The Life-Changing Power of a Healthy Mouth and Smile

As Dr. David Satcher, a former US Surgeon General, said in the first-ever report on oral health, “Oral health is integral to overall health. Simply put, that means you cannot be healthy without oral health. In the past half-century, we have come to recognize that the mouth is a mirror of the body, it is a sentinel of disease, and it is critical to overall health and well-being.”¹ Dr. Satcher also said, “Serious oral disorders may undermine self-image and self-esteem, discourage normal social interaction, and lead to chronic stress.”² A major theme of this report is that oral health means much more than healthy teeth.
For too many years, people limited their thinking about dentists to “teeth.” Then “gums” became part of the public’s perception of what dentists do. Today we’ve moved to “implants,” so the public perception of dentistry has happily broadened. The catchwords “cosmetic dentistry” have also been with us for several decades since Dr. Irwin Smigel first introduced bonding to the general public in the late 1970s on the TV show That’s Incredible.
It’s been said by many that you’re never fully dressed without a smile. Songs have been written that include the word “smile” in their lyrics or titles. And as stated in Psychology Today³ “Smiles are such an important part of communication that we see them far more clearly than any other expression. We can pick up a smile at 300 feet—the length of a football field.” The smile is the most recognizable human communication signal in the world.³
In dentistry, we are privileged to be able to help people become healthier, and to look better. Sometimes it’s easy to forget to include emotional/mental health in the definition of health. It is important to recognize that how a person feels about their appearance is an integral part of self-esteem, which in turn contributes to mental and emotional health and well-being.
This article is about a case that was extremely challenging technically. More importantly, it relates to how the final result impacted on the patient’s emotions and life. The patient gave me permission to tell her story, as well as to share the images associated with her treatment. While the images speak volumes, her personal account is even more compelling.

Before. Preoperative full face with attempted smile.	After. Postoperative full-face and smile.

BACKGROUND
Carmen had a history of physical and mental abuse, and a problem with drugs. She shared with me that there was a point she sank so low that she felt there was no reason to live. In her own words, “…through the grace of God, my daughter, who is my best friend in the world…gave birth to my grandson, Jordan. Jordan’s birth is what I call my intervention. With his birth, and the fact that my daughter was having a rough time, I decided then that I had to get myself together for both of them.” She told me “I stayed and took care of the baby, left drugs alone, and went to a job-readiness school. There I took courses in computers and learned how to prepare myself for the business world.” That is the point at which Carmen came to my office.

CASE REPORT
Clinical Findings

Figure 1. Preoperative retracted view.	Figure 2. Preoperative smile in repose.
Figure 3. Retracted view showing malposition of tooth No. 8.	Figure 4. Articulated models showing first vertical stop.
Figure 5. Articulated models showing second vertical stop.	Figure 6. Models showing canine extrusion and palatal impingement.

When she presented, it was obvious she had very poor oral health and her dental appearance was seriously compromised. Pretreatment images reveal the state of her mouth and how difficult it was for her to smile (Figures 1 and 2).
A complete medical history was obtained, a full set of x-rays taken, and upper and lower impressions for diagnostic models were taken. A comprehensive clinical examination revealed the following:
Periodontal tissues were very inflamed; extraoral palpation and intraoral soft tissue examinations were negative; and many teeth had caries. Some teeth were clearly not savable. She was missing her upper left lateral incisor, and the upper left canine had drifted into the area where the lateral should have been. In addition, the upper left first bicuspid was now in the position of the canine.
Although Carmen had many missing teeth, she had several posterior occlusal contacts. This meant that the appearance of her anterior teeth, which suggested that her vertical dimension was overclosed, was misleading. These anterior teeth had simply extruded because there were no opposing occlusal contacts. In addition to the large diastema between her upper central incisors, her upper right central incisor was in severe palatoversion (Figure 3). Articulated diagnostic models confirmed the existence of posterior occlusal vertical stops (Figures 4 and 5), and indicated the severe extrusion of her lower canines had caused functional soft-tissue indentations on her palate (Figure 6).

