Show Your Work: Age Is Just a Number by Christofer Hatzis and Dr. Sanna Charlie

Dentaltown Magazine

Restoring youth and aesthetics of aging populations using minimally invasive dental measures

by Christofer Hatzis and Dr. Sanna Charlie

This case report recounts the indirect rehabilitation of an elderly patient’s smile to restore youth and vibrancy. Our goal was to achieve a more youthful, harmonious smile to reinforce the patient’s subjective age. We define “subjective age” as asking patients how old they feel; feeling younger than one’s chronological age is a sign of health and a positive predictor of lower mortality, positive expectations and better cognitive abilities. Treatment planning and managing care in the elderly population can be complicated by a variety of factors but should be individualized to implement the patient’s functions, both social and community, rather than simply one’s numerical age.

Diagnosis and treatment planning

A 92-year-old patient presented with the chief complaint: “My front tooth is too long and my teeth are not straight how they used to be. I miss my old smile, but every dentist I’ve gone to tells me it’s fine given my age.”

Clinical intraoral examination revealed maxillary anterior crowding, incisal wear, a previous single anterior PFM restoration with poor aesthetics and excessive incisal length, and Class III caries. Patient was undergoing warfarin therapy, which was taken into consideration (specifically, tissue management for capturing an accurate impressions). Patient’s oral hygiene was well managed through routine prophylaxis and diligent home care.

During the interview, the patient complained of disfigurement and reported that she was self-conscious because her smile had changed through the years. Immediately noticeable was the mismatch of her anterior crown with her natural teeth, faulty restorations and interproximal caries.

Clinical findings and diagnosis assessed during treatment planning included:

• Interproximal caries on teeth #7, #9 and #10.

• Patient presents with low smile line while inmaximum phase.

• Tooth #8 previously endodontic treated with PFM, excessive incisal length and poor contour/aesthetics. Mismatched shades with natural teeth.

• Occlusal wear facets on all anterior teeth, anterior crowding.

• Angle’s Class 1 malocclusion, minimal A–P overjet.

Preoperative phase

Appointment 1: Preliminary impressions, facebow, photographic documentation, radiographic analysis

While our primary consideration was to provide the patient with the highest possible aesthetic result, all available treatment avenues were considered and weighed, including ceramic versus composite and indirect versus direct veneers. Because of the patient’s high aesthetic desire and compromised tooth structure, four full-coverage lithium disilicate crowns were selected for an aesthetic and functional rehabilitation. During this appointment, her consent was obtained and preliminary impressions, facebow, photographic and radiographic analyses were captured (Figs. 1 and 2).

Because of the interproximal caries, the patient received a caries risk assessment and was given an extensive oral hygiene regimen that included a prescription of Clinpro 5000 toothpaste and daily implementation of ACT mouthwash.

Restorative phase

Appointment 2: Restorative phase + provisional

Treatment was conducted as follows:

1. Profound anesthesia completed with two carpules of 2%?lidocaine with 1:100,000 epinephrine via ASA nerve block and local infiltration among teeth #7–10.

2. Sectioned previous PFM restoration on #8; excavacated all carious lesions present on teeth #7–10. Rebuilt compromised tooth structure using glass ionomer (Fuji II LC) resin-modified restorations.

3. Teeth #7–#10 were then prepared for lithium disilicate all-ceramic restorations.

4. Shade was selected using Vita 3D Master Shade Guide.

    All factors were assessed, including:

    a. Value: Overall lightness, how light or dark a color is.

    b. Hue: What we normally think of as “color”: red, blue, purple, etc.

    c. Chroma: analogous to “saturation,” the strength or dominance of the hue.

Stump shade was also selected for optimal enhancement of shade selection (Fig. 3). Photographs were taken using IPS natural die material shade guide (Ivoclar Vivadent).

With the given age and medication use of our patient, we used a back-to-back double-cord impression technique with epinephrine-free, 25% buffered aluminum chloride Gingi-Aid to manage heme and retraction of gingiva to capture margins accurately. PVS heavy- and light-body were used to capture final impression.

Fast-set PVS putty impression of diagnostic wax-up was used to fabricate a splinted provisional with bisacrylic composite as such: #7–8, #9–10.

Articulation paper used to verify occlusion and temporization was polished, and the patient dismissed (Fig. 4).

Delivery of final restorations (unsuccessful)

Appointment 3: Final delivery/Treatment modification

The patient presented for final delivery of e.Max restorations, but upon try-in she expressed discomfort with the lingual “bulk” of the restorations. Different avenues were explored, and the material was modified to include porcelain with lingual metal collar to offer minimum thickness of lingual to improve patient comfort.

With patient approval, Star VPS Clear Bite was used to capture a new impression of the e.Max restorations. PVS is dimensionally stable and exceptionally accurate, and using Clear Bite allows us to have full visibility of any bubbles or voids presented during fabrication of the provisional restorations. New provisionals were fabricated with bisacrylic composite, and the lingual was reduced and adjusted to patient comfort. All occlusal and excursive interferences were measured and verified. It was ultimately determined that porcelain with a lingual collar would provide the patient with maximum comfort. A new impression and modification request were sent to lab for refabrication.

