DENTAL and AESTHETIC CARE

Minor Dental Adjustments With Main Affect



INTRODUCTION

Within the area of aesthetic dentistry, new supplies are continuously being launched, but the strategies themselves haven’t seen any adjustments within the final 3 a long time—that’s, till now.

The optical properties of enamel are influenced by its chemical composition. Visualization utilizing unique daylight doesn’t at all times suffice to permit an in-depth evaluation and analysis of the tooth construction, thereby risking jeopardizing and even compromising shade selection for an optimum shade match beneath completely different lighting situations.1 Fluorescent mild was efficiently utilized to beat the dilemma. Excitation utilizing fluorescent mild has been proven to ease resin identification and differentiation from pure tooth construction.2-5

The surgical half, in addition to the restorative a part of the depicted remedy sequence, was aided by way of fluorescence-enhanced theragnosis—on this case, the REVEAL (Designs for Imaginative and prescient)  know-how: “An outlined mild spectrum emitted by an exterior supply directed intraorally has the potential to create photoluminescence (emission) as a result of autogenous properties (fluorescence) of the pure tooth construction in addition to as a result of bacterial aspect merchandise outlined as porphyrins. To permit visualization of the emission wavelength (fluorescence), filters are wanted.”1

Aesthetics Simplified With Fluorescence

Recurrently used loupes can supply magnification however don’t enable the consumer to see supplies in several hues as fluorescence loupes do. This know-how makes it straightforward to see the completely different onerous tissues and supplies and eliminates the skilled “guesswork” related to best veneer preparations. The clinician may also see the hard-to-discern interface between restorative supplies and tooth construction, such because the remaining bonding supplies on the tooth floor and extra resin/cement remnants on the restoration margins.

Throughout the next case presentation, we’ll take a step-by-step, descriptive method to indicate how this know-how has aided within the completion of this aesthetic case.

CASE REPORT

A 15-year-old affected person introduced after completion of orthodontic remedy with chief complaints of a “gummy smile” and, as per affected person description, “dinosaur enamel” (Determine 1).

Minor Dental Adjustments With Main Affect

Determine 1. Preoperative smile displaying extreme gingival show and lateral incisors of various, insufficient sizes.

A complete analysis confirmed that the affected person had peg laterals of various sizes and exquisite remaining dentition with satisfactory mesiodistal dimensions. Resulting from extreme gingival show, the crown lengths from her maxillary central incisors all the best way posteriorly to the primary molars weren’t totally seen and due to this fact appeared like inadequately sized enamel.

The choice was made to refer the affected person out for crown lengthening surgical procedure previous to the graduation of the restorative remedy part.

Extreme gingival show attributable to altered passive eruption is a medical situation the place the alveolar crest of bone supporting anterior enamel approximates the CEJ, leading to gingiva protecting extra of the medical crown than what is taken into account to be inside aesthetic limits.6 Aesthetic crown lengthening is a predictable and efficient method to improve the quantity of medical crown displaying in sufferers with extreme gingival show.7 Aesthetic crown lengthening by way of gingivectomy, together with osseous resection surgical procedure, has turn out to be essentially the most broadly used and accepted methodology to perform this process. It has repeatedly been reported that gingivectomy alone is extremely vulnerable to relapse.8,9 Different elements, resembling bacterial plaque, may also result in the event of gingivitis.10 Irritation of the gingival tissues may cause an inflated look of the interproximal papilla that distorts the gingival margin.11 Elimination of bacterial plaque permits for best scalloping and contouring of the gingival margins, an important part to acquiring best outcomes with respect to symmetry and aesthetics surrounding the anterior enamel. Bioluminescence is a predictable and efficient manner to make sure full removing of the bacterial plaque previous to surgical procedure and through postoperative visits to idealize the outcomes of the surgical procedure by the therapeutic part. 

Surgical Remedy

Native anesthesia was administered, and a gingivectomy was accomplished on enamel Nos. 4 to 13 to idealize medical crown show (Determine 2).

A full-thickness mucoperiosteal flap was mirrored on the facial surfaces of enamel Nos. 3 to 14 previous the mucogingival junction. No flap was mirrored on the palatal side. An ostectomy and osteoplasty with rotary devices have been accomplished to determine a bone margin 3 to 4 mm from the CEJs of enamel Nos. 4 to 13 (Determine 3). 

Determine 2. Gingivectomy carried out on tooth No. 8 for visualization of desired tissue top, pre-bone removing.

Determine 3. Full-thickness mucoperiosteal flap mirrored from enamel Nos. 3 to 14 and bone removing 3 to 4 mm away from the CEJ.

The institution of the facial bone margin 3 to 4 mm away from the CEJs of anterior enamel has been proven to create essentially the most steady gingival margin post-op.7 A gingival margin positioned lower than 3 mm from the bone margin on facial surfaces of anterior enamel tends to expertise gingival rebound of roughly 1 mm.7 It is usually vital to make sure that satisfactory bone removing is accomplished previous the road angles towards the interproximal top of bone with out eradicating the peaks of bone immediately interproximally. Publish-op, interproximal papillae will seem bulbous if inadequate bone is eliminated close to the road angles. Avoidance of a palatal flap and removing of interproximal peaks of bone help in sustaining full interproximal papilla fill after therapeutic. Hand instrumentation was used to wash the basis surfaces to assist within the reattachment of the flap margin and institution of a brand new, apically positioned gingival margin. Interrupted 4-0 chromic intestine sutures have been used to fixate the flap (Determine 4). 

