“Giving Back a Smile…and a Life”
(ARTICLE WRITTEN BY DR. ARNOLD FOR SUMMER 2008, JOURNAL OF COSMETIC DENTISTRY)
James H. Arnold, D.D.S.
My team and I were thrilled to meet Carol when she walked into our office in August 2007. We had been volunteers for Give Back a Smile™ (GBAS) for four years, but had not yet had a patient. We were eager to help someone to change her life, and Carol was the perfect person for us to work with. She had heard about GBAS on television and prayed that she would qualify for the program. She was extremely nervous about having dental work done, but was also eager to find out what we could do for her.
Carol had been abused by a former boyfriend in 1999. He had kicked her in the face and chest repeatedly, causing damage to her teeth and breasts. Several teeth were broken, and she had severe dental pain due to the trauma and resulting malocclusion. Carol had been a model as a teenager, but she had rarely smiled since the abuse (Fig 1). Her broken teeth made her self-conscious about even opening her mouth in public, and she was careful not to show her teeth in photographs.
After eight years of living with little hope of correcting this dental handicap, Carol heard about the Give Back a Smile Program. She hoped to regain her smile, self-confidence, and faith in people as a result of her experience with us. She cried with gratitude when I told her that we could help.
We performed a comprehensive evaluation with a full series of radiographs, digital photographs, diagnostic models, clinical examination of the teeth and periodontium, and patient interview. In addition to the broken teeth, Carol’s teeth were severely affected by tetracycline staining, heavy attrition, inadequate restorations, extensive decay, and lack of professional dental care. This lack of dental care, combined with many years of smoking, had led to moderate periodontal disease and the loss of several posterior teeth. Carol’s Shimbashi measurement (measured from the cemento-enamel junction [CEJ] of the maxillary central incisors to the CEJ of the mandibular central incisors) was only 11 mm, as a result of the heavy wear on her remaining teeth (Figs 2-4). She exhibited Class I occlusion, so we would generally expect to see a Shimbashi measurement of about 16 to 18 mm.
INITIAL PERIODONTAL THERAPY
The first priority was to address Carol’s periodontal disease. Comprehensive oral hygiene instructions were given, root-planing appointments were scheduled immediately, and she began using a chlorhexidine rinse twice daily. After her teeth were thoroughly cleaned under local anesthesia in two visits, we reevaluated her periodontal health at the follow-up cleaning four weeks later. She had already improved tremendously—there was a general decrease in pocket depths (from 4 to 5 mm down to 2 to 4 mm), bleeding upon probing was eliminated, the gingival apparatus appeared to be pink and healthy, and her plaque score improved significantly. Carol was very committed to following through with treatment, and she proved this by her renewed devotion to home care. We proceeded with additional records to finalize our restorative treatment plan.
ADDITIONAL DIAGNOSTIC RECORDS AND TREATMENT PLANNING
Because her dental needs were so great, we decided to do more than just repair the teeth that were damaged as a result of the abuse. Carol needed a more comprehensive solution to her dental condition, so we opted to perform full-mouth rehabilitation. New diagnostic records were taken in preparation for the creation of a diagnostic wax-up.
An NTI appliance was fabricated for her to wear for several nights in an attempt to deprogram (or relax) her very tense masticatory muscles. This facilitated a more accurate centric relation (CR) measurement with an anterior and two posterior bite registrations. Facebow and stick-bite records were also made and photographs were taken to aid our ceramist and laboratory (Marv Staggs, Precision Dental Restorations [PDR]; Salem, Oregon) in accurately mounting Carol’s models for an ideal wax-up. We reviewed and discussed photographs from several smile guides to decide how to design Carol’s new smile. We determined starting points for the shape, embrasures, line angles, and texture of the teeth. We also discussed the desired shades and incisal translucency to be utilized. Lengthening her anterior teeth was one of our priorities, so we mocked-up ##6-11 with flowable composite (3M ESPE; St. Paul, MN) to get an idea of how much length we could add. We increased her maxillary centrals from 6.5 mm to 11 mm, and this seemed to fit well with her lip line and facial profile. We took photographs and made another polyvinyl siloxane (PVS) impression with Aquasil Ultra (Dentsply International; Your, PA) to give the laboratory a good starting point for her incisal edge position.
