INTRODUCTION
Eating disorders are conditions characterized by restricted food intake or binge eating and often by self-induced vomiting. In addition to having the potential to impair both physical health and psychosocial functioning, these disorders could also have an impact on oral health. Among the oral complications is dental erosion, an irreversible loss of tooth substance as a consequence of exposure to acids that do not involve bacteria. Such acids may enter the oral cavity from extrinsic (eg, acidic foodstuff) as well as intrinsic sources (gastric acid from bulimia or reflux).1
According to Spear,2,3 erosion can be present in locations where there is or is not occlusal contact. The wear is typically not sharp and flat as seen in attrition but rather has a soft, satin, and rounded appearance. Regurgitated acid tends to produce wear on the lingual and occlusal surfaces, while ingested acid tends to produce wear on the facial and occlusal surfaces.
The location and extent of tooth damage in the regurgitated (intrinsic) types is often dependent on head posture and cause. Gastroesophageal reflux disease (GERD) often occurs in a vertical or horizontal position and is involuntary. Bulimia is a more voluntary behavior with the person typically tipped forward, and the regurgitation is physically induced at high velocity. This produces massive wear on the maxillary anterior teeth and often the lingual of the first premolars. Compared to GERD, there is much less wear on the maxillary and mandibular posterior teeth. In addition, GERD produces wear on the lingual of the maxillary anterior teeth but may not significantly reduce their length. Bulimia often devastates the length and lingual thickness of the maxillary anteriors.2,3
Because of the extent of anterior damage with bulimia, the smile can be horribly disfigured by alteration of tooth shape and position that alters gingival margin location, which adds more psychosocial challenges to the sufferer. Oftentimes, this creates a regional defect in the smile that causes the damaged teeth to be over-erupted. Correcting this requires strategic planning and treatment in a multidisciplinary manner, often with a combination of orthodontic periodontal interventions.4-6
The goal of this article is to present a case study to demonstrate this level of care.
CASE REPORT
A 34-year-old mother of 2 came to our office for a consultation about her smile. Her teeth were disfigured and had become extruded, showing an irregularity in gum symmetry that was affecting a balance of pink and white in the smile. Interestingly, her biggest concern was the amount of negative space (or blackness) shown in pictures (Figures 1 and 2). In addition, the gum architecture was a Kois normal thickness type. She had become very self-conscious about this and yearned for the smile that she always had. Thankfully, our patient was well-prepared and brought a picture of her smile from when she was a teenager.
Figure 1. The full-face view shows a slight vertical decrease in lower third of the patient’s face, which ideally should be equal to the midface, though it was not enough to justify the extent and expense of opening both arches.
Figure 2. The shortening of the centrals was caused by erosion. The super-eruption affected the pink-white balance. In addition, the black space surrounding the teeth created the biggest concern for the patient’s smile confidence.
Upon closer examination, her occlusal photos showed a loss of enamel on the lingual of teeth Nos. 7 to 10 (Figure 3). As part of our collaborative discussion, I questioned her about this unusual finding instead of confronting her about what could be a very emotional subject. Fortunately, she was quite honest that she had been bulimic from the time she was 18 to 26 years old, which was a very emotional time for her. After that, she met the “man of her dreams,” who was very supportive and gave her the confidence to stop purging. Since then, she had been raising a family and wanted to improve her appearance so that she could compete in her new sales position, as well as enjoy more social assurance to support her husband’s advancing career and be more active at her children’s events. We were her fourth consultation about this matter. The recommendations ranged from full-mouth bite opening to extractions of the centrals with bridgework and gum sculpting of the laterals.
Figure 3. The picture of the lack of enamel on teeth Nos. 7 to 10 led to an open discussion about risk factors and consequences.
Reviewing all of the clinical data, it was quite obvious that a more sophisticated approach that dealt with reversing the effects of the bulimia would be best. Loss of tooth volume had drastically affected the shape of the teeth, causing the negative space around the remaining incisal edges of teeth Nos. 7 to 10. With a lack of occlusal stops, the teeth had also extruded 3.5 mm. Though there was posterior tooth wear from occlusal trauma, there was not enough damage to justify full-mouth bite opening. The cause and effect was an anterior issue.
