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DOSI SGL Template

Topic: Esthetics

Before After
Scenario: A 33 y/o female has presented for a comprehensive exam. She has no
medical conditions, medications, or allergies. Her CC is: “I want my teeth to look better.
I had “veneers” done about 10 years ago, but I don’t like how my smile looks anymore!
My biggest concern is that I feel like my front teeth are “boxy” and that I have a “gummy
smile.” The “veneers” I have look gray to me. Also, sometimes in photos, I feel like it
can look like I’m missing a tooth.”

After reviewing her “smile satisfaction questionnaire” and discussing her objectives, you
determine she would like to:

-lengthen the central incisors


-broaden the smile
-make smile less “gummy”
-change the shape/ shade of the teeth

You complete your extraoral and intraoral exam and the findings are within normal
limits (no swelling or lymphadenopathy). After completing the odontogram,
periodontal charting, and caries risk assessment,
your findings include:

-#6 and #11 porcelain veneers


-#7, 8, 9, 10 – porcelain crowns
-#12- OB direct composite veneer
-Localized 5mm PDs at teeth #7-10
-Localized moderate BOP maxillary anterior teeth
-low caries risk
Q: Why might there be such extensive localized inflammation? What are
common reasons for inflammation around indirect restorations?

You determine an FMX is needed. Your assistant takes the prescribed radiographs.
After reviewing the full set, you focus your attention to the images of the maxillary
anterior teeth.

Q: After reviewing these images, what are the radiographic findings? Do


you see anything that correlates with the problematic findings of the IOE?

Prior to completing a comprehensive treatment plan, you decide to do an esthetic


assessment to establish the ideal smile design and address her chief complaint.

Q: What are the criteria you will assess for smile design? (Images from Article:
Principles of Smile Design, Journal of Conservative Dentistry 2010) Fill in the blanks.

Facial
________________ _____________

Hard Tissue

Soft Tissue
You take a series of intraoral photographs to best review your findings with the patient,
identify objectives of the new smile design, and communicate with the lab.

Q: What do you think of the midline? Gingival heights? Width:height ratio?


Q. Esthetically, what do we know about midline? How important is it for
the maxillary midline to be coincidental with the mandibular?

Q: What do you think of the Buccal corridor here? What can we do to


better “fill” the buccal corridor?

Q: What do you think about the amount of gingival display? What would be
some tx options for addressing the “gummy” smile in this case?

Q: Do the Smile line and lower lip line follow the same arc?

Q: Using these side photos, how many teeth do you think will need to be
included to successfully blend in changes of shade/ shape?
After assessing the patient’s facial and dental features, you observe:

-mildly deficient buccal corridor


- 1-2mm of excess anterior gingival display

You decide the patient would benefit esthetically from:

-filling the buccal corridor


-gingivectomy/ gingivoplasty (re-contouring)

You discuss your findings (see table below) and present your optimal plan:
Tooth Problem Optimal Tx Option
Tooth #5 OK All-ceramic crown
Tooth #6 All-ceramic All-ceramic Veneer
veneer
Tooth #7 All-ceramic All Ceramic Crown
crown
Tooth #8 All-ceramic All Ceramic Crown
crown w/
Open margins
Tooth #9 All-ceramic All Ceramic Crown
crown w/
Open margins
Tooth #10 All-ceramic All Ceramic Crown
crown
Tooth #11 All-ceramic All-ceramic Veneer
veneer
Tooth #12 Failing OB direct All-ceramic crown
composite
veneer

Q: What is something you could do to help your patient visualize your smile
design plan?
Here are the Diagnostic Wax-Ups:
You review your treatment options with your patient. She is excited and accepts your
optimal tx plan, but she has some questions for you:

Q: I want to make sure my smile is brighter this time. If I want my natural


teeth to match the crowns and veneers, what are my options for bleaching?

Provide evidence of the effective nature of different bleaching options

Q: How long do I bleach? Can we start on my crowns/ veneers as soon as I


finish whitening?

Q: I’ve heard my teeth and gums will hurt. What can I do to keep that from
happening?

After completing bleaching, you have the patient return for the maxillary anterior rehab.
You mentioned to the patient that there would be different options for the type of
crowns. Your patient has some concerns:

Q: My friend got her teeth done some years ago after an accident and now
you can see a gray line along the gum line. I want to make sure that doesn’t
happen to me! What are my options for the new crowns so that they are as
bright and natural-looking as possible?

 Discuss different esthetic anterior crown options

Q: You decide to place lithium disilicate crowns/ veneers (eMax). What are
some considerations when prepping and cementing? I.e. cement types,
isolation while cementing, and temporary cements.

The patient presents for the delivery date. After removal of your provisional, the try-in
appears to go smoothly and the patient is satisfied with the esthetics. You bond the
restorations with a resin cement.
The next day, the patient contacts the office dissatisfied with the results and sends
several photos she took with her camera phone. She says that the look doesn’t seem to
match the “temporary” that she had been in…

Since you had used the wax-ups to fabricate the provisional, you’re thinking the results
should be a match…

Q: Compare the photos to the wax-ups. Do you notice any discrepancy?

You advise the patient to return for a follow-up. As you examine the smile, you agree
that the lab had not “followed the wax-ups” per your lab prescription.

You determine to drill off #5 and 12. A new final impression is captured and sent to the
lab for remakes.

Two weeks later the patient returns. The morphology is appropriate this time and the
emax crowns are bonded in. The patient is dismissed and is extremely satisfied with her
new smile.

References

Bhuvaneswaran, M. “Principles of Smile Design.” J Conserv Dent. 2010; 13(4): 225-32.

Kihn, P. “Vital Tooth Whitening.” The Dental Clinics of North America. 2007: 319-31.
Kelly, J. Robert. “Dental Ceramics: What is this stuff anyways?” JADA 2008; 129(suppl
4) 4S-7S.

Acknowledgements

Dr. Anna Organ-Boshes

Dr. Anakarina Bedran-Russo

Dr. Rand Harlow

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