Reshaping a smile without braces

A 21 year old female presented as a first time patient to the dental office. Her chief complaint was she was unhappy with smile, specifically the position of teeth #6, 10 and 27. Both upper and lower arches were severely crowded. Another dentist had suggested braces as the only treatment but the patient absolutely refused it as a treatment option. It was explained that orthodontics was the best treatment option, but not the only one.

For teeth #6 and 10, alternative treatment options to address the patient’s chief complaint were crowns, veneers or cosmetic bondings. All benefits and risks were explained. The patient’s finances limited her options to cosmetic bonding. Due to the labial flare of #6 and 10, sculpting (reshaping) the teeth would require removal of a significant amount of tooth structure. This would lead to nerve exposure so root canal therapy was strongly planned.

On the lower arch tooth #27 was completely lingually displaced from the arch. There was no room for this tooth in the arch, so the only reasonable non-orthodontic treatment option was extraction of #27. On the day of the extraction the patient was anesthetized with 3.6cc of lidocaine, and the extraction was completed by an Oral Surgeon without complication. A simple chromic suture was placed to allow soft tissue approximation and healing by primary intention. The 1 week re-evaluation showed the area of #27 had epithelialized over the wound and healed properly. Treatment of the remaining minor crowding in the mandibular arch was not desired by the patient.

At the next visit, prophylactic root canal therapy on # 6 and 10 was completed by the endodontist. Tooth #6 was anesthetized with 1.7 cc Septocaine and isolated with rubber damn. Access was obtained, and the single canal found was instrumented to 25mm, obturated with gutta percha and cement, and temporized. Tooth #10 was anesthetized with 1.7 cc Septocaine and isolated with rubber damn. Access was obtained, and the single canal found was instrumented to 22mm, obturated with gutta percha and cement, and temporized.

During the following visit, bonding and sculpting of #6 and 10 began. Tooth #6 was completed by an NYU senior dental student, and tooth #10 was completed by a Columbia University senior dental student. No anesthesia was necessary, as the teeth were root canal treated. The temporary fillings on the lingual of #6 and 10 from endodontic access was removed and replaced with a permanent composite filling. The lingual surfaces were roughened with a bur to allow for better retention. Next, the labial surface of the teeth were etched, bonded and MIDLF surfaces were built incrementally with Herculite bonding shade A1. The facial surfaces of the teeth were sculpted, bringing the teeth back into the arch. The occlusion was adjusted as needed. The patient was satisfied with the cosmetic results.

During a followup visit the patient requested a few cosmetic adjustments. The facial surface of #10 was etched, bonded and built up with Herculite bonding shade A4 followed by a external layer of XL2 bonding cover shade. The final contours were sculpted and the occlusion was adjusted. The patient was satisfied with cosmetic results.

After acclimating to the cosmetic bonding on #10, the patient scheduled another visit for cosmetic bleaching of the surrounding teeth. The teeth were isolated with a liquid dam to protect the gingival tissue. Two rounds of bleaching at 10 minute intervals on both upper and lower arches were completed. Patient informed that some white spots are normal and will resolve with time as the color of the teeth settles. Patient was satisfied with the color. Tooth #6 facial composite bonding was adjusted to improve color and give uniformity to the facial surface. Tooth #6 was reduced 1mm facially, etched, bonded and 1mm increments of XL2 composite were added on the facial; Bonding was sculpted and the occlusion adjusted. Patient was satisfied with cosmetic result.

The patient was encouraged to return for any other dental work needed, regarding the cosmetic bonding done, or any future treatment. She was advised to avoid hard foods on teeth #6 and #10. In the future if financially possible, she was encouraged to have porcelain crowns placed on #6 and #10. She was very happy with the final outcome and less timid about smiling and showing off her new teeth. Overall the treatment was delivered in a satisfactory and timely manner.

N.D., New York University College of Dentistry

Categorised in: Dental Student Experiences

This post was written by Interns