Total Dental Aesthetics

INTRODUCTION
For years, those who teach aesthetic dentistry have given lip service (no pun intended) to the oral and maxillofacial areas surrounding the teeth and the importance of the extraoral soft tissue to aesthetic dentistry. I would like to challenge this thought process and say that we as dental clinicians and educators have been wrong for the last 30 years. The facial soft tissue is part and parcel of aesthetic dentistry and is as important or, dare I say, more important than the teeth in delivering a great-looking smile. Perhaps the patient has beautiful teeth with the new crowns you placed and has maxillary gingival excess (gummy smile); is that all there is to aesthetic dentistry? Maybe you have just placed and restored 6 anterior implants, and then the patient leaves your care with deficient lip volume and radial lip-lines. Is that aesthetic dentistry? What is the purpose of placing 20 veneers if patients cannot show their teeth because they can’t raise their upper lip? In the past few years, with thousands of dentists being trained in the use of nonsurgical, minimally invasive facial injectables, such as Botox and dermal fillers, dental aesthetic and dental therapeutic (temporomandibular disorders, bruxism, myofascial pain), treatment has changed dentistry forever.
This article will present a case that clearly demonstrates how the right choices of dental technology, materials, and facial injectables in the oral and maxillofacial areas directly contribute to aesthetic dentistry in terms of function, smile-lines, lip-lines, and phonetics. You will see that the totality of intraoral and extraoral maxillofacial treatment is all truly aesthetic dentistry and with the right training, can be performed by every general dentist.

CASE REPORT
A few years ago, this patient had 2 all-ceramic crowns placed on her upper central incisors. In addition, she also had veneers placed on the upper and lower teeth (Figure 1). One day, she noticed that her upper left central incisor crown (tooth No. 9) seemed loose, and she came into the office with the chief complaint that her tooth was “wiggly.” I touched the tooth and it was indeed wiggly! A radiograph was taken and it was immediately clear that she had a horizontal fracture (Figure 2). This tooth was obviously nonrestorable, so it was extracted and a bone level implant was placed (Figure 3). The implant was restored with a Procera (Nobel Biocare) crown, and the patient enjoyed newfound stability of this tooth. What she did not enjoy was the creation of deficient interdental papilla known as “black triangles” (Figure 4). This is one of the most frustrating aesthetic challenges that can happen with any kind of implant or crown and bridge procedure. An innovative procedure, pioneered by this author and the American Academy of Facial Esthetics (facialesthetics.org), is using dermal fillers (Juvederm Ultra XC) to replace volume to the interdental papilla to eliminate black triangles (Figure 5).

Figure 1. Patient presents with a loose crown on upper left central incisor.	Figure 2. Horizontal fracture apparent on radiograph.
Figure 3. Implant placed using conventional techniques.	Figure 4. Deficient interdental papilla (black triangles) as a result of implant surgery.

Figure 5. Dermal fillers used to restore interdental volume and eliminate black triangles.

One Thing Leads to Another
After this initial treatment, the patient became interested in retreatment of her crowns and veneers. The issues that she complained about can be seen in Figure 6. The new crown on the upper left central incisor was a slightly darker shade than the other teeth and, when she smiled fully, she did not show as many teeth as she would have liked. She also wanted whiter teeth. The lower veneers were also chipping slowly throughout the last few years (Figure 7) and she had experienced annoying veneer debonds that would have to be recemented from time to time. She stated, “My lower teeth look short and stubby.” This patient also presented with a very deep overbite (Figure 8).

Figure 6. Smile is limited because of facial aging.	Figure 7. Close-up view shows significant chipping of existing veneers made from a low strength ceramic.

I, along with anyone who has had proper training in both oral and facial aesthetics, can give you a new perspective as to what to look for now in this kind of case, and how the facial conditions observed here are part of her dental aesthetic diagnosis and treatment. Here is what I mean in this case, as clearly demonstrated in Figure 6. Look at this patient when she goes into her widest smile. The buccal corridors in the bicuspid region are hidden, preventing her from showing a full and aesthetic smile. Because dental professionals are typically only focused on the dentition, most dentists assume that the only way to correct this is to restore the bicuspids with crowns or veneers to correct the buccal corridor deficiency. On this patient, and those like her, there are no dental solutions that would solve this aesthetic challenge because of the loss of midface volume. Adding volume to her midface would also correct the aesthetic relationship of her upper lip and teeth. In a full smile, the bottom of her upper lip should straddle the gingival margins of the upper central incisors. This was to be part of our treatment plan as we both restored her teeth and corrected the volume deficiency.

