Actress-Model Competitive With Wider, Softer Smile
By Irwin Smigel, DDS
Occasionally the obvious defies detection. We become so immersed in our own area of expertise that cases are viewed through tunnel vision - and only when they are resolved elsewhere do we observe them objectively. The case of Fern, an attractive actress and model, aptly illustrates this point.
Fern, competing in a highly competitive field, was told by an agent that her smile was detrimental to her career. This came as no surprise. She'd always been uncomfortable smiling and was especially unhappy about the diastema between her maxillary centrals. The agent's suggestion, however, spurred her into action. She inquired around and was recommended to a bonding "specialist." The "specialist," assuring her he would eliminate the problem, bonded both centrals to close the diastema.
The procedure itself was properly performed and she looked slightly better, but it had dealt only with the superficial. Her smile (Figs 1, 4, and 6) was still a drawback. Fern showed too much tissue and not enough teeth-an unflattering effect further exaggerated by very short teeth. Closing the diastemas had done little toward improving her appearance and her agent was unimpressed.
Fern returned to her family dentist for advice. He sent her to my office requesting I consult him prior to initiating treatment. At the first visit, after x-rays and an examination, the diagnosis was obvious. I told Fern that before I could perform a corrective aesthetic procedure, periodontal intervention was essential for a successful resolution of her case.
Fern had presented with an "altered passive eruption" in her maxilla. The gingival tissue had not receded to its normal position at the cemento-enamel junction and aesthetically restoring the stunted clinical crowns required crown lengthening surgery on the gingivas. After the corrective periodontal surgery, eight porcelain laminates from first premolar to first premolar would complete the smile alteration.
Her dentist called soon afterwards. He agreed wholeheartedly with my treatment plan, and asked if I would mind having Dr. Burton Langer perform the surgery.
Not in the least, I'd known and worked with Dr. Langer for years. One of the outstanding periodontists and implantalogists in the country. Dr. Langer is not only highly respected scientifically, but is an aesthetic authority as well.
Fern returned to my office to re-discuss her treatment. I wanted to make certain she understood the approach. Fern not only comprehended but couldn't wait to implement it.
Dr. Langer's task involved several procedures. He started by elevating internal bevel flaps and removing a collar of tissue to expose the cemento-enamel junction. Osseous surgery was then performed to ensure the approximate presence of a 3mm height between the alveolar crest of bone and the cementoenamel junction - the physiologic width of periodontal gingival fibers and epithelial attachment above the crest of the bone. The gingiva was repositioned at the cemento-enamel junction. Positioning it beyond that could cause root exposure and unnecessary disfigurement or sensitivity. In essence, Dr. Langer undid nature's failure in the eruptive process.
It was three months later (after healing and maturation had reformed a normal gingival sulcus), that I saw Fern again. She was a new person. Dr. Langer had taken a pretty girl with an immature smile and returned a very attractive lady (Figs. 2 and 7) who had the potential to be truly beautiful.
My responsibility was to help Fern realize that potential. But where would I start and how should I shape the teeth and why?
There is, of course, no definitive rule of thumb that can apply to every situation. The images we conceive are frequently dependent on a patient's size, facial dimensions, and personality. Yet there are concepts that must be considered-particularly when they are inherent to the vision of aesthetics of that particular time.
I recently had the privilege of sharing a seminar with Dr. Jeff Golub, a highly esteemed aesthetic dentist in New York City. It was my first experience with Jeff and I was gratified to discover we share similar views on aesthetic essentials. We both believe that smile concepts in the eighties have evolved into a new, exciting dimension. Teeth today in part energy and vitality to the face as well as contribute to its support from within. Accomplishing this however, often necessitates large anterior teeth and overcontoured premolars.
Observe Figs. 2 and 4. In Fig 2. Fern's smile is dominated by her anterior teeth because her premolars are recessive. In Fig. 4 her centrals and lateral incisors unaesthetically tilt lingually. I was determined to reverse this by building the incisal half of her central and lateral incisors labially. I also intended lengthening her incisors without making the anterior dominance more apparent.
Proper preparation (Fig. 8) was essential. I removed all the composite from her centrals (observe the size of her original diastema) and reduced the central and lateral incisors more gingivally than incisally. This enabled me to change the alignment of her anterior teeth without their appearing overcontoured. The canines were shortened and prepared normally, but the first premolars were only reduced minimally.
All her life Fern had suffered with a large diastema, short protruding anteriors and premolars that were barely visible. Each would now be undone ... Her wide diastema was the least problem. Long teeth always appear narrower than shorter ones of a similar width. Extending her centrals and laterals allowed me to close the diastema without the anterior teeth appearing unnaturally wide (Fig. 9). After blending in her canines, I built the premolars out facially as far as practical so they could be readily seen (Fig. 3). This both widened and softened her smile and enhanced the illusion of delicate anterior teeth.
The results (Figs. 3, 5 and 9) speak for themselves. Fern's smile exudes energy. The centrals no longer lean inward (Fig. 5), and instead 0 tissue her smile (Figs. 3 and 9) emphasizes her teeth.
I frequently use Fern's case at seminars, always emphasizing the importance of referring to special ists. There is no way, I explain, this result could have been obtained without Dr. Langer's intervention. Yet the significance of the case goes far beyond personalities. It reaches to the core of the general dentist's responsibility. Is it enough to only be proficient in one's own area of expertise? I don't believe so. Each of us should continually expand our knowledge - not necessarily to perform but at the least to recognize and refer.
Dr. Gordon Christensen maintains that our profession is advancing so rapidly in so many different areas that those who do not attend lectures or keep up with the literature can in no time fall light years behind. Fern's case was begging for a specific treatment. She lives in New York but grew to maturity in a similar city. In that sophisticated area with so many dentists, why was it not suggested before?