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Contents... 1 Adult Orthodontics......................................................................6

4 Treatment of the worn dentition..........................................32

Patient Exceptions..........................................................................6

Composite resin mock-up..............................................................32

Appliance Types.............................................................................10

Treatment planning........................................................................33

How discreet are ‘invisible. braces?.............................................10

Occlusal equilibration....................................................................33

Access to treatment.......................................................................12

Laboratory instruction.....................................................................33

Periodontal considerations............................................................12

Definitive clinical procedure.........................................................34

Temporomandibular joint considerations....................................13

Major preparation...........................................................................34

References.......................................................................................14

Provisionals assessed.......................................................................35

Fit appointment...............................................................................35

Review appointments....................................................................36

Direct Composite Resin..................................................................16

Gingival surgery...............................................................................36

Trial Smile..........................................................................................16

Long-term maintenance................................................................36

Diastema closure technique.........................................................16

Composite resin placement..........................................................18

Case report......................................................................................18

Legal Situation.................................................................................38

Main complaint...............................................................................19

Methods of tooth whitening..........................................................40

Composite ‘mock-up’....................................................................19

Applied in-practice........................................................................40

Alternative aesthetic options considered....................................19

Applied by the patient...................................................................40

Aesthetic treatment options..........................................................20

Over-the-counter products...........................................................42

Occlusal examination and diagnosis...........................................21

Sensitivity..........................................................................................42

Definitive treatment plan...............................................................21

Completed treatment plan...........................................................22

References.......................................................................................43

2 Dealing with a Diastema.........................................................16

Results...............................................................................................22

5 Tooth whitening revisited...................................................38

Length of treatment.......................................................................42

6 Treating the lower third of the face with botulinum toxin a...........................................................................................44

Discussion.........................................................................................23

3 The components of a smile....................................................26

Bunny Lines......................................................................................44

The influence of the lips..................................................................26

Smoker’s lines...................................................................................45

Tooth shape.....................................................................................27

Corners of the mouth.....................................................................47

Tooth colour.....................................................................................28

Gummy smile...................................................................................48

Tooth type........................................................................................28

Masseter...........................................................................................48

Smiles in advertising........................................................................29

Chin .................................................................................................49

References.......................................................................................30

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ADULT ORTHODONTICS A new world in dental aesthetics

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Essentially orthodontics employs the same techniques and is guided by the same principles whatever age the patient. Traditionally it has been regarded as a treatment most usually undertaken on teenagers but much has changed in recent years and the advent of new fixed appliances coupled with increasing patient awareness of the possibilities of aesthetic dentistry in enhancing smiles has led to an increase in demand for adult orthodontics. A UK survey involving a questionnaire-based study estimated that the number of adult orthodontic cases started annually per GDC listed Specialist in Orthodontics was 20.9 in the NHS and 28.2 privately1. Extrapolated, this would give the overall number of adults treated at approximately 51,000 per annum and rising. This figure includes those undergoing a full treatment plan of orthodontics only, estimated at 72.5%, with the rest having it as part of a multi-disciplinary approach involving some tooth movement to accommodate implants, crowns and other restorative procedures. There has been similar growth in the USA where practice surveys reported in the Journal of Clinical Orthodontics have shown the number of adults starting orthodontic treatment rising from 15.4% of cases in 1981 to 23.0% in 2013. Similarly, to meet demand, the percentage of orthodontists offering adult orthodontics grew from 51% to 98.6% over the same time period. While the reasons why adults seek orthodontic treatment fall into two main categories, which may be classified as aesthetics and function, it is the former that proves to be the main motivation. Reasons given include straightening teeth, improving smiles and closing spaces while a lesser number were hoping to improve their bite, stop tooth wear or improve oral hygiene. Whatever the direct incentive of adults seeking treatment, for the clinician the complexities of record taking, sharing communication and discussing options before finalising the treatment plan and gaining meaningful consent are increasing. Patient expectations Also of crucial importance is the need to carefully assess the patientâ&#x20AC;&#x2122;s expectations. As in any aesthetic treatment the successful outcome, or otherwise, is significantly

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tied to this subjective measure. There is no doubt, from the experience of indemnity organisations and many other sources that the key aspect to managing patient expectations is communication. This aspect is critical in many aspects of adult orthodontics including for example, understanding exactly what the patient might mean by ‘straight teeth’ or ‘a better smile’ and just how that might be delivered and ‘seen’ literally and metaphorically, in reality. In many cases where there is a good rapport between the orthodontist and the patient problems do not arise but there is a spectrum and, as an example, at one end is a condition known as Body Dysmorphic Disorder (BDD)3. This is characterised by the obsessive idea that some aspect of one’s own appearance is severely flawed and warrants exceptional measures to hide or fix it. In BDD’s delusional variant the flaw is imagined whereas if the flaw is actual, its importance is severely exaggerated. Either way, thoughts about it are pervasive and intrusive, occupying up to several hours a day and recognition of such patients is important as not only is it much more likely that they will never be satisfied with an outcome but can even become suicidal. The estimated prevalence of BDD in a survey of adults seeking orthodontic treatment was 7.5% compared with an estimated prevalence in the community of 0.7-3.0% and 10% in patients seeking orthognathic surgery. It is therefore likely that clinicians will come across such patients from time-to-time. NICE guidance is available for further details and advice on recognition of such patients (http://www. nice.org.uk/guidance/cg31). For these reasons the examination and discussion of treatment possibilities with adults is often more complex than with an adolescent patient. Adult orthodontic patients frequently have different considerations to children/young adults such as2:

• The expectation of more discreet orthodontic appliances

• They frequently have more restored teeth or indeed missing teeth

• Tooth wear

• Periodontal problems

• Attachment loss

• Recession

• Absence of growth

• Higher prevalence of TMD

• Aesthetic demands

• Retention protocols.

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Appliance types The type of appliance needed for the treatment is often a key part of the treatment planning process and consent procedure and there is a wide variety of types and brands now available. Promising merely that appliances will be ‘aesthetic’ is not satisfactory and an honest description and illustration of the equipment or appliance is necessary to achieve the agreed goal and considered good practice. Marketing materials produced by orthodontic appliance manufacturers may be misleading in terms of the appearance of the appliances. Many adults are keen on removable aligner style appliances, but when the commitment to time and the impact of normal daily habits are discussed realistically, they often realise that they thought that removable appliance were ‘night time only’ wear which is quite likely not sufficient for safe and predictable tooth movement. Lingual orthodontic appliances are regarded as very desirable as they are ‘invisible’ and therefore can be in danger of being easily represented as the optimal appliance for aesthetics. However, they need to be accompanied with an explanation of the impact on eating and speech and possible limitations on treatment outcomes as well as any need for labial auxiliaries to achieve the desired result. It is therefore important that clinicians do not ‘sell’ aesthetics to adult patients but we should be obliged to give potential patients a realistic and unrealistic picture of what they may look like and experience during treatment. Equally, where the need is anticipated for compliance-demanding elastics this should be documented in the treatment proposal, presentation and consent process. How discreet are ‘invisible’ braces? ‘Invisible braces’ is a term used to describe a range of more inconspicuous braces. These include clear fixed braces, clear aligners and lingual braces. While none of these options are actually invisible they are very discreet. Lingual braces (Figure 1) are completely hidden behind the teeth, so they are virtually undetectable. Clear aligners such as the brand Invisalign blend in with the teeth and so are likely to go unnoticed by the vast majority of people. Clear fixed braces are more visible, but still unobtrusive compared to their metal counterparts.

