Changing The Face of Dentistry

Author: Louis Malcmacher DDS MAGD

Figure 1.

Dentistry is not just about teeth any more, as will be demonstrated in this case presentation article. Over the past few years, with thousands of dentists being trained in the use of non-surgical, minimally invasive facial injectables (such as Botox and dermal fillers), dental esthetic and functional treatment has changed for the better. This article will clearly demonstrate how the use of facial injectables in the oral and maxillofacial areas directly relates to the teeth in terms of function, smile lines, lip lines, phonetics, and esthetic dentistry, and clearly show how the totality of this oral and maxillofacial treatment is indeed dental treatment.

Figure 2 .	Figure 3.

Figure 4 .	Figure 5.

Figure 6 .	Figure 7.

This patient’s story starts a few years ago when she had two all-ceramic crowns on the upper right and upper left central incisors as well as veneers placed on the upper and lower teeth (Figure 1). One day, she notices that her upper left central incisor crown seems loose. A radiograph was taken and you can clearly see in Figure 2 that a horizontal fracture is present. This tooth is obviously nonrestorable and so it was extracted and an implant was placed, as shown in Figure 3. The implant was restored with a Procera crown and the patient is enjoying the newfound stability of this tooth. What she does not enjoy is the creation of deficient interdental papilla known as “black triangles” (Figure 4). This is one of the most frustrating esthetic challenges that can happen in any kind of implant or crown and bridge procedure. A new innovative procedure pioneered by this author and the American Academy of Facial Esthetics www.FacialEsthetics.org involves using dermal fillers (Juvederm Ultra XC) to plump the interdental papilla to eliminate these black triangles, which was successful as seen in Figure 5.

A few months later, the patient is interested in retreatment of her crowns and veneers, as she would like whiter teeth and a fuller smile. Some of the issues that she complains about with her present smile (as seen in Figure 6) is that the new crown on the upper left central incisor is a slightly darker shade than the other teeth and when she goes into a full smile, she does not show as many teeth as she would like. She also requests that all of the teeth be whiter. She has also exhibited over the past few years a number of chips of the veneers especially on the lower teeth (Figure 7), and an occasional veneer popoff that would have to be re-cemented from time to time. This has resulted in making the lower teeth “look very short and stubby”, in her own words. This patient also has a very deep overbite as demonstrated in Figure 8.

With proper training in both oral and maxillofacial esthetics, let me give you my perspective as to what I look for now in this kind of case and why the facial conditions here are part of her dental esthetic treatment. Let’s take a look again at this patient in a full-face picture and in a full smile preoperatively in Figure 6. Here in a full smile, she does not clearly show the buccal corridors, which would give her a fuller looking smile. As dentists, in the past, we would never think about why she is unable to go ahead and deliver a full looking smile. We would just assume that we should place veneers on the bicuspids and that will be enough, when in most cases, it will not provide the desired result because other factors are at play here. Also notice in this photograph that in her present full smile, the upper lip is not in an esthetic relationship with the teeth. Ideally, for esthetic lip lines and smile lines, when the patient goes into a full smile, the bottom of the upper lip should straddle the gingival margins of the central incisors and cuspids, which should also ideally be at the same heights.

This patient clearly demonstrates a very typical scenario with facial aging, especially after the patient reaches age 50. Dermal collagen and facial fat are lost in the oral and maxillofacial regions and the midfacial tissues begin to sag and drop. This results in patients showing less of their upper teeth and more of their lower teeth. This patient reports, and clearly demonstrates by pictures of her in her youth, that she had higher cheekbones and more volume in her face. At that point in her life, she had a much fuller smile. You can clearly see in this full-face photograph (Figure 6) that she has lost some of the volume in her face and try as she might, she can’t pull her upper lip higher in a full smile because of the loss of volume Changing The Face Of Dentistry Louis Malcmacher DDS MAGD D Figure 1. 4 in the zygomatic areas of her midface. As a result of this facial aging and loss of support, she also has deeper nasolabial folds, which again puts more pressure on depressing the upper lip in a full smile. All of these factors taken together result in a dental esthetic challenge and are easily treated with Botox and dermal fillers by properly trained clinicians in addition to the use of veneers. The main point here is this – with her loss of facial volume as it stands now, you can place a whole mouth full of veneers and she still won’t show the bicuspids and buccal corridors because her full smile is not a function of her teeth but rather of the oral and maxillofacial structures.