Turning Back the Hands of Time
It is going to happen to all of us. People typically lose dermal collagen and facial fat from approximately age 40 years and on, with accelerating changes starting at about age 50 years. This causes the oral and maxillofacial areas to sag and drop. This patient is a good example of this, and she demonstrates this facial aging pattern clinically by showing less of her upper teeth and more of her lower teeth. Because of this natural aging progress, she does not have the high cheekbones that she used to have, and she also has deeper nasolabial folds; and all of this contributes to the fact that her upper lip does not have the support it used to have and hides some of her teeth, especially in the posterior regions of her mouth. This challenge in aesthetic dentistry cannot be solved with restorative dentistry alone. Botox and dermal fillers are necessary, in addition to veneers, to solve the combination of dental and facial aesthetic challenges seen in this case.
Figure 9 shows the result using Botox and dermal fillers to correct muscular activity as well as the midfacial volume loss. Her zygomatic areas are now well supported and the volume restored. Now, she demonstrates the proper aesthetic smile and lip-lines when she is in function as described above. Her nasolabial folds demonstrate much less prominence, and now her upper lip has the support needed to show a wider smile. It is important in treatment planning a patient like this to have a well thought out plan of coordinating the soft-tissue treatment with the restorative dentistry.
In this case, a total 2.4 mL of a calcium hydroxylapatite dermal filler (Radiesse) was placed in the left and right zygomatic area, which supports the nasolabial folds and the upper lip. The nasolabial folds were treated with a total of 1.9 mL of a hyaluronic acid dermal filler (Juvederm Ultra XC) to restore them to more fullness and further support the upper lip. This case shows that treatment of this midface area is as much a part of aesthetic and therapeutic dentistry as is treating the dentition.

Changing the Face Changes the Smile
Veneer retreatment can now be accomplished to complete the aesthetic dentistry. This patient can now show more teeth and is ready for the new veneers. Now we can properly address the challenges discussed previously. One other issue that the patient became concerned about is this: the upper left central incisor had a higher gingival margin than the upper right central incisor because that was the area where an implant was placed (Figure 10). This challenge would now be integrated into our treatment plan. The treatment plan consisted of 10 new veneers on the upper teeth and 10 new veneers on the lower teeth. The upper central incisors, though, did produce a challenge. Cutting off a Procera crown on a tooth with an implant is no dentist’s idea of fun in the office. As a matter of fact, significant damage can be done to the implant abutment, and it is not a wise choice if other options are available. In this case, we chose the option of bonding a porcelain veneer onto the existing upper central incisor crowns instead of trying to remove them. The system we chose to use was Cristal Veneers (Aurum Ceramics). Cristal Veneers are the next generation of a no-to-minimal preparation veneer system with veneers that can be made as thin as 0.3 mm and exhibit very high strength and excellent aesthetics. Cristal Veneers can also be made as thick as any other veneer.

Figure 8. Patient demonstrates a deep overbite.	Figure 9. Patient shows a much wider smile after cheek and lower face volume restoration with dermal fillers.
Figure 10. The central incisors have uneven gingival margins.	Figure 11. Prep guide used for minimal and full veneer preparations.
Figure 12. Lower minimal veneer preparations.	Figure 13. Veneer preparations and precise laser osseous closed sulcus crown lengthening to even the gingival margins (WaterLase iPlus [BIOLASE]).

All of the previous veneers were removed on the upper and lower teeth, and minimally invasive preparations were done on all of the teeth based on their treatment history. This case would have multiple thicknesses on every one of the veneers. Figure 11 shows the prep guide (Aurum Ceramics) and demonstrates the very minimal preparation on the 2 upper central incisor crowns so that the Cristal Veneers on these teeth will be approximately 0.3 mm in thickness while the veneers on the lateral incisors will be anywhere between 2.5 mm to 3 mm in thickness. All of the other veneers were of various thicknesses, as well as you can imagine by also looking at the lower no/minimal veneer preparations of the lower teeth in Figure 12.
At the veneer preparation appointment, the upper central incisor gingival levels were addressed. A hard- and soft-tissue laser (WaterLase iPlus [BIOLASE]) was used on the upper right central incisor to perform not only a gingivectomy, but also a closed sulcus crown lengthening procedure to match the gingival height of the upper left central incisor. The closed sulcus crown lengthening procedure is easy to accomplish with the proper technology and training. It can be done very precisely and conservatively with the WaterLase iPlus. Because of the predictable nature of this procedure, we were able to take the final impression on the very same day. You can see the teeth after preparation as well as after crown lengthening surgery in Figure 13. Because of the surgical aspect, precise temporization is especially crucial to make sure the gingiva can heal properly at the established gingival level. A new temporary material Dentocrown (Itena USA) was used because of its stability, excellent gingival adaptation, and its self-polishing abilities which promote gingival health, was used as the temporary material of choice (Figure 14). The temporary performed very well during the time needed for healing and veneer fabrication.