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Access to treatment The British Orthodontic Society, formed of orthodontic specialists and practitioners have a lot of guidance on their website www.bos.or.uk for both patients and professionals including details of the Index of Orthodontic Treatment Need (IOTN) which is widely used for orthodontic assessments. There is also a quick reference guide to orthodontic assessment and referral including one for the permanent dentition. This defines normal development as an acceptable skeletal base, all permanent teeth present, Class I incisors, a Class I molar relationship, average overjet 2-4mm, average overbite (1/3rd -½ lower incisor coverage) and well aligned arches. The guide also details clear cut indications for referral for orthodontic treatment. If the patient has an IOTN score of 3/6 or above they are eligible for NHS treatment. Below that score the Society recommends discussing a private referral, although notes that adults may qualify for NHS treatment if they require complex multidisciplinary care. The BOS describes how treatment can be obtained in a practice or a hospital, depending on needs or choice of clinician. A referral is needed for treatment in a hospital but the patient can choose the practice where they want to have treatment. However, the BOS also advises the patient to seek reassurance that the proposed provider has the ‘necessary skill and experience’ and further urges ‘if you are unsure, you can always seek a second opinion’. Keenly supportive towards adult orthodontic treatment but with prudent caution, the BOS advises that if the patient has lived with crooked teeth for most of their life, other problems may have arisen such as wear caused by badly positioned teeth. ‘This will need treating by your dentist once the teeth have been straightened’. Sounding a similar note of caution the BOS also advises that ‘In recent years there has been a growth in quick and short term orthodontic techniques which tend to focus on fast results but with limited objectives. The intention may be to improve the smile only, without giving equal emphasis to the bite and function. Before your treatment starts, ensure you are completely clear about what can and cannot be achieved. It’s important to understand how your bite may be affected if the treatment concentrates on your smile only. The risks of treatment should always be explained’. Periodontal considerations In the UK there are currently no agreed guidelines for periodontal screening before commencement of orthodontic treatment in adult patients. In contrast, the British Society of Paediatric Dentistry and The British Society of Periodontology (BSP) recently 12

agreed guidelines for screening of children and adolescents using a simplified BPE (Basic Periodontal Examination) and stated that all children should have this before referral for orthodontic treatment. The BSP guidelines recommend that all new patients in general practice should have a BPE and if any teeth score grade 4 (probing depth >5.5 mm) the patient should have a full pocket chart of the dentition. Orthodontists generally obtain an OPG and in some cases a lateral cephalogram as part of the diagnostic process. They frequently do not have the equipment necessary for obtaining periapical and other small images. It is therefore in the patient’s interest if the GDP and orthodontist share all radiographic images avoiding duplication of exposures and improving the diagnostic process. Temporomandibular joint considerations Adults differ from children and may often present a range of different issues but there are obviously overlaps. One such is that of temporomandibular disorders (TMDs). Frequently seen as an adult problem, this is not entirely true as TMDs tend to start in adolescence but become increasingly common with age. There has been much confusion over the role orthodontics or the occlusion has in the causation and/or treatment of TMDs. Unfortunately, this has led to a number of medico-legal issues both in the USA and UK with several dentists in the UK coming under severe scrutiny by the GDC with regard to their practice and how and why they applied it to their patients. Reasons for this confusion may be related to factors such as:

• There is a close match between the population who want braces (the majority

are females); and those that get TMDs (where the majority are also females),

making it easy to jump to conclusions

• Insufficient appreciation of the relevance of the epidemiology of TMDs to their

causes: the cause of any disease or condition should also ‘explain’ the

epidemiology

• Simplistic understanding of the rigour needed to establish cause and effect

• Poor research: conclusions drawn from small, poorly devised (often

uncontrolled) studies or which were based on opinion and anecdote

• Lack of critical appraisal skills in researchers and clinicians to evaluate research

• Lack of awareness of new developments in medical/dental research. For

findings and thus their potential validity

example, chronic pain conditions may affect areas of the body other than

around the jaws and may have factors in common which are important to take

account of (comorbid conditions)

• Failure of clinicians to translate new evidence into action, for example, through

lack of continuing professional development or perhaps due to financial

conflicts of interest2.

Practical advice for those providing adult orthodontic treatment is also provided by the BOS in an Advice Sheet and in essence, this advice indicates that:

At diagnosis, patients should be assessed for TMDs and a history taken where

there is a positive finding

The positive findings should be discussed frankly with the patient including a

discussion of TMD aetiology – bearing in mind that the clinician may not

be aware of any preconceptions the patient may have or have been given

by someone else, including the media with regard to TMDs

If braces are offered, then it should be made explicit that this is to treat the

malocclusion – not the TMD. Ensure the patient is fully aware of this and

explain that their condition may get worse, better or stay the same

regardless of any braces treatment. However, if the condition becomes bad

enough, then appropriate referral may be beneficial

Patients who develop a TMD during braces treatment should have the

matter frankly discussed with regard to the causes of TMDs; possible

conservative management options; possible resolution (including

spontaneously) or recurrence and possible need for referral if simple

measures such as jaw rest and limiting strain do not seem to help.

Unfortunately, the issue of referral may be problematic as while referral to

a hospital department such as Oral and Maxillofacial surgery may be

possible, it is acknowledged that ideally, referral to a pain clinic would be the

ideal but such clinics are currently scarce in the UK.

References

[1]

Cedro M K, Moles D R, Hodges S J. Adult orthodontics–who’s doing what?

J Orthod 2010; 37: 107–117.

Christensen L, Luther F. Adults seeking orthodontic treatment: expectations,

[2]

periodontal and TMD issues. Br Dent J 2015; 218: 111–117.

Newton JT, Cunningham SJ. Great expectations: what do patients expect

[3]

and how can expectations be managed? J Orthod 2013; 40: 112–117.

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A R C H W I R E S

DEALING WITH A DIASTEMA By Ken Harris

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As dental techniques have evolved, there is increasing unease about the removal of healthy tooth tissue for purely aesthetic improvement when alternative approaches such as orthodontics are now more widely available. Equally, the improvements in composite resin materials have also allowed direct restorations to be considered a realistic minimally invasive restorative approach in selected cases. However, where spaces are present, an additive approach lends itself well to direct composite resin techniques. Direct composite resin Spacing between teeth undoubtedly causes aesthetic concerns for many patients yet such cases remain a significant challenge to treat with direct restorations. Traditionally a busy practitioner has perhaps been tempted to save chairside time (and clinical embarrassment) by placing indirect porcelain veneers rather than address the concerns with direct restorations. However, such ‘no-prep’ direct composite resin restorations can provide a surprisingly acceptable result for patients while simultaneously satisfying the aspiration of the caring practitioner to ‘first do no harm’. Trial smile Freehand placement of restorative material requires immense artistic skill and patience, and it is the courageous, perhaps foolhardy, clinician who sets out to restore without planning. A sensible first step is to ‘mock-up’ the finished result with a laboratory produced wax-up. However, a free-hand composite resin mock-up placed directly in the patient’s mouth can provide a similar result while simultaneously saving time and money. The creation of such a direct mock-up also benefits the practitioner by acting as a ‘trial run’ to help identify possible difficulties when placing the definitive restorations. A putty matrix of either approach can then be utilised to guide placement of the definitive composite. Diastema closure technique The enamel is first cleaned with gentle sandblasting to remove debris, etched with 35% phosphoric acid and then rinsed thoroughly before drying. A thin coat of unfilled

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resin (Heliomolar; Ivoclar) is then carefully applied to the ‘frosty’ enamel and light cured. The putty matrix is then replaced to determine the impact on the papilla. Excess soft tissue (papilla) can usually be controlled by placing multiple strands of thick retraction cord interstitially or, in extremis, by gingival surgery. Care must be taken only to ‘sculpt’ the tissue contour, and not risk violating biologic width by deepening the sulcus significantly if surgery is necessary. Composite resin of various shades (HFO; Micerium) is then systematically placed in conjunction with the customised ‘stent’ using a stratified placement technique. Care is taken to ensure the teeth will conform to the principles of smile design and that the midline remains vertical in the smile. Composite resin placement

1) Steps for stratified composite resin build-up using HFO composite resin:

2) Palatal and incisal edge ‘shell’ fabricated using stent

3) Initial dentine layer

4) Secondary dentine layer

5) Incisal edge and translucency - if required

6) Final enamel layer placed

7) Initial contouring with carbides and refinement with Soflex discs (3M)

8) Secondary polish with sequential polishing system (Shiny; Micerium).