Using digital imaging of an ideal smile that followed the curvature of the lower lip and had an upper gumline that matched the CEJ of the canines, as well as a mockup of a more attractive central incisor that had a width-to-length ratio of 0.75 to 0.80, I was able to give the patient and her husband a less technical vision of a better smile (Figure 4). To help reach these objectives, we recommended orthodontically intruding teeth Nos. 7 to 10 closer to their original vertical positions, as espoused in the literature.4-6 Though this was not a direction that excited the patient, with some encouragement from her spouse, she was more accepting of this approach.
Figure 4. Doing smile imaging helped us educate a fearful patient on her options.
Intruding teeth requires more torque than aligner therapy. Using a pre-bent wire in straight-wire orthodontics provides more energy force to vertically move teeth. Using the Six Month Smiles technique (Six Months Smiles) with clear brackets made this easier for our patient to tolerate aesthetically. To help our patient visualize our goal of moving the gingival margins superiorly, we took a pretreatment photo of the desired levels using floss (Figure 5).
Figure 5. Using floss as a visual goal, we could evaluate intrusive orthodontic progress.
Figure 6. Progress after 10 weeks of intruding Nos. 7 to 10.
Figure 7. Diagnostic wax-up of new tooth shapes and lengths needed for periodontal closed-flap gingival and osseous contouring.
After 10 weeks of orthodontics, the gingival margins had moved about 2 mm (Figure 6). We removed the wires to take records for a diagnostic wax-up of the new ideal incisal edge positions, buccal and labial contours, and gingival margins. In addition, since the improved gingival margins would need to be modified more directly, it was helpful that the lab provided a numeric guestimate of that change (Figure 7). Even more helpful was using the labial incisal matrix (Ivoclar) to precisely transfer the information from the wax-up tooth length using digital calipers and mark the gingival length, zenith, and margins for optimizing aesthetic gingival contours (Figures 8 and 9).
Figure 8. Digital calipers aided in setting tooth length and gingival zenith using the incisal lingual matrix.
Figure 9. Gingival zenith targets were established and verified.
After anesthesia using the PASA (Palatal Anterior Superior Alveolar Injection) technique with the Wand (Milestone Scientific), atraumatic facial margin gingival reshaping of Nos. 7 to 10 was done with an Er,Cr:YSGG 2,780 nm [BIOLASE]) at 2 W following the outlined design (Figure 10). Biological width was evaluated by sounding to bone. Since the depth was less than 3 mm, osseous adjustments were needed to optimize gingival health and appearance (Figure 11).
Figure 10. An Er,Cr:YSGG laser was initially used at 2.0 W to sculpt the gingival contour.
Figure 11. Biological width was evaluated by sounding to bone. Since the depth was less than 3 mm, osseous adjustments were needed to optimize gingival health and appearance.
Because the lingual and incisal dimensions had been established by the bulimia, circumferential shoulder preparation was done with a coarse diamond while focusing on preserving enamel labially and interproximally (Figure 12). Provisionals were created using a relined putty matrix of the wax-up to create natural and accurate contours. In addition, the Luxatemp Bisacryl (DMG America) was splinted together and gingivally sculpted to match to preserve the previous laser shaping, enhance home care, avoid plaque buildup, and conveniently act as an orthodontic retainer during the 3-month healing and stabilization phase (Figure 13).
Figure 12. A prep reduction guide verified the proper thicknesses of future porcelain restorations. Note the preservation of enamel facially and interproximally.
Figure 13. An accurate lined putty matrix of the wax-up allowed ideal margination for the splinted aesthetic provisionals that also acted as a retainer.
Because preserving biological width was one of our other goals in treatment, closed-flap crown lengthening was performed on the labial of teeth Nos. 7 to 10 using a narrow tip with a 3.0-mm mark inserted subgingivally to adjust the bony to crest to gingival margin to ideal dimensions.7 The settings were 2.5 W and 20 mHz. Low-level laser therapy was performed with the Waterlase laser (BIOLASE) after curetting any granulation tissue from the sulci to biostimulate the healing response (Figures 14 and 15). The patient was thrilled with her new smile. Postoperative care was focused on meticulous flossing and using a rubber tip stimulator for 4 months. The patient was checked for periodontal health and home whitening every 8 weeks to assess her progress. Healthy tissue and gingival stippling was noted after 4 months (Figure 16).
