Townie Clinical: Multiple Technologies for Cosmetic Reconstruction By: Glenn van As, BSc, DMD

Those of you familiar with the DentalTown online community already know I’m very involved with many advanced technologies available including microscopes, lasers and loupes. It is incredible how much these hi-tech ‘tools’ allow me to perform dental procedures and obtain amazing results with a very low stress level.

I want to share a cosmetic case I recently posted within DentalTown’s online presentation forum. It involves a patient who had a bad fall as a teenager and desired a cosmetic restoration. I feel this is an excellent way for you to see how multiple advanced technologies—microscopes, hard and soft-tissue lasers, ultrasonics and digital photography can be integrated into the provision of cosmetic dentistry. This is not to suggest traditional methods would not produce excellent results but rather how incorporating some of these technologies may make the process easier.

To begin this case, I took a pre-op smile photo using a digital SLR camera (Nikon D1) (Photos 1-4) then moved over to the dental operating microscope and took some pictures of the wax-up and study models (Photos 5-7).

		Photo 1 Pre-op smile showing discolored old composites.
		Photo 2 Pre-op right side.
		Photo 3 Pre-op left side.
		Photo 4 Pre-op palatal view.
		Photo 5 Pre-op periapical radiograph of the maxillary incisors with pin retained restorations in maxillary anterior.
		Photo 6 Pre-op model showing heights of contour of tissue that aren’t even. Elective soft-tissue laser recontouring of the maxillary laterals was chosen to even out the heights of contour on the maxillary anterior teeth.
		Photo 7 Pre-operative wax-up done of maxillary anterior teeth to help with temporary restorations.
		Photo 8 The gingival height of contour was a bit off on the two laterals. I used the Delight Erbium YAG laser to lengthen them after probing (4mm tissue on them) to obtain the same height as the centrals. Photo 8 shows the facial view after the erbium laser was used to perform the gingivectomy on the maxillary laterals. Approximately 1/2-1mm was removed to preserve the biologic width and provide a more esthetic end result.
		Photo 9 When prepping the lateral, I discovered through higher magnification, the mesial surface of the canine had a small carious lesion which needed to be removed.
		Photo 10 Ultrasonic tips from Spartan Obtura (Sheets SL tips) were used for their unique angulation to minimally prepare the tooth without removal of large amounts of tooth structure.
		Photo 11 High magnification view of the prep was completed with the ultrasonics and a slow speed bur for final caries removal. The preparation depth is at 3mm with a periodontal probe.
		Photo 12 Flowable being placed in interproximal preparation under resin filter on the microscope.
		Photo 13 High magnification view of the completed restoration.
		Photo 14 Preparations completed and gingival tissue management accomplished with laser for troughing around the teeth. A diode laser (Diodent by Hoya Con Bio) was used for the procedure of tissue troughing.
		Photo 15 The preps were done and then I noticed the frenum was quite thick, so I removed it with the erbium laser—hence no bleeding. Hemostasis was obtained through pressure with gauze and the patient was dismissed.
		Photo 16 High magnification view of the completed frenectomy.
		Photo 17 Low magnification of provisional restorations at insertion of crowns appointment. Note healing of frenectomy at 2 weeks.
		Photo 18 Magnified view of right side of provisionals.
		Photo 19 Photos 19 and 20 show the facial and palatal view of the crowns on dies.
		Photo 20
		Photo 21 Photos 21 and 22 show high magnification view of right and left sides.
		Photo 22

I have found using enhanced magnification and illumination in performing this kind of complex case to be essential in delivering excellent results. The ability to document with digital micro-videography or digital micro-photography is simple when these devices are hooked right up to the microscope. I use Global Surgical’s dental operating microscope (D.O.M) to provide me with improved visual acuity. Most often, I treat these cases with 6.4X-16X magnification. Little deficiencies in preparation design become obvious with this level of magnification. The savings in time alone, combined with the extreme magnification possible when documenting with the D.O.M. makes it extremely beneficial when compared to traditional methods of photographing or videotaping the intraoral procedure.