Case report The patient was a 19-year-old girl referred by her regular dentist for a ‘full smile makeover’ due to the multiple diastemata in her upper incisors (Figure 1).

When in full closure there was absolutely no space to further retract the upper teeth due to the position of the lower teeth so space closure by simple orthodontics was not an option

The dentist had initially provided tray bleaching with 10% Carbamide Peroxide gel, but then felt the challenge of such a dramatic treatment plan as a ‘full smile makeover’ beyond his expertise, hence the referral. However, he did wish to continue providing routine care.

Main complaint The patient was generally unhappy with her smile despite successful bleaching. She had multiple spaces between her upper incisors and was intent upon cosmetic treatment. A significant challenge in practice today is how to provide for patients’ legitimate cosmetic needs without resorting to extreme measures, and as the patient was relatively young and had only a single restoration, I hoped to apply a minimal approach. I felt we could satisfy her needs by closing the diastemata with carefully placed direct composite resin restorations without any tooth preparation. The patient demanded a ‘full smile makeover’ with porcelain veneers, and initially seemed disinclined to listen to alternative approaches. Furthermore, she was also blissfully ignorant of the process and the loss of tooth tissue involved with such an extreme request. Such cases are a minefield when seeking informed consent and the sensible practitioner will ensure such consent is correctly granted. Composite ‘mock-up’ The first step is to confirm the patient’s expectations from treatment; she repeated again that she wanted her spaces closing with porcelain veneers. To show her how she may look with the diastemata closed, we initially applied composite resin and sculpted it free-hand (Figure 2). To show her how she may look with the diastemata closed, composite resin was initially applied and sculpted free-hand. The shape was recorded with a putty matrix to use when placing the later definitive restorations

The patient was impressed and agreed that if we could duplicate the ‘mock-up’ using direct composite resin, she might consider this less aggressive alternative to veneers. Alternative aesthetic options considered Her teeth had some supragingival calculus present, so she agreed to a hygienist appointment. Orthodontic therapy with one of the newly popular proprietary named systems might have equally seemed an obvious alternative. However, despite the temptations the inexperienced practitioner must be aware of the limitations of such systems, and be careful not to embark upon a course of ‘rapid orthodontics’ which

is doomed to failure from the start. Even a cursory examination revealed that when in full closure there was absolutely no space to further retract the upper teeth due to the position of the lower teeth. This case would require complex orthodontic care delivered by an experienced orthodontic specialist, and a significant time period to complete; to say nothing of the probable lifelong retention required. Consequently, when informed of this, she declined such complex orthodontic treatment out of hand. The multiple spacing did give some leeway to provide minimally invasive veneers, but some tooth tissue would still be sacrificed. It was explained to the patient that up to 30% of tooth tissue may be removed when preparing teeth for veneers yet she still seemed keen on them. The advantages and disadvantages of composite versus porcelain restorations were fully explained for the patient’s information and she eventually agreed that composite resin was the best option due to the less destructive process, her relative youth and her minimal caries experience. Although the occlusion was far from ideal, I felt we could proceed with this treatment plan with a reasonable chance of success in the short to medium term if regular occlusal checks were carried out. She was ultimately happy to accept the reduced life expectancy of composite compared to porcelain in return for the benefits of a minimal approach as indeed was I. Furthermore, the probability of future occlusal therapy and the option of porcelain restorations later in life were also explained. Direct composite restorations closing the spaces between the six upper anteriors was therefore agreed by the patient as the best aesthetic compromise. A full examination was then carried out. We identified an occlusal interference with Bi-Manual manipulation, but the patient declined any occlusal therapy. Furthermore, as she was only 19, it was felt her skeletal development was not stabilised enough to allow meaningful occlusal therapy. Despite noticeable incisal edge wear we agreed to a ‘conformative’ occlusal approach. However, she accepted that future regular occlusal examinations were indicated with specific monitoring of the incisal wear. The patient admitted she had a hectic lifestyle and agreed her oral hygiene could be better. Some bleeding on probing was noted in molar areas, but with minimal bone loss. Gingivae were generally pink and stippled. Aesthetic treatment options

• Complex orthodontic therapy (patient declined)

• Indirect porcelain restorations for all teeth on show (patient’s request;

very aggressive) 20

• Direct composite restorations to close upper spaces (dentist’s suggestion;

minimal). Occlusal examination and diagnosis As the patient was only 19, it was felt she was not yet stabilised for meaningful occlusal therapy. However, it was recommended that regular future occlusal examinations were indicated with specific observations of the incisal wear. Occlusal treatment: It was agreed that porcelain veneers could best satisfy her need for improved aesthetics, despite the invasive nature of this approach. However, it was also explained that a course of occlusal therapy would first be advisable if such a major treatment plan was to be carried out. This would significantly extend the treatment time. The agreed treatment with direct composite would not be changing the current occlusal pattern. Treatment would be carried out ‘conformatively’ without any occlusal change and could therefore begin at once. Future occlusal therapy was not discounted, and suggested as very likely. She therefore chose to be treated conformatively with direct composite resin for now with the acceptance that any future treatment would probably necessitate an occlusal element. Definitive treatment plan

• Patient consent and financial agreement letter signed

• Hygiene therapy: supra-gingival tartar removal and oral hygiene instruction

• Direct composite mock up: new tooth morphology recorded with silicone

putty matrix

• Closure of spaces between upper six anterior teeth with direct composite resin.

Direct composite resin restorations: The HFO composite resin system (Micerium) was used in conjunction with a customised putty matrix and a stratified composite placement technique. Review of restorations: One week later, occlusal review to confirm her ‘envelope of function’ was not infringed by the palatal anatomy of the new restorations (Kois Occlusal Principles) and equally that her anterior guidance also remained unchanged (Dawson Occlusal Principles). As expected, there was no occlusal adjustment necessary as we had used a ‘stent’ of the successful ‘mock-up’ as a guide when placing the definitive restorations. Aesthetics were refined, and fine polishing of the restorations was completed.

Completed treatment plan

• Tooth whitening with trays was completed before this course of treatment

• Hygiene therapy (now maintenance)

Direct Composite resin restorations placed interstitially:

• Both upper central Incisors; (mesial-incisal, and distal incisal)

• Both upper lateral Incisors (mesial-incisal, and distal incisal)

• Both upper canines (mesial incisal).

Results The patient was very happy with the result, (Figures 3, 4) especially that her teeth were not damaged in any way.

