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Smile Power/ Cosmetic Crown Lengthening
"Girly" Smile Transformed
GETTING THE FRAME BEFORE THE PICTURE
This shows numerous examples before and after of cosmetic crown lengthening. The most import point is that bone has to be removed in order to achieve the most ideal clinical crown possible. Simply trimming tissue helps in the short term and sometimes adequate but longer lasting, better results need to have the bone underneath affected.
This is a nice case demonstrating sequence and timing of treatment. This patient needed gingival tissue removed prior to orthodontic bracket placement and a gingivectomy (gum trimming) was performed due to her young age, 12. The second picture shows more tooth exposed to allow brackets to be placed. The third photo is after braces around age 16. Yes it is gorgeous but there is more tooth length to be revealed (beauty is in the eye of the beholder). This time in order to obtain the most clinical crown exposure, tissue and bone needs to be removed.
Several before and after examples of getting the “frame”/gingival contours correct before placing the “picture”/restorations. The general dentist should predict that lengthening the teeth would benefit the patient from a cosmetic and often health/inflammation perspective as well. Restorations of the top front teeth should be analyzed for length/ gingival display prior to proceeding.
GUM TRIMMING DURING BRACES
Sometimes gingival tissue swells during orthodontic therapy. Often the patient is not cleaning well or they are trying to clean but the swollen tissue makes it extremely difficult. The swelling is due to the brackets impinging upon soft tissue as well as the bone. If they are close to completing orthodontic therapy and tissue removal isn’t needed to close spaces, removing braces first may be indicated. This will allow healing and tissue swelling may go away on its own before treating. BUT if the patient still has longer to go in orthodontics, isn’t able to clean properly, or concerned cosmetically, then treatment during ortho can be done. Depending upon age <15, I will usually trim the tissue away, review OHI, and place the patient on a more frequent recall schedule with his general dentist. This will hopefully “buy some time” and allow patient to get through tooth movement without having the following results : Decalcification.
Decalcification such as this is unfortunately seen sometimes after braces are removed. Poor home care, high soda/Gatorade intake and or gum swelling as shown prior can be the cause. Restoring this properly will never be as nice as the original tooth itself. Preventing this is imperative.
SWELLING DURING AND AFTER BRACES
These are more examples of tissue swelling and the removal of brackets alone not being enough to obtain health. These patients were fortunately close to the end of the orthodontic therapy. Braces were removed, swelling allowed to go down but obviously not enough. Gum trimming or gum lifting was done based upon patient’s age.
GUM GRAFTING LOWER TEETH
The lower front teeth are a common area of gum recession for multiple reasons. The tissue is very thin in this area, susceptible to injury, and bacterial plaque builds up quickly. My preference is to take tissue from the roof of the mouth. My main goal is to increase the healthy thick tissue to aid in proper home care for many years to come. Sometimes the recession isn’t or can’t be completely covered, but the gain in healthy/keratinized tissue will greatly improve the prognosis of the teeth.
WAITING TOO LONG
Unfortunately due to health concerns, this patient did not proceed with recommended grafting lower anterior. She presented 2 years later with much worse recession and bone loss
GRAFTING WITH DONOR MATERIAL
Here are several examples of grafting, mainly using a donor material. The use a donor avoids a second surgery site, allows multiple teeth to be treated at one time, as well as helps minimize post operative complications/discomfort.
MEDICATION AND GUM SWELLING
The connection between gum disease and systemic disease continues to grow. Diabetes control and gum disease control go hand in hand. The severe gum disease as pictured in this diabetic patient is not only bad for the patient’s teeth and gums but harmful to the overall health of the patient. A diabetic patient does not fight off infection well and periodontal disease is a constant insult to diabetic control. We treat not only to benefit the teeth and gums but also the overall systemic health.
