A banker’s bond: When less is more
This banking executive was an existing patient who wanted to improve his smile. It all started with the patient wanting to find a way to make his upper canines less prominent and pointy (Figs. 1A, 2). We recommended he try orthodontics and whitening first, and then possibly something cosmetic afterward, depending on the desired result.
The patient was adamant about not having orthodontics again, so we did a mockup on his canines to see if he liked the way it would look if we bonded his teeth sans ortho treatment. He loved them and was immediately motivated to whiten his teeth and get his teeth bonded.
His teeth were deep bleached and the mesial surfaces of the canines were bonded to diminish the pointiness of his canines. He loved how the bonding created a more natural and less aggressive look (Fig. 3). That was about three years ago.
More recently, he came in for his routine prophylaxis appointment and again wanted to improve his smile a little more. This time, he wanted to see how we could make his teeth look more aligned, and again, without the aid of orthodontics. He asked about porcelain veneers for all his teeth, wondering if this was a feasible option.
Closer clinical examination revealed several cosmetic issues including, but not limited to:
- palatally inclined lateral incisors,
- prominent and mesially rotated canines,
- #9 slightly more retroclined than #8,
- an uneven gumline due mainly to a large cervical divot on #8 with associated gingival overgrowth,
- anterior crowding and
- retruded premolars that made the smile end at the canines in a narrow arch form (Fig. 3).
We discussed all these factors with the patient and then, as before, we did a mockup of teeth #7 through #10 to show the patient what he would look like with four resin veneers (Fig. 5).
The patient did not understand the need for the gumlift on #8, so we added bonding to the gumline to give the illusion of a more uniform gumline that the patient could see and understand.
At this stage, we pointed out how his premolars seemed to drop off his smile and get lost in the buccal corridor. The premolars on one side were mocked up as resin veneers so he could see the difference the extra teeth would make in comparison to the other side if left undone.
Multiple images were taken of the various mockup options and e-mailed to the patient, along with multiple treatment plan options After careful consideration, the patient opted to do the resin veneers on teeth #7 through #10 as well as the gumlift.
It was because of the mockup and photographs that the patient realized the value of the gumlift in creating a more ideal smile. He wanted to think about the resin veneers for the premolars and possibly have them done in the future.
The patient presented for the bonding appointment with his teeth whitened and ready to go. We began by placing topical anesthetic before anesthetizing teeth #7 through #10 with The Wand.
Subsequent injections of Lidocaine were placed around the gumline of teeth #7 through #10 before electrosurgery of the gums.
Using Bident, a bipolar electrosurgery unit, the gingiva around #8 was contoured to ideal proportions (Fig. 7). Once the gingiva was removed, it was discovered that the underlying bone had grown into the cervical divot of #8, right on top to the enamel.
It was then decided that crown lengthening would be indicated, so a small, round diamond bur was used to contour the bone to match the ideal gumline.
We proceeded to contour the gingiva on the mesials of #7 and #10 and to create symmetry of #9 with that of tooth #8 (Fig. 8).
The Bident unit allowed for gentle, clean coagulation in a wet field. There was no grounding needed, and because the unit is meant to be used with water, there was no tissue charring or shrinkage.
A more effective, more precise and safer result was achieved with essentially no post-op bleeding — a perfect scenario for bonding teeth immediately with no worries of a contaminated field.
The teeth were now ready to be bonded. They were carefully cleaned with pumice to remove any surface debris and stains. Metal strips were placed interproximally to isolate each tooth.
Then they were microetched with aluminum oxide to allow for better mechanical retention. Thirty-seven percent phosphoric etch was placed and rinsed before the application of a bonding agent, such as OptiBond Solo Plus Unidose.
Tooth #8 was bonded first using various layers of composite, starting with a microhybrid (Premise) and ending with a microfilled composite (Renamel). This tooth was contoured and polished with a series of polishing discs (Shofu) before proceeding so the next tooth (#9) could be matched to this tooth without being bonded to it.
Teeth #7, #9 and #10 were bonded in a similar fashion with various shades to create a more natural, graded appearance.
As before, each tooth was polished before bonding the next one. Final contouring and polishing were achieved and a high shine was gained with a Twist-2-It and polishing paste.
In about two hours, the patient had a new smile! Even the gumline looked amazing immediately post-op with no bleeding (Fig. 9).
Gentle Gel, an aloe vera and herbal-based gel, was placed along the gumline and given to the patient to apply at home to help soothe the gums and provide for quicker healing.
The patient was amazed and in love with his new smile, even immediately post-op.
When he returned for his two-week follow-up visit, the gums were ideally contoured and the resin veneers looked wonderful, and the patient said they felt wonderful, too (Fig. 10).
No polishing was needed, so we just did another high shine polish to make them sparkle. Post-op photographs were taken and the patient loved the results (Fig. 11).
He also mentioned that he had no post-op pain originally and the gums looked and felt better in just a couple days after the bonding appointment.
Overall, the patient was ecstatic about the dramatic improvement, especially how contouring the gumline contributed immensely to the final cosmetic result.
He also loved the fact that orthodontics was avoided and a beautiful smile was achieved in a single bonding appointment with a minimally invasive approach — less is more.
Now he is already thinking about and looking forward to his next dental venture — resin veneers for his premolars.
About the author
Sarah Kong, DDS, graduated from Baylor College of Dentistry, where she served as a professor in restorative dentistry. She focuses on preventive and restorative dentistry, transitionals, anesthesia and periodontal care. Kong is an active member of numerous professional organizations, including the American Dental Association, the Academy of General Dentistry, the American Academy of Cosmetic Dentistry, the Texas Dental Association and the Dallas County Dental Society. You may contact her at firstname.lastname@example.org.