No teeth were harmed during the production of this smile

The width to length ratios, particularly of the lateral, are not ideal, but the over wide teeth still offer a significantly improved appearance

The patient also agreed that minimal treatment was the sensible option in the end, even though she was initially adamant that a full smile makeover was all she would settle for. Ultimately, she was very happy to be persuaded into a much less radical solution, and as a clinician I was equally pleased to solve her aesthetic concerns with a much more minimal approach. However, we have both accepted the future may well involve porcelain.

Future treatment will include:

• Hygiene: Regular visits for maintenance

• Occlusion: Annual occlusal check and adjustment where necessary

• Bleaching: Regular top up therapy to maintain an acceptable shade

• Dietary Concerns: Eating habits to be reviewed

Warnings about pen chewing and fingernail biting

• Further treatment: Regular maintenance of the composite restorations will

involve polishing and repair as necessary as time goes by.

Discussion As a dentist it was gratifying to complete such a minimal treatment plan in the face of such a harsh media driven request initially. The treatment is fully reversible and ‘no teeth were harmed during the making of this new smile’. I feel the aesthetic result could have been more ‘perfect’, and the procedure much less demanding clinically if we had opted for porcelain veneers. However, the aesthetic compromises were a result of the initial dental anatomy which could not be altered if we were to follow a no-prep approach as planned. Obviously case selection plays a huge part in the final result, and this minimal approach would not work for every case. Furthermore, I would never suggest a poor final result could be mitigated by claiming a minimally invasive approach was taken; many cases will still need porcelain restorations despite the inevitable outrage of some. For example the case I have used to demonstrate the technique in this article was not perfect as the resulting centrals were far too wide. In this particular case the central incisors did not end up completely symmetrical as is the usual requirement; I prefer the shape of 21 for example (Figure 5).

This 1:1 photograph was taken using a black background to allow the fine detail created within the restorations to be inspected at close quarters. However, the asymmetric papilla is also more visible in close up

Equally the midline is not perfectly correct (Figure 6), yet the overall result is, I feel, ‘natural’ and more importantly, acceptable to the patient.

The front retracted view leaves nowhere to hide: the midline is canted and not fully vertical in the smile

I would further suggest this result is perhaps more ‘ethical’, and of less biological cost, than when slavishly aiming for an ‘ideal’ standardised result based largely upon geometry. Arbitrary smile rules such as ‘golden proportion’ do not occur too frequently in nature, perhaps as low as 17% in some studies which begs the question, why are we striving to create unnatural smiles?

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THE COMPONENTS OF A SMILE Recent Research Results

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Beauty is subjective but it is the role of the clinician to attempt to replicate, create or enhance a beautiful smile, or at least a smile that is viewed and perceived by the patient, and his or her family, friends and colleagues as beautiful. There are many elements to a smile, a complex dynamic expression involving aspects of the face beyond the ‘aesthetic zone’ of the teeth and immediately surrounding tissues. Of particular importance are the lips – sometimes regarded as the frame to the smile but a multitude of facial muscles also work together during a smile. They animate the lips and effectively open up the smile to reveal teeth and periodontal structures. There has been much research into the characteristics of a good smile and some recent papers have looked at the influence of lips and soft tissues, tooth shape, tooth colour, types of teeth and the use of smiles in advertising. The influence of the lips Chan et al.1 investigated how the lips and teeth may affect the perceived aesthetics of a given smile. Lips and teeth were collectively assessed in different fields of view to see how they may contribute to smile aesthetics. The perception of ‘beauty’ was assessed to determine whether differences existed between; dentists, non-dentists, males and females. Their work involved five subjects who were photographed to produce the following views of each of them:

1) retracted anterior teeth;

2) lips at rest;

3) zoomed smile; and

4) smile showing the lower face.

Images were compiled into a survey questionnaire and shown to respondents who ranked the subjects in order of aesthetic appeal. All groups viewing the images demonstrated statistically significant agreement in the perception of beauty. Both the teeth and lips seemed to contribute similarly to the attractiveness of a smile. Dentists seemed to be more influenced by teeth in a zoomed smile view, however, this was negated when viewing a broader field of view. All other groups showed no

difference in perception of aesthetics with changing field of view. The authors conclude that both the lips and teeth seem to contribute to the aesthetic appeal of a smile, and may have a similar magnitude of influence. Whether or not one aspect has more weight on the aesthetic outcome, seems to depend on the patient. Due to this, it is important and clinically relevant to assess the smile in its entirety rather than â&#x20AC;&#x2DC;teeth onlyâ&#x20AC;&#x2122; for the aesthetically driven patient. The clinician and dental team members should therefore give due consideration to the lips and soft tissues as well as the teeth when treatment planning aesthetic improvements in the smile. Dentists are more likely influenced by teeth when evaluating a smile up close compared to non-dentists. However, the results of this investigation show that when looking at the lower face to evaluate the smile, this bias is nullified. This is a relevant aspect to note, so that the clinician can truly understand what the patient sees. Tooth shape In another piece of research Shetty and co-authors investigated tooth dimensions, relationships and ethnic variations in these parameters in the planning and provision of aesthetic dentistry2. The upper anterior teeth in young adults of Indian origin living in an urban location in the UK were studied qualitatively. Fifty male and 50 female young adult Indians were recruited to the study, according to predetermined criteria. Upper and lower, full arch impressions were obtained for each of the 100 participants and stone casts were obtained from these impressions. The width and length of each upper anterior tooth included in the casts were measured using precision callipers. Anterior arch length was determined using a flexible measuring tape. All measurements were repeated at least three times to obtain consistent values. The data obtained were analysed, compared with existing data on tooth dimensions and used to investigate the presence of Golden Proportion relationships. Results showed that the measurements obtained had a normal distribution. Statistical analysis revealed significant differences in the overall data for left and right canine width and length. No such differences were noted in respect of the upper central and lateral incisors. Also, significant differences were found to exist between male and female subjects in respect of the width of all anterior tooth types, except for the upper right lateral incisor. There were significant differences in the length of the upper left central incisor and upper right and left canines between male and female subjects. Significant differences were found in the width to length ratios between right and left canines. No such differences were observed for incisors. There was an absence of Golden Proportion relationships.

The authors concluded that it is inappropriate to adopt a formulaic, left/right symmetrical approach to smile design in the provision, in this case, of aesthetic dentistry for young adults of Indian origin but it seems likely that such an approach would be pragmatic across all racial groups. Tooth colour In other research the extent to which objective parameters of the colour of one’s own teeth affected the social and emotional dimensions of young adults’ lives was studied3. Here, the sample included 134 university students (65% female) aged 19 to 28 years all of whom had six intact maxillary anterior teeth without restorations or severe malocclusions and healthy gingiva with no signs of inflammation. Tooth colour was assessed intraorally using a spectrophotometer. Lightness, chroma, and translucency of the right maxillary central incisors (the reference teeth) were calculated and used for analysis. Subjects reported dimensions of their oral healthrelated quality of life (OHRQoL) using three assessment scales; the Oral Health Impact Profile (OHIP), Orofacial Esthetic Scale (OES), and the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ). Various statistical relationships were tested using the resulting data. Dental self-confidence, aesthetic concerns, orofacial appearance, social impact and psychological impact were not related to lightness, chroma, or translucency of the subjects’ teeth. Satisfaction with smile aesthetics was only related to translucency where subjects with moderate translucency were least likely to be satisfied. Women tended to report greater psychosocial impacts than men regardless of their tooth colour. According to the results of this study objective, measurable, quantitative parameters of tooth colour did not accurately predict psychosocial dimensions of OHRQoL in the study population indicating once again that ‘beauty’ is very difficult to quantify and that each patient will have their own individual take on what colour teeth is ‘them’. Tooth type One might expect that the presence (or absence) of particular tooth types in the aesthetic zone could draw definite opinions of patients and lay people. Most claims on the importance of maxillary canines, for example, have been based on expert opinions and clinician-based studies. So, to measure this, a research project in Chesterfield tested the assumption that maxillary canines are generally considered important both cosmetically and functionally4. The objective was to investigate whether there was any difference in the perceptions of patients’ smiles treated by extracting either maxillary canines or first premolars, as judged by orthodontists, dentists, and lay people. 28

