As recently as 25 years ago, Dentists were identified solely as well-meaning, necessary evils.
Dentists were important for the relief of pain, but otherwise, they were avoided except in dire circumstances. The occasional dental article in the lay press rarely explored the profession's accomplishments, so consumers thought of practitioners as a static profession.
The lay perception of dentistry today is completely opposite. It is considered an art form and it is appreciated as a profession on the cutting edge. It is next to impossible to pass newsstand without seeing at least one, and frequently several, observations about the profession. This metamorphosis did not occur gradually. It was rapid and dramatic, and it was catalyzed specifically by tooth bonding.
Dental aesthetics has built bridges to sources previously unconversant with the profession. The perception that dentists had the materials and the inclination to pursue this avenue changed dentistry's image, and it generated a public awareness and admiration that is stronger today than at its inception.
While bonding. porcelain Laminates, bleaching, and now aesthetic superstructures (over implants) have augmented this phenomenon, there remains one area that has not yet been fully explored-the dental face lift, the potential to non surgically alter facial structure.
Most dentists are cognizant and appreciative of orthognathic surgery. It Is an important aesthetic adjunct for both dentists and plastic surgeons, but it is surgery. The non-surgical approach is less traumatic and more subtle. It involves Muscle, rather than bone, and is, of course, bloodless.
Fig.I illustrates the muscles of facial expression. The four most consequential are the buccinator, zygomatic, obicularis oris and the triangulars. These muscles intertwine at the corners of the lips to form the intrinsic lip structure. The way in which this muscle complex is supported, extended to a Proper Physiologic Length, determines facial contour. This is most apparent In denture construction where a 'denture look' (loss of the vermilion border of the lips, sagging of the naso-labial folds, etc.) can be eliminated by properly supporting these muscles. The bottom line is a quote from Dr. Judson C. Hickey: "When the contours of the face are not natural, no level of creativity in other aesthetic aspects can achieve a satisfactory appearance."
The following case illustrates this point. Catherine (Figs. 2. 4) presented herself to my office unhappy with her appearance. Not quite certain as to what disturbed her, she vaguely expressed discontent with her smfle.
"I'm considering having my front teeth bonded,' she stated. 'You did it for a friend of mine a few years ago, and I like the way it looked."
Her diagnosis was not logical, but after examining her, I felt she might be pursuing a short-range solution. Her anterior teeth (Figs. 4, 6) were reasonably healthy and attractive, and while they could be improved, I believed the problem was elsewhere.
Catherine's face belies her age. She is in her 20s, vibrant and very intelligent. Yet the image she presented (Fig. 2) was older and tired. Her face sagged, she had no cheek bone effect, and there were deep nasolabial folds. The issue was not her four anterior teeth, but rather, her depressed Premolars and the subsequent lack of support for the buccinator and zygomatic muscles.
I determined to change the misalignment of her smile and enhance the support of her muscles of facial expression. I would do this by bonding porcelain laminates onto the maxilla Canines and premolars on each side, increasing the buccal contour as we progressed distally until her face and smile were properly proportioned.
Although the primary problem was depressed premolars, there was justification for including the canines. Both canines were overcontoured, and their convexities accentuated the depression of the premolars. As the premolars would have to be overcontoured considerably, maintaining these similarly overcontoured canines would have resulted in too much of a full-blown smile.
I discussed the diagnosis with Catherine, carefully explaining how the treatment would alter the shape of her face and broaden her smile. She grasped the concept instantly, and leaped at the opportunity to improve herself.
The initial step was preparation (Figs. 7,9,10,12). This first appeared to be simple. The premolars seemed to require very little reduction, and it seemed the canines only had to be brought into line. Not quite. The canines had to be reduced considerably for a final harmonious alignment (observe the reduction of the distal lobe of the right canine in Fig. 10), and though the overall preparation of the premolars was moderate, proper gingival reduction was essential. The premolar laminates were to be overcontoured considerably so it was vital there be appropriate gingival reduction to allow for a normal gingival emergence without excessive bulk.
My associate, Dr. Bijari Gohari, and I discussed and formulated our approach, and Dr. Gohari meticulously prepared and impressioned the canines and premolars for laminates.
The laboratory prescription posed another problem. It was impossible to predict how far the laminates were to be built out. It was uncertain how much bulk would be needed to attain the required results, so how could my technician (Adrian Jurim. McAndrews Restoradent), who was far less familiar with the case, possibly know?
This was overcome by submitting a very broad, exaggerated outline of what I wanted. It necessitated his overbuilding the laminates considerably, far more than usual. The ultimate responsibility had to be mine.
A second problem for Adrian was the shade. Laminates are generally .5mm thick and when placed over a normally shaded tooth, they yield a naturalness that is unsurpassed. Catherine's premolar laminates were considerably thicker, and thicker porcelain lessens the influence of the underlying tooth, and intensities the effect of the porcelain. If this situation is not painstakingly approached, an unnatural effect would certainly result.
Catherine's shade was between A2 and A3. I prescribed A3 to attain a more natural effect, specifically insisting there be no superficial staining. The laminates would be ground considerably, and I wanted a color that would sustain.
Notwithstanding the vehicle used, be it dentures, full coverage or bonding, altering facial structure necessitates meticulous trial and error manipulation. It took six hours to shape and refine Catherine's laminates. My objective was twofold: Improve her smile and support her muscles at their proper physiologic length, without accomplishing one at the expense of the other. The laminates were gradually reduced with a chipless stone (Shofu), and I had Catherine stand after they were inserted. This was done to more naturally view their effect. When the laminates finally satisfied us both, I smoothed them with a prepolisher (Cerapol, Pfingst and Co.), and then mechanically glazed them with a diamond-impregnated polish and felt wheel (Diaglaze Antraco Inc.).
The change in Catherine's smile is considerable (Figs. 3, 5, 8, 11, 13). She appears younger and more vibrant. The improvement in her facial structure is even more dramatic. The beforc-and-after pictures are only two days apart, yet in Fig. 3, she has cheek bones, her face does not sag, and her nasolabial folds are reduced and refined.
There are two questions that invariably arise about this procedure. How many dentists are performing these procedures? I don't know the number, but the list is growing. I've lectured on this topic for the past 20 years (I recently uncovered a 1971 "Greater New York" manual that showed I lectured on it then). Just recently, Dr. Harvey Silverman, from Cleveland, and Dr. Robert Wolf from Denver, sent me pictures of completed cases that I would have been proud to have produced. And the omnipresent Dr. George Freedman, from Toronto, not only shows me cases he has executed masterfully, he now lectures on this subject as well. How long does it last? This question generally comes from dentists who have experienced plastic surgery directly or who have had members of their immediate family treated, and after a period of time, they have had to have the work "touched up" or re-done. Dental cases have no real relationship to plastic surgery except, hopefully, the results. What I do is not invasive, and it involves both a positive and negative connotation. Dental accomplishments are far less dramatic than those of plastic surgeons. Dentists help in a relatively limited area. If that area is understood, along with its limitations, the clinician can perform an important, worthwhile service. When dentists return the muscles of facial expression to their proper psychological length, the tissue tone and blood supply to that area is improved. With no scalpel, there is no tissue damage. How long does it last? Every situation is, of course, different, but cases I have completed years ago look every bit as good today.
