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Recent Article Publised by Matthew Holyoak

17 June 2019

Article submitted by Matthew Holyoak and printed in The Probe magazine" March 2011

This article demonstrates the use of tooth coloured filling materials (composite) to restore teeth and improve a young patient's smile.



Restoring a patient's smile and confidence


Basic periodontal screening showed inadequate gingival health, with several fast bleeding sites in the upper and lower arches. There was a lot of reformed calculus, lingually in the lower teeth, as well as on the buccal surfaces of the upper molars. Tooth mobility was physiological and there was no evidence of bruxing. Bitewing radiographs showed no interproximal caries and normal horizontal bone levels.

More significantly, the initial examination revealed an anterior open bite and less than ideal width-length ratios. According to Dr Holyoak, "The central incisors had a ratio of 8.8mm/10.5mm (83 per cent), which is at the boundary of the acceptable proportions (75-85 per cent). The anterior occlusal plane was slanted and the embrasures needed improving. Increasing the length of the upper centrals would improve the proportions and give the patient a more balanced smile."

20-year-old female presented requesting an improved smile with which to start her new career as a beautician. She told Dr Matthew Holyoak, she wanted, "brighter teeth that show more when I smile." The patient had already considered and ruled out maxillofacial surgery and fixed appliance therapy when younger. She was looking for a quick and effective solution.

Aesthetic assessment criteria:

• Anterior tooth display at rest

• Midline & cant• Dominance

• Buccal corridor

• Anterior occlusal plane

• Lip line

• Embrasures

• Tooth form

• Gingival heights & zeniths

• Axial inclination

An oral hygiene session removed the root surface debris, and a more effective brushing technique restored the patient's oral health. One week later, there was a big improvement in gingival condition, with a greatly reduced bleeding index.

Options and treatment

The restorative options considered with the patient included:

• No treatment,

• Indirect restorations

• Bleaching followed by direct composite restorations.

The goal was to restore balanced, natural-looking central incisors and increase tooth display. The treatment would also correct the slanted anterior occlusal plane and improve the embrasure pattern, to reduce the aggressive harsh appearance of upper canines.

Dr Holyoak recommended the following treatment plan: Tray bleaching and direct freehand composite build-up with no preparation of the existing teeth (upper 3-3, and lower 3-3).

The bleaching system recommended is, in Dr Holyoak's opinion, more predictable than powerbleaching. The method uses 10 per cent carbamide peroxide and opalescence gel over two weeks. The trays were fabricated without reservoirs.

Dr Holyoak said, "A minimally invasive treatment was chosen because the non-preparation technique is very low risk and no local anaesthetic is required. In this case, I preferred freehand assessment and clinical judgement, rather than a 3

There was a two-week delay prior to commencement of the adhesive bonding procedures with direct freehand build, using SB1 Heraeus Venus enamel. "Venus composite was used for the restorations because of the material's handling characteristics and shade selection. It has chameleon-like qualities of simple build-up, rather than complex stratification, which I felt was not required in this case."

The teeth were prepared using 38 per cent acid-etch prior to bonding. A rubber dam was used to isolate the areas to be treated, prevent contamination with moisture and protect the patient's airway.

Restorations placed included incisally upper-right 12, upper left 12 and incisally lower 2-2. Mesial-incisal restorations were added to upper right 3 and upper left 3. The composite restorative shades were selected by Dr Holyoak to match the post-bleaching result. Pre-bleaching, the shades were A2 upper 2-2 and A3 canines. After bleaching, the shades were B1 or brighter.

"The anterior tooth display and tooth form were improved, the uneven incisal edges were removed and the upper canines were made less aggressive. The dominance of the central incisors was re-established, and the slanted anterior occlusal plane was corrected. The different upper anterior gingival levels were acceptable because of the low lip line. The midline, cant and axial inclinations were not issues in this case".

The treatment was undertaken mainly during two appointments: 90 minutes for the upper 3-3, with a review next day to refine, and a 30-minute appointment for direct restoration of the incisal edges of the lower 2-2 with Venus SB1. Polishing and a final review were undertaken one week later. The bleeding indexes were zero and the periodontal [probing depths] were normal.

This patient now has a job where she feels appearance is very important.

Dr Holyoak concluded, "It was immediately clear from the way she smiled that she was pleased with the results. She said her confidence had been boosted by the restorative treatment, and she was more comfortable dealing with her own customers wanting beauty therapy.

"It was a cost-effective solution, which was biologically minimally invasive. It avoided an expensive treatment cycle, so often involved in indirect restorations, especially important in such a 'young' patient."

One year later, there was no incidence of debonding or chipping to the minimally restored incisal edges. New bleaching trays have been made so the patient can maintain brighter teeth from time-to-time. n

Dwax up, using silicon indexes to guide the build up."

Reader enquiry: 102

Dr Matthew Holyoak

provides a cost-effective and minimally invasive case study, which improved a patient's smile for a new career where appearances matter...

About Dr Matthew Holyoak

Dr Matthew Holyoak BDS, Dip Rest Dent (RCS Eng), MSc (Rest Dent), lectures on aesthetic dentistry for the Diploma in Restorative Dentistry for the Royal College of Surgeons. He has an MSc in Restorative Dentistry and has been involved with implant prosthetics for more than 15 years. He is a member of the British Academy of Aesthetic Dentistry and the Association of Dental Implantology UK.

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