Aesthetics Now 2017

PROFESSIONAL DENTISTRY PRESENTS...

AESTHETICS NOW 2017 Edition

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LTS U S E R T E G BEFORE

BEFORE BEFORE

AFTER

AFTER

AFTER

FOR KIDS

FOR RS IO N JU

FOR TEENS

FOR ADULTS

Over the last 25 years Myofunctional Research Co. (MRC) have developed orthodontic appliances to improve the dental and facial development of children from 5 -15 years of age, using myofunctional orthodontic techniques instead of traditional orthodontics. This technique not only straightens teeth (often without braces) but also treats the causes of crooked teeth and incorrect jaw development.

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Contents...

1

Alignment, bleaching and veneers to correct big . and unsightly front teeth..........................................................6

4

Interdisciplinary smile design with personality...........50

Introduction.....................................................................................50

Comprehensive clinical examination...........................................8

Treatment options...........................................................................8

Treatment plan................................................................................10

Four months later............................................................................51

Treatment progression....................................................................10

One month later..............................................................................51

Orthodontic treatment...................................................................10

Diagnosis..........................................................................................52

Tooth whitening...............................................................................12

Diagnostic wax-up..........................................................................12

Treatment.........................................................................................53

The prep visit....................................................................................12

Study casts.......................................................................................53

Review of provisionals....................................................................16

Crown lengthening.........................................................................53

Porcelain veneer fit visit..................................................................18

Tooth whitening...............................................................................53

Final review......................................................................................20

Study casts and occlusion.............................................................55

Veneer preparation and provisionalisation.................................55

2

Patient history..................................................................................50 Clinical findings...............................................................................51

The use of Botulinum Toxin Type A to reduce the appearance of fine lines and wrinkles in the forehead, frown and eyes......................................................22

Treatment plan................................................................................52

Cementation...................................................................................55 Discussion.........................................................................................56 Conclusion.......................................................................................56

Growth in aesthetics.......................................................................22

What do patients want?................................................................22

What do patients not want?.........................................................22

What is Botulinum Toxin Type A and how does it work?.............24

5

Assessment of the patient..............................................................28

History...............................................................................................58

Acknowledgment...........................................................................56 References.......................................................................................57

Interdisciplinary success.........................................................58

Consultation....................................................................................28

Case assessment.............................................................................59

Anatomical considerations............................................................28

Treatment plan................................................................................59

Options.............................................................................................30

Endodontic re-treatment...............................................................60

Consent............................................................................................30

Treatment process..........................................................................61

Clinical procedure..........................................................................32

Conclusion.......................................................................................64

Preparation......................................................................................32

References.......................................................................................65

Injecting technique........................................................................32

Review and results..........................................................................36

6

The gold standard for single tooth replacement.......66

Summary..........................................................................................38

Introduction and chief complaint................................................66

References.......................................................................................40

Medical and dental history............................................................66

Diagnosis and treatment plan.......................................................67

Clinical treatment...........................................................................67

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Composite resins in anterior aesthetics..........................42

Introduction to the case................................................................42

Conclusion.......................................................................................69

Medical and dental history............................................................43

Acknowledgements.......................................................................70

Diagnosis and treatment planning discussions...........................44

Armamentarium..............................................................................70

Clinical progress..............................................................................44

The equipment and materials used included:............................46

Final result.........................................................................................47

References.......................................................................................48

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(A) Further reading.........................................................................71

Alignment, bleaching and veneers to correct big and unsightly front teeth.

Anoop Maini BDS (Lond), DGDP (UK)

Having recently got engaged, this pleasant lady wanted to improve the appearance of her upper central incisors before her wedding in a year’s time. She felt they were big and unsightly. She also wanted to have her teeth whitened (Figure 1).

She attended as a healthy 40+year old, non-smoking, non-drinking regular dental patient with a history of periodontal treatment at a London dental hospital. Her dentition was fairly heavily restored, with several crowns that were quite old. As a teenager she had had fixed orthodontics with the removal of some of her premolars.

The 45 was extracted due to a failed root canal treatment and the patient has chosen not to restore the space. She reported brushing her teeth twice a day and using interdental brushes.

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Comprehensive clinical examination This revealed no evidence of pathology of the TMJ or associated muscles. Her soft tissues were all normal. There was evidence of parafunctional activity, with signs of wear on her anterior teeth and canine tips. She also exhibited some wear/ tooth structure breakdown at the cervical areas of her posterior teeth. All her teeth responded normally to vitality testing with an electric pulp tester, with no response only from the root filled 26 and 35, 36, 37.

The existing restorations appeared sound although the patient expressed a desire to replace some of the crowns in the future due to unsightly gingival recession and loss of cervical tooth structure. Her BPE score was 1/0/2 : 2/1/2. She exhibited a number of larger interdental spaces, due to loss of papillae and generalised recession, associated no doubt with her history of periodontal disease and its treatment. Her occlusion was Class 1 canine left, class 2 molar left, Class 2 canine right and Class 1 molar right. There was a small horizontal slide between RCP and ICP. In both right and left lateral excursion, she had group function (canines and lateral incisors) with non-working side interferences on the 37 and the 16. Protrusive guidance was on the upper central incisors.

Not unexpectedly, there was evidence of generalised bone loss due to a previous episode of periodontitis. There was no radiographic evidence of carious lesions.

Treatment options Having established the overall health of the patient’s teeth and oral tissues, the following options to improve the aesthetics of 11 and 21 were discussed: • Comprehensive orthodontics to align and level the arches, correct her

malocclusion to class 1 and possibly recreate space at 45 for an implant. This

would be followed by veneers on 11 and 21. The patient declined the

treatment on the grounds of time.

• Due to the anterior upper incisor crowding, if we were to use veneers only, the

preparations on 11 and 21 would be very aggressive as these teeth were significantly rotated and over erupted. The patient wanted to know if it was

possible to do this with a reduced amount of preparation.

• We then discussed specific goal, fixed orthodontics to improve the alignment

of the upper incisors and to intrude 11 and 21 in order to reduce the

overeruption, followed by porcelain veneers on these teeth. Estimated

treatment time for the braces was about 16 weeks. The patient found this

option acceptable.

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Treatment plan 1. Referral to hygienist for prophylaxis and OHI reinforcement 2. Placement of upper fixed appliance 3. Diagnostic wax up of 11 and 21 veneers 4. Professional tooth whitening 5. Under local anaesthetic, veneer preparation and provisionalisation of 11 and 21 6. Fitting of 11 and 21 veneers and placement of a bonded upper orthodontic

retainer to prevent relapse

7. Review and fabrication of a full coverage hard occlusal splint for night-time

wear, in order to protect the dentition and new restorations from

parafunctional habits 8. Regular dental examinations and hygienist recall.

Treatment progression Orthodontic treatment Impressions were taken for an indirect bracket bonding tray for the upper arch.

Brackets were bonded and 012, 016 & 020 x 020 Niti wires were used sequentially to level and align the anterior incisors with a ‘wire under bracket’ technique to intrude 11 and 21 (Figure 2).

The posterior segments were ligated to avoid any changes to the posterior occlusion.

Treatment time was three months.

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Tooth whitening Once the teeth were better aligned the appliance was removed and a removable Essix retainer was provided which acted as a whitening tray, with a conventional bleaching tray provided for the lower arch. The patient then proceeded to use 10% carbamide peroxide overnight for two weeks to whiten her teeth in the trays and her shade improved from B4 to A1 (Figure 3).

Diagnostic wax-up To assist with the fabrication of the diagnostic wax up of the 11 and 21 proposed veneers, an addition cured silicone impression was taken for both arches. This together with a stick bite in her habitual bite, a facebow transfer and photographs were sent to the laboratory (Simplee Dental Ceramics). The laboratory also fabricated a Silteck putty matrix, special tray and labial preparation guide as well as a stiff transparent vacuum formed stent. The wax up was reviewed with the patient and she was happy to proceed with treatment.

