Smile enhancement using minimally invasive concepts to create subtle changes

After (left) Before (right)

by Gary M. Radz, DDS

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Not all smile “makeovers” require tooth preparation, porcelain, and full-arch impressions. Sometimes all a smile needs and all a patient wants are minor additions or subtractions to create that “ideal” result he or she is looking to achieve.

The starting point is to listen to the patient’s chief complaints. By having a good understanding of your patient’s goals, you can present different treatment options that will provide the desired results. As the treatment options are presented, it is important that patients understand the risks and benefits of each option. For many patients, the concept of noninvasive cosmetic dentistry is very appealing. Today’s materials and techniques give dentists the ability to offer more noninvasive options than ever before.

As cosmetic dentistry has evolved in the last 20 years, there has been much debate over the elective preparation of healthy teeth for the sake of enhancing appearance. The current trend in elective dentistry is to look for ways to create the desired effect using minimally invasive or noninvasive techniques.

The following case study demonstrates how current materials, techniques, and equipment can create subtle changes that will develop a new smile and meet a patient’s desired goals.

Case study

A 25-year-old female patient presents for cosmetic consultation (before, above). Her chief complaint is that she doesn’t like the midline diastema and she’d like to have her teeth a little whiter. Once the patient’s concerns are understood, an esthetic diagnosis will be used to develop treatment options.

The patient had orthodontic treatment that was completed eight years ago. She says she continues to wear her orthodontic retainer on a nightly basis. Her occlusion, periodontal condition, and joints are all within normal limits. She has a 1 mm midline diastema. The height-to-width ratio of the central incisors is 90%. The height of the centrals is 9 mm. There is 4 mm of gingival display in her “E” lip position.

Fig. 2

The patient reports that she completed dentist-supervised, take-home whitening four years ago. Currently, the shade of her centrals is A1.5, as measured with a digital shade-taking device (EasyShade, Vita).

Fig. 3

With this diagnostic information created, a treatment plan can be presented to the patient. This diagnostic information is important because it will help the dentist provide a treatment plan that will offer the best opportunity to maximize the patient’s smile.

Without this information it would be easy for the dentist to simply put in some composite in 20 minutes on consultation day, close the diastema, and be done with treatment. But this would fall short of the potential improvement that could be made.The diagnostic data allows us to present a more complete treatment plan that can give the patient an opportunity to have a more ideal final result.

Shade

An A1.5 shade is a pleasing color. But it’s been four years since the patient bleached her teeth, so there is a possibility that they could be made slightly whiter/higher in value. If the patient wants to bleach her teeth, this would need to be done before addressing the diastema. The option is presented to the patient, informing her that since she has already bleached recently, she should not expect a dramatic color change. But a slight increase in value with bleaching is a reasonable expectation.

The patient states that she would like to get her teeth as white as possible and that she is interested in bleaching.

An effective and economical treatment option is to have the patient complete a two-week tray bleaching treatment. The bleaching therapy we prescribed was to wear the bleaching tray in the evening, using a 16% carbamide peroxide solution (NiteWhite ACP, Discus) for one week. We would increase the dosage to a 22% carbamide peroxide solution (NiteWhite ACP, Discus) the second week. Upon completing the bleaching sequence, the patient raised the value of her teeth to a B1 shade as measured with the digital shade-taking device.

Tooth proportion and gingival display

The ideal height-to-width ratio of the maxillary central incisors is 75% to 80%. The patient’s centrals are a bit short of that. Also, when the diastema is closed, the width will increase as the height stays the same. Treatment to close the diastema will move the height-to-width ratio in the wrong direction. However, if the tooth is made longer, this ratio can be improved. Increasing the length of the teeth in an incisal direction would be inappropriate. But if there is room to increase the length of the centrals in an apical direction, you have the opportunity not only to improve the height-to-width ratio, but to address the excess gingival display.

Using photos of the patient’s smile, we present the option and benefits of increasing the length of the centrals. She is very interested in decreasing the amount of gingival display and asks to pursue this treatment option.

To determine the amount of tooth that can be exposed, it is imperative to measure the height of the bone on the facial aspect of the teeth to be considered. The height of the bone will determine if treatment is soft tissue only (gingivectomy) or hard/soft tissue (osseous crown lengthening). For this patient, it is determined that we can safely remove 1.5 mm of gingival tissue on the facial aspect of teeth Nos. 8 and 9. After diastema closure, this will create a height-to-width ratio close to 80% and decrease the amount of gingival display by almost 40%.

A diode laser is an excellent tool to perform gingivectomy procedures. A cordless, lightweight diode (NV, Discus) is used to perform the surgical procedure. First, a topical anesthetic is applied for three minutes to the gingival tissue to be removed. Then, using the pulsed mode at 0.8 W, excess tissue is removed (Fig. 1). Figure 2 compares the tissue removal on No. 9 and the recontouring of tissue on No. 10 to the untreated Nos. 7 and 8, demonstrating the subtle difference the removal of a small amount of tissue can make. Figure 3 is the immediate postop photo showing the increased length of the centrals and recontouring of tissue on the laterals to create better symmetry.

Diastema closure

Upon completion of the laser gingivectomy and at the same appointment, we can now address the patient’s chief complaint of closing the small diastema.

Using composite resin, a noninvasive restoration can be placed. The interproximal area mesial to Nos. 8 and 9 is roughened slightly with a fine diamond finishing strip (Axis). The teeth are restored individually starting with No. 8.

The most challenging part of this procedure is to get an excellent color match. To achieve this, a new composite material, Nuance by Discus, is used. Nuance has multifaceted filler particles that reflect surrounding light and create a “chameleon effect,” allowing the restoration to blend to surrounding tooth structure. To create the desired effect, the lingual aspect of the restorations are created by placing a layer B1 shade with a final thin facial layer of EG, a translucent shade.

The B1 Universal shade will match the base shade of the teeth. The translucence will create a depth of color and allow the restoration to blend into the natural tooth color. Although Nuance’s Single Shade Solution replicates the dentin and enamel opacities of a tooth, I prefer the layering technique for a nicer blend into the natural tooth.

The “after” photo on the first page of this article shows the final result at the patient’s two-week recall. The patient is very pleased with the final results. Her goals have been met and exceeded.

Not only is her diastema closed, but her teeth are also whiter and her smile is less “gummy.” She was very happy to spend a little extra time to achieve this result.

Conclusion

There are many ways to treat any clinical situation. However, it is important to listen to what the patient wants. The dentist can then let the patient know if there are treatments available that will help reach this goal, in addition to any other options that the patient may be unaware of that will improve the final result. All the while the dentist should be mindful not to overtreat.

This case is a good example. The patient’s goal was not complex, but with some simple, conservative procedures she had a final result that exceeded her treatment expectations.Understanding current materials and appropriate use of the latest technologies can open the door to a conservatively based cosmetic practice where all parties come out looking good!

References available upon request.

Dr. Gary Radz maintains a private practice in downtown Denver, Colo. He is an associate clinical professor at the University of Colorado School of Dentistry. For more information, go to www.garyradz.com.