General&Restorative Dentistry of Milwaukee

September/October 1998	Jorge Pinero, DDS
Contemporary Esthetics
The Smile Lift Procedure

State-of-the-art techniques and materials can be used to correct an unesthetic diastema caused by tooth position or discrepancies in the size of teeth and arch structure. Proper attention to the proportion of clinical crowns, gingival height, and dental occlusion is essential to a successful outcome.

This article describes the treatment of two patients using veneers and all-ceramic restorations, laser-assisted crown lengthening, and the latest luting systems. It will also demonstrate the integration of comprehensive diagnostics and specialized clinical techniques to achieve desirable final restorations.

Esthetics

Facial

Facial esthetics is an individual detail that most people focus their entire life on. If we look at the cosmetics industry and its products, we are assured that this is an overwhelming concern for many. To most of the population, the definition of a beautiful appearance focuses primarily on overall facial esthetics.

Dental

Unless the person is continually smiling, however, dental esthetics is often secondary in the realm of facial esthetics. When one person speaks to another, they focus first on that individual’s eyes and then on the anterior teeth. If all is harmonious and proportionally balanced, the person’s attention focuses back to the eyes and other facial features. For this reason, there are many people whose primary focus is on the appearance of their smile and dental esthetics.

Unesthetics

Diastemas and Short Teeth

Figure 1a
A large diastema is a challenging concern for the patient and clinician

Many of these same people refuse to smile or laugh for fear and/or embarrassment of the appearance of their smile. For most people, the largest concern of a smile relationship is often the anterior six incisors and their relationship to the lip line and papillary line. Of the many unesthetic problems we see, diastemas and short teeth are the most noticeable (Figure 1A).

A large maxillary diastema is very unesthetic and may cause a suppression in smiling or laughter for many people. The reason for this embarrassment is the large dark spaces and short teeth that give the appearance of a gummy, unattractive smile. Many of these patients are concerned with others fixating their attention on their inelegant smile.

The successful outcome of this esthetic smile lift comes from attention to the patient’s demands, expectations, and their clinical limitations. Careful pretreatment planning is the key to a successful outcome for the patient and the clinician.

Patient Evaluation and Treatment Planning

S.W.O.T.

Initial comprehensive examinations, smile analysis, and occlusion evaluation are prerequisites to any restorative therapy.1,2 Before treatment planning, the patient’s expectations were measured with a S.W.O.T. (Strengths, Weaknesses, Opportunities, and Threats) Evaluation.

Cotreatment Plan

After this initial dialogue between the patient and clinician, the clinician should have the patient’s clear objectives in mind before formulating a treatment plan. A cotreatment plan should emerge to provide the most favorable approach to meeting the patient’s and clinician’s expectations.

The Golden Proportion

To determine the most favorable esthetic outcome, treatment planning for the Smile Lift Procedure™ can be an elaborate process. The mesiodistal widths and incisocervical lengths of the teeth based on averages are the basis for the ideal treatment plan. The Golden Proportion was used to determine the average mesiodistal width of the centrals, laterals, and canines. The Golden Proportion was also used to determine the width/length ratio of the corresponding teeth.3

Clinical Crown Length

The increase in clinical crown length is often needed to provide the ideal width/length ratios. This can be accomplished by a variety of methods, including conventional gingivectomy, electrosurgical gingivectomy, and for the purpose of this article, a CO2 laser-assisted gingivectomy/gingivoplasty procedure.4 The increase in length can also be accomplished with veneers or ceramic crowns.5

Limiting Factors

The limiting factors are the gingival attachments, periodontal health, and the incisal edges of the teeth with relationship to the occlusion and phonetics. For most diastema-closure procedures, there is a requirement of increasing the length of all anterior teeth and the widths of the laterals and canines adjusted to the Golden Proportion rules.6

Gingivectomy/Gingivoplasty Technique

CO2 Laser

The author uses a technique that involves a gingivectomy/gingivoplasty procedure to increase clinical crown lengths. This procedure used a Luxar CO2 Laser (Luxar Corporation). Before the CO2 laser procedure, the free and attached gingival height is marked with a periodontal probe to determine the postsurgical gingival height without disturbing the periodontal health.

Benefits

CO2 lasers are extremely beneficial in the field of esthetic dentistry. Their use is very quick and efficient, often resulting in diminished pain from the traditional periodontal modalities. Also, the CO2 laser leaves a dry, bloodless field, often allowing preparations to be completed on the same day.7 In addition, a very favorable tissue response is noted within 1 to 2 weeks of the surgical procedure. The author prefers its use rather than electrosurgery because electrosurgery has a deeper penetration of thermal effects on the periodontal tissues and surrounding teeth.8

Protecting Hard Tissues

One of the key determinants of any laser usage is the protection of any hard-tissue structure, such as the teeth and alveolar bone, from the laser beam.9 This can be accomplished by using a #7 beavertail spatula and placing the broad blade in the gingival sulcus while the tissue is excised with the laser.4 The author recommends the use of low energy in a gated or interrupted mode, because this generates a lower thermal effect on the surrounding tissues.

Gingival Height Reduction

The Luxar CO2 laser has the ability to reach difficult areas because of its contra-angle handpiece design on a hollow wave-guide delivery system. A fine ceramic tip insert on the handpiece is used parallel to the long axis of the tooth wall. A circumferential troughing approach is first used to eliminate the height of the gingival crest to about 1-mm shy of the demarcated periodontal markings.

Recontouring Tissue

After a gingival height reduction is made, a gingivoplasty technique is performed to recontour the tissue to optimal esthetics. A contra-angle laser handpiece and ceramic tip are used to recontour the gingival tissue in a defocused setting.