The prep visit Local anaesthetic, 1 ml articaine with 1:100,000 adrenaline, was administered by buccal infiltration. Optragate was applied for retraction of the lips. The clear stent was used first to assist with some pre-preparation recontouring, especially on the distal aspects of the central incisors. The teeth were recontoured to allow the clear stent to fully seat. Following this, using the silicone matrix and A1 Luxatemp (DMG) an 12

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Aesthetic Pre-evaluation Temporary (APT) was fabricated over the unprepared teeth to assist with ensuring that an adequate yet minimal amount of enamel would be removed. Thicker veneers were required to mask the discoloured dentine so 0.5mm horizontal depth cuts and 1mm incisal depth cuts were made. The depth cuts were then marked with a pencil and the APT was removed. The veneers were prepared using a tapered diamond bur, creating supragingival finishing margins and the facial was prepared to the depth of the depth cuts. The preparations were then smoothed with a blank carbide bur followed by a white stone. A yellow fine Vision IPR strip was used interproximally. The preparation space was also evaluated using a putty labial preparation guide. An addition cured silicone impression was taken using a special tray. Photographs with Vita A1 tab (to show intended shade) and ND8 & ND2 stump shades were taken to convey to the technician the underlying tooth shades and adjacent tooth characterisation (Figure 4).

A stick bite in the patient’s habit bite (CO) was recorded and a Denar facebow transfer was taken. A silicone opposing impression was also taken.

The teeth were then spot etched for 15 seconds, Gluma desensitiser was applied followed by the adhesive from Optibond FL (Kerr) which was air thinned and then light cured. The siltek provisional putty matrix loaded with Luxatemp A1 was then placed over the preparations and allowed to self cure. The matrix was removed and the provisionals were trimmed to remove excess materials beyond the margins

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2 Day Clinical Occlusion & the Management of Tooth Wear in General Dental Practice 12 hours verifiable CPD Saturday 13th - Sunday 14th May 2017 Saturday 11th - Sunday 12th Nov 2017

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Smile Design Creating a Beautiful Smile 6hours verifiable CPD Tuesday 21st Mar 2017 Tuesday 31st Oct 2017

Essential Hands On Skills For Minor Oral Surgery In General Dental Practice 6 hours verifiable CPD Thursday 9th Mar 2017 Thursday 21st Sep 2017

An A-Z of Antimicrobial Prescribing for Oral Infections & Principles of Infection Control in GDP Thursday 29th Jun 2017 Thursday 23rd Nov 2017

Hands on Periodontal Surgery: Skills for General Practice 6 hours verifiable CPD Tuesday 2nd May 2017 Tuesday 5th Dec 2017

GDC Recommended CPD: Legal, Ethics, Complaints and Oral Cancer 6 hours verifiable CPD Monday 19th Jun 2017 Tuesday 14th Nov2017

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using a fine fluted carbide bur. The gingival embrasures were opened to allow for interdental cleaning and the occlusion was checked.

The laboratory prescription was filled requesting Emax (Ivoclar) pressed veneers. A light texture, polished gloss and 1 mm incisal translucency was defined. The shade was detailed as Vita A1. Photographs of the stick bite and preparations were sent to the laboratory.

Review of provisionals The patient was reviewed one week later to evaluate the provisionals. The gingival health was confirmed. Using a pencil the line, angles were drawn to confirm symmetry. The incisal embrasures were further defined. Phonetics and occlusion were also checked. The patient was happy with the aesthetic outcome and the shade was confirmed with the patient as Vita A1. Photographs were taken and an addition cured silicone impression of the provisionals was sent to the laboratory to index and assist with the fabrication of the definitive veneers.

Porcelain veneer fit visit After administration of local anaesthetic, an Optragate retractor was placed and the area was further isolated with cotton wool rolls, gauze and high volume suction.

The provisionals were removed by sectioning. The preparations were then cleaned with a white stone bur to remove any residual composite resin adhesive. The veneers were tried on the teeth one by one dry to check for accuracy of fit.

The veneers were then tried in with a translucent try in cement (Vitique, DMG) to assess the shade. A colour modification was deemed necessary to reduce the value so an A1 try in cement was assessed. The Optragate was then removed and the patient was given the opportunity to review the veneers.

The patient was happy with the try-in and so the veneers were then cleaned and prepared in the following way: • The fit surface etched with 10% hydrofluoric acid for 60 seconds • The fit surfaces washed copiously and dried • The veneers placed in an ultrasonic bath with 95% alcohol for 4 minutes to

remove any precipitated acid salt crystals

• The veneers are then dried and freshly mixed silane applied and allowed to air dry • Optibond FL adhesive applied to the fit surface and air thinned and the

veneers placed under a light sensitive cover 16

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• Rubber dam applied to the teeth using a canine to canine split dam technique.

The teeth were then treated as follows: • Etched with 37% phosphoric acid for 30 seconds and then washed copiously

and lightly air dried. The 11 composite was sandblasted using silanised 50

micron particles • Gluma desensitiser was then applied to the teeth and lightly air thinned • Optibond FL Primer was then applied to the teeth for 20 seconds with agitation

and then air thinned

• Optibond FL adhesive was then applied to the teeth and air thinned • Vitique A1 light cure cement was then applied to the fit surface of the veneers

and the veneers were applied to the teeth. Excess cement was removed using

a brush • The veneers were then light cured using a tacking tip mid facially to secure the veneers. The excess cement was then removed interdentally using floss. The

veneers were then covered with glycerine (to prevent oxygen inhibition) and

fully cured for 40 seconds each cervically, interproximally and incisally.

The interdental areas were opened with a serrated strip (Komet) where necessary and then final polished with the red and yellow vision polishing strips (Komet). The cervical and incisal margin areas were cleaned of excess resin with a curved No.12 scalpel blade and then with a fine fluted composite finishing carbide bur.

Fine composite polishing rubber points were then used at the margins followed by diamond polishing paste with a bristle brush.

The rubber dam was removed and the occlusion was checked and adjusted.

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Final review The patient was reviewed a week later to check for any residual cement and to check occlusion, phonetics and the final aesthetics (Figure 5).

Upper and lower addition cured putty and wash, two-stage impressions were taken in metal trays and an open bite CR record taken after placing an anterior Lucia jig deprogrammer for 60 minutes. These impressions were sent to Hanham dental laboratory to construct a lower Tanner appliance.

After fabrication, the lower Tanner appliance was fitted and adjusted to ensure even posterior contacts and anterior disclusion. The patient was satisfied with the outcome and a suitable maintenance recall period was recommended and agreed.

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The use of Botulinum Toxin Type A to reduce the appearance of fine lines and wrinkles in the forehead, frown and eyes

By Dr Harry Singh - www.botoxtrainingclub.co.uk

Growth in aesthetics The trend today is away from traditional cosmetic surgery and toward less expensive minimally invasive procedures1. The use of cosmetic procedures to reduce the signs of ageing has increased dramatically over the past 10 years2.

However, the rapidly rising demand for botulinum toxin and dermal filler treatments together with increasingly complex injection procedures present a growing challenge for today’s expanding aesthetic community. According to industry estimates for 2013, for example, a total of 1.5 million toxin and dermal filler procedures were carried out in the UK3.

What do patients want?

The goal is to help our patients appear more naturally fresh-faced and youthful.

I’m in agreement with my colleagues4 that patients today want treatments that help maintain a natural look, rather than extreme changes. I use the 3 Rs of possible treatment modalities when trying to regain youthfulness: • Rebalance • Revolumerisation • Reposition.

What do patients not want?

One of the biggest concerns among patients seeking aesthetic treatment is to avoid looking unnatural4. These same patients are worried whether others will notice if they have had treatment, since research has shown half of these patients don’t want others to know5, or at least be able to tell, that they’ve had cosmetic procedures done6.

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What is Botulinum Toxin Type A and how does it work?

In this article I will be discussing the use of Botulinum Toxin A as a muscle relaxant. It is essential to have a firm understanding of what it is exactly and its mechanism of action as your patients will ask you and they may have some misconceptions about it from their friends and the media.

