Esthetic procedures update

Sept. 1, 2003
Borrowing the lyrics from one of the rap songs I hear my teenagers listening to, I think dentistry "is like whoa." This has to be the most incredible time ever imaginable to be a dentist. Many colleagues who have retired in the last 10 years or nearing retirement have remarked to me how they wished they were just now starting. Dentistry is exciting! We can do so many things to help people in ways never before possible.

Here's one man's take on why dentistry "is like whoa."

By Kevin Winters, DDS

Borrowing the lyrics from one of the rap songs I hear my teenagers listening to, I think dentistry "is like whoa." This has to be the most incredible time ever imaginable to be a dentist. Many colleagues who have retired in the last 10 years or nearing retirement have remarked to me how they wished they were just now starting. Dentistry is exciting! We can do so many things to help people in ways never before possible.

It is really hard for me to imagine how a dentist can feel burned out or bored with dentistry. If you are still doing pin-retained amalgams with dycal liners, doing nothing but prophys instead of addressing periodontal conditions, doing porcelain-fused-to-metal anterior crowns, then yeah, maybe you're bored — but whose fault is that? Why not learn how to take an old, failing PFM case and turn it into an outstanding functional and esthetic masterpiece?

Here is an example of such a case. A woman came to our office wanting her two front teeth fixed (figure 1). She did not like the darkness at the gumline of #8. After I guided her through a "smile analysis," only then did she notice how #8 and 9 had different angulations, how the color was dark, how deficient she was in the buccal corridor area, how #7 protruded, and so on (figure 2). Now, instead of wanting to fix her two front teeth, the question became, "How can you help me with all of these problems?" Of course, the answer was very simple. Bonded, all-porcelain dentistry made from a thorough esthetic and functional plan could very reliably take care of all of these problems. The end results (figures 3 and 4) were outstanding and the patient was ecstatic!

If you feel like your knowledge is not quite to the point of handling an entire smile, why not start with some basics? All of us replace failing amalgam fillings (figure 5). I would only choose composite for my own mouth, so that is what I use on my patients. While the benefits of composite versus amalgam are numerous, there is certainly at least one thing you can do with composite that you can't do with amalgam. Who among us has not been surprised a time or two by a pulp horn sticking up unexpectedly (figure 6)? This usually means a root canal for the tooth.

How about this? Stop the bleeding, clean things up with a chlorhexidine scrub like Consepsis, apply phosphoric acid and a dentin bonding agent like Optibond Solo Plus, place a layer of a flowable composite (Revolution, Flow-It, or several others) and rebuild the tooth with a composite. For this case, we used Point 4 in multiple layers. After finishing and polishing, the tooth looked like it did in its virgin state (figure 7). Whoa!

That is an example of fun, everyday dentistry. What is it that would make a practitioner want to restore that tooth with a root canal, post, and PFM? Hopefully it isn't greed, rather just a lack of understanding. Educational opportunities abound where dentists can begin their journey of learning cutting-edge techniques. From take-home study courses, online courses, and everything from local meetings and study clubs to the ultimate learning experience like the Las Vegas Institute for Advanced Dental Studies, learning new procedures can start at any level. It has been my experience that, once dentists experience some of these newer materials and techniques, the level of enthusiasm for dentistry soars. And, not coincidentally, profits tend to follow as well.

Here is another common problem that can help you get out of the "same ol', same ol' approach." A patient had an endodontically treated tooth break off at the gumline (figure 8). Also noted was the appearance of internal resorption. The only solution was extraction, but then what? Well, certainly a porcelain-to-metal bridge would work, but there are other things to consider. After extraction, the ridge will begin to collapse. Let's place a very simple-to-use material called HTR (hard tissue replacement) into the socket for an immediate, post-extraction, bone-replacement graft. This will prevent the walls from collapsing and creating an esthetic problem. Other considerations were certainly an implant and crown, which were presented. However, the patient opted not to have this performed. A temporary bridge was fabricated. As a design feature of the temporary, the extraction site healed with an ovate pontic form in place. This allowed lifelike esthetics in the pontic area of the metal-free, all-porcelain Cercon bridge (figure 9). This bridge can be cemented with conventional cements or with a composite luting cement.

OK, so you have seen the light of adhesive dentistry and taken several courses, attended seminars about the subject, and feel fairly comfortable with the concepts. Let's take a case that initially looks like it would finish very nicely in the orthodontic sense. However, after looking more closely, there is an obvious tooth/arch size discrepancy (figure 10). Orthodontic treatment was offered as an option, but the patient chose a different route. She wanted to not only close the spaces (figure 11), but also create a "perfect" smile. This could be accomplished very nicely with porcelain veneers.

Teeth 4-13 were prepared for veneers using Empress porcelain. The diastema between 24-25 was closed with Esthet-X direct composite, using Prime and Bond NT. The end results were both natural and beautiful (figure 12). The transformation of her smile was wonderful. The teeth now are proportional and her smile is gorgeous (figure 13). If affecting someone's life in this manner doesn't create excitement and joy within you as a professional, I'm not sure what would.

Our ability to help people and change their lives is a reality now more than ever before. No longer do we have to be the dreaded bearers of pain. No longer do people despise us and hate coming to see us. By offering services of this magnitude, now people can seek us out as professionals who can help them in ways they truly desire. Everyone wants to look good and feel good. Now dentistry can join plastic surgeons, fitness centers, etc., as providers of this service.

The preeminent service in dentistry is seemingly the full-mouth rehabilitation. This has traditionally been an arduous, time-consuming task that few dentists ever felt comfortable approaching. Once again, using an approach different than what most of us have learned, this service can become one that is quite simple, amazingly quick, and is a culmination of many different aspects of dentistry, including adhesive dentistry, materials, and occlusion.

Here is an example of one such case. A woman exhibited an anterior open bite, poor posterior occlusion with much evidence of occlusal disease, TMD-like symptoms, and obvious esthetic concerns (figures 14 and 15). Using a neuromuscular approach, including use of an orthotic for three months to alleviate symptoms and verify correct mandibular position, this rehabilitation was accomplished in two appointments. The preparation appointment required approximately four hours and the seat appointment approximately three hours.

The results are quite dramatic. As you can see, the open bite is closed (figure 16). With the occlusal disease now under control and occlusal contacts managed meticulously, TMD symptoms have resolved. The esthetic concerns have been handled beautifully and the result is a very happy patient. Not only does she feel much better, now she also looks better (figure 17).

Dentistry is the greatest profession. If only more practitioners would get out and avail themselves to the multitude of continuing-education programs available, I think we would have many, many more happy dentists. The rewards you receive from performing advanced procedures — like those illustrated above — will keep us all from experiencing the burnout and fatigue we too often hear about.

I love to hear my patients say "whoa" when they look in the mirror.

Dr. Kevin Winters graduated from the University of Missouri-Kansas City in 1989. After completing a GPR at the University of Louisville-Humana Hospital, he opened a general practice in Claremore, Okla. After developing a successful general practice and being awarded the Young Dentist of the Year award in 1995, Dr. Winters transitioned his general practice to one that concentrates on esthetics and reconstruction. Dr. Winters is one of the original clinical instructors at the Las Vegas Institute. He also lectures and conducts seminars across the nation. Dr. Winters may be reached at (918) 341-4403 or by e-mail at [email protected].