The tissue is lased at a 90-degree angle to the beam in an “eraser”-like fashion, recontouring the tissue to a rounded esthetic contour that possesses the proper emergence profile. This is accomplished in all teeth before the preparation of the restorations.

“Bandaging” the Tissues

When the “periodontal lift” is attained, the teeth are prepared for their intended restorations to the gingival height. The gingival tissues should be relased at a low wattage (2 watts) in a defocused mode to ablate all surgical areas until they have a grey coloration. This “grey membrane” acts as a bandage of the tissues, which promotes the rapid healing and pain-free periodontal surgery.

This tissue is essentially cauterized gingiva that has the vessels, lymphatics, and nerve endings “sealed” to the environment.10 The results are little to no pain, minimal swelling, and of the multiple cases the author has completed, show no resorption of gingival height, which is often the case with other conventional or electrosurgical procedures.11

Case Studies

Case 1

Figure 1B
Preoperative view of the diastema.

A 62-year-old woman presented with a single large diastema between the central incisors (Figure 1B). For this patient, the diastema was a significant esthetic concern for many years. Previously, she had veneers placed on the maxillary centrals to close the gap. The result was an improved appearance; however, ideal esthetics was not achieved because of the large centrals and shorter laterals and canines.

Treatment Plan

The patient fractured a veneer on the right central incisor and wanted to replace it with a veneer. A comprehensive examination, including an occlusal evaluation, was accomplished. The patient’s requests were discussed via the S.W.O.T. evaluation and diagnostic video imaging of the maxillary and mandibular teeth to improve the facial esthetics.

The clinical concerns and limitations were discussed with the patient, and a treatment plan was developed to include the following:

Closure of diastema between the maxillary central incisors.
Increase gingival height of all anterior teeth.
Increase incisal length of centrals and laterals.
Increase width of laterals and canines to ideal proportions.
Equilibration of occlusion to proper anterior guidance.
Improve mandibular plane of occlusion.
Improve phonetics.
Improve the esthetics of the lip position-teeth position-periodontal triad.
Improve total facial esthetics via the Smile Lift Procedure™.

The primary focus of this treatment plan was to take an excessive mesiodistal width of the maxillary arch with the resulting small incisocervical length of the maxillary anterior teeth and the large diastema present.

Crown Lengthening

Figure 1C
Facial view of preparations and line demarcation for crown lengthening.

To have a more favorable incisocervical relationship, clinical crown length was increased by the use of the CO2 laser in the technique described above (Figure 1C). The areas of primary concern were the lateral incisors and canines with very short clinical crowns. The centrals also had an undesirable length/width ratio.

Preparing Maxillaries

Figure 1D
CO2 laser-assisted gingivectomy/ gingivoplasty technique.

Gingival recontouring showed a dramatic improvement in esthetics before the preparations of the maxillary teeth. The six maxillary teeth were prepared in the conventional manner for veneers in the canines and full-coverage ceramic restorations in the central and lateral incisors (Figure 1D). As a result of the translucency of the all-ceramic restorations, the final restorations do not require a subgingival placement. Therefore, preparations extended to the gingival height.

Provisionals

Figure 1E
Provisionals fabricated at the crown-lengthening appointment.

Figure 1F
Final restorations at try-in appointment. Note healing after 2 weeks.

Final impressions were taken with ExtrudeŒ (KerrŒ Corporation) vinyl polysiloxane impression system. Provisional restorations were fabricated with InterTemp™ (E&D/KerrŒ) and the use of a custom omnivac shell to the proposed final prosthetic dimensions and esthetics (Figure 1E). These provisionals were spot bonded to facilitate removal at the final try-in visit.

A diagnostic impression was taken to provide the laboratory with a guide to fabricate the restorations. Laboratory fabrication of the belleGlass™ HP (belle de st. claire) restorations was completed using the model of the provisionals. The final restorations duplicated the superb esthetics and shape of the provisionals (Figure 1F).

Restoration Try In

The provisional restorations were removed, and the teeth were polished with a flour of pumice slurry, scrubbed with an antibacterial 4% chlorhexidine solution, and rinsed with water. The belleGlass™ HP restorations were tried in with K-Y Jelly (Johnson & Johnson). The use of a water soluble, clear try-in gel aids in the determination of the proper hue, value, and chroma of the restorations before final placement. The need for custom staining in the adhesive luting materials is demonstrated by the differences in color of the opposing dentition.

Final Color and Placement

Figure 1G
Final restorations placed with custom color-modified adhesive technique.

A trial mixture of composite stains (Kolor+Plus™, KerrŒ Corporation) was used to modify the final color blend of the restorations before final placement. After patient approval, the final restorations were placed via the total-etch adhesive wet-bond technique (Figure 1G).12

Patient and Clinician Gratification

The treatment outcome was a significant change in this patient’s life.

Figure 1H
Facia view of the Smile Lifté Procedure shoing esthetic improvement.

Beautiful teeth gave her a new reason to smile and complemented her facial esthetics (Figure 1H). As dentists, we are rewarded with extreme professional gratification when we can provide a life-changing experience for a patient.

Case 2

Figure 2A
Preoperative view of diastema and PFM restorations.

A 43-year-old woman presented with a large maxillary diastema and a long history of attempts to improve the esthetics of her smile and resulting facial esthetics (Figure 2A).

Previous treatment included orthodontics, veneers on the maxillary central incisors, followed by full-coverage porcelain-fused-to-metal (PFM) restorations. The patient was very dissatisfied with the outcome of all previous attempts.