Botulinum Toxin Type A is a protein produced by the bacterium Clostridium Botulinum.

To my patients I explain it is a purified protein and comes from bacteria similar to antibiotics. In addition, I explain that it is like any other medicine, in correct low doses it is therapeutic and in high/dangerous doses it is toxic. Numerous studies have been conducted to confirm the safety aspect of this drug7.

In simple terms Botulinum Toxin Type A interferes with neural transmissions by blocking the release of acetylcholine, the principal neurotransmitter at the neuromuscular junction, causing muscle paralysis8. This is why the effects are temporary as the nerve begins to branch out to send new nerve ending to the muscle to tell it to move9. The greatest misconception clinicians have is they should inject into the muscle, however the biggest benefit is obtained from aiming for the neuromuscular region.

Currently there are three types of Botulinum Toxin Type A available for aesthetic treatments: • AbobotulinumtoxinA - Azzalure®; Galderma • Incobotulinumtoxina- Bocouture®; Merz Aesthetics • OnabotulinumtoxinA - Botox®; Allergan.

In the rest of this article I will be describing Azzalure® which is a registered trademark of Galderma and is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines seen at frown. You can still administer it for the forehead and eyes but it will be off licence in these two areas. My preference for Azzalure® is due to its fast onset10, long duration of action and high level of patient satisfaction11. The potency of Azzalure® is measured in Speywood Units and these are specific to its preparation and are not interchangeable with units of other preparations.

24

“The IAS Academy is about The Right Person, doing The Right Thing, for The Right Patient”.

Professor Ross Hobson

Inman Aligner is an effective and predictable way to treat simple anterior alignment cases so it’s the perfect start to the IAS Academy.

This module is an ideal solution for alignment of the anterior eight teeth.

It is the recommended second step in the IAS Academy pathway.

Key features of IAS Inman Aligner

Key features of IAS Clear Aligner

One removable appliance Two spring loaded, opposing aligner bows, using constant, light forces Low cost/risk. Ideal for GDPs Safe, aesthetic, progressive space creation Ideal for ABB and pre-alignment before ceramics Ongoing case mentoring via free Support Forum Shared IAS diagnostic protocols: ArchwizeTM, Spacewize+TM & Guides

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Lower lab costs allowing more affordable treatments

Archwize simulations to ensure expectations met and consent gained

Quality Training - Both the hands on course and ongoing online mentoring

Accurate Space Creation Guides for predictable results

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For dentists with no orthodontic experience

This module is designed to achieve a level of knowledge & skill equivalent to that of a Diploma in Primary Care Orthodontics.

IAS Advanced Modules Orthodontic assessment, diagnosis and treatment planning Assessing the evidence Fixed appliance and typodont Removables and functionals Treatment planning 1: Class 1 and Class lI div 1 cases Treatment planning 2: Class II div 2 and Class III cases Aetiology of malocclusion Dental materials: Wire bending practical Orthodontics & inter-disciplinary treatment Retention

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Other courses available: IAS Lingual Course, IAS Ortho Restorative Course, IAS Photography Course

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Peace of mind for you and your patients

The placement and restoration of dental implants is becoming a more popular choice for patients. Patients may feel the completion of their treatment is the end of the journey for them, enjoying the function and aesthetic advantage of restored implants. Their treating dentist and dental therapist will know however that perhaps the most important part of this particular journey is in fact just beginning.

Patients are encouraged to return to the treating dentist to ensure the site of the implant and the soft tissue surrounding it remains healthy. Continuing care by the treating dentist is an important factor in helping to mitigate possible problems in the future and can help to reduce the risk of litigation.

Unfortunately, some patients do not attend implant review appointments with the treating dentist and his or her therapist, preferring instead to rely upon the interventions of their general dentist who, whilst continuing to provide care to the patient, is not responsible for the course of treatment undertaken by another provider.

This common issue can arise due to the patient’s lack of understanding of the specialist or complex nature of the treatment undertaken and who is responsible for this aspect of their dental health. Cost objection is another factor, with patients questioning why they need to pay twice to continue to be reviewed by their implant dentist in addition to being cared for by their general practitioner.

If you place and restore dental implants you may be interested to learn about the implant maintenance programme powered by Privilege Plan. Some of our clients who place and restore implants want more predictable long-term treatment outcomes, particularly when they are offering extended warranties for the work carried out. If patients don’t attend on a regular basis, or are referred back to their general practice for their ongoing care, it can be more challenging to identify early signs of poor oral hygiene maintenance or inflammation and bone loss at the site of the implant. The implant maintenance programme provides comprehensive post-implant care, together with inclusive accident and emergency insurance, giving both you and your patient peace of mind.

27

Assessment of the patient Consultation A full facial assessment is essential to diagnose and offer the best solutions.

Prescription without diagnosis is malpractice. There are 3 questions I would ask at the consultation12: • What are you hoping to achieve?

• How long has this bothered you?

• Why have you explored a solution now?

Beware of patients suffering from Body Dysmorphic Disorder (BDD) which is a psychiatric anxiety disorder related to body image13. These patients will be excessively concerned with a minor defect in physical appearance. Aesthetic procedures are unlikely to solve the patient’s misperception and therefore you need to consider carefully whether to treat them.

Anatomical considerations You need to understand the facial muscle anatomy in order firstly to avoid complications and secondary to give your patients the best results possible. When looking at the upper third of the face there are three areas we will consider14: 1. Forehead - Frontalis - the contraction of this muscle elevates the brow and this

action causes horizontal/transverse wrinkles across the forehead.

2. Frown (Glabellar area) - Procerus - contraction of this muscle draws the medial

aspect of the eyebrows down and this causes a horizontal wrinkle over the

nasal bridge.

Corrugator Supercilii - contraction of this muscle slightly depresses the eyebrow,

moving it downwards and medially, this will eventually cause vertical creases

(frown lines) 3. Eyes - Orbicularis Oculi - this ringed muscle forms a sheet around the eye and

contraction of this muscle causes the smile lines (crows’ feet)

28

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Options Today, aesthetic practitioners can use a variety of tools and techniques that make procedures such as wrinkle reduction more accessible and affordable1. I refer to these procedures as ‘minimally invasive’ due to the short treatment time and reduced downtime post-procedure. Why would patients consider these minimally invasive cosmetic procedures? Some reasons15 for the popularity of these treatments include: • They are relatively painless • They can be performed quickly • Very little downtime afterward (no bed rest needed) • Normal activities can usually resume within 1/2 days • Common side effects can include, but are not limited to, redness, swelling and bruising • Side effects usually resolve within a week • A series of affordable treatments spread out over time.

Minimally invasive cosmetic procedures that may reduce the signs of ageing include (but are not limited to): • Botulinum Toxin A • Microdermabrasion • Chemical peel • Radio frequency • Laser skin resurfacing • Dermal fillers • Cosmeceuticals.

Consent You cannot stop patients from suing you but you can stop them from suing you successfully. To obtain informed consent you need to have satisfied the following criteria16:

30

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31

• Do they have the mental capacity to make an informed decision?

• Was it a voluntary decision - no family pressure/gift voucher?

• Were all risks and downside of treatment explained?

• Were all alternative options discussed (even if you don’t provide them)?

• Were images shown of potential side effects - bruising, swelling, etc?

Always take ‘before’ photographs, many patients are asymmetrical but don’t realise this and only pick it up after you have treated them and blame you for causing this.

If you have evidence in a photograph and have highlighted this asymmetry before starting treatment you will be on firmer ground.

Clinical procedure Preparation Azzalure® is available in single (1 vial) or twin packs (2 vials) of 125 Speywood units each. Inject 0.63ml NaCl 0.9% solution (use the green 21G supplied with the vial) for injection into an Azzalure® vial and mix gently. The resultant solution contains 125 Speywood units of Azzalure® in total or 10 Speywood units of Azzalure® per 0.05ml.

Injecting technique Draw up the mixed Azzalure® from the vial using the insulin BD 0.5ml syringe 30G 13mm.

