Electronic Surgery for Improved Estheticspdf
Electronic Surgery for Improved Estheticspdf
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  1. Elliot Feinberg, DDS, FICD, FACDReprinted fromDental Clinics of North AmericaVOLUME 26, NUMBER 4, OCTOBER 1982
  2. Symposium on ElectrosurgeryElectronic Surgery for ImprovedEstheticsElliot Feinberg, D.D.S., F.I.C.D., F A.C.D.*Cosmetic improvement is playing an increasingly important rolein modern society. Patients are becoming more and more aware of theimportant effect their teeth have on their facial appearance and theirsmile, and of the effect the smile has on other people during everydaysocial and business contacts.This awareness is creating increased demand, and greater empha-sis on esthetics in dental restorations. Anterior restorations in particu-lar require an artistic approach to fulfill the demand, and any clinicalprocedure that can help achieve it should be utilized.Discussions of dental esthetics usually relate to proper shade andcolor of the teeth, but these are not the sole important considerations.Granted, color is critically important when isolated teeth are to berestored since they must match the adjacent existing dentition. How-ever, when all of the anterior teeth are to be restored, proper shadeand color alone are not enough; tooth shape and form that will createa harmonious smile line and improve visual appearance then be-come key factors for achieving maximum esthetics routinely.When anterio. crowns are to be fabricated, it is incorrect to as-sume that each patient is born with optimal esthetic tooth size, shapeand form, or an overall dental architecture that blends with his or herfacial configuration and smile. Many patients actually present unhar-monious visual and oral relationships produced by abnormal growthand development, and hereditary aberrations. The rapidly expandingfield of plastic surgery is evidence of the medical profession's recogni-tion of their importance. In dentistry, these factors create a need toinstitute corrective measures to alter the existing tooth form andmarginal level in order to create a satisfactory esthetic appearance withthe new restorations.The most important esthetic objective in restoring the maxillaryanterior teeth is to create restorations that are not too conspicuous and"Associate Clinical Professor, Department of Removable Prosthodontics, TempleUniversity. School of Dentistry, Philadelphia, Pennsylvania; Fellow, AmericanCollege of Dentistry and International College ofDentistryDental Clinic~f North America- Vol. 26, No.4, October 1982891
  3. 892 ELLIOT FEINBERGdo not present an artificial so-called replacement look. In many in-stances, creation of a symmetric visual appearance on either side ofthe midline is a prime factor in achieving this esthetic objective.If the patient has a high smile line, in which the marginal gingi-val line is visible, there should be definite harmony of the gingivalline in relation to the incisal curve of the anterior teeth to accomplishthis goal. In this type of patient, the gingival line has the equivalentimportance in its relation to the teeth that a jewelry setting offers to aprecious gem.If the patient has a high smile line and the gingival margins areexposed by speech or smiling (Fig. I), the desfred symmetric andharmonious setting for the final restoration can be accomplished onlyby raising the level of the marginal gingivae to reshape the clinicalcrowns and re contour the gingival tissues. Electronic surgery is indis-pensable for reshaping and recontouring the tissues to create the newgingival architectural environment for the restoration. The gingivaltissue is sculptured to the desired height around each tooth, using aplaning or shaving motion with a surgical straight wire electrode witharight angle head for increased access. All gingival areas that havebeen reduced should then be beveled to create a thin gingival marginat the desired height (Fig. 2). This is done using points EFIL andEFIR* with the coagulating current. Clinical application of thiste-chnique for over 25 years has demonstrated that by creating ananatomically thin marginal gingiva using the beveling electrodes, thetissue will heal and maintain itself at the same level (Fig. 3).A complete evaluation of the existing esthetics should be apart ofthe diagnostic work-up before treatment is instituted. This can bedone best by observing the patient out of the chair while he or she isin a more relaxed state. With the patient's teeth at eye level, attentionshould be directed to the overall esthetic appearance of the teeth inrelation to the complete oral apparatus. This should include a study ofthe facial contour, length, shape and form of the teeth, the amount ofstructure exposed in normal speech, height of the smile line, andsymmetry on either side of the midline. If the diagnosis demonstratesthat architectural alterations might improve the final result, it is best tocheck out the co-ntemplated changes on a mounted set of study mod-els.The teeth on the study models can be waxed to the intended planof treatment ahd compared with the original models. This methodprovides a visual architectural blueprint of the finalized treatmentplan and can be a great asset in case presentation. After patientacceptance, the model can also be used for fabricating the temporarycoverings that will be used during treatment. Many times, the castmay be grossly prepared and Ion Crowns placed in position torepresent the finished case. By connecting them with Cyano-acrylateglue, they may be used later as a temporary splint by rebasing them onthe patient's prepared teeth once treatment is instituted. The use of*Ellman International Manufacturing Company, 1135 Railroad Avenue, Hewlett,New York 11557.
  4. SURGERY FOR IMPROVED ESTHETICS893Figure I. A, Upper an-terior teeth before being re-stored. Note the level of the gin- Agival line (arrow) of ULl andUL2, which has produced smallclinical crowns. B, New restora-tions in place on anteriQr teeth.The gingival margin has beenraised (dark area) on ULI-UL2to match URI-2. Note estheticimprovement due to symmetricappearance that now exists oneither side of the midline.Bstudy models is extremely advantageous when the diagnosis is ques-tionable and requires a decision for selecting the best treatment planto solve the existing problem.The following clinical cases show the different esthetic ap-proaches that were employed after this type of complete evaluation.Figure 2. Electrodes used for architectural reshaping of the gingiva. (EFIL andEFIR, Ellman International Manufacturing, Inc.)
