Optimal aesthetics IDA galway 2010

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IDA pearls of wisdom Galway 15 May 2010

Optimal aesthetics

Dr Aisling O'Mahony & Dr Anne O'Donoghue

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Optimal aesthetics IDA galway 2010

  1. 1. Tips for optimal aesthetics of anterior teeth Sat 15 May 2010
  2. 2. Today‟s Speakers Dr Aisling O‟Mahony Restorative Dentistry Dr Anne O‟Donoghue Periodontology & Implant Dentistry
  3. 3. Scientific Principles of Aesthetic Dentistry Smile Diagnosis/Analysis
  4. 4. Non Negotiables!!  Good oral health  Comprehensive assessment  Necessary radiographs  Study casts – mounted?  Photographs  Diagnostic wax up  Understand patient desires/expectations  Road Map  Diagnostic wax up  Diagnostic try in  Agree the goal of treatment – KNOW END POINT FIRST  Can we deliver?
  5. 5. Smile Diagnosis/Analysis  Determine patient‟s concerns and expectations  Evaluate what is present  Diagnose the problems  Treatment options
  6. 6. Use what we were taught for dentures and morphology!! 1. Facial Reference Lines 2. Dimensions & Proportions
  7. 7. Facial Reference Lines 1. Interpupillary line 2. Upper lip line 3. Lower lip line 4. Midline 5. Incisal Plane Scientific Principles of Aesthetic Dentistry
  8. 8. 1. Interpupillary Line  Evaluate:  Gingival Margins  Orientation of the incisal plane
  9. 9. Concave Gum Line
  10. 10. Facial Reference Lines 1. Interpupillary line 2. Upper lip line 3. Lower lip line 4. Midline 5. Incisal Plane Scientific Principles of Aesthetic Dentistry
  11. 11. 2. Upper Lip Line  Evaluate:  Incisor length at rest  Men show on average 1.91mm tooth when lip is at rest  Women show on average 3.4mm tooth when the lip is at rest  Younger people show more (3.3mm) than older people (1.26mm) Vig and Brundo 1978
  12. 12. 2. Upper Lip Line  Evaluate:  Gingival marginal position during smile  Asymmetry ─ ─ ─ ─ ─ ─
  13. 13. 2. Upper Lip Line  Evaluate:  Gingival marginal position during smile  Asymmetry “High lip line” “Low lip line”
  14. 14. „Gummy smile‟ or Vertical Maxillary Excess How much is too much?? 2-3mm good >3mm ???
  15. 15. Facial Reference Lines 1. Interpupillary line 2. Upper lip line 3. Lower lip line 4. Midline 5. Incisal Plane Scientific Principles of Aesthetic Dentistry
  16. 16. 3. Lower Lip Line  Occlusal cants
  17. 17. Facial Reference Lines 1. Interpupillary line 2. Upper lip line 3. Lower lip line 4. Midline 5. Incisal Plane Scientific Principles of Aesthetic Dentistry
  18. 18. 4. Midline - Facial vs dental  Run perpendicular to the interpupillary line  Midline of central incisors coincides with midline of face in 70% cases Miller et al. 1979
  19. 19. 4. Midline - Facial vs dental  Max and mandibular midlines do not match in 75% cases – not a problem
  20. 20. 4. Midline greater than 4mm off centre is a problem 4mm
  21. 21. Facial Reference Lines 1. Interpupillary line 2. Upper lip line 3. Lower lip line 4. Midline 5. Incisal Plane Scientific Principles of Aesthetic Dentistry
  22. 22. 5. Incisal plane  Curvature emphasised by lower lip line
  23. 23. 5. Incisal plane  Curvature emphasised by lower lip line
  24. 24. Tooth Dimensions & Proportions  Central tooth is DOMINANT tooth  Lateral is always smaller
  25. 25. Tooth proportions  Central is dominant tooth  Longer than it is wide • 10.5-11.5mm long • 8-9mm wide • <6.5mm wide ( too skinny) • > 9mm maximum (too square)
  26. 26. Tooth proportions  Lateral is always smaller  2/3 width of the central (Golden Proportion)  Canine • 2/3 width of the lateral
  27. 27. Need to know the dimensions of teeth!!!  Proportion and Idealism  Optimum size of central incisor  Optimum size between central, lateral and canine  Symmetry  Perspective and Illusion  The art of camouflage
  28. 28. Symmetry very important
  29. 29. Symmetry  Good result  Lateralise the canine  Asymmetry of arch  Veneer the central-length  Hypoplasia of central  Veneer the first premolar  Missing lateral incisor
  30. 30. Facial Reference Lines 1. Interpupillary line 2. Upper lip line 3. Lower lip line 4. Midline 5. Incisal Plane Scientific Principles of Aesthetic Dentistry
  31. 31. Scientific Principles of Aesthetic Dentistry Morphotypes & Hygiene