You need the patient to carry out certain expressions so you can mark out where you will inject. For the forehead, they should be able to easily lift their eyebrows.

Regarding the frown, some patients find it hard to frown when you tell them, so I instruct them to scrunch their nose and this really breaks up the glabellar complex.

Lastly the eyes, same again, patients won’t give you a full smile when you ask them to smile so I tell them to squeeze their eyes closed and you will see their crow’s feet in all their glory.

As mentioned previously the best results are obtained by aiming for the neuromuscular site and not the main mass of the muscle. For example with the Corrugator Supercilii muscle you would aim at the end of the muscle where the most nerve endings are.

32

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For most of my patients I will use the following Speywood Units of Azzalure® as a guide and tailor make if for the individual.

Frontalis - 40 Speywood Units Total - 4 x 10.

I will inject superficially in only the upper half of the forehead and under dose this area to avoid ptsosi (drooping) of the eyelid/eyebrow.

Glabellar - 60 Speywood Units Total Procerus - 1 x 20 Speywood Units Corrugator -2 x 20 Speywood Units Make sure you are deep with these injections and be aware of the supratrochea

Oribculus Oculi - 25 Speywood Units Total 3 x 4 each side Be at least 1cm away from the orbital rim and inject superficially. Be wary when low down not to inject the Zygomaticus Major and cause a drooping of the corners of the mouth.

Please use this template as a guide on how much and where to inject. You must make your treatment protocol specific to the patient that is presented in front of you. Your treatment protocol will be dependent on what they want to achieve, their muscle mass and their anatomy. With experience you will use different doses and dilutions to achieve optimal results. Aesthetic treatments are scientific in nature but is an art form too.

34

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Review and results I always make a review appointment for all my patients two weeks after the procedure. You want to see the results obtained, any concerns they may have and what they experienced during the two-week period. There are a number of benefits of this top up/review appointment: • Gives the patient confidence that you will administer free top ups • Builds better relationship with the patient • You can take your after photos for your portfolio • The patient can see the benefits of the treatment and will be more receptive to refer others • You can discuss the long term treatment plan with them as you have dealt with

their main concern satisfactorily.

Most of the time they will need a top up in the lower half of the forehand where they may come back with reverse smile lines immediately above the eyebrows. Here you can inject very superficially (intra dermal) 1/2 Speywood Units maximum. In my experience they would normally see these top ups working within 3/4 days.

Before

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Summary My protocol is at the initial visit to treat the patient’s main underlying concern/ problem and then formulate a treatment plan over the next couple of years where we would look at combined therapies to achieve a more youthful look. The majority of aesthetic patients will be concerned with the upper third of the face initially and the three areas discussed here. Once they have built trust and you have demonstrated your skills you can then consider more advanced procedures such as the lower face with dermal fillers and advanced toxin procedures.

According to physicians5, the trend is towards a multiple-treatment approach.

Instead of focussing on only one area (such as the lips) or having a surgical face lift, more people are opting for a subtler approach using a variety of treatments to produce small improvements across the entire face. These treatments may reduce wrinkles and remove fine lines17. But they also help improve skin tone and skin quality, giving a more youthful glow.

In conclusion, it can be said that we are making our patients happier with safe and predictable treatments. Finzi18 argues that Botulinum Toxin Type A helps control the flow of negative emotions by inhibiting frowning, and that this feeds back to our brain to make us happier.

38

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References 1.

Goldberg D. Breakthrough in US dermal fillers for facial soft-tissue augmentation. J Cosmetic Laser Therapy 2009; 11: 240-247

2.

Riggs L. The globalization of cosmetic surgery: Examining BRIC and beyond.”

12-14-2012. University of San Francisco Master Thesis. (http://repository. usfcaedu/thes) Accessed 1 March 2014.

3.

Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment - 2nd Edition.

4. Gladerma Press Release (Feb 26, 2014). New Clinical Survey Reveals Consumer Trends.

5.

6.

Gladerma Clinical Survey October 2013. (A survey completed by 308 Gladerma aesthetic and dermatological physicians and clinical practitioners in more than 30 countries around the world in October 2013 with a statistical confidence level of 95% +/- 5%) The changing face of aesthetic treatments. Gladerma 2014.

7. Carruthers, A & J. Long-term safety review of subjects treated with Botulinum Toxin Type A for cosmetic use. 13th Cong Eur Acad Dermatol Venereol, Florence, 2004, PO2.18 8. Nigam, PK, Nigam, A. Botulinum Toxin. http//www.ncbi.nlm.nih.gov/pmc/ articles/PMC2856357/ 9.

Kane MA, The Botox Book - everything you need to know.

10.

Azzalure® Summary of Product Characteristics

11.

Ascher B et al. J Am Acad Dermatol 2004; 51: 223-233.

12.

Stuart T. www.nbstraining.co.uk

13. Pavan C, Simonato P, Marini M et al. Psychopathologic aspects of body dysmorphic disorder: a literature review. Aesthetic Plast Surg 2008; 32: 4 73-484.

14.

Carruthers A, Carruthers J. Botulinum Toxin. 2nd Edition

15.

Hugh L. Non-invasive cosmetic surgery will rule in 2013. Global healthcare. com, Jan 30, 2012 (http://www.healthcareglobal.com/fianace_insurance/ non-invasive-cosmetic-surgery-will-rule-this-2012) Accessed 21 March 2014.

16. Legal Framework and Issue in Aesthetic Medicine, Delegate Workbook, GCS Training ltd, 2014.

17. Rohrich R et al. Lexicon for soft tissue implants. Dermatol Surg 2009; 35: 1605 1611.

18.

Finzi E, The Face of Emotion: How Botox Affects Our Moods and Relationships.

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Composite resins in anterior aesthetics Dr. Arun Darbar (DGDP)

Today’s cosmetic dentist is able to offer much more than just indirect restorations to solve complex aesthetic problems. In this article complex resin bonding is used by Dr Arun Darbar, a laser dentistry aficionado, as he takes us through a case similar to those that many clinicians will encounter in practising life.

Introduction to the case The main concern for this patient was that the upper left central incisor appeared darker on photographs and her immanent role as a bridesmaid motivated her to seek some treatment. She had been given options to replace the old composites, and the endodontically treated, 21 appeared dark in colour which was the patient’s main concern (Figures 1-3).

42

She was happy with her other teeth for the meanwhile, saying that she would seek advice for them in due course, the urgency was the discoloured incisor1-3.

Medical and dental history Medically she was perfectly healthy. Her dental history included a childhood accident with a pushbike resulting in trauma to the incisors, necessitating root canal treatment to the 21, composite restorations in both upper central incisors and a palatal amalgam plug on the 21, which had discoloured the tooth over time.

43

Periodontal health was reasonable and well maintained. The patient was aware of occasional clenching but had no TMD related problems; she was also aware of malocclusion.

Diagnosis and treatment planning discussions The options considered included amongst others whitening, veneers, and crowns.

The possibility of orthodontic treatment was also discussed but as the immediate concern was aesthetics for the wedding this was something the patient said she would consider at a later date. Consequently, a very conservative approach, focusing on restoring and maintaining tooth anatomy, was deemed most suitable.

The root filling previously provided was adequate but lacked an effective seal and it was decided to re-treat this in preparation for internal whitening, which would be followed by home and in-practice whitening before replacement of the restoration with composite resin.

The agreed treatment plan included: • Oral hygiene appointments to precede all other treatment and laser (laser

curettage) used with the technique called ‘PMPT’ - Photo Modulated

Periodontal Therapy4. This stimulates repair and regeneration and is used in

pockets to remove soft plaque, reduce bacterial counts and bio stimulate

gingival tissues5. Physical removal of irritants including bacteria and calcified

plaques from tooth & root surfaces are facilitated by an ultrasonic scaler6.

• Re-treat upper left central incisor (21) root canal • Modify internal cavity seal with U-shape for internal whitening, follow up with

home and power whitening with Laser accelerated materials1

• Replace the restoration with composite resin 2-3 weeks after whitening6,7.

