IDA pearls of wisdom Galway 15 May 2010 Optimal aesthetics Dr Aisling O'Mahony & Dr Anne O'Donoghue

1. Tips for optimal aesthetics
of
anterior teeth
Sat 15 May 2010

5. Today‟s Speakers
Dr Aisling O‟Mahony
Restorative Dentistry
Dr Anne O‟Donoghue
Periodontology & Implant Dentistry

6. Scientific Principles of Aesthetic
Dentistry
Smile Diagnosis/Analysis

7. 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?

8. Smile Diagnosis/Analysis
 Determine patient‟s concerns and expectations
 Evaluate what is present
 Diagnose the problems
 Treatment options

9. Use what we were taught for dentures
and morphology!!
1. Facial Reference
Lines
2. Dimensions &
Proportions

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. 1. Interpupillary Line
 Evaluate:
 Gingival Margins
 Orientation of the incisal plane

12. Concave Gum Line

13. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry

14. 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

15. 2. Upper Lip Line
 Evaluate:
 Gingival marginal position during smile
 Asymmetry
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16. 2. Upper Lip Line
 Evaluate:
 Gingival marginal position during smile
 Asymmetry
“High lip line” “Low lip line”

17. „Gummy smile‟ or Vertical Maxillary Excess
How much is too much??
2-3mm good
>3mm ???

18. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry

19. 3. Lower Lip Line
 Occlusal cants

20. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry

21. 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

22. 4. Midline - Facial vs dental
 Max and mandibular midlines do not match in
75% cases – not a problem

23. 4. Midline greater than 4mm off centre is
a problem
4mm

24. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry

25. 5. Incisal plane
 Curvature emphasised by lower
lip line

26. 5. Incisal plane
 Curvature emphasised by lower
lip line

27. Tooth Dimensions & Proportions
 Central tooth is DOMINANT tooth
 Lateral is always smaller

28. 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)

29. Tooth proportions
 Lateral is always smaller
 2/3 width of the central
(Golden Proportion)
 Canine
• 2/3 width of the lateral

30. 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

31. Symmetry very important

32. Symmetry
 Good result  Lateralise the canine
 Asymmetry of arch  Veneer the central-length
 Hypoplasia of central  Veneer the first premolar
 Missing lateral incisor

33. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry

34. Scientific Principles of Aesthetic
Dentistry
Morphotypes & Hygiene

35. 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

36. Specific oral hygiene
 subtitle

37. Treat inflammation prior to any surgery

38. Soft tissue health
Erosive lichen planus
No keratinised mucosa

39. Gingival Morphotypes
Low scalloped High scalloped
thick thin
simple complex

40. Scientific Principles of Aesthetic
Dentistry
Treatment Planning

41. Treatment Planning
 Multidisciplinary approach
Perio/pros/ortho/endo/surgery –
combination
 Customised roadmap

42. c/o „do not like my front teeth‟
 Short incisors
 Edge to edge occlusion
 Difficult restorative

43. Orthodontics
 Creates horizontal overlap
 Simplifies restorative treatment

44. Treatment Planning

45. Treatment Planning

46. Treatment planning

47. 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

48. Diagnostic composite addition
 No etch, no bond - Mock up
Quick
Simple
Easily removed

49. Diagnostic composite addition
 Helps patients understand why changes in
gingival architecture are necessary

50. Diagnostic composite addition
 Diastema closure?

51. Diagnostic Protemp addition
 Improves communication with patient

52. Scientific Principles of Aesthetic
Dentistry
Crown Lengthening

53. Understand anatomy

54. 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

55. Diagnostic composite addition
 Gives visible treatment prediction
 Can be used as during crown lengthening
surgery

56. Pre-surgery
Planning and discussion with the patient

57. Pre-surgery
Planning and discussion with the patient


58. Get the right instruments

59. SM 63
SM 69 POINTED
SM 64 SINGLE SIDE
SM 68 CURVED
SM63

63. Patient expectations
Black triangle disease

65. 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

66. What we don‟t want to do???

67. Crown lengthening with implant
placement

68. Scientific principles of aesthetic
dentistry
Implant site development

69. 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

70. Preserve the extraction socket
 Control marginal
inflammation
 Control apical
infection
 Minimal
disturbance of soft
tissue
 Blood clot

71. Preserve the extraction socket and tissue

72. Over bulking soft tissue

73. Two levels of tension on the flap
resorbable/non resorbable
Suture for CT graft

74. Over bulking soft tissue

75. Tissue moulding and temporary
restoration
Placement of
immediate temporary
bridge

76. How we temporise matters

77. Respecting the rules

78. Lack of Planning

79. Applying the same rules no
matter how complex

81. Scientific principles of aesthetic
dentistry
Bleaching

82. 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.

84. Night guard vital bleaching (NGVB)

85. Tooth Whitening - Routine Patients
 2-6 weeks
 Go to a B1 or A1
shade
 Bleach for 2 hours
or whole night

86. Tooth Whitening - Smokers
 1-3 months
 Shade change is not
as predictable

87. „Inside outside‟ bleaching
 CP in access cavity, Sealed or
patient inserted
 Veneer may not need opaque
cement
 Wait 2 weeks for full bond
strength

88. Tooth Whitening - Restorations
↓
Restorations do not change shade and may need to be
replaced

89. Tetracycline Staining
 6-18 months
Haywood VB, Leonard
RH, Dickinson GL 1997.
Leonard RH. 2003.
 .

90. 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.

91. Higher concentrations of CP?
 Greater chance of sensitivity
 No better outcome
 May be faster, but also less stable

92. 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

93. Scientific principles of aesthetic
dentistry
Treatment of Recession

94. 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?

95. 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

96. 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

97. Connective tissue graft
added to buccal tissue
▪ Sutured to the buccal flap
▪ Different shapes of grafts

98. Connective tissue graft

99. What is Straumann®
Emdogain?
• Resorbable, implantable
material
• Enamel matrix protein
(Amelogenin)
• Gel for easy handling

100. 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

101. 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.

102. 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).

103. 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)

104. Coronally repositioned flap
in a cleft lip and palate patient

105. Emdogain

106. Emdogain+CRF

107. Evolving technology...

108. Mucograft®
 Collagen Matrix
 Collagen Type I + III
 Porcine
 FDA
 BioGuide
 Bilayer
 Thicker
 2.5-5mm (dry)
 1mm (wet)
 Indications…

109. 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

110. 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

111. Mucograft- Recession

112. Mucograft
One week later

113. Root Coverage LL1

114. ↑ KT(keratinised tissue) width UR1

115. ↑ KT width UR1

116. ↑ KT width UR1

117. Mucograft-UR 3 -recession

118. Root Coverage UR3

119. No Absolute Fixed Standard
 Harmony
 Balance
 Symmetry
 Continuity of form
But we have Excellent Basic Guidelines

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