  32. 32. Aesthetic risk assessment for periodontal-plastic surgery Aesthetic risk low medium high factors Medical status No med history Surgical risk Periodontal Non susceptible Early onset P.D. status thick tissue Thin tissue Smoking habits Non smoker Less than Greater than 10 a day 10 a day Patients Low Medium High aesthetic expectations Lip line Low Medium High
  33. 33. Specific oral hygiene  subtitle
  34. 34. Treat inflammation prior to any surgery
  35. 35. Soft tissue health Erosive lichen planus No keratinised mucosa
  36. 36. Gingival Morphotypes Low scalloped High scalloped thick thin simple complex
  37. 37. Scientific Principles of Aesthetic Dentistry Treatment Planning
  38. 38. Treatment Planning  Multidisciplinary approach Perio/pros/ortho/endo/surgery – combination  Customised roadmap
  39. 39. c/o „do not like my front teeth‟  Short incisors  Edge to edge occlusion  Difficult restorative
  40. 40. Orthodontics  Creates horizontal overlap  Simplifies restorative treatment
  41. 41. Treatment Planning
  42. 42. Treatment Planning
  43. 43. Treatment planning
  44. 44. Road Map  Decide end point first  Establish correct incisal length  Dominant centrals  Convex smile line  Check tooth anatomy –dimensions, proportions etc  How bright?  What Jaw position?  Diagnostic casts and wax ups?  Conveying this information to the patient
  45. 45. Diagnostic composite addition  No etch, no bond - Mock up Quick Simple Easily removed
  46. 46. Diagnostic composite addition  Helps patients understand why changes in gingival architecture are necessary
  47. 47. Diagnostic composite addition  Diastema closure?
  48. 48. Diagnostic Protemp addition  Improves communication with patient
  49. 49. Scientific Principles of Aesthetic Dentistry Crown Lengthening
  50. 50. Understand anatomy
  51. 51. TIPS IN CROWN LENGTHENING FOR AESTHETICS  Patient Expectations  Lip Smile Lines  Extent of The Aesthetic Issues  Tissue Quality / Condition  Biotype of the Tissues  Probability & Predictability of Achieving Success  Potential Complications
  52. 52. Diagnostic composite addition  Gives visible treatment prediction  Can be used as during crown lengthening surgery
  53. 53. Pre-surgery Planning and discussion with the patient
  54. 54. Pre-surgery Planning and discussion with the patient 
  55. 55. Get the right instruments
  56. 56. SM 63 SM 69 POINTED SM 64 SINGLE SIDE SM 68 CURVED SM63
  57. 57. Patient expectations Black triangle disease
  58. 58. Post crown lengthening when to restore with final restoration.  If bone removal is carried out a healing period of six months prior to definitive restoration is advised Pontoreiro & Carnevale 2001  Recommended waiting 6 months after osseous surgery before final restoration; the gingival margin can continue to alter its position even after 6 months Kois
  59. 59. What we don‟t want to do???
  60. 60. Crown lengthening with implant placement
  61. 61. Scientific principles of aesthetic dentistry Implant site development
  62. 62. Rules in aesthetics for implants  “The bone sets the tone but the tissue is the issue”  Preserve the extraction socket  Remember basis surgical techniques  Overbulking with soft tissue  Tissue moulding  Temporary restoration
  63. 63. Preserve the extraction socket  Control marginal inflammation  Control apical infection  Minimal disturbance of soft tissue  Blood clot
  64. 64. Preserve the extraction socket and tissue
  65. 65. Over bulking soft tissue
  66. 66. Two levels of tension on the flap resorbable/non resorbable Suture for CT graft
  67. 67. Over bulking soft tissue
  68. 68. Tissue moulding and temporary restoration Placement of immediate temporary bridge
  69. 69. How we temporise matters
  70. 70. Respecting the rules
  71. 71. Lack of Planning
  72. 72. Applying the same rules no matter how complex
  73. 73. Scientific principles of aesthetic dentistry Bleaching
  74. 74. Tooth Whitening Carbamide Peroxide 10% (ADA approved )  Hydrogen Peroxide 3.5%  Urea 6.5%  Penetrates to the pulp in 5-15 mins Cooper , Bokmeyer , Bowles. 1992. Haywood , Heymann . 1989.
  75. 75. Night guard vital bleaching (NGVB)
  76. 76. Tooth Whitening - Routine Patients  2-6 weeks  Go to a B1 or A1 shade  Bleach for 2 hours or whole night
  77. 77. Tooth Whitening - Smokers  1-3 months  Shade change is not as predictable