Clinical progress Once all the stages of treatment were explained and understood by the patient a number of upper and lower impressions were taken to fabricate study models and trays for whitening. A layering technique as described by Vanini2 was going to be used to provide the restorations, so a diagnostic wax up of the two central incisors was done to fabricate a putty index as a guide for the final restorations.

44

Once the hygiene stages were completed, the root canal of the 21 was re-treated and a cavity was prepared for internal whitening about 1.5-2.0 mm below the cemento-enamel junction (CEJ) with a U-shaped seal used to enable the placement and aid the efficacy of the internal whitening material.

The internal whitening was carried out using a laser-accelerated product called ‘White 10’, which was made specifically as a targeted chromophore technique for this wavelength (810 nm). The gel (35% hydrogen peroxide base) was placed and the tooth irradiated at specific settings and protocols as devised by the manufacturer. A small amount of gel and a cotton wool pellet was sealed into the cavity using a temporary filling material placed after completion of the first stage of in-practice whitening. Before and after images were taken, and a remarkable difference was noticeable even at that stage.

The patient was dismissed for that day with instructions for the home whitening using 16% carbamide peroxide gel for two weeks, following which she would return for in-practice power whitening. Following this, the access cavity on 21 was sealed but not bonded. For the appointment to replace the composite resins on the two central incisors, a rubber dam was placed to expose the six front teeth, 13-23, for colour matching (Figures 4 and 5).

45

No anaesthetic was used for the removal of the old composite and the teeth were prepared using a hard tissue laser with different settings and protocols to achieve an enhanced bonding surface8. Enamel margins were also bevelled with the laser using different settings and protocols. The teeth were etched with a buffered etch and seal (35% phosphoric acid), washed thoroughly, and a self-curing enamel / dentine bond was used in the cavity and on the root surface. The materials used were etch and seal and tenure A & B bonding system. The putty matrix was then used to fabricate the core structure of the restorations.

The teeth were built up using the Vanani2 layering technique and the first surfaces to be built up were the palatal surfaces and the incisal edges using a very thin layer of the enamel composite; in this case GE3 (a light colour) was chosen due to the patient’s age. The subsequent layers were built up using UD3, UD2 and UD1 for internal dentine walls and incisal characteristics and markings were produced using IW (intensive white) OBN translucent enamel with a blue tint. The two teeth were reconstructed in layers and at the same time, to keep the colour mapping easier.

Once the restorations were built up, they were refined and polished using different grades of polishing wheels, carbide burs and polishing discs. The finishing armamentarium included a jiffy brush and ABC polishing agents from the Enamel Plus Shiny Kit. The equipment and materials used included: 1. Nikon D200 camera with Macro and RICI flash system 2. Various cheek and lip retractors and mirrors 3. Digital x-ray system – Dexis 4. Laser Systems – various hard and soft tissue lasers

-

Biolase MD hard and soft tissue laser

-

Laser Smile 810 Diode

-

Ezlase 940 Diode

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LaserSmile bleaching H/P + Modifications

5. Loops 4.8 magnification and surgical microscope.(Global) 6. LED curing light Instruments: Standard mirrors, tweezers, probes etc.

Composite placement instrument from Coltene Perio probes, various color coded and measuring tips Miller forceps and various articulating papers (colours, sizes and thickness) 8. Composite material: Enamel Plus System Enamel Plus Shiny polishing system 9. Bonding System: Tenure A+B, self-curing systems.u 10.Standard rubber dam and accessories.

46

Final result The patient was very happy that we were able to complete the treatment before her big day as a bridesmaid (Figures 6-8).

We were also pleased about having the possibility to improve the final results without major reconstruction of any work already provided. Now we wait for the next stage.

47

References 1. Christansen G, Tooth bleaching, State of the art 97. CRA newsletter 1997 21: 1-4.

2. Vanini L. Light and color in anterior composite restorations. Pract Periodontics

Aesthet Dent 1996 8: 673-682.

3. Takeda FH, Harashima T, Kimura Y, Matsuoka K. Efficacy of Er:YAG laser

irraditaionin removing debris and smear layer on root canal walls. J Endod 1998

24: 584-551.

4. Darbar A. Proc of SPIE 2006 vol 6140-61400E-2: 5. Ando Y, Watanbe H, I KshjkawaI. Bactreial effect of Erbium YAG laser on

periodontal bacteria. Lasers Med Surg 1996 19: 190-200.

6. Myers TD, Murphy DG, WhiteJM, Gold SI. Conservative soft tissue management

with low powered pulsed Nd:Yag pulsed laser. Pract Periodont Aesthet Dent

1992 4: 27-32: 6-12.

7. Epstein SR. Curettage revisited: laser therapy. Pract Periodont Aesthet Dent 1992 4: 27-32.

8. Apel C, Gutnecht N. Bond strength of composites on Er:YAG and Er, Cr: YSGG

laser- irraditated enamel. SPIE, 1999.

48

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Interdisciplinary smile design with personality Oliver Harman BDS. LDS. RCS. MSc (Man.) BACD Fellow

This case included the replacement of four existing porcelain veneers to treat a gummy smile and incorporated osseous surgical crown lengthening by a periodontist.

Introduction Sarah first attended the practice when porcelain veneers were placed on 11,12 and 13 and 21. She remained a fairly regular patient and about eight years later, after the birth of her first child she decided to seek replacement of the veneers as they were in her opinion looking ‘tired’. She was interested in whether it was possible to do anything about her gummy smile and her small teeth and whether she could have a brighter colour (Figures 1 and 2).

Patient history Medical health Sarah was in good health and was eight months pregnant at the initial consultation to improve her smile.

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Clinical findings Clinical examination c/o: Fractured 14. Regular patient at practice Face Head Neck: NAD TMJ: Muscles relaxed with normal opening Oral hygiene: Fair- electric toothbrush, floss 1-2x a week Perio: Currently had pregnancy gingivitis with interdental bleeding and a BPE score of 222/222. Chronic swelling of gingiva around anterior veneers. Light calculus on the lower anterior teeth.

Teeth: Sound but margins of veneers detectable.

Tooth wear: Light wear facets on 46 and 47 Mobility: None Occlusion: Class I with no muscle tenderness, no heavy wear facets, no history of bruxism. Group Function on either side with balanced non-working side interferences.

Appearance: Considering replacement of veneers after baby born. Dislikes small teeth and gummy smile. A full smile assessment was carried out X-rays: Reviewed routine bitewings and periapical radiographs of 12-22 taken previously – all sound. No radiographs taken at appointment.

Patient had dental hygiene appointment to reinforce interdental cleaning and s/p.

Four months later Patient had acute post pregnancy gingivitis around existing veneers on 11-13 and 21 – she attended an emergency appointment at another practice where they prescribed Corsodyl mouthwash. Currently breastfeeding baby but about to stop. A session was arranged with the hygienist to reinforce oral hygiene and the patient was given Peroxyl to use four times daily for two weeks.

One month later Patient returned for detailed planning of veneer replacements. Bonding mock-up of potential surgical gum lift carried out.

51

Diagnosis Chronic gingivitis around the anterior veneers (11-13 and 21), suggesting poor oral hygiene or problems with the veneer margins. The gingival inflammation was made worse by pregnancy and post pregnancy gingivitis.

The appearance of the existing veneers and teeth was yellow with an unnatural profile to the veneers. The gingival line was low on the 11,12 and 21.

Treatment plan The basic parameters of Sarah’s smile were sound and the task was to improve the size, shape and colour of her teeth. The following treatment plan was proposed:

The initial plan was:

• Surgically lengthen and align 12, 21 and 22 gingival profile, with thinning of the bony plate over the 11 and 21 • Lighten all teeth to 1M1 shade • Place minimal porcelain veneers on 11-14 to match 22 and 23.

Following failure to attain a bright enough result with bleaching the plan was modified to:

• Placement of 11-14 and 21-24 with eight minimal feldspathic porcelain veneers.