Treatment Plan
After a long discussion with Carmen, we agreed on the following treatment plan:

• Extract teeth that cannot be saved.
• Prophylaxis and oral hygiene in­struc­tion with floss and Sonicare brush (Philips Sonicare).
• Periodontal treatment as needed (root planing, scaling, surgery if needed).
• Reduction, recontouring, and polishing of lower canines.
• Temporaries to be worn for several weeks in order to confirm tooth and edge positions, smile line, proportions, gradation, axial inclinations, function, and speech.
• Porcelain veneers from upper right second bicuspid to upper left first bicuspid inclusive.
• Upper and lower removable partial dentures (metal-free Valpast [Valpast International]) to replace lower incisors and posterior teeth.

Carmen is a vertical chewer. When having her demonstrate how she chewed, it was clear she closed in a vertical direction with no lateral slides. Her lower anterior and lower posterior teeth were on different levels. In my experience, patients who exhibit this biplane occlusion are usually vertical chewers. To try to restore her to a canine-guided occlusion would have been inappropriate, and probably would have created problems with her masticatory muscles and her teeth.

Treatment-Planning Consultation

Figure 7. Aesthetic wax-up.	Figure 8. Preparation model.

In certain cases we must consult with the dental laboratory technician(s) prior to discussing treatment with the patient.4 This is such a case. After a treatment plan consultation with all the dental laboratories involved, an aes­thetic wax-up was created for Carmen to see (Figure 7). This wax-up would also serve as the basis for temporization.
The issue of gingival heights and gingival zeniths would not be addressed because these areas were not visible in a wide smile and she did not object to the slight differences in gingival heights. We would revisit this and confirm or modify these characteristics during the temporization phase. The upper right bicuspids were not modified on the aesthetic wax-up since they were in proper alignment with the new smile. A preparation model was also created to serve as a guide to be used when preparing the teeth for veneers (Figure 8).

Treatment Begins

Figure 9. Canines marked for reduction.	Figure 10. Canines after reduction, recontouring, and polishing.

Carmen was referred to an oral surgeon for multiple extractions of teeth that were not savable. She returned from those visits very excited about the next phase of treatment and saying “I already feel healthier.” We spent several visits scaling and root planing her remaining teeth and reviewing oral hygiene techniques including flossing and use of a Sonicare automatic toothbrush. After several weeks, it was apparent that she was taking good care of her mouth, her periodontal pockets had diminished significantly, and she did not need osseous surgery. We were then ready to move forward.
A SeeMORE 4-way retractor (Discus Dental) was placed, and the amount the canines needed to be shortened (to look as if they belonged in Carmen’s dentition) was marked (Figure 9). Using a No. 770.8 fine chamfer diamond (Premier Dental), the reduction was done incrementally so I could monitor any sensitivity that she might experience. No sensitivity occurred during the entire reduction and she was given GC MI Paste Plus (GC America) to use for desensitization should sensitivity occur at home. To create teeth that would look like canines should, the canines were recontoured with an 89,022 medium and an 89,026 fine flame burs, followed by C2S polishers (Jazz polishers [SS White]) (Figure 10).

Figure 11. Retraction cords (Ultrapak [Ultradent Products]) in place and incisal edge No. 8 filled in.	Figure 12. Impregum impression with SeeMORE (Discus Dental) retractor in place.

Figure 13. Temporaries (Integrity [DENTSPLY Caulk])before trimming.