With this case, I have shown how multiple technologies, including microscopes, hard tissue lasers, soft tissue lasers, ultrasonics and digital photography, can be integrated into the provision of cosmetic dentistry. This is not to suggest traditional means of handling these cases or alternative methods are not possible. There are advantages to using various technologies for a given procedure, and my hope in providing visual images of the technologies at work may stimulate you to think about integrating some of these technologies into your practice. I really encourage all of you who currently do not use microscopes, lasers, loupes or digital photography to gradually introduce these incredible tools into your everyday dentistry.

Some of the questions/comments Townies made concerning this case follow. If you have any additional questions, please join us online at DentalTown’s case presentations. You can find this and many other extremely interesting clinical cases by visiting DentalTown’s homepage at www.dentaltown.com, clicking on the Forums tab and Case Presentations—Main.

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Dr. Glenn A. van As graduated from the University of British Columbia with his DMD in 1987. He immediately went into private practice sharing space with his dad. In addition to being in private practice, Glenn has been on the faculty of the dental school as an assistant clinical professor in both the faculties of Oral Medicine and Operative and Prosthodontic sections. He is an active member of the admissions committee for the dental school.

An active member for many study clubs in orthodontics, prosthodontics and endodontics, he has strived to continually improve his knowledge about all areas of clinical dentistry. Since 1998, Glenn has been practicing all of his restorative dentistry through the surgical operating microscope.

Glenn can be reached by email at: glennvanas@shaw.ca.

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Townie comments on using multiple technologies for cosmetic reconstruction

socalsam 7/1/2003 10:51:33 AM		I think Glenn did a beautiful job with prep, tissue, and documentation. Your lab should have done a better job with the final restorations. Try a different lab. Also, your photos come out looking yellow so that might be throwing the color off. It’s probably difficult if not impossible to correct with the microscope.
mapleleafs 7/15/2003 12:00:21 AM		Hi Glenn, you have certainly implemented a plethora of different dental technologies in your case. There is no doubt alternatives exist to every step and piece of equipment that were involved. It is purely academic to discuss which is superior or less so. The most important thing is that the end result justified the means. I applaud you for the fine treatment that you have provided your patient. The greatest common thread in your treatment progress is the use of the Dental Operating Microscope. It not only allows you to work under variable magnification and shadowless light, thereby you cannot help but produce more precision enhanced handling of the soft tissue and the hard tissue. Your beautiful end result speaks for itself. The scope as you have shown is a fantastic tool to not only communicate the treatment progress to your patient (who has the choice to view it through a live video feed via your digital camera on the X-mount), but likely the most convenient way to document the case for all to share. It is through sharing like you so generously and willingly provide that we all benefit from.
rootdmd 7/15/2003 4:20:55 AM		Glenn, you are a true pioneer my friend. Keep on preaching about the value of scopes. Some day you will get the true recognition you deserve. You have helped me and many others immensely. I can’t begin to describe the incredible difference it has made having a scope in my practice. It’s like being in a different profession. I’ve always enjoyed my work as a dentist, but having the scope has allowed me to attain such an increased sense of confidence in my work so as to make this more like a fun hobby as opposed to being just a job. While I’m now limited to endo, prior to getting to this point I used the scope for general practice. I can tell you if I were practicing general dentistry again, I’d do it just like you, using the scope for most everything.
arturo5203 7/15/2003 7:41:26 AM		Glenn, what a nice, thoroughly documented case. This case is a great example of how useful and powerful the dental microscope can be for the restorative dentist. The fact that you are not only able to treat but document and educate at the same time is invaluable. I have been using a dental microscope for restorative dentistry, full time, for over four years and am always amazed at the level of precision and clarity that can be achieved with the microscope. I always learn a lot from reading your articles and posts. It is well known that microscopes have caused an evolution and revolution in Endodontics. It is becoming apparent that microscopes will cause the same quantum leap forward in restorative dentistry thanks to the input of talented dentists like you. Keep up the good work!