be successful in treating the modern cosmetic patient. Gen Dent. 2016;64:10-13.
- Morley J. The role of cosmetic dentistry in restoring a youthful appearance. J Am Dent Assoc. 1999;130:1166-1172.
- Hempton TJ, Dominici JT. Contemporary crown-lengthening therapy: a review. J Am Dent Assoc. 2010;141:647-655.
- Kois JC. Altering gingival levels: the restorative connection part 1: biologic variables. J Esthet Restor Dent. 1994;6:3-7.
- Kois JC. The restorative-periodontal interface: biological parameters. Periodontol 2000. 1996;11:29-38.
- Rajtilak G, Deepa S, Rajasekar V, et al. Anterior teeth and smile designing: a prospective view. International Journal of Prosthodontics and Restorative Dentistry. 2012;2:117-127.
- Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132:39-45.
- Gracis S, Fradeani M, Celletti R, et al. Biological integration of aesthetic restorations: factors influencing appearance and long-term success. Periodontol 2000. 2001;27:29-44.
- Frush JP, Fisher RD. How dentogenics interprets the personality factor. J Prosthet Dent. 1956;6:441-449.
- Suh BI. Principles of Adhesion Dentistry: A Theoretical and Clinical Guide for Dentists. Newtown, PA: Aegis Communications; 2013:99-117.
Dr. Okuda practices in Honolulu, Hawaii. He is the past national president (2002 to 2003), board-accredited member, and board-accredited Fellow of the American Academy of Cosmetic Dentistry (AACD). He has been an international speaker for more than 20 years and has authored numerous articles on cosmetic and restorative dentistry topics. Dr. Okuda is a Fellow of both the International College of Dentists and the International Congress of Oral Implantologists. He is also the Esthetic Dentistry Expert to the National Dental Expert Advisory Board of the AGD and the esthetic columnist for General Dentistry. Since 2007, Dr. Okuda has been listed in Dentistry Today’s Leaders in CE. In 2007, Contemporary Esthetics presented the coveted “National Cosmetic Practice of the Year” award to Dr. Okuda’s practice. He is also the co-founder of the Give Back a Smile program: a national charitable foundation of the AACD, which helps survivors of domestic violence throughout the nation to restore their smiles and lives. He may be reached at okudacosmeticdentistry.com.
Disclosure: Dr. Okuda reports no disclosures.
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