Now the Big Challenge
Now that the veneers were fabricated and returned from the laboratory, the real challenges began. Local anesthesia was delivered and the temporaries were removed. The laser bony crown lengthening procedure was successful and the excellent gingival health (Figure 15) was a result of the laser precision and the unique temporary material used in this case.
Seating this case had a number of challenges. The first challenge was being able to effectively etch and bond to a variety of dental surfaces including enamel, dentin, cementum, and porcelain. Figure 16 shows the use of phosphoric acid etch on all enamel, dentin, and cementum surfaces; and a 4% buffered hydrofluoric acid etch Porcelain Etch (Ultradent Products) on all porcelain surfaces. The effectiveness of the etchant materials used can be seen in Figure 17. Silane was placed and thinned on the porcelain surfaces and Iperbond Ultra (Itena USA), a universal next generation bonding agent with excellent bonding strengths to all dental surfaces and substrates including many types of porcelains and zirconium, was placed on all the etched surfaces.

Figure 14. Temporization of case with a unique temporary material (Dentocrown [Itena USA]).	Figure 15. Excellent gingival health can be seen after temporary removal.
Figure 16. Knowledge of how to etch various dental substrates is imperative.	Figure 17. Proper acid etching achieved as demonstrated by “frosty” appearance.
Figure 18. Final Cristal veneers (Aurum Ceramics). Note the even gingival margins on central incisors.	Figure 19. Total dental and facial aesthetics completed with porcelain veneers, Botox, and dermal fillers.

Anyone who has ever placed veneers with different thicknesses knows the biggest challenge is trying to match up the final shade. Seating these veneers is very time consuming in the office as the dentist is trying to use different resin cement shades and even different values of the resin cement shade to achieve a color match of all of the veneers. Personally, I have always believed that this should not be the dentist’s problem. It should be the laboratory team’s responsibility if they have the aesthetic expertise necessary and really understand the ceramics that they are using. Cristal Veneers porcelain was developed by Aurum Ceramics, giving them the aesthetic expertise to understand the optical qualities of the porcelain as well as the different opacities that will go into a challenging veneer case such as this one. This case came back to my office with all of the different thicknesses of porcelain veneers (and sometimes there are even different thicknesses on the same porcelain veneer), and because of this laboratory’s expertise in producing these veneers, I was able to seat all of these veneers with one shade of cement. It is a huge advantage to have such a talented laboratory team, and here is where your choice of laboratories can make all of the difference in the world in terms of the ease of cementation, saving time, and producing an aesthetic result that you and the patient are proud of.
The chosen veneer shade was 020 for this case and the corresponding cement was used. I used a light-curing porcelain veneer cement (Nexus 3 [Kerr]) because of its ease of use, color stability, and great texture for seating any kind of veneer, whether thick or thin. Figure 18 shows the veneers cemented into place. The challenges presented above have been addressed completely. Look at the gingival margin of the upper right central incisor as it now exactly matches the gingival margin of the upper left central incisor. Remember that the veneers on the central incisors are approximately 0.3 mm and the rest of the veneers are anywhere from 1.0 to 3.5 mm in thickness and all of these veneers are the exact same shade. There was absolutely no need to try to use different shades of cement to achieve a final matching shade, but only one shade of cement was used. Notice also that the lower veneers now restore the proper height to the teeth, and they are no longer short and stubby, as the patient complained about before.
Bonding veneers to existing porcelain crowns includes the use of a number of agents and a sequenced approach. (Please go to my Web site commonsensedentistry.com for a full step-by-step technique as how to bond a porcelain veneer to an existing porcelain crown.)
Figure 19 shows a very happy patient who has been treated with total facial aesthetics, and we have addressed all of her concerns. The final dental aesthetic and therapeutic result is a combination of all of the oral and maxillofacial treatment both in and around the mouth. What is interesting about this case and similar treatment plans that include Botox, dermal fillers, and dental materials, is that the facial injectable treatment is much easier to perform with proper training.

CLOSING COMMENTS
This article clearly demonstrates that aesthetic dentistry is not limited to only inside the oral cavity as previously thought. Treatment of the oral and maxillofacial areas with intraoral treatment is true and total dental aesthetics.

Dr. Malcmacher is a practicing general dentist and an internationally known lecturer and author. He is president of the American Academy of Facial Esthetics. His Web site, commonsensedentistry.com, contains information about his lecture schedule, live patient hands-on Botox and dermal filler training courses, Frontline TMJ/headaches/facial pain training course, his resource list, and free monthly e-newsletter. He can be reached at (800) 952-0521 or at drlouis@facialesthetics.com.

Disclosure: Dr. Malcmacher is president of the American Academy Facial Esthetics.