Delivery of final restorations (successful)

Appointment 4: Final delivery

Before delivery, all PFM crowns were first verified on diagnostic casts to confirm design. Anesthesia was achieved; rubber dam matrix was used for moisture isolation. Provisional restorations on teeth #7–10 were then removed. Teeth were pumiced and rinsed with water to adequately remove all residual cement and debris.

The final PFM restorations were individually verified and, upon obtaining patient approval, aesthetic rehabilitation was assembled using a thin layer of FujiCEM resin-modified glass ionomer cement (GC America), gently rocking the restorations into place using a light finger pressure.

Once cement excess was removed with a microbrush, all margins were flossed and polished. The rubber dam was removed, and occlusion was checked for light centric contact and ideal lateral excursions. After all adjustments were completed, all porcelain surfaces were repolished. Patient confirmed satisfaction as the aesthetic outcome of therapy surpassed all her expectations (Figs. 5 and 6, p. 34).


All factors should be considered to maintain teeth to remain functional and attractive throughout a person’s life, regardless of their numerical age. Personal care of preventive minimal restorations can support a beautiful healthy smile. Aesthetic dentistry offers myriad opportunities for older adults who want to improve their smile, oral function and self-esteem.

In this case report, our patient had dental concerns that were previously disregarded or overlooked because of her age. With the right attention and minimally invasive approach, we were able to restore the patient’s aesthetics and function.

Considerations made while doing so:

1. Why forgo gingivectomy/gingival recontouring?

Lengthening, thinning and volume loss of the lips and perioral area are common in the geriatric population. In this case, it resulted in a low lip line and smile line. Gingivectomy and gingival recontouring had been considered to treat the gingival zenith discrepancy; however, when considering the patient’s low smile line and warfarin therapy, the patient ultimately decided to go forward with a less invasive option.

2. Why choose e.Max instead of PFM?

Initially, we treatment-planned to use e.Max because of its aesthetic and strength properties; however, after the initial try-in, the patient expressed discomfort because of the “thickness on the back of the teeth.” Modifying the restorations to PFM allowed us to maintain aesthetics while providing maximum comfort—in this case, minimally noticeable.

3. Why use FujiCEM as the adhesive material?

We chose this cement as a definitive luting material because of its stability, lack of thermal expansion and minimal microleakage.1

As life expectancy has increased over the decades, every adult regardless of numerical age deserves to feel good about his or her smile, because several aspects of adult life are intrinsically tied to one’s appearance. With this in mind, it’s important that oral health professions remain up to date and attentive on providing and maintaining care of older generations. The most common dental issues among older populations are the appearance and structure of teeth; however, this can be underlying to other issues such as systemic diseases, periodontal and restorative issues—all of which have been shown to directly affect a patient’s health, self-confidence and, ultimately, quality of life.

Closing comments

Dental professionals will have increasing responsibility to find relations between oral health and overall health among the aging population. Some studies have shown that aging causes the smile to vertically narrow and widen transversely, while other studies suggest that muscle’s ability to form also decreases with age.2

Clinical decision-making in dentistry tends to be based upon subjective decisions by the provider, usually based upon patient age, associated by physiological, social and biological profiles.3 As the number of elderly citizens in the population increases, dentists should stay committed to enhancing patient oral health, because the outcome is directly related to one’s quality of life, regardless of an individual’s numerical age.

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Fig. 1: Patient presents with a low smile line, exposing only half of the teeth while in repose.
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Fig. 2: Preoperative intraoral view, highlighting interproximal caries, incisal anterior wear, uneven length of central incisors, and inconsistent shade between restorations and natural teeth.
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Fig. 3: Preparation complete and stump shade selection.
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Fig. 4: Patient retemporized with modifications.
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Fig. 5: Final seat of restorations of #7–10—incisal length restored, shade match of restorations with natural teeth achieved.
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Fig. 6: Final restorations enhancing with low smile line.

1. Rossetti P.H., do Valle A.L., de Carvalho R.M., De Goes M.F., and Pegoraro L.F.,
“Correlation Between Margin Fit and Microleakage in Complete Crowns Cemented With
Three Luting Agents,” Journal of Applied Oral Science, Vol. 16, No. 1, pp. 64–69, 2008.
2. Desai S, Upadhyay M, and Nanda R. “Dynamic Smile Analysis: Changes With Age.”
Am J Orthod Dentofacial Orthop. 2009; 136:310. e1- 310.e10.
3. Grembowski D, Milgrom P, and Fiset L. “Factors Influencing Dental Decision Making.”
J Public Health Dent 1988; 48(3):159–67.

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Author Bio
Author Dr. Sanna Charlie received her bachelor’s degree from the University of California, Irvine. She received her dental degree from Meharry Medical College in Nashville and completed her residency training in advanced education in general dentistry from the University of California, San Francisco. Charlie is an active member of the AGD, the AACD, the CDA, the American Academy of Implant Dentistry and the American Dental Association. Email:
Author Christofer Hatzis received his bachelor’s degree from Wayne State University in Detroit and is a fourth-year graduating student at the University of California School of Dentistry. Hatzis is an active member of the Academy of General Dentistry, the American Academy of Cosmetic Dentistry and the California Dental Association. Email:

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