Figure 14. Closed-flap osseous contouring was carefully performed to an ideal depth of 3 mm using the black mark on the tip as a guide.
Figure 15. Minimal trauma from the laser was seen immediately postoperatively, and low-level laser therapy was done to promote healing.
Figure 16. Notice the healthy contours and lack of inflammation after 8 weeks.
In the final restorative phase, after the provisionals were removed, final PVS impressions were taken with Panasil (Kettenbach), and transfer bites were taken with Futar (Kettenbach) to remount on an articulator. To help the ceramist, caliper measurements and impressions of the approved prototypes were taken to improve the accuracy of the primary anatomy, and prep shades were taken to help improve layering and chromatization of restorative color (Figure 17).
Figure 17. Prep shades helped the ceramist create opacity and color layering for a natural result.
IN SUMMARY
Following bonding of the new restorations with Variolink Esthetic resin cement (Ivoclar), our patient and her spouse were thrilled with the final results aesthetically (Figures 18 and 19). They were grateful that our interdisciplinary perspective allowed an appropriate approach to cause and effect (Figure 20) and avoided a substantial financial outlay at the beginning of treatment. They also understood that long-term commitment to home care, wearing a night-time bite appliance, and strengthening the posterior teeth would enhance future results. Certainly, being vigilant about not repeating further bulimic activity is paramount as well.
Figure 18. The patient and her husband were excited that her new smile naturally fit her face.
Figure 19. Having a full smile gave our patient renewed confidence in her smile.
Figure 20. Intraoral photos revealed improved anatomy of the anterior sextant. Of course, optimizing the posterior teeth will create a more stable foundation for function and health.
As a clinician, it was gratifying to solve the puzzle for our patient with well-thought-out and -executed modalities rather than a one-size-fits-all approach.
REFERENCES
- Uhlen MM, Tveit AB, Stenhagen KR, et al. Self-induced vomiting and dental erosion—a clinical study. BMC Oral Health. 2014;14:92. doi:10.1186/1472-6831-14-92
- Spear FM. Where, oh where, did that tooth wear come from? Part 1. Spear Education. 2015.
- Spear FM. Where, oh where, did that tooth wear come from? Part 2. Spear Education. 2015.
- Bellamy LJ, Kokich VG, Weissman JA. Using orthodontic intrusion of abraded incisors to facilitate restoration: the technique’s effects on alveolar bone level and root length. J Am Dent Assoc. 2008;139(6):725–33. doi:10.14219/jada.archive.2008.0254
- Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry. Dent Clin North Am. 2007 Apr;51(2):487-505, x-xi. doi:10.1016/j.cden.2006.12.007
- Spear FM. Treating the Worn Dentition. Lecture present at: AACD European Meeting; September 25, 2010; London, England.
- Tianmitrapap P, Srisuwantha R, Laosrisin N. Flapless Er,Cr:YSGG laser versus traditional flap in crown lengthening procedure. J Dent Sci. 2022;17(1):89-95. doi:10.1016/j.jds.2021.05.004
ABOUT THE AUTHOR
Dr. Flax is internationally known for his leadership in cosmetic dentistry. An accredited member and past president of the American Academy of Cosmetic Dentistry (AACD), he is an author and has lectured in Europe, Japan, Canada, and the United States on lasers, smile design, and advanced restorative techniques to enhance the skills of dental teams in making their care world-class for their patients. He is on the editorial board of the Journal of Cosmetic Dentistry and has been the chairperson of many AACD meetings. He also founded the Georgia Academy of Cosmetic Dentistry. Outside of the AACD, Dr. Flax was a 15-year member of Catapult Education Speakers Group and a certified Fellow with the World Clinical Laser Institute. In addition, he is a Master with the International Congress of Oral Implantologists, an Associate Fellow of the American Academy of Implant Dentistry, a Diplomate of the American Board of Aesthetic Dentistry, and a Kois Center graduate. Lastly, he is visiting faculty at the Dental School of Georgia. Recently, Dr. Flax published a consumer book called A Smile is Always in Style to help those looking for a better smile and dental wellness to be more educated and savvier with their choices for the best results. Proceeds from the book go to educational scholarships. He can be reached at h.flax@flaxdental.com.
Disclosure: Dr. Flax reports no disclosures.