  78. 78. „Inside outside‟ bleaching  CP in access cavity, Sealed or patient inserted  Veneer may not need opaque cement  Wait 2 weeks for full bond strength
  79. 79. Tooth Whitening - Restorations ↓ Restorations do not change shade and may need to be replaced
  80. 80. Tetracycline Staining  6-18 months Haywood VB, Leonard RH, Dickinson GL 1997. Leonard RH. 2003.  .
  81. 81. Safety of night guard bleaching (10% CP) 10 year recalls of 2-6 weeks nightly treatment  No root canals required  No external or internal resorption  No sensitivity outside normal limits  No detrimental effects on tooth structure Ritter AV, Leonard RH, et al. 2002. Leonard RH. 2003.
  82. 82. Higher concentrations of CP?  Greater chance of sensitivity  No better outcome  May be faster, but also less stable
  83. 83. How long does NGVB last with no touch- up or re-treatment? Ritter et al. 2002. Safety and Stability of NGVB: 9-12 years Post Treatment. J Esthet Restor Dent
  84. 84. Scientific principles of aesthetic dentistry Treatment of Recession
  85. 85. Recession? make it longer, thicker, thinner, better?  Free Gingival Grafts (FGG)  Coronally Repositioned Flap (CRF)  Connective Tissue Graft (CTG)  Enamel Matrix Proteins (Emdogain)  Matrix ( Mucograft)  OR ALL THE ABOVE?
  86. 86. Free gingival graft Do not restore area of recession  Advantages  Patients own tissue  Reduce cost  Disadvantages  Donor site  Technically difficult  Maybe adjunctive to other procedures
  87. 87. Connective tissue graft addition to buccal tisssue  Advantages  Patients own tissue  No colour match or over bulking of tissue  Disadvantages  Donor site  Technically difficult  Inadequate tissue
  88. 88. Connective tissue graft added to buccal tissue ▪ Sutured to the buccal flap ▪ Different shapes of grafts
  89. 89. Connective tissue graft
  90. 90. What is Straumann® Emdogain? • Resorbable, implantable material • Enamel matrix protein (Amelogenin) • Gel for easy handling
  91. 91. What is Straumann® PrefGel? • pH neutral, 24% EDTA root conditioner • Removal of “smear layer” before the application of Straumann® Emdogain • Sold separately or co- packaged with Straumann® Emdogain
  92. 92. Emdogain Enamel matrix proteins of animal origin  In February 2008, at a meeting at Ittengen, Switzerland, the 6th European Academy of Periodontology produced three reports supporting the use of Enamel Matrix Derivatives in Periodontal generation.
  93. 93. CONCLUSIONS  The combination of emdogain and coronally repositioned flaps (CRF) in miller type1 and 11 defects was comparable to CRF and connective tissue grafts(CT).
  94. 94. Coronally repositioned flap+emdogain Pull the flap to cover the defect  Advantages  No donor site  Disadvantages  Technically difficult  Unpredictable  Maybe adjunctive to another technique i.e. Emdogain, free gingival graft, mucograft,dermal graft (cost)
  95. 95. Coronally repositioned flap in a cleft lip and palate patient
  96. 96. Emdogain
  97. 97. Emdogain+CRF
  98. 98. Evolving technology...
  99. 99. Mucograft®  Collagen Matrix  Collagen Type I + III  Porcine  FDA  BioGuide  Bilayer  Thicker  2.5-5mm (dry)  1mm (wet)  Indications…
  100. 100. Mucograft® Smooth side (outer)  Cell occlusive  Barrier  Peritoneum  Towards soft tissue  Elastic properties allow suturing Porous side (inner)  Collagen fibers in loose porous arrangement  Cell invasion  Pig skin  Towards the bone defect
  101. 101. Sanz et al. 2009 J Clin Periodontol Clinical evaluation of a new collagen matrix (Mucograft prototype) to enhance the width of keratinized tissue in patients with fixed prosthetic restorations: a randomized prospective clinical trial.  Increasing width of KT  CTG vs CM  CTG increased KTW by 1.7mm  CM increased KTW by 1.6mm  Shrinkage (60%,67%)  Morbidity
  102. 102. Mucograft- Recession
  103. 103. Mucograft One week later
  104. 104. Root Coverage LL1
  105. 105. ↑ KT(keratinised tissue) width UR1
  106. 106. ↑ KT width UR1
  107. 107. ↑ KT width UR1
  108. 108. Mucograft-UR 3 -recession
  109. 109. Root Coverage UR3
  110. 110. No Absolute Fixed Standard  Harmony  Balance  Symmetry  Continuity of form But we have Excellent Basic Guidelines
  111. 111. Join our free dentist directory Join today at www.nidm.ie  Improve your practice visibility  Join a growing network of practitioners

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