This retrospective study included 24 participants who had unilateral or bilateral extraction of maxillary permanent canines and fixed appliances in the maxillary and mandibular arches to comprehensively correct the malocclusion, selected from orthodontic patients treated at Chesterfield Royal Hospital over the previous 20 years. The control group of patients had extraction of maxillary first premolars followed by fixed appliances and finished to an extremely high standard judged by the requirement that they had been submitted for the Membership in Orthodontics examination. End-of-treatment frontal extra-oral smiling and frontal intra-oral images were presented for both groups. The photographs were blinded for extraction choice and standardised for size and brightness using computer software. The assessor panel consisted of 30 members (10 orthodontists, 10 dentists, and 10 lay people) who rated the appearances on a 10-point Likert scale. Perhaps surprisingly, no statistically significant difference was found in the smile attractiveness between canine extraction and premolar extraction patients as assessed by general dentists, lay people, and orthodontists. Smiles in advertising So where does all this leave us in terms of societyâ&#x20AC;&#x2122;s view of beautiful smiles? Perhaps one more objective measure might be revealed in a real commercial sense by analysing the use of smiles in advertising. In the last piece of research featured in this article, the frequency, smile characteristics, context of the smile and target audience in newspaper advertisements were the points of interest5. Four examiners analysed 600 advertisements from 46 European magazines and newspapers by using content and framing analysis including the presence of people, smile characteristics, context of smile use, impression of success and health, and targeted audience. People were present in over 70% of the newspapers advertisements, and almost 80% of them were smiling, relating the product or service with a positive context more often than with a neutral or negative context. The advertisements with smiles were targeted at adults most frequently (70.6%) followed by adolescents, less often the elderly (22.2%) and children (4.2%); women (45.9%) or both genders (29.2%) were targeted more often than solely men (2.6%). The smile image generally filled at least one quarter of the size of the entire advertisement (97%), with spontaneous and posed smiles being used equally. In 82% of cases teeth were visible in the smile, and buccal corridors were present in 39% of them although the parameters of micro-smile aesthetics were not the focus of the advertisements.

The clear message emanating from these studies has to be that there are no hard and fast rules, which might be the conclusion that one would intuitively expect. There are guiding principles and suggestions for do’s and don’ts but ultimately all aesthetic dentistry has to be a personal matter between each individual clinician and patient. References

[1]

Chan MYS, Mehta SB, Banerji S. An evaluation of the influence of teeth and the labial soft tissues on the perceived aesthetics of a smile. BDJ 2017; 223:

272–278.

[2]

Shetty TB, Beyuo F, Wilson NHF. Upper anterior tooth dimensions in a youngadult Indian population in the UK: implications for aesthetic dentistry. BDJ

2017 223: 781–786.

[3]

Kovacevic Pavicic D et al. Tooth color as a predictor of oral health-related quality of life in young adults. J Prosthodont 2017; Oct 31. doi: 10.1111/

jopr.12666.

[4]

Thiruvenkatachari B et al. Extraction of maxillary canines: Esthetic perceptions

of patient smiles among dental professionals and laypeople. Am J Orthod

Dentofacial Orthop 2017; 152: 509-515.

Luke A et al. Frequency, context and characteristics of smile used in

[5]

advertising. Acta Stomatol Croat 2017; 1: 41-47.

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TREATMENT OF THE WORN DENTITION Six Indirect Upper Restorations - By Ken Harris

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This case involved a 35-year-old male who felt that his upper front teeth were ‘disappearing’ from his smile in recent years and wished them to be lengthened so as to be displayed when he smiled, as previously (Figure 1). He was happy with the colour of his teeth, having undergone bleaching, and the two veneers placed on the lower right canine and lateral incisor had survived well for over five years, prompting him to suggest veneers would be the ideal treatment to restore the length of his worn upper incisors. His intra-oral tissues generally appeared disease-free, but there was significant, gingival recession, perhaps, 2mm beyond the cement-enamel junction and although the gingival tissue appeared pink, firm and stippled, there were characteristic ‘V’ shaped notches mid-labially, which exposed significant areas of the root surface. The patient said he always wanted very white teeth and was an aggressive brusher, which was probably the cause. This gum damage was visible generally, but specifically on the upper jaw from canine to canine; however, the central incisors still measured 11.5mm (just beyond the classical 11mm) from incisal edge to the gingival crest (Figures 2 and 3). As the average length for a healthy upper central incisor is 10-11mm, why was the patient concerned about short teeth if they had already measured almost 11mm long? In order to establish why the patient’s teeth appeared short it was necessary to check the position of the incisal edge, as it appeared in his smile. A selection of photographs was taken with his lips in repose, in a normal smile position and with the most extreme smile he could muster. The results of the photographs suggested his upper incisors were perhaps 2.5mm short when viewed in his smile and this was followed with a direct mock-up of the proposed new incisal edge position using composite resin. Composite resin mock-up The resin was added to the surface of the upper six anterior teeth and sculpted into shape before curing in order to give the patient some idea of what could be achieved and to help establish the exact position for the incisal edge in relation to his smile. This method is preferred to computer imaging as it gives a better indication

of what is possible in the mouth and created central incisors 14mm long. However, the patient liked the results. His significant gingival recession suggested that the cosmetic result could benefit from a connective tissue graft, which the patient agreed to. Also, the root exposure meant that lengthening the teeth with porcelain would make them appear far too long cosmetically, especially as his upper lip measured the conventional 24mm revealing his upper gingival margins when he smiled. Treatment planning A comprehensive treatment plan, including occlusal therapy followed by placement of porcelain restorations with connective tissue grafting as the final phase was proposed. Following the intra- oral mock-up, it was agreed that the patient would like six upper anterior units restored with porcelain. He was happy with the wear on his lower incisors, and it was agreed that it would not be necessary to treat them if he underwent his occlusal therapy as the first stage of treatment. It was also agreed that the upper anterior gum recession would need attention after the placement of the porcelain veneers with the graft being taken from his palate. Most importantly, the patient appreciated that underlying the entire process was the need to establish a stable and functional occlusal pattern, and this would need to be completed before any definitive porcelain work could be fitted or gingival surgery carried out. Occlusal equilibration Upper and lower impressions were taken and the lab instructed to fabricate a Kois Occlusal de-programmer for the patient, which is a modified removable Hawley orthodontic appliance with a small, level platform of acrylic resin added just behind the upper incisors in the position of the incisive foramen to act like a Lucia jig. The patient was instructed to wear it at least 20 hours a day; removing it only for meals. Laboratory instruction Records were taken of the six upper units for the lab to create a functional wax-up with reference to the Golden Proportion with the study models mounted in centric relation. The lab was informed that equilibration had taken place, and that they should mount the equilibrated study models in maximum intercuspation. Upper and lower silicone impressions and a face bow record were taken using a Kois dentofacial analyser face bow (Optident, Bradford). The aesthetic occlusal plane is also recorded with this piece of equipment, as long as a full face photograph is included. The photos of the original composite mock-up were consulted and a smile design agreed with the patient, and the lab informed of the desired outcome. All the photos were sent to the lab and detailed communication was also carried out by email. 33