Determine 4. Intestine sutures in place after bone and soft-tissue removing.

The affected person was instructed to make use of a chlorhexidine mouth rinse twice each day with mild swishing for 10 days post-op. It was beneficial to take 400 to 600 mg of ibuprofen orally each 6 hours for the primary 48 hours following the process to scale back swelling, irritation, and post-op discomfort. The affected person introduced for a 2-week post-op go to to make sure therapeutic was uneventful. This affected person didn’t expertise any post-op issues. In roughly 10% of sufferers, gingival margins after crown lengthening procedures might proceed to alter as much as 6 months after crown lengthening surgical procedure is accomplished.12 Nonetheless, within the overwhelming majority of sufferers, gingival margins are steady at 3 months after a crown lengthening process.13 This must be thought-about when utilizing aesthetic crown lengthening at the side of restorative dentistry to make sure optimum aesthetics are achieved for sufferers. 

Following the post-crown lengthening surgical procedure therapeutic part, the affected person was reappointed, and impressions have been taken for the fabrication of bleaching trays. The affected person bleached for roughly 2 weeks with LumiSmile 16% (DenMat). In consequence, she attained vital lightening of her whole dentition (Determine 5). 

Utilizing a replica of her fashions, I personally waxed up enamel Nos. 7 and 10 to my desired, proposed form (Determine 6).

Determine 5. Publish-healing view of maxillary anterior dentition.

Determine 6. Wax-up of lateral central incisors.

This was an vital step to finish as a result of it gave me 5 completely different advantages:

1. It allowed me to see what form facially and incisally greatest match aesthetically with the affected person’s dentition, maintaining the concord of her whole smile in thoughts.

2. It gave the porcelain technician a good suggestion of what I used to be in search of by way of common form.

3. It allowed me to measure and assess the gingival tissue heights on the enamel to be ready.

4. It allowed me to have a stent made previous to the prep appointment for straightforward short-term fabrication.

5. It allowed the affected person and myself to judge the custom-made temporaries and be capable of make desired adjustments previous to the fabrication of the ultimate veneers.

The preparation appointment was began by anesthetizing the affected person with one carpule of lidocaine with 1:100,000 Epinephrine, adopted by gingival recontouring on enamel Nos. 7 and 10. Though the final form was satisfactory, there have been some small variations between the gingival contours of these enamel that I felt wanted to be addressed within the hope of achieving a super end result. This was achieved with the assistance of an electrosurgery unit (Determine 7).

The REVEAL glasses have been then applied to obviously navigate the enamel on the deformed lateral incisors and execute a preparation that was stored totally in enamel. With the assistance of the fluorescence know-how, I used to be in a position to clearly see the areas that had thinner enamel growth and keep away from extreme removing. Upon completion of the preparations, a full-arch impression was taken with a polyvinyl siloxane materials (Kerr) within the sandwich method fashion, which captured the marginal element extraordinarily nicely (Determine 8). 

Determine 7. Minor gingivectomy carried out at prep appointment for enamel Nos. 7 and 20 to realize best tissue contours.

Determine 8. Polyvinyl siloxane impression taken of prepped enamel Nos. 7 and 10.

The preparations have been then spot-etched and temporized. OptiBond (Kerr) was spot-cured onto the preparation. The short-term veneers have been then fabricated immediately with Protemp short-term materials (3M) and partially bonded into place. Upon closing analysis of the short-term veneers, small changes have been made to their shapes, and the outcomes have been photographically recorded for higher lab communication (Determine 9).

The feldspathic veneers have been then artistically created by Edwin Fajardo with Excel Dental Studios, Chatsworth, Calif (Determine 10).

Determine 9. Customized temporaries in place.

Determine 10. Newly fabricated feldspathic porcelain veneers on stone dyes.

On the seating appointment, the affected person was anesthetized, and the REVEAL loupes have been once more applied (Determine 11). This time, they allowed me to see the short-term materials and take away it with ease. Moreover, they allowed me to obviously see the realm I had spot-etched and spot-bonded for the adhesion of the temporaries and clear the enamel of undesired remnants. That is extraordinarily vital as a result of typically with common loupes, one can’t see small band/composite remnants on the facial floor, and practitioners generally find yourself with both cracked veneers or rocking restorations. The veneers have been then tried in for match and bonded into place with NX3 Nexus Third Technology Common Adhesive Resin Cement (Kerr). For all bonding procedures, the curing mild used was the Radii Xpert (SDI).

Determine 11. REVEAL loupes (Designs for Imaginative and prescient).