Project management sheet including Gnatt Chart prepared to aid communication with the periodontist, the patient and the management team1.

52

Treatment Initial therapy with our dental hygienist was focused on achieving good gingival health following the pregnancy gingivitis. Emphasis was placed on achieving and maintaining good oral hygiene using the Philips Sonicare electric toothbrush combined with floss and interdental brushes. Full mouth fine scaling and polishing was carried out.

Study casts Upper and lower silicone impressions taken, face bow and silicone bites in the habit bite position and in centric relation (CR) using a Lucia jig2. A diagnostic wax-up was commissioned for 11-14 and 21-24. The new gum lines and improvements in shape were discussed by email/phone with photographs, following which the first draft of the wax-up was sent back to the lab for modification. Agreement was reached with the patient on the second wax-up and a vacuum-formed surgical template was made to aid gingival alignment with biological width3.

Crown lengthening With the patient’s informed consent gained, crown lengthening surgery was booked.

It involved intracrevicular/paramarginal incision from 13-23, osseous surgery to 1222; raising of the gingival level and thinning of the thick bony plate over 11 and 21. Following a review visit, further slight modification under local anaesthetic was carried out at four weeks. The total healing time allowed was12 weeks.

Tooth whitening When full healing of the periodontal crown lengthening was complete, all teeth were whitened using 10% ‘Bwhite’ carbamide peroxide gel in custom home trays overnight. 30 nights of bleaching were carried out resulting in a colour shift from 3M1 to 2M1. However, the patient wanted 1M1+ref4.

Following a discussion with the patient it was decided to treatment plan minimal veneers on the 22 and 23 in order to achieve her desired final colour of 1M1+. Colour checks were done manually with the Vita 3D Guide, under colour corrected lighting and using the Spectrashade colour analyser from Metalor.

53

54

Study casts and occlusion Upper and lower silicone impressions, face bow and bite were taken for the final diagnostic wax-up. When Steve Rea, dental technician, started the final wax-up he was concerned about the lack of immediate canine guidance. It was therefore decided to use a Kois deprogrammer for a week and then take new occlusal records in accurate centric relation. The rearticulated models showed IC almost incident with CR. Occlusal equilibration was completed. New impressions and bite records were taken and sent to the lab for completion of the wax-up5,6.

Veneer preparation and provisionalisation Teeth 14-24 were prepared for new veneers. Those on 22 and 23 were prepared minimally invasively using depth-cutting burs7,8. The existing veneers were removed and the preparations refined to the new cervical margin and smoothed. Working impressions were taken with Doric QuickTime putty and wash. Quicktemp A1 provisionals were placed with clear Tempbond/Revolution flowable composite tags.

Photographs of the preps, Spectrashade and UD2 HFO stump sample were sent to lab9. The provisionals were checked at 1 week for colour, speech and function. The patient was happy.

Cementation Try-in of veneers with xlbase/12.5% opaque.

The feldspathic porcelain veneers were cemented with warmed Variolink II, shade XL base, with 10% opaque to increase value and chroma, under split rubber dam.

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Discussion This case proved challenging as it was a shift for me away from pressed ceramic veneers to do a feldspathic porcelain case (currently I love the minimal work we are doing with emax). In retrospect I will need to source a different veneer cement rather than variolink as it is to too thick even when warmed to cement feldspathic veneers safely. I feel it was the right call to cement the 23 veneer even though it cracked on cementation. Eighteen months on there has been no change or staining of the crack and it is unnoticeable at normal vision. It is always difficult to match a replacement veneer if it is not made at the same time so we will replace it when the need arises (since the veneer is bonded to enamel it may well last as long as the others).

The only change in the case has been a slight down-growth of the gingiva on the 12 that was trimmed back with electro-surgery. In retrospect I think more bone could have been removed at the periodontal surgery by current thinking: biological width of 3mm cervically and 4 mm interdentally9.

In terms of the smile design the axial inclination of the first premolars is too vertical for the canines. However, we were trying to strike a balance between a wider buccal corridor and the maintenance of canine guidance and I think the compromise is acceptable.

Conclusion I was delighted with Sarah’s result (Figures 3 and 4). She is very petite and the slightly large central incisors in this case illustrate an example where it is possible to depart from the classic ‘American’ smile design dictates (AACD criteria10), to create a more natural and interesting ‘European’ look11.

Acknowledgment Technical work by Steve Rea of Reatech Laboratory. Periodontal surgery by Maria Retzepi.

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References 1. Microsoft. Tutorials on the use of Microsoft Project. Microsoft Project Tutorials, 2007.

2. Setchell D, Capp N et al. Occlussion (10 day Comprehensive Programme at the Eastman Hospital), Eastman Hospital, 1986.

3. Tarnow DP, Magner AW et al. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992 63: 995-996.

4. Van Haywood B. Nightguard vital bleaching: indications andlimitations. US Dentistry Oct 2006.

5. Harris K. The Kois Deprogrammer. BACD Study Club Lecture, BDA Headoffice London, 2008.

6. Kois, J. Case Assessment & Treatment Planning. Coltene Whaledent European Conference, Montreux, 2007.

7. Gurel G.Predictable, precise, and repeatable tooth preparation for porcelain laminate veneers. Pract Proced Aesthet Dent 2003 15: 17-24; quiz 26.

8. Gurel G. Porcelain laminate veneers: minimal tooth preparation by design. Dent Clin North Am 2007 51: 419-431, ix.

9. Chu S. Fundementals of Colour and Shade Taking. BACD Annual Conference, London, 2007.

10. AACD. Diagnosis and Treatment Evaluation in Cosmetic Dentistry: A Guide to Accreditation Criteria AACD, 2009.

11. Delloca LL. Facial harmony: little things can make a big defference. StraumannUK Gatwick, BACD, 2008.

57

Interdisciplinary success Neil Gerrard

In this interdisciplinary case the treatment consisted of the endodontic re-treatment of 13, 12, 11, 21, 22 and 23; orthodontic extrusion of 22; free connective tissue graft to 22 and indirect full coverage restorations of 12 maxillary teeth.

History The patient, a 34-year-old female in good health, attended the practice with a history of extensive restorative treatment to her maxillary teeth over many years as a result of enamel hypoplasia and tetracycline staining as a child. The patient had recently undertaken treatment via another GDP with a view to replacing crowns she had received as a teenager along with reduction of a ‘gummy smile’ in an attempt to improve things further, but found the results to be far from satisfactory (Figure 1).

Recent treatment included surgical crown lengthening from 15 to 25 by a registered periodontist, followed by two sets of anterior crowns 13 to 23 by the GDP managing the case. The first set of crowns (all ceramic restorations) failed to mask the underlying discolourations of the preparations and the patient was informed that the only alternative was to use porcelain fused to metal crowns. This second set of crowns was also rejected by the patient on the grounds that they were bright white and looked artificial. Other areas of concern to the patient included the asymmetrical gingival levels of the lateral incisors, the gingival zenith of the 22 sitting at the same level as the 21 and 23 (apparently she had been informed that nothing could be done to correct this situation), and the grey shadowing at the gingival margins of the majority of upper anterior teeth.

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Case assessment A comprehensive assessment was completed prior to formulation of a treatment plan. Examination of soft tissues, muscles of mastication and TMJ indicated no abnormalities detected. A number of teeth were missing with an asymmetrical occlusal relationship recorded – Class I right side, Class II left side. An anterior slide to the left approximately of 1 mm was noted. It was also noted that all upper incisor teeth and both canines had been root treated and although asymptomatic, radiographic examination indicated the presence of multiple post-crowns, incompletely obturated canals and peri-apical pathology. Aesthetic assessment of the smile indicated increased gingival display (though not of concern to the patient), with canting of the gingival level running apically from right to left with an associated midline cant. The teeth also appeared on the longer side.