Definitive clinical procedure Following equilibration, the plan was at the next session to prepare the six upper anterior teeth for indirect porcelain veneers and place provisional restorations. Although significant gingival recession was evident, it was decided to finish the cervical margin of the veneers still on the enamel for better bonding, and not take the gingival shoulder preparation margin on to the root surface. This allowed the definitive bond of the ceramic onto enamel rather than on to the cementum of the root surface. Equally, this prevented the creation of an over long porcelain restoration (14mm) and the plan was to eventually cover the root surfaces with a connective tissue graft anyway. With this approach there were no issues with biologic width infringement to contend with, and happily, there were no gingival embrasures, so alleviating the need to seriously consider â&#x20AC;&#x2DC;black triangleâ&#x20AC;&#x2122; formation before the definitive preparation appointment was scheduled. Major preparation The functional wax-up shape was transferred on to the patientâ&#x20AC;&#x2122;s teeth with provisional resin material (Integrity, Dentsply) using a stent of the wax-up before any actual tooth preparation was started. The aim was to remove only the actual tooth tissue required to achieve the functional and aesthetic aims by referring to the surfaces of the final restorations as indicated by the wax-up rather than the surfaces of the original teeth. Using the transferred wax-up pattern as a guide for reduction, the relevant units of the upper arch were prepared with a minimal tooth reduction technique using depth cutting burs. Conventional 3-plane labial surface reduction was completed and refined and once again the stent was used to transfer the wax-up to the prepared teeth to confirm adequate tooth reduction had been achieved by checking for showthrough. With the help of x4.5 magnification loupes, gingival margins were refined with a Kavo sonic-flex hand piece, and all sharp angles within the preps rounded off with soflex discs (3M). The small amount of exposed dentine in the cervical region was hybridised to seal the tubules, and silicone impressions were then taken. A CR interocclusal record of the prepped teeth and a separate stick bite registration were recorded along with prep stump shades, and lots more photographs. Working provisionals were then fabricated in self-curing, bis-acryl composite acrylic resin (Integrity, Dentsply) once again using the wax-up stent, and fitted carefully to prevent full bonding to the recently hybridised dentine surfaces of the preps. The provisional margins were then finely polished to facilitate gingival health during the

porcelain construction phase, and occlusal adjustment of the provisionals carried out. Provisionals assessed Three days later the patient returned for a detailed review of the provisionals without the numb lip! Occlusion, speech and aesthetics were again checked and refined before the provisionals were finally accepted. Silicone impressions and incisal edge position records were then taken of the acceptable provisionals to help the lab fabricate the definitive restorations. The length of the provisional central incisors was measured (14mm) and photos taken. The final shade was agreed with the patient and everything was sent overnight delivery to the lab in the USA. Fit appointment The porcelain restorations were shown to the patient, and agreement was reached to fit the restorations before any local anaesthetic was administered or any provisionals removed. The preps were gently sandblasted (prepstart) and then cleaned with chlorhexidine (Consepsis scrub, Ultradent). Each restoration was then tried in individually, and then all were tried in together; initially dry to check fit, and then with water to test that the final shade was acceptable to the patient. Try-in pastes were available but not required. Once again the patientâ&#x20AC;&#x2122;s approval was obtained before the definitive fit stage. The fit surface of the veneers were then etched at chairside with HF acid (Ultradent), and then placed in an ultrasonic bath for cleaning. They were then dried with suction as the air supply has to be oil free. Multiple coats of Silane coupling agent (3M) were then applied and sequentially evaporated with warm air for 5 minutes using a warm air dryer. Meanwhile at the chairside, utilising a team of two nurses, rubber dam (split dam technique) was placed and the preps were cleaned again with chlorhexidine, and using 35% phosphoric acid, the total etch system was used to allow all six units to be fitted at the same time. The preps were etched in groups of three so as to avoid over-etching, and kept hydrated with densensitiser (Aquaseal, Aquamed Industries). A 4th generation bonding system (Optibond FL, Kerr) was applied as directed by the manufacturer, with separate primer and adhesive components used. Light cured resin cement (Vitique, DMG) in transparent shade was applied to the veneers and to the preps and the veneers were seated. The veneers were spot cured using the 2.0mm diameter curing tip to initially tack them down, and the excess resin cement removed before thorough, final curing with the wide diameter light tip. If veneers fit correctly there is no need to use rotary instruments to refine the gingival margins, and a curved scalpel (Swann Morton no 12) was all that was needed to

clear excess resin away. Resin in the contact point areas was also removed and the areas polished with diamond strips (Visonflex; Brassler Komet) and checked for smoothness with dental floss. Finally, occlusal adjustment was addressed and basic porcelain polishing carried out. The patient was then dismissed to return later for further review. Review appointments The patient returned seven days later for final occlusal checks and aesthetic refinement at a more relaxed pace and without the numb lip. Final radiographs were taken to confirm no excess resin cement was left subgingivally and the adjusted porcelain occlusal surfaces were fully polished with graded silicone points (Ceramiste Kit, Shofu) and diamond paste (Luminescence, Premier). The aim was to reduce wear on opposing teeth and also remove any surface marks and crazes which can act as a focus for crack propagation and future porcelain breakage. Equally important, it is also smoother to the patientâ&#x20AC;&#x2122;s tongue. Gingival surgery The patient expressed himself to be so delighted with the results (Figures 4-6) that he decided he did not wish to undergo the connective tissue graft procedure, which was part of the initial treatment plan. He felt that to undergo surgery for what he considered to be little improvement was a daunting prospect and so declined. However, he did say that if the issue became a problem he would consider the procedure for the future. Long-term maintenance As a long-term patient of the practice, he will return regularly for hygienist therapy as he has done for the past 15 years and the occlusal position will be checked on a 12 monthly basis with adjustment as necessary. The patient was advised about extreme eating habits in order to protect the incisal edges of his new porcelain although in this case the patient was not offered a hard acrylic splint as he had no signs of bruxism, and had been successfully equilibrated earlier. It would have been a more complete treatment with the connective tissue graft to improve the gingival appearance but the patient was happy with the result without the surgery. The resultant smile does not fully comply with classical smile design principles, and some practitioners may feel that the veneers should have finished at the crest of the gingival tissue, but it was preferred to have all the margins finishing on enamel where possible rather than on the dentine and cementum of exposed root surfaces.

The new occlusal design has been trouble-free for several years now, but an annual occlusion review appointment is scheduled in order to specifically monitor any future occlusal changes. Currently, the appearance of the lower incisors is acceptable to the patient despite there being previous wear issues, and it hoped that following the occlusal therapy he has undergone, this wear situation will not develop further. However, as already stated, the occlusal review protocol will allow diagnosis of any changes as soon as they happen.