After full curing, eradicating all seen extra luting agent, and sharpening of the margins and occlusal changes, the REVEAL loupes have been once more activated with the fluorescent mild, and thorough marginal integrity was checked. Small items of any remaining extra, hardened luting materials have been additionally eliminated. Not eradicating these miniscule quantities of retained luting resin from the margins would seemingly have had future periodontal implications.

The affected person was then photographed for closing documentation (Figures 12 to 14).

Determine 12. Veneers seated and bonded in place.

Determine 13. The postoperative smile.

Determine 14. (a) The pre-op smile in comparison with (b) the post-op smile, 2 weeks submit remedy completion.


CONCLUSION

In conclusion, using fluorescence improved the standard of remedy we have been in a position to ship by permitting us to see particulars and make corrections accordingly. In our skilled opinion, this method will turn out to be the latest indispensable arsenal addition to each trendy dental apply.


REFERENCES

1. Lee JY, Kim HJ, Lee ES, et al. Quantitative light-induced fluorescence as a possible instrument for detection of enamel chemical composition. Photodiagnosis Photodyn Ther. 2020;32:102054. Doi:10.1016/j.pdpdt.2020.102054

2. Dettwiler C, Meller C, Eggmann F, et al. Analysis of a Fluorescence-aided Identification Method (FIT) for removing of composite bonded trauma splints. Dent Traumatol. 2018;34(5):353–9. Doi:10.1111/edt.12425

3. Stadler O, Dettwiler C, Meller C, et al. Analysis of a Fluorescence-aided Identification Method (FIT) to help clean-up after orthodontic bracket debonding. Angle Orthod. 2019;89(6):876–82. Doi:10.2319/100318714.1

4. Conceição LD, Masotti AS, Forgie AH, et al. New fluorescence and reflectance analyses to assist dental materials detection in human identification. Forensic Sci Int. 2019;305:110032. Doi:10.1016/j.forsciint.2019.110032

5. Fairly IA, Smith PW, Edgar WM, et al. Using quantitative light-induced fluorescence (QLF) to determine composite restorations in forensic examinations. J Forensic Sci. 2002 Jul;47(4):831–6. 

6. Miron H, Calderon S, Allon D. Higher lip adjustments and gingival publicity on smiling: Vertical dimension evaluation. Am J Orthod Dentofacial Orthop. 2012;141(1):87-93. Doi:10.1016/j.ajodo.2011.07.017 

7. Deas DE, Mackey SA, Sagun RS Jr, et al. Crown lengthening within the maxillary anterior area: a 6-month potential medical research. Int J Periodontics Restorative Dent. 2014;34(3):365–73. Doi:10.11607/prd.1926. 

8. Allen EP. Use of mucogingival surgical procedures to reinforce esthetics. Dent Clin North Am. 1988;32:307–30. 

9. Camargo PM, Melnick PR, Camargo LM. Medical crown lengthening within the esthetic zone. J Calif Dent Assoc. 2007;35:487–98.

10. Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol. 1965;36:177–87. Doi:10.1902/jop.1965.36.3.177 

11. Engelberger T, Hefti A, Kallenberger A, et al. Correlations amongst Papilla Bleeding Index, different medical indices and histologically decided irritation of gingival papilla. J Clin Periodontol. 1983;10(6):579–89. Doi:10.1111/j.1600-051x.1983.tb01296.x 

12. Brägger U, Lauchenauer D, Lang NP. Surgical lengthening of the medical crown. J Clin Periodontol. 1992;19(1):58-63. Doi:10.1111/j.1600-051x.1992.tb01150.x 

13. Lanning SK, Waldrop TC, Gunsolley JC, et al. Surgical crown lengthening: analysis of the organic width. J Periodontol. 2003;74(4):468–74. Doi:10.1902/ jop.2003.74.4.468 


ABOUT THE AUTHORS

Dr. Cuevas obtained her DDS diploma from the College of Texas, San Antonio, the place, submit commencement, she additionally served on the college within the aesthetic restorative division for a number of years. She is a member of quite a few dental associations and has served as a contributing editor for the Journal of Beauty Dentistry. Dr. Cuevas has printed quite a few skilled articles on direct and oblique bonding strategies and has lectured nationally and internationally on aesthetic dentistry. She is an lively advisor for a number of dental producers within the space of recent product growth and refinement. Dr. Cuevas is an evaluator for and serves on the board of REALITY Scores & Opinions. Dr. Cuevas maintains a personal apply, the Institute of Esthetic Dentistry, in San Antonio, emphasizing aesthetic and restorative dentistry, and is a medical school assistant professor on the College of Texas Faculty of Dentistry in San Antonio. She may be reached at [email protected]. 

Dr. Walker grew up in Boulder, Colo, and attended the College of Colorado Faculty of Dental Drugs. He moved to Texas to finish his specialty coaching in periodontics and obtained his Grasp’s diploma in Dental Science from the College of Texas Well being Science Middle at San Antonio. Dr. Walker carried out medical analysis regarding bone grafting and dental implants throughout his residency for completion of his Grasp’s diploma that was printed within the Journal of Periodontology. He may be reached at [email protected].

Disclosure: The authors report no disclosures. 

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