Local anesthetic was administered so that we could “sound” the bone to determine whether we could do any gingival recontouring. We were able to do laser modification of her gingival contours to improve symmetry, and additional PVS impressions were made.
After discussing options with our ceramist, we decided that our treatment plan would consist of restoring what was left of Carol’s upper and lower arches with crowns and a bridge. Because her teeth were very short, we decided that bonding her restorations instead of cementing them would yield a better result. Additionally, strength and maximizing esthetics were very important to our patient and us.
For these reasons, we believed that Empress (Ivoclar Vivadent; Amherst, NY) crowns for teeth ##4-11 and ##21-29; and a Lava (3M ESPE) bridge for ##12-14 would be the best option. Carol’s treatment will eventually be completed with the placement of four posterior implants or the fabrication of a lower removable partial denture.
PDR provided us with an excellent full-mouth mounted wax-up, preparation guides, Sil-Tech (Ivoclar Vivadent) stints, and initial reduction guides. We evaluated the wax-up with Carol at the preparation appointment and we were both very pleased.
We used the reduction models as guides to modify several teeth so that we could preoperatively transfer the wax-up to the mouth with Luxatemp (Zenith/DMG; Englewood, NJ). This allowed us to verify our records, lengths of teeth, desired CEJ-to-CEJ measurements, proper canine and anterior guidance, and occlusion. We were able to do an initial esthetic evaluation, and the full-mouth Luxatemp mock-up also served as an ideal intraoral preparation guide.
Depth cuts were made into the Luxatemp and tooth structure, which allowed us to maintain even reduction and ideal orientation within the arch form. We prepared ##6-11 first and made a bite registration (LuxaBite, Zenith/DMG), maintaining the new vertical dimension that had been established with the mock-up.
Next we prepared #4 and #5, inserted the anterior bite registration, and made an additional bite registration for the upper right. We repeated this sequence for #12 and #14, continuing to maintain the new vertical dimension by reinserting the anterior and right LuxaBite segments while making a bite registration on the left.
Once the maxillary preparations were completed, we checked the preparation shades, took photographs, and made a maxillary final impression. We used the Sil-Tech stint again to make temporaries, which we sectioned into three segments for the upper arch. The CEJ-to-CEJ measurements and tooth lengths were again verified.
The same methodology was used in preparing ##21-29. Sequential bite registration records were made for the anterior and both posterior sections. We recorded both the relationship from the lower to upper preparations and the lower preparations to the upper temporaries systematically, to ensure that the new vertical dimension was maintained and that all models could be easily cross-mounted by the laboratory.
Once the mandibular impression was made, we temporized ##21-29 with Luxatemp and recorded the bite relationship between the maxillary preparations and the mandibular temporaries. Then we temporarily cemented the maxillary temps and recorded the bite relationship between the upper and lower temps, further ensuring the easy mounting of all models.
A facebow record and stick bite were both made, and photographs of each were taken. Photographs and PVS impressions of the temporaries completed the preparation appointment.
On the laboratory prescription, we specified all of our esthetic and functional goals and provided specific instructions for utilizing the series of bite registrations. We sent all of the relevant photos to PDR on a disc.
Our goal was to restore Carol to a vertical dimension that would allow for ideal function, comfort, and maximum esthetics. Her Shimbashi measurement was increased from 11 to 17 mm, and her occlusion was restored to CR in the temporary stage. Carol tolerated the procedures very well, and she was very comfortable at her one-, two-, and four-week postoperative appointments. If she had any problems with the increased vertical dimension, we could easily have adjusted her temporaries to a position of greater comfort while maintaining proper function.
Her self-confidence had already increased tremendously with her temporary restorations, and she had received many compliments on her improved appearance. She was still learning to smile naturally, but this was becoming easier each day as her inner joy was reflected on the surface. Carol was looking forward to a new future filled with hope and happiness.
A little more than three months after our first consultation, we were ready to deliver exquisite porcelain restorations (Figs 5-7). Once we received the case from PDR, we verified that the occlusion and guidance both looked good on the mounted models. The length, shape, shade, and fit of each restoration looked great, and we received the case exactly as requested.