  5. ELLIOT FEINBERG
  6. SURGERY FOR IMPROVED ESTHEnCS895Figure 4. A, Patient has an exist-ihg jacket on the upper right lateralincisor. Note the small clinical crownlength as compared with that of theupper left lateral tooth. B, Gingivalmargin was elevated and beveled tomatch the gingival level of the otherlateral incisor. G, The finished crownrestoration on the prepared lateral in-cisor now harmonizes with the nonpre-pared lateral on the other side.appearance of the anterior restorations and harmony between the gingivalmarginal line and the plane of the incisal edges. Visually, the crowns on eitherside of the midline now have approximately the same size and present aharmon.ious esthetic look (Fig. 5C).Figure 5. A, This patient has threeanterior porcelain jackets. The replace-ment is evident owing to uneven heightof the gingival line, resulting in a difIer-ence in the clinical crown length oneither side of the midline. B, The gin-gival margin is elevated on the right sideto match the gingival height of the teethon the other side of the midline. G, Withthe finished restoration in place thesymmetry in shape and size of the crownis evident.
  7. 896ELLIOT FEINBERGCase Study 3A woman with congenitally missing laterals reached a stage in her per-sonal life at which she wanted to jacket the upper anterior teeth to improveher cosmetic appearance (Fig. 6A). A complete diagnostic evaluation indi-cated that fabricating routine porcelain jackets for the anterior teeth wouldfurther compound the esthetic problem, since the restorations would appearlarge and artificial when the intraproximal spaces were closed. The estheticapproach must include surgical modification of the supporting structures tocreate a new architectural environment, one that will compensate for theabnormal growth and development pattern that occurred as a result of thecongenitally missing laterals. The final treatment plan must include the fol-lowing: raising the gingival line over the centrals to create a symmetric curvefrom premolar to premolar, and raising the incisal edges of the centrals tocreate a new incisal plane of the anterior teeth. These two steps would givethe visual illusion of raising the centrals in the maxillae (Fig. 6B). The ele-vation of the gingival line of the centrals and cuspids would now place theshoulder of the prepared teeth at a more narrow area of the tooth and offer theability to create more tapered final restorations. This, with lingualized in-traproximal contacts, would make the final restorations look smaller than theirFigure 6. A, This patient with congenitally missing laterals desired anteriorrestorations. B, Arrows show the gingivallirie to be raised on both centrals. The newmarginal gingiva will follow the symmetric curve (dotted line). Incisal level of the newcentral restorations will coincide with dotted lines. C, Final preparation of the sixanterior teeth after gingival healing. Canines have been prepared as laterals andpremolars as canines. D, Architectural surgery has produced harmony between the oralenvironment and the porcelain jackets. The patient no longer exhibits a broad expanseof gingiva anteriorly in her smile line, and the restorations are now symmetric in sizeand form.
  8. SURGERY FOR IMPROVED EsTHEnCS 897actual mesiodistal size. In addition, to present a more normalized look of thesix anterior teeth, the cuspids must be prepared for lateral replacements andthe first bicuspids for cuspid replacements (Fig. 6C).Surgical modification of the architectural environment has made it pos-sible to create marked improvement in cosmetic appearance by altering toothform and shape rather than the color and shade of the final restorations (Fig.6D).Case Study 4Because her appearance was affecting her personal relationships, a17-year-old woman desired closure of the anterior spaces for cosmetic reasons(Fig. 7A). A diagnostic evaluation revealed that closure of the interproximalspaces with porcelain jackets would probably result in unsuitably largereplacements. The treatment plan included corrective surgery of the gingivaand bone so that the new clinical crowns would be of a narrower circumfer-ence than the individual teeth (Fig. 78). This provided the architecturalenvironment to create a more tapered restoration. Despite the increasedmesiodistal diameter of the final restorations, the overall cosmetic appearancehas created the illusion of normal-sized anterior teeth (Fig. 7C).Case Study 5A female patient who had been fitted with a six-unit anterior fixed bridgeto replace the missing laterals desired a new and different cosmetic appear-ance. The diagnostic evaluation revealed that there was very little physicalspace for lateral replacements and that the anterior teeth appeared large andunsightly (Fig. SA). To create more room for replacing the laterals, electronicsurgery was used to elevate the clinical crowns of the teeth as well as thepontic saddle areas. As a result the teeth now harmonize in size and shapewith her overall dentition and smile line (Fig. 88).Figure 7. A, This young girldesired closure of space for cosmeticreasons. B, Six anterior teeth are pre-pared. The gingival line has beenraised to create a new crown formand shape. The shoulders of the pre-pared teeth are of narrower circum-ference than those of the individllalteeth. G, Anterior porcelain jackets.Note that the teeth do not appear tohave large mesiodistal diameters,owing to surgical preparation of thegingival tissue.
  9. 898ELLIOT FEINBERGFigure 8. A, Patient has asix-unit fixed restoration replac-ing the laterals. B, New anteriorrestoration in place. Electronicsurgery to create a new architec-tural environment has made itpossible to eliminate "the re-placement look."CONCLUSIONIn many cases, abnormal growth and development factors requiresurgical modification of the architectural environment in order tocreate restorations that better harmonize with the patient's smileline.To accomplish this, a complete esthetic improvement approachmust include the use of electronic surgery to reshape and redefinethe gingival marginal line wherever indicated.Harwood BuildingSuite 322Scarsdale, New York 10'583
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