Figure 8 .	Figure 9.

Figure 10 .	Figure 11.

Figure 12 .	Figure 13.

Figure 9 shows the patient post facial injectable treatment with Botox and dermal fillers and you can see the desired result of showing more teeth and proper lip and smile lines before the re-treatment of the veneers. Take a close look at her cheeks and you will find significantly more volume as well as much less prominence of her nasolabial folds. Now when she goes into a full smile, she shows a lot more teeth than before because her upper lip now has greater support from the added volume in the midface. This was accomplished by using a calcium hydroxylapatite dermal filler (Radiesse) with 1.3 ml used in the left zygomatic area and 1.1 ml in the right zygomatic area. A hyaluronic acid dermal filler (Juvederm Ultra XC) was used in the naso-labial folds with 1 ml used in the left nasolabial fold and .9 ml used in the right nasolabial fold. You can now see when she goes into a full smile in Figure 9 that she has the proper lip lines and smile lines and the bottom of her upper lip straddles the gingival margin of the upper central incisors and cuspids. This clearly shows the direct relationship between dermal filler procedures in the naso-labial and zygomatic areas as dental esthetic and therapeutic treatment.

Now that this patient can see her teeth better and shows more teeth, she wants new veneers to make the teeth whiter. Now we can address the challenges discussed above by now proceeding with the veneers. One other issue that the patient now is concerned about (because she now has such a broad smile) is that the upper left central incisor also has a higher gingival margin than the upper right central incisor because that is the area where an implant was placed (Figure 10). As we have now addressed the underlyingcause of her deficient smile, we are ready to proceed with new porcelain veneers.

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, do produce somewhat of 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 Aurum’s Cristal® Veneers by Aurum Ceramic/Classic. Aurum’s Cristal Veneers are the next generation of a no/minimal preparation veneer system with veneers that can be made as thin as .3 mm and exhibit very high
strength and excellent esthetics. Aurum’s Cristal Veneers can also be made as thick as any other veneer. This case will have multiple thicknesses of every type of veneer possible. You can see in Figure 11 the teeth after preparation. All of the previous veneers were removed on the upper and lower teeth. A hard and soft tissue laser (Waterlase Iplus by 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 at this point is a very well established procedure and can be done very precisely and conservatively with an erbium laser such as the Waterlase Iplus. As a matter of fact, at this same veneer preparation appointment, we performed this closed sulcus crown lengthening and because of its predictable nature, we were able to take the final impression on the very same day. Figure 12 shows the prep guide created by Aurum Ceramic/Classic and demonstrates the very minimal preparation on the two upper central incisor crowns so that the Aurum’s Cristal Veneers on these teeth will be approximately .3 mm in thickness while the veneers on the lateral incisors will be anywhere between 2 ½ 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 13.

Figure 14 .	Figure 15.

Let’s talk about this issue for a moment because this is a challenge when seating a veneer case such as this one. Every dentist knows that when they are seating veneers with different thicknesses, their biggest challenge is trying to match up the final shade. Many times 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 colour match of all of the veneers. Personally, I have always believed that this should not be the dentist’s problem but it should be the laboratory’s responsibility if they have the esthetic expertise necessary and know the porcelains that they are using. Aurum’s Cristal Veneers porcelain was developed by Aurum Ceramic/Classic and they have the esthetic expertise to understand the optical qualities of the porcelain they are using, as well as the different opacities that will go into a challenging veneer case such as this one. This case then comes 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 am able to seat all of these veneers with one shade of cement. It is a huge advantage to have such a talented laboratory 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 esthetic result that you and the patient are proud of.

Figure 14 shows all of the veneers cemented into place. The veneer shade is 020. My choice of porcelain veneer cement is Nexus 3 by Sybron Kerr because of its ease of use, colour stability, and it has the perfect texture for seating any kind of veneer, especially very thin veneers.

Note a few of 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 .3 mm and the rest of the veneers are anywhere from 1 to 3 ½ 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 website www.commonsensedentistry.com for a full step-by-step technique as how to bond a porcelain veneer to an existing porcelain crown.

Figure 15 shows a very happy patient that has been treated with total facial esthetics and we have addressed all of her concerns. The final dental esthetic and therapeutic result is a combination of all of the oral and maxillofacial treatment both in and around the mouth. This article clearly demonstrates how the use of Botox and dermal fillers in the face are as much responsible for the success of dental esthetic cases as are porcelain veneers, crowns, and implants.