SEATING THE CASE
When Carol arrived for her seating appointment, she was still very comfortable. The occlusion with the temporaries looked good, which led us to believe that the condylar position was stable. After administering local anesthesia, we removed the maxillary temporaries and cleaned up the prepared teeth. We tried in each restoration individually and then all restorations together. This ensured that they fit well separately and collectively. We very carefully verified that the maxillary restorations occluded well with the mandibular temporaries.
We utilized two shades of RelyX (3M ESPE) try-in paste, one on each side, to see which would yield a more esthetic result. After determining that we both preferred the translucent shade, the maxillary restorations were bonded utilizing standard bonding protocol and the “tack-and-wave” technique.
The maxillary restorations were placed at the same time and were individually “tacked” in with the Bluephase (Ivoclar Vivadent) curing light with tacking tip for one second each. The regular tip was then used in order to “wave” across the arch for a few seconds on the facial and lingual sides. The “wave” allowed the cement to harden to the point where the gross excess could be simply removed with an explorer in large pieces. After carefully flossing, Liquid Strip (Ivoclar Vivadent) was placed around all of the margins (to ensure that the oxygen-inhibition layer cured completely), and final curing was completed.
Maxillary cleanup was completed while the lower arch was anesthetized. After the mandibular temporaries were removed, we utilized the same try-in and seating techniques that we used in the maxillary arch. Occlusion was adjusted slightly, photographs were taken, and postoperative instructions were given.
Carol cried elatedly when she held up the mirror to observe her beautiful new smile (Fig 8). The warm hugs that she gave to my dental team and me made all of the work well worthwhile. Being able to help someone like Carol in such a significant way was humbling for all of us; we all felt that we received far more from this experience than we gave (Fig 9).
Carol has continued to maintain her new restorations with diligent home care and regular dental visits. We are all very proud of her for making the necessary changes in her life and for giving up smoking. She knows that this is a gift that she needs to make the most of, and she intends to do so.
Additionally, she has committed herself to helping other women who have been the victims of domestic violence. She will be the guest speaker at an event that we are planning to benefit the women’s shelters in our area. Her dream is to one day appear on “Oprah” to tell her story and to inspire other women to take control of their lives and to heal the physical and emotional wounds that have afflicted them.
My team and I feel blessed to have participated in Carol’s dental and emotional rehabilitation. I believe that it is our responsibility to give back with the gifts and talents we possess; and that the more we have, the more we have to give. I have tried to surround myself with people who feel the same way, and they showed that same commitment through their generous support of Carol in her life-changing journey with us.
“Dr. Arnold and his team have given me so much; they are truly angels. To give back a smile is to give back a whole new life. I want to live that new life to the fullest and to give back to others. So few people are willing to help others, and often no one wants to get involved.
Dr. Arnold was very gentle and compassionate, and he created a very relaxing atmosphere for my care. My treatment went very well. Fixing the outside is also helping me to fix what’s on the inside.
Unfortunately, people judge you by your appearance, and I’m happy that I no longer have to worry about laughing, smiling, or speaking when I’m with others.
I feel so good, and I’m trying to “pay it forward”; I want to touch as many lives as possible. I would like to appear on “Oprah” to draw attention to the dangers of domestic violence, and I would like to create a Web site that will provide support and help for victims of abuse.
I am so blessed and am forever grateful.”
Dr. Arnold extends deep appreciation to Marv Staggs, C.D.T., owner of Precision Dental Restorations, not only for creating the beautiful restorations in this case, but also for generously donating all 20 porcelain units to help Carol create a new life for herself.
Figure 1: Before surgery, Carol strains to smile for the camera.
Figure 2: Carol’s heavily worn teeth have significantly decreased her CEJ-to-CEJ measurement.
Figure 3: The maxillary teeth show heavy wear, large restorations, and recurrent decay.
Figure 4: The mandibular teeth show heavy wear.
Figure 5: Carol’s beautiful new restorations restored her collapsed vertical dimension.
Figure 6: The maxillary restorations restored broken, decayed, and worn-down teeth.
Figure 7: The mandibular restorations add length and improve overall esthetics and function.
Figure 8: Carol is learning to smile again.
Figure 9: Carol and Dr. Arnold celebrate her new life.