Treatment plan Multiple treatment options were presented to the patient including the following: 1. Endodontic re-treatment of all anterior maxillary teeth 2. Additional crown lengthening to correct canted gingival level 3. Pre-restorative orthodontic treatment to extrude 22 and/or level gingival levels

or multiple teeth

4. Replacement of 25 with a dental implant and connective tissue graft (CTG) to

create correct gingival form, or 3-unit bridge with CTG

5. Selective CTG placement to increase labial tissue thickness in 13 to 23 with view

to masking discoloured roots

6. Occlusal deprogramming to create a harmonious occlusal scheme 7. Placement of all-ceramic crowns for improved aesthetic result (with direct post

and cores as required).

Up to this point the patient had previously been promised much and was very sceptical of claims to provide a better outcome, as previous results had failed to deliver. As such a number of treatment proposals were immediately rejected, including any soft tissue surgery and extensive orthodontic treatment. The patient also declined re-endodontic treatment of her anterior teeth, while opting for a 3-unit bridge to replace 25 in preference to a dental implant.

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In order to restore the patient’s trust a treatment plan which immediately improved aesthetics with the placement of provisional crowns was agreed. Once the patient could visualise her new smile with the provisionals we would re-visit adjunctive treatment options and progress accordingly.

Utilising a pre-operative diagnostic wax-up and silicone stent, provisional crowns were created chair-side (splinted in three sections) and the patient was left to live with these changes for a number of weeks. At her review appointment an immediate change in the demeanour of the patient was noted, not only was she happier with the results of the provisional crowns, but she was much more amenable to consideration of adjunctive treatments, not only to improve aesthetic results, but long term stability of health. It was agreed that an endodontic opinion be sought regarding the six anterior teeth and associated treatment as deemed necessary. The patient was referred to a local endodontic specialist with a request to assess all six teeth and make recommendations to re-treat based on likely long term prognosis.

This resulted in the recommendation to re-treat three teeth at a minimum. Additional discussion between the author, the endodontist and the patient resulted in the conclusion that for long term stability, re-treatment of all six teeth was of greatest benefit as any future need for additional re-treatment would result in either the need to compromise or destroy her new crowns, or undertake further attempts at repeat apical surgery.

After careful consideration the patient was willing to proceed with re-endodontic treatment of all six teeth as well as undertake sectional orthodontic extrusion of 22.

Further soft tissue surgery and implant placement was still declined and the patient accepted the compromise that a degree of canting would be visible post-treatment (whether gingival level or midline/occlusal cant).

Endodontic re-treatment Endodontic re-treatment presented a number of challenges, including: existing posts and cores, increased root lengths (13 and 23) and wide canals and apices associated with 21 and 22.

All existing posts and cores were removed using high frequency agitation using ultrasonics to find intact root systems devoid of root fractures. Extra long canal systems of the canines (27 mm plus) were negotiated with extra long files. Orthograde obturation of 13, 12, 11, 23 was completed with gutta-percha, with MTA used to obturate the wide canals of 21 and 22 (the aim to create both a hermetic seal and stimulate a degree of apexification).

60

Direct fibre posts and cores were also placed by the endodontist in 21 and 22 to achieve an immediate seal and aid core retention. The patient was referred back to the author by the endodontist for direct/indirect placement of posts and cores in the remaining teeth as deemed appropriate.

Treatment process During the process of endodontic re-treatment rapid orthodontic extrusion of the 22 was initiated with a small fixed sectional orthodontic appliance bonded labially to 21 and 23 (Figure 2).

The provisional crown on 22 was sectioned from the adjacent teeth and cemented to the tooth with zinc-polycarboxylate cement to prevent displacement. The aim of treatment was to extrude the tooth while coronally advancing the associated gingival zenith of 22 to a level matching the contra-lateral tooth. The patient was reviewed every 10 days to shorten the incisal length of the provisional crown and reposition the sectional appliance as required. Once the gingival zenith reached that of the contra-lateral incisor the provisional crown was re-bonded to the 21 and 23 to act as a retainer and allow time for crestal bone growth to catch up with the new soft tissue architecture. Total treatment time for extrusion was five weeks.

Following the rapid change to the position of 22 the patient again wished to re-visit the original treatment proposals. While she still declined the use of an implant to replace 25, she appreciated that the greying of 22 was due to the dark preparation under the provisional crown and a thinner translucent biotype.

As such she accepted the proposal for soft tissue augmentation in the 22 region utilising a connective tissue graft (CTG) to thicken the labial tissue and thus mask the discoloured root/prep. The literature supports the view that a tissue thickness of 3mm or greater will mask dark restorative materials such as titanium, or in this instance dark tooth substrate1,2.

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Treatment of the labial tissue utilised a cervical tunnelling approach to free attached gingiva around the 22, thus creating a pocket in which to place a free CTG harvested from the palate (Figure 3).

The graft was located and secured in position apically with a resorbable suture, with micro-surgical techniques used to secure the coronal portion of the graft with 6.0 prolene mono-filament suture. The aim of this treatment was not to coronally advance the gingival margin as the tooth had already been extruded, but to bulk labial tissue only. As with all free grafts the tissue was over-bulked with some coronal repositioning in order to accommodate tissue shrinkage during healing.

Following endodontic re-treatment of all six anterior teeth, further discussion with the endodontist resulted in the recommendation to replace and/or place a number of posts and cores. Direct titanium posts with composite cores were therefore placed in 13, 12, 11 and 23 prior to final impressions.

The opportunity to create a harmonious occlusal scheme was taken via reorganisation of the occlusion with the aid of a Kois deprogrammer3. While the patient presented with signs of wear to the lower incisor teeth this was most likely due to contacts with previous crowns as no evidence of posterior wear could be seen.

The patient was found to be deprogrammed within two weeks (with a repeatable stop on the occlusal platform), presenting with no visible signs of wear on the deprogrammer suggesting absence of parafunctional activity. A centric occlusion bite was recorded with the aid of the deprogrammer in order to create a maximum inter-cuspal position (MIP) coincident with centric relation.

Prior to impressions, refinement of all crown margins was completed sounding to bone in order to create sub-gingival margins to aid masking of the dark stump shades without invading biological width (Figure 4)4,5. Typically all margins were taken to 2.5 mm to crestal bone.

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Finally, before signing off the general form of the provisional crowns an attempt was made to force perspective in relation to the occlusal cant, i.e. make it appear vertical within the face without drawing attention to the soft tissue cant – a happy medium between the two. In this instance the result was to draw more attention to the soft tissues, so an occlusal cant was chosen in preference by the patient as a compromise, similar to what she presented with pre-operatively.

The restorative material of choice was lithium disilicate (e-max) for all single units and zirconia all ceramic frame laminated with feldspathic porcelain for the 3-unit bridge 24 to 26.

Seating of the new crowns was completed using a cohesive cementation protocol with air-abrasion of tooth substrate followed by crown cementation with self-etching dual cure cement.

When seating restorations with subgingival margins meticulous attention to cementation protocol is required, thus the use of retraction cord was employed. The net result of this is invariably some trauma to the tissues which in this case resulted in some uneven soft tissue forms in the region of the CTG. When smiling, the patient appeared to have a black triangle between her teeth (22/23 region). The cause of this was diagnosed as shadowing cast by the irregular tissue form. This was resolved via some gingivoplasty under local anaesthetic with a round diamond bur to smooth the form in the region of the distal papilla of 22.

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Conclusion While previous treatment had generally followed an acceptable treatment protocol, poor execution of the treatment via creation of a gingival cant, uneven gingival zeniths and poor crown aesthetics, meant this would always be a challenging case to correct with likely compromises (Figures 5 and 6).

In this instance, utilising an interdisciplinary approach, the author was able to resolve those concerns which bothered the patient the most and provide the best long term prognosis possible regarding multiple root treated teeth following appropriate referral to a specialist endodontist.

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References 1. Jung RE, Sailer I, Hammerele CH, Attin T, Shmidlin P. In vitro colour changes

of the covering mucosa caused by restorative materials made of titanium and

ceramic. Int Periodont Rest Dent 2007; 27: 251-257.