The upper teeth were prepared for porcelain veneers using a No. 834-021 depth-cutting diamond (AXIS Dental), and a No. 850-014 veneer preparation diamond (AXIS Dental) in a GENTLEsilence LUX 6500B (KaVo Dental). air-driven fiber-optic high-speed handpiece. Ultrapak No. 000 (Ultradent Products) retraction cords were placed using a Fischer Ultrapak Cord Packer (Ultradent Products) (Figure 11). The incisal edge defect on tooth No. 8 was filled in using the Clearfil Protect Bond (Kuraray Dental) self-etch system and Clearfil Majesty Esthetic composite (Kuraray Dental) (Figure 12). An impression for the veneers was made with Impregum Penta Soft (Medium Body) Impression Material (3M ESPE) and Permadyne Garant 2:1 Impression Material (3M ESPE) in a COE Brand Disposable Tray (GC America), with the SeeMORE (Discus Dental) retractor left in place (Figure 12). A bite registration was made using O-Bite (DMG America). Digital images of the shades of the prepared teeth were made so they could be sent to the dental laboratory via e-mail in addition to the written prescription.
The prepared teeth were temporized by injecting temporary crown and bridge material (Integrity [DENTSPLY Caulk]) into an impression of the aesthetic wax-up, and then seating the impression over the preparations. The temporary material was allowed to set (Figure 13). Using Dimension-3 Dental Loupes for magnification and a No. 8396-012 needle-shaped diamond (Brasseler USA), the excess flash was carefully trimmed away and the embrasures made accessible for threading floss. Instructions were given on how to gently clean the interproximal embrasures with floss threaders.

INSERTION DAY

Figure 14. Clearfil Esthetic Cement and DC Bond (Kuraray) kit.

The temporaries were sectioned before removal because they were locked into the diastemas. Each veneer was tried in individually for proper fit. All veneers were then tried in together for overall appearance and to ensure there was no excess pressure in any interproximal area. Finally, the veneers were tried in with the Clear, then Universal shades of water soluble Clearfil Esthetic Try-In Paste (Kuraray Dental). Universal was chosen because it gave a more lifelike appearance to the veneers. The Clearfil Esthetic Cement and DC Bond kit (Kuraray Dental) (Figure 14) was chosen for its ease of use and adaptability to multiple techniques for cementing restorations.
In veneer cases, I traditionally use etch and rinse techniques (total etch) with light-cured adhesives and ce­ments. However, I was concerned about light penetration through the thickness of porcelain necessary to close the huge diastema between the central incisors; and through the amount of porcelain needed to create proper alignment for the severely palatoverted right central incisor. Clearfil Esthetic Cement (Kuraray Dental) is a dual-cure cement when used in combination with the dual-cure Clearfil DC Bond (Kuraray Dental). However, the cement becomes a light-cured cement when used with a conventional light-cured adhesive. This one system allowed me to use self-etch and dual-cure cementation on the centrals; and conventional etch/rinse with light curing for cementing the veneers on the other teeth.
When all the try-in paste was cleaned from the veneers, they were washed, dried, and silanated. Clearfil Ceramic Primer (Kuraray Dental) was applied to the inner surfaces of the central incisor veneers, and RelyX Ceramic Primer (3M ESPE) was ap­plied to all the other veneers. The teeth were cleaned using ICB brushes and Consepsis Scrub (Ultra­dent Products) and any residual debris removed with a Microetcher IIA (Danville Materials). Following the manufacturer’s instructions, Clearfil DC Bond liquids A and B were mixed for 5 seconds, applied to the central incisors, and left in place for 20 seconds. After removing excess bond and evaporating the solvent with air and aspiration, the adhesive was light-cured for 10 seconds using a Demetron 501 (Kerr) halogen light. The veneers, which had been pre-loaded with the Universal shade, were seated and cured in place.
All remaining veneers were placed using the following protocol:
Ultra-Etch (Ultradent Products) 35% phosphoric acid, washing and drying, was followed by applying and curing a thin layer of Adper Single Bond Plus (3M ESPE). The pre-loaded veneers were placed and cured sequentially while holding each veneer in place during curing to ensure that no movement occurred. Any interproximal flash was removed and proximal surfaces were repolished with NTI Serrated Diamond Finishing Strips (AXIS Dental), followed by Epitex strips (GC America).

Figure 15. Checking occlusion after insertion of veneers.	Figure 16. Postoperative view after finishing and polishing veneers.
Figure 17. Flexible partial dentures (Valplast [Valplast International]) inserted showing full complement of teeth.	Figure 18. Patient and doctor sharing the success.