TOOTH WHITENING REVISITED

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Recent years have seen a huge increase in interest in tooth whitening. Here we review the current state of the subject and how the various techniques work. Despite the wide availability of tooth whitening kits and services the starting point for any enquiry by a patient or consumer about the process should really be an examination by a dentist. This is for two reasons, firstly the full process of tooth whitening is regarded by the General Dental Council (GDC) as the practice of dentistry and secondly because there are a wide variety of reasons as to why teeth are, or have become, discoloured and correct diagnosis is therefore important. Discolouration can be the result of the natural darkening of the teeth through ageing, extrinsic staining, genetically discoloured teeth, drug interactions such as tetracycline staining, trauma, caries, existing mismatched restorations of composite or other materials, dark lingual or palatal restorations showing through, abscessed or non-vital teeth, internal or external resorption and thin transparent enamel from gastroesophageal reflux or bruxism. Straightforward bleaching will not solve some of these problems and so needs to be part of a wider treatment plan. A distinction should be made between ‘bleaching’ and ‘whitening,’ since many over-the-counter products make the claim of ‘whitening’ to rival dentists’ bleaching treatments. ‘Whitening’ is only removing surface stains, but ‘bleaching’ changes the inherent colour of the tooth1. Legal situation The legal situation over tooth whitening and bleaching can be confusing but the law is clear in at least some respects. Applying materials and carrying out procedures designed to improve the aesthetic appearance of teeth is the practice of dentistry, as governed by the Dentists Act 1984. This was confirmed by the High Court in May 2013 and anyone who practises dentistry illegally risks being prosecuted by the GDC in the criminal courts. Dental hygienists and dental therapists can carry out tooth whitening on the prescription of a dentist if they have the necessary additional skills. There is also an obligation to ensure an appropriate level of safety at all times. The taking of impressions and making bleaching trays to a dentist’s prescription are also both

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within the scope of additional skills for dental nurses. The GDC have prosecuted a number of individuals for the illegal practice of dentistry following complaints from members of the public and dental professionals. Reporting of someone illegally practising dentistry can be done by emailing illegalpractice@gdc-uk.org or contacting the GDC’s Illegal Practice Team (0845 222 4141). Historically, the legal position in Europe relating to tooth whitening has also been confusing, with different interpretations of the relevant EU Directive being applied in different countries. In the UK a House of Lords judgement in June 2001 confirmed that tooth whitening products were covered by the EU Cosmetics Directive and not the Medical Devices Directive. Following extensive lobbying by the BDA and others, the EU Cosmetics Directive was finally amended in 2011, as a result of this the UK Cosmetic Product (Safety) (Amendment) Regulations 2012 mean that:

• Products containing or releasing over 0.1% hydrogen peroxide cannot be

• Products containing or releasing between 0.1 and 6% hydrogen peroxide can

supplied directly to the consumer

only be sold to dental practitioners

• Products containing or releasing between 0.1 and 6% hydrogen peroxide can

only be made available to patients following an examination by a dentist

with the first episode of treatment being provided by a dentist, or by a hygienist

or therapist under supervision of a dentist (i.e. within the same dental setting)

after which they can be supplied to the patient to complete the cycle of use

• Products containing or releasing over 0.1% cannot be supplied to persons under

18 years of age

• It is illegal to supply any product containing or releasing over 6% hydrogen

peroxide

• The restrictions set out above apply equally to internal tooth whitening

treatments. Carbamide peroxide based whitening products are covered by the regulations as they release hydrogen peroxide when applied. Products containing 10% carbamide peroxide will release approximately 3.6% hydrogen peroxide. Therefore approximately 16.62% carbamide peroxide will release hydrogen peroxide at the legal limit of 6%. These levels should be taken into account when selecting suitable carbamide peroxide based whitening products. Product manufacturers should be able to provide confirmation of the amount of hydrogen peroxide released from the products they supply.

In May 2014 the GDC stated that products containing or releasing between 0.1 and 6% hydrogen peroxide can be used on any person under 18 years of age where such use is ‘intended wholly for the purpose of treating or preventing disease.’ However, given the current UK cosmetic regulations, those considering performing treatment on under 18s should contact their defence organisation for advice before proceeding - even if the treatment appears to be in the best interests of the patient. Methods of tooth whitening Applied in-practice In-practice whitening is the most established form of the procedure and usually involves the teeth being isolated with a rubber dam before a high concentration of the whitening solution or gel, usually hydrogen peroxide, is applied. This can be for various lengths of time (20–60 minutes) depending on the individual requirements of the case and the concentration of the active agent. Although some systems recommend the use of light activation, research has shown the light does not change the outcome of the process. This method has the advantage of the clinician being in control of the process, and patient compliance is not required, other than to identify if they feel discomfort or pain during the procedure. On the down side are the cost, safety and efficacy since it can take a number of visits (1–6 range) to get a satisfactory result unless the teeth are initially lighter than a Vita A2 shade. An immediate evaluation after in-practice whitening may show some effect but the teeth are also whiter due to dehydration from isolation. The clinician and patient will have to wait over two weeks and possibly as long as six weeks to determine the actual colour change from any procedure. However, the outcome of this method is not better than the tray technique (see below) regardless of the number of applications. The limiting factor for any such treatment is how the teeth respond rather than a higher concentration or a particular product. The cost to the patient and time of use, as well as the unpredictable nature, along with tissue discomfort make it less popular, which is why the tray bleaching has become the standard. In-practice is best used as a single application motivator followed by tray application to complete the process. Applied by the patient This technique consists of tray application of low concentration bleaching products and was introduced in 1989 with a non-scalloped, no reservoir tray with 10% carbamide peroxide overnight1. Later techniques have utilised hydrogen peroxide for daytime wear. The dentist performs the initial examination and constructs the custom-fitted tray. Tray application requires compliance, which is not guaranteed

as we know from other treatments requiring patient motivation. However, when compliance is met the technique seems to be able to deliver favourable outcomes due to the slow rate of change in the teeth. Other names for this method include night guard vital bleaching, dentist-prescribed, home-applied bleaching or tray home-bleaching. Over-the-counter products These products are bought by the consumer without the advantage of a dental examination and diagnosis of the cause of discoloration. Most are hydrogen peroxide products, although some contain carbamide peroxide. They use various delivery methods from ‘boil and form’ trays to strips that are placed on the teeth. Sensitivity The most frequently expressed drawback to bleaching is tooth sensitivity, closely followed by gingival sensitivity. This sensitivity is related to the easy passage of the agent through intact enamel and dentine to the pulp over a period of 5–15 minutes which indicates a symptom of reversible pulpitis. The lower the concentration of material, the less the sensitivity is present. Patients who have the most sensitivity during bleaching usually have either a history of sensitivity or apply the material more than once a day/night. There are several ways of avoiding or minimising this discomfort including reducing the concentration of the agent and if possible using one which also incorporates potassium nitrate to penetrate the tooth and reduce the excitability of the nerve during the pain cycle. The patient should be advised to brush with a potassium nitrate containing toothpaste or other sensitivity-reducing toothpaste for two weeks before starting treatment as well as applying the paste in the tray for 10–30 minutes as needed. Gingival sensitivity can also be avoided by having a well-fitted tray from a proper alginate impression that does not rub the tissue while in use. Mint or other irritating flavours of bleaching material should also be avoided, especially in patients with food allergies. Length of treatment The length of treatment will be different for each patient based on the type and location of the discolouration, patient compliance, and the amount of tooth or gingival sensitivity. Some patients with normal darker teeth show bleaching results in as little as three days and others take as long as six weeks. At the tray and bleach delivery appointment, a current shade of the patient’s teeth should be taken and recorded. Extra-oral photographs can be helpful for charting as well as patient education to determine progress. Monitoring can be undertaken at various periods; 42

weekly, monthly or at the end of treatment. Weekly evaluations may increase compliance, but also increase operating cost. Monthly monitoring could also use that visit to determine the need for a further amount of bleaching material or for a refill kit. While common discolorations average a treatment time of about two weeks, nicotine stains may average 1–3 months and tetracycline stains 2–12 months with an average of 3–4 months with nightly application. With a shift away from treatment of disease towards an emphasis on health and fitness the likelihood is that the desire for whiter looking teeth will also increase. Dental professionals are well placed to advise on this as well as taking the opportunity to improve the patient’s awareness of other areas of oral and general health. References

[1]

Haywood VB, Sword RJ. Tooth bleaching questions answered. BDJ 2017, 223:

369-380.