2. Jung RE, Holderegger C, Sailer I, Khraisat A, Suter A, Hämmerle CH. The effect of

all-ceramic and porcelain-fused-to-metal restorations on marginal peri-implant

soft tissue color: a randomized controlled clinical trial. Int J Periodont Rest Dent

2008; 28: 357-365.

3. Kois JC. Functional occlusion: science-driven management. J Cosmetic Dent

2007; 23: 29-32.

4. Kois JC. Altering Gingival Levels: The Restorative Connection Part 1: Biological

Variables. J Esthet Dent 1994; 6: 3-9.

5. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact

point to the crest of bone on the presence or absence of the interproximal

dental papilla. J Peridontol 1992; 63: 995-996.

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The gold standard for single tooth replacement David Bloom

Introduction and chief complaint This new patient attended complaining of a missing front tooth. The debilitating effects of missing a front tooth can be seen in the pre-operative pictures (Figures 1 and 2).

Whilst historically a removable option or bridgework would have been the only treatment options, with the advent of dental implants we now have what could be considered the gold standard for replacing a single missing tooth.

Medical and dental history The patient’s medical history was unremarkable. Tooth 11 was lost after failure of a post-retained crown which was placed following injury to this tooth as a child.

The patient was aware of the mild anterior crowding with misalignment of 43, but she was not concerned enough about it to consider treatment. Her periodontal condition was fair with some mild plaque-induced gingivitis and mild bleeding on probing, mostly in the posterior interdental areas.

There were some old posterior amalgams present but again, the patient elected not to have these treated at this time. The restorations showed some marginal discolouration but no caries was evident. There was early occlusal fissure caries in 47.

66

Diagnosis and treatment plan The patient attended with a pre-existing acrylic ‘flipper’ partial denture replacing 11 (Figure 3).

Following a comprehensive dental examination and discussion of various options, her treatment plan was agreed as follows: 1. Periodontal care to treat the mild gingivitis 2. Composite sealant restoration 47 3. Combined power and home whitening 4. Implant abutment placement and provision of a temporary crown for ‘tissue training’ 5. Final crown placement.

Clinical treatment After periodontal care with the practice hygienist, impressions were taken for a diagnostic wax up and the laboratory was advised to match the contour of 11 to 21. A stent was produced by the laboratory to guide the implant placement by a specialist colleague. A Nobel Biocare replace select regular platform implant was placed in the desired position using the stent supplied to the implant surgeon (Figure 4). The patient continued to wear her partial flipper denture.

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One week prior to implant exposure the patient had power whitening using the Zoom system. Custom fitted, home whitening trays were used to complete the whitening using Carbamide peroxide (Discus Dental).

Following the healing period and after confirming satisfactory soft tissue healing, a fixture head impression was recorded using addition cured vinyl polysiloxane material. No local anaesthetic was required for this impression. A radiograph was taken to confirm that the impression post was fully seated and the laboratory was instructed to pour this impression and construct a soft tissue model as well. The technician was asked to construct the final custom abutment with the margins of this abutment approximately 1 mm sub-gingival and also to construct a temporary crown coping and final crown coping. The temporary coping was made from Luxatemp and the final coping scanned to get a Procera crown coping constructed.

By constructing the temporary and final crown copings in the laboratory on the final abutment it means it is not necessary to use any retraction cord to record the final margins placed by the lab on the implant abutment even though these will be somewhat subgingival. This means that there is less risk of inducing traumatic gingival recession from the retraction cord and at the same time greater accuracy is ensured.

The abutment was torqued into place at 35 Newton centimetres after a check radiograph to confirm complete seating of the abutment and a temporary filling material placed in the screw assess hole. It is my preference to use cement-retained crowns particularly in the aesthetic zone. Finally, a temporary crown was constructed chair-side using Luxatemp1/3 bleaching light and 2/3rds B1 on the lab made temporary coping. This was made using a putty matrix of the wax-up and made concave in the gingival crevice region to encourage soft tissue migration incisally and ensure the correct gingival architecture – a technique known as ‘tissue training’.

Once I was happy with the final gingival architecture, final impressions were taken in an addition-cured vinyl polysiloxane and the permanent Procera coping picked up in the master impression. Face bow records, an apposing arch impression and bite records were also taken, along with final photographs to assist the ceramist. The patient also visited the ceramist for custom shade matching. If this had not been possible then more photographs would have been taken with shade tabs in place to aid the ceramist with the colour matching process. The ceramist was instructed to copy the contours of the temporary crown as this had been contoured in the patient’s mouth to accurately match the other central.

The crown was returned for a biscuit bake try-in to allow for refinement of the occlusion and confirm the correct contours. The patient then attended the ceramist

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for a final ‘custom finish’. Once the patient and I were satisfied, the crown was cemented using a permanent, resin-modified glass ionomer cement (GC Fuji Cem), with good ‘clean-up’ properties (Figures 5 and 6).

The latter helps ensure that no cement remains sub-gingivally. Whilst this cement can expand by up to 0.5%, the Procera coping can withstand this expansion.

Conclusion Whilst colour matching a single central incisor can be a challenge in itself, the added challenge of ensuring the correct gingival architecture around an anterior implant makes the replacement of a single missing central incisor one of the toughest challenges facing us as modern dental professionals. However, with good interdisciplinary skills and communication between restorative dentist, implant surgeon and ceramist, great results can be achieved as demonstrated by this case.

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Acknowledgements Thank you to Luke Barnet Ceramics for the laboratory work and to my implant surgeon Guy Mclellan for the surgical stages.

Armamentarium • Nikon D100 Digital camera with macro capability • Retractors and mirrors (Photomed Industries) • Schick CDR Digital radiography system (Schick Industries) • Dental loupes x2.2 magnification (Orascoptic) • Impression coping regular platform (Nobel Biocare) • Denar Slidematic Facebow (Teledyne; Prestige) • Blu mousse bite-registration material (Prestige) • Coopr8 seminars preparation and polish kits (Brasseler Komet) • Front-surface reflecting dental mirror (Claudius Ash) • Silicone impression material (Honigum, DMG) • Alginate (Henry Schein) • Rimlock metal impression trays (Prestige Dental) • Eezitray stock impression trays (Henry Schein) • GC Fuji cem (GC Corporation) • Bis-acrylic provisional crown material (Luxatemp, DMG) • Luxaglaze (DMG) • Benda Brushes (Centrix) • Disposable plastic Dappens dishes • Flowable composite resin (Revolution- Kerr) • Halogen curing light (Bisco VIP light) - 11 mm diameter curing light tip (Kerr) • Soflex ET contouring and polishing discs (3m ESPE) • Ultrafine rotary diamond burs (Brasseler Komet) • Silicone porcelain polishing kit (Ceramiste; Shofu) • Aluminium oxide impregnated rubber polishers (Flexipoint and Flexicups, blue

and pink; Cosmodent)

• Diamond polishing paste (Luminescence; Premier) • Rubber polishing cups for contra-angled handpeice • Epitex finishing strips (GC Industries)

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• Dental floss • Interdental brushes (Tepe) • Accu film II articulating foil, black and red (Parkell) • Miller’s foceps • Shimstock foil • Straight probe and Williams probe • Tweezers, flat plastic and excavator • Cotton wool rolls and gauze 2x2 squares

(A)Further reading Dawson P. Functional occlusion from TMJ to smile design. Mosby, 2007.

Kusey BK, Fraser DC. The Procera abutment, the fifth generation abutment for dental implants. J Canadian Dent Assoc 2000 66: 445-449.

Vigolo P, Givani A, Majzoup Z, Cordoli G. Cemented versus screw-retained implantsupported single –tooth crowns: a 4-year prospective clinical study. Int J Oral Maxillofac Implants 2004 19: 260-265.

Vigolo P, Fonzi F, Majzoup Z, Cordoli G. An in-vitro evaluation of titanium, zirconia and aluminium Procera abutments with hexagonal connection. Int J Oral Maxillofac Implants 2006 21: 575-580.

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