The occlusion was checked, (Figure 15) adjusted as necessary, and porcelain surfaces re-polished with the Jazz P3S Porcelain and Metal 3-Step Polishing System (SS White Burs).
When all the veneers were seated, (Figure 16) impressions for the removable partials were made. At a subsequent visit, the Valpast flexible partial dentures were inserted, giving Carmen a full complement of teeth (Figure 17). Within 3 weeks, and some minor adjustments, she had adjusted to her new mouth and could not stop smiling (Figure 18). She said she felt much healthier and was thrilled to not be ashamed of her mouth. A few months later, on a recall visit, Carmen told me she was doing something special. She proudly told me that she had recently finished a training program and was now teaching new mothers how to care for their infants. The transformation of her mouth and life was complete.

PATIENT COMMENTS/CONCLUSION
As a part of the conclusion to this article, I would like to share some personal comments that Carmen made to us during and after treatment.
“I look forward to my appointments with him because I always leave feeling reborn. Now I feel like a whole new person. Dr. Fier has given me back my self-esteem, and most especially a whole new smile. To me it’s as if God looked down from heaven and decided to send me his best angel. He made me feel like a member of his family introducing me to his beautiful wife and his wonderful secretary. I can’t imagine what heaven is like now that one of its angels is right here on earth.”
The clinical treatment of this case is one part of this article. The impact of the treatment is perhaps an even more important part. Many of you will have heard or even used the words “chang­ing lives” as part of educating the public and your patients about dental services, particularly cosmetic procedures. Carmen’s story gives true meaning to those words.
It is important to realize that any dentistry, not only what has become known as “cosmetic dentistry,” has the power to transform a person and contribute to major improvements in his or her quality of life. This patient’s experience confirms “Serious oral disorders may undermine self-image and self-esteem” as stated by Dr. Satcher in the introduction to this article. I thank Carmen for allowing me to share her clinical photos so that others may learn. However, I am even more grateful for her allowing me to share her personal story and illustrate the power of dentistry in giving her a healthy mouth and beautiful smile.

Acknowledgments
For their contributions to Carmen’s case I extend heartfelt thanks to the following people:

• Drs. David Fisher and Marlon Moore; Oral Sur­geons, Bronx, NY
• Robert Renza, MDT; Bob Renza Dental Studio, New City, NY
• Daniel Materdomini, MDT; daVinci Dental Studios, Wood­land Hills, Calif
• Slavic Lambach, CDT; Central Valley, NY.

References

1. Remarks at the release of Oral Health in America: A Report of the Surgeon General. Washington, DC: Office of the Surgeon General, US Dept of Health and Human Services; May 25, 2000. Available at: http://www.surgeongeneral.gov/library/oralhealth/spchoral.htm. Accessed July 26, 2009.
2. Executive Summary of Oral Health in America: A Report of the Surgeon General. Bethesda, Md: National Institute of Dental and Craniofacial Research, National Institutes of Health; July 2000. Available at: http://www.nid­cr.nih.gov/Data­Sta­tistics/­Surgeon­General/sgr/execsum.htm#part3. Accessed July 26, 2009.
3. Blum D. Face it! Psych Today. 1998; Sept/Oct. Available at: http://www.psychologytoday.com/articles/pto-19980901-000024.html. Accessed July 26, 2009.
4. Adams DC. The treatment planning consultation: the doctor/technician partnership. Dent Today. 2004;23:92-95.

Dr. Fier is a full-time practicing clinician and highly respected lecturer in the United States and internationally. He is executive vice-president of the American Society for Dental Aesthetics. He has been honored with Fellowships in the American College of Dentists, the International College of Dentists, and the Academy of Dentistry International. He is board-certified as a Diplomate of the American Board of Aesthetic Dentistry, a contributing editor for REALITY, and is on the Advisory Board of Dentistry Today. He can be reached at (845) 354-4300 or docmarv@optonline.net.

Disclosure: From time to time, Dr. Fier re­ceives materials, honoraria, and lecture support from many of the companies mentioned herein.