TREATING THE LOWER THIRD OF THE FACE WITH BOTULINUM TOXIN A By Dr Harry Singh

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In this article I will look at the areas we can treat in the lower third of the face. Before we look at specific areas, I need to draw your attention to the slightly different approach we have for treating the lower third of the face compared to the upper third. The majority of patients seeking treatment for fine lines and wrinkles will be initially concerned with the upper third of the face, notably the forehead, frown and eye areas. In practice I have found that once they have experienced your clinical and patient skills they will seek additional areas to be corrected with Botulinum Toxin A. In the upper third of the face the muscles are large and generally independent of each other, therefore we are not overly concerned with the spread and diffusion of the toxin. However, in the lower third of the face, the muscles are generally much smaller and in closer proximity to a number of other muscles and structures. Therefore we need to be wary of the diffusion and spread of our toxin much more. I practice the technique of ‘baby stepping’ when treating the lower third of the face with toxin. I would rather they come back for a review appointment and administer any top ups than overdose and cause unwanted side effects on neighbouring muscles which cannot be corrected. When discussing specific units, I will be referring to Azzalure® and Speywood units in the following examples. Bunny lines Not technically in the lower third of the face, but I thought it would be advantageous to discuss this area. These lines appear on the side of the nose when the patient scrunches their nose Figures 1 and 2. The lines are the result of the contraction of the naslis muscles. I would normally inject (Figure 3) 10 Speywood units on each side at a superficial level, no more than 4mm depth maximum. It is important not to go too deep otherwise there is a risk of hitting bone, which will be painful to the patient. Inject where the biggest mass of muscle is (Figures 4 and 5).

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Smokerâ&#x20AC;&#x2122;s lines These are vertical rhytides that occur in the upper lip and lower lip region â&#x20AC;&#x201C; Figures 6 and 7. These lines occur from the contraction of the oribcularis oris muscle. This is a circular muscle around the lower and upper lip. It is responsible for the closure of the lip and pushing the lips forward (puckering/pouting). These lines are common, but not limited to smokers.

Figure 6.

Figure 7. 45

There are three ways to treat these lines: • Toxin only • Dermal fillers only • Combination of both. My criterion for treating with toxin only is if the lines are superficial, worsen when the patient pouts their lips and the patient does not want any fillers to increase the size of their lips. I do warn these patients that we cannot guarantee to eliminate the lines. The toxin is placed very superficially (Figures 8 and 9) and I would place as a starting point no more than five Speywood units per injection site. I avoid the philtrum area and inject close to the vermillion border. I warn the patient that they may feel numb and find it hard to whistle or say certain letters for a couple of days post procedure (Figures 10-12).

Figure 8.

Figure 9.

Figure 10.

Figure 11.

Figure 12.

Dermal fillers would be used in isolation if the patient’s main concerns are the lack of volume in the lips or lack of definition of the vermillion border. There are also a small proportion of patients that do not want any toxin placed. If the lines are very deep and do not worsen when the patient pouts their lips, then I would use a combination of toxin and dermal fillers. The toxin will help relax the muscle and the dermal filler will increase the volume of the lips/borders to help stretch the skin and reduce the appearance of these lines. In addition to placing fillers in the lip borders and lips themselves, I will also consider using a fine filler to directly ‘fill’ the smoker’s lines. My protocol is to use toxin first and when reviewing, assess whether we need to place a fine filler directly. I always tell my patients that we cannot guarantee to eliminate the smoker’s lines and they may need additional treatments such as laser skin resurfacing. Corners of the mouth Some patients have a reverse smile where the corners of the mouth are going downwards (Figures 13 and 14). This is the result of an over-active Depressor Anguli Oris (DAO) which is responsible for lowering the corners of the lips and subsequently Marionette lines. The DAO is a triangularly shaped muscle. The easiest way to locate this muscle is to get the patient to do a sad face and you will see the muscle contracting just above the jaw line. It can also normally be found by drawing a line from the corner of the nose down to the corner of the mouth and continue this line just above the jaw. I inject 10 Speywood units per side - (Figures 15 and 16), perpendicular to the muscle and superficially. Complications can occur if you inject too medially. The toxin can potentially diffuse into the Depressor labii inferiors and cause a protrusion of the lower lip, known as a Gomer Pyle appearance. If you inject too laterally, the toxin can diffuse into the Buccinator, causing the patient to bite and traumatise the buccal mucosa (Figure 17).

Figure 13.

Figure 14.

Figure 15.

Figure 16.

Figure 17.

Gummy smile This is the result of an over active Levator Labii Superioris Alaeque nasi (LLSAN) muscle. By administration toxin into the LLSAN you can lengthen the upper lip. You are looking to inject in the naso facial groove which is adjacent to the Ala. I inject at 45 degrees, deep and 5 Speywood units per side (Figures 18-21).

Figure 18.

Figure 19.

Figure 20.

Figure 21.

It is worth keeping in mind Rubin’s three classifications of smile patterns:

• Mona Lisa smile - dominated by the Zygomaticus Major which elevates the

oral commissures as the highest point of the smile. Do not treat with toxin as this

will exaggerate the Mona Lisa smile pattern

• Canine smile pattern - dominated by the Levator Labii Superioris where the

highest part of the smile is the central upper lip

• Gummy smile - excessive display of the upper gingival when smiling.

I will sit the patient down and will get them to look at a mirror at eye level, then I will push the upper lip down by 3/4mm to show then the expected result and if agreeable, then will carry out the procedure. Masseter Over activity of this muscle can cause a square jaw look and potentially bruxism. I would get my patient to clench their teeth and observe where the bulk of the muscle is contracting and bulging. I normally give three injection sites per side ((Figures 22 and 23) and would start off with 15 Speywood units per injection site and then review after two weeks for any top ups that might be needed. Overdosing can reduce the biting force. I would inject deep into the belly of the muscle at 30 degrees to the muscle.

Figure 22.

Figure 23.

Chin The Mentalis is responsible for pushing out the lower lip and contributes to chin wrinkles, also known as â&#x20AC;&#x2DC;orange peelâ&#x20AC;&#x2122;. This appearance is more common amongst gummy smilers and in anterior open bites. Even though the Mentalis is a pair of muscles, my preferred injection technique is for one injection site in the midline, very deep at 90 degrees. I would normally inject 10 Speywood units (Figures 23-26).

Figure 24.

Figure 25.

Figure 26.

Contraction of the Platysma can lead to bands and premature ageing of the neck region. Toxin is rarely used in isolation in this area and normally treatments to improve the skin complexion such as mesotherapy will yield the optimal results for the patient. Ask the patient to contract their neck via clenching their teeth and then mark along the bands (Figure 25). I would normally inject between 4/5 sites per band and 10 Speywood units per site very superficially whilst the non-injecting hand is pulling out and squeezing the band (Figure 26). In conclusion, I would rather under dose and get the patient back for any necessary top ups than be over optimistic on the first visit and overdose causing complications. By baby stepping in the lower third of the face you will greatly reduce the risks and have a happier patient and less sleepless nights. Further information on these techniques at: www.botoxtrainingclub.co.uk 49

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