Sometimes medications can cause the gingival tissue to swell and exacerbate periodontal disease. Blood pressure medications (norvasc/amlodopine) in the calcium channel blocker drug class are often the culprit, as well as some other less common. Changing the medication in conjunction with the patient’s medical doctor and making sure the change is good for the patient is a first step to treatment. The first before and after photo speaks volumes about the destruction the swelling can cause. No treatment was rendered except changing the medication and allowing time to heal. The remaining photos are common swellings that are difficult to clean at home and professionally. The swelling creates a “pseudo-pocket” that continues to harbor the harmful bacteria.
Inflammation of gingival tissue for reasons other than bacterial plaque is considered desquamative gingivitis. The underlying cause can be several factors, ranging from pemphigus, pemphigoid, erosive lichen planus, and other systemic disease. A biopsy of the area to try to determine the exact cause is indicated.
GOOD-HOME AND PROFESSIONAL CARE
To oversimplify periodontal treatment, I think of treatment options as good, better, best. GOOD is what you do at home in caring for your teeth and gums and having your teeth cleaned professionally. My ideal is for patients (based upon needs) have alternating cleanings between their dentist and our office. I think of it as the best of both worlds. The general dentist will monitor your teeth and I will monitor your home care and periodontal health
BETTER: DEEP CLEANING
Dr. Sullivan will explain this in great detail at your initial consult. These results show how deep cleaning/root planing/Phase 1 of treatment can give great results. I refer to this as better than what you are able to do at home or what can be done professionally at your regular cleaning visit. Often root planing is definitive treatment for mild/moderate periodontal disease.
BEST: SURGICAL ACCESS
Surgery is needed when the disease is more severe and further access is indicated. There are multiple reasons for this approach which will be explained. A common reason is to visualize the remaining buildup/calculus on the teeth. When there is calculus visible on the x-rays (or not), complete removal is impossible with deep cleaning alone. Surgery is needed to completely eliminate the cause of the infection/disease.
LANAP LASER TREATMENT
LAPIP AND PERI-IMPLANTITIS
LANAP, laser assisted new attachment procedure, continues to show amazing results for treating and keeping the tooth itself as opposed to extraction, and the need to replace the missing tooth. Bone fill is evident in multiple cases using the no cut, no sew procedure. Not everyone is a candidate for this procedure and educating the patient about options and expectations is always important. To see more about this visit the Laser Info tab.
Ailing and failing implants are becoming more frequent but unfortunately a reality of implant placement and how to treat this infection/bone loss is controversial. This patient had symptoms/draining infection at presentation to the office. Follow the before, during and after radiographs and see how bone appears to have regenerated and her symptoms are gone. LAPIP, laser assisted peri-implantitis procedure is promising to help prolong the life of implants that are infected/ailing. It is a good place to start and see how the patient responds, since it is not a difficult procedure to have done and the sterilization of the site during LAPIP is critical to the results seen.
It is unfortunate when we start to see bone loss around an implant and the reason this happens is frustrating. It can be multi-factorial: lack of initial integration, overloading, patient compliance, lack of patient care, smoking, existing periodontal disease, poor design, systemic health, the list can go on. This shows the debris/infected exudate that was expressed out when the patient was numbed up to do LAPIP around this implant. , use same photos with xray first as is now
To graft or remove the frenum (muscle pull) is sometimes difficult to decide and varies based upon the clinician. The frenum was removed and the patient able to maintain the site better with home care. Of course following the area to determine if it is stable long term is an important part of therapy.
Exposing impacted teeth while preserving the attached tissue is sometimes more difficult that cutting a window around the tooth. My goal is to expose the soft tissue impacted tooth and preserve the keratinized tissue at the same time by apically positioning the tissue. This doesn’t expose as much tooth structure but ultimately produces a healthier soft tissue environment.
I included this since I find myself saying this at least daily often more. I don’t restore caries, your general dentist will do any restorations, etc. I want to show people and educate them on the harmful effects that soda, candy/mints, Gatorade, even milk can have on teeth. In my opinion what you drink is not as important as how you drink it. To drink a product quickly and be done with it is far better than “sipping” on whatever you decide, the only exception being water. The acids in soda and Gatorade like products are devastating to enamel. To sip on a drink all day long “marinates” your teeth in that product. Your saliva is unable to neutralize the insult and caries can become rampant.
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