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The Art of a Beautiful Smile

Part 1 - Review of the case

George Kirtley, DDS
Dr. Kirtley will walk you through the patient's pre-op photos

Hello, my name is George Kirtley and I’m an esthetic restorative dentist in Indianapolis, Indiana and a credited member of the American Academy of Cosmetic Dentistry and the British Academy of Cosmetic Dentistry. We’re here today to discuss a case that we’re going to be treated in the ensuing few weeks. First part of which is going to be today. I like to take an opportunity today to kind of review with you this case that we’re going to be treating and try to give you a perspective on how it is that I approach esthetics and what it is that I’m looking at and how it is that I can impact this patient’s smile. So if we take a look at the photograph that you’ll be seeing, the concern that this patient had when the came to me for a smile consultation was a number of things. Primarily, this patient was concerned about the wear that they had on their anterior teeth and the chipping and fragmenting along with some of the spacing in as much as that is a concern there are other things that we’re able to look at and other things that we’re able to educate the patient on as to what it is they’re truly seeing. In addition to those things mentioned, we were able to determine that there was a lack of presence in the buccal corridor areas, which is a very common thing to see and certainly something that when we changed it can be very impactful on the overall esthetics and appearance of the lower third of the face particularly in women. As we look at the side view of this patient, the lateral view, and this is a view that I think is extremely revealing. Because it ultimately determines how many teeth that we minimally need to involve to attain the esthetic result that both the patient and I would like to see, a patient being first. But I think often times, the patient fail to understand or to realize what they look like from the lateral view perspective. And so in my case, one of the things we always do in our workups is to take a battery of 12-14 photographs. And some of those photographs are the lateral view relax smile perspective. Now what this does and what I simply say to the patient when they see this, and often times they’re doing their own self diagnosis and that is “Gosh, I never realize what I look like from that perspective.” But what it reveals is how many teeth are exposed in their normal animations, their normal smile and in animations of laughing. And so what this does is gives me and the patient a perspective of how many teeth again that we’re going to want to involve in this design or this change. And clearly you can see in Kathy that some of the concerns, she a pretty broad smile. She shows back to really the mesial half of her upper first molars. And that we can clearly see that there is a display of gingival tissue in that particular smile. And what I say to the patient in this is that in a social setting this is how you’re being seen. You may not realize this, but when you and I are speaking see the frontal view. We see it as straight on. Or if you’re looking into a mirror, you see the straight on shoot. But in a social setting if you’re at a party or some social event, people are actually viewing you from that lateral perspective from that side. So it’s important that we create uniformity and consistency throughout of the smile when we set to design it. I do this from both sides as you can see here so I won’t go through that again. And again we will look at these photographs and some of the other things that we see in there are reveal to us are there fractions that are occurring signally possibly some pathology in the patient’s bite. Patient don’t see this and often times they don’t understand why that’s occurring. A good thing that we had her is good shade to work with. The patient’s shade of teeth is kind of white. So I know that there’s a great likelihood I’m going to see an underlying shade that’s good also. And the other thing about this particular case is I feel that we’re going to be able to be really pretty minimally invasive in our preparation design for this case in these teeth. In the treatment here we’re going to involve her upper ten teeth, second bicuspid to second bicuspid with the idea of creating and eliminating the reverse smile line that she has. Of course, addressing the chipping and the spacing that she has between her teeth and also to build out her buccal corridors and give her a little more presence there. The other thing here that I’m pointing out to the patient, that we see here, is there’s a clear evidence here of some bruxing and grinding habits that have resulted in the attrition of the enamel and breakdown of the teeth in the cervical areas. So that’s from an occlusion standpoint. You know one of the things that we will address is certainly to be able to stabilize that through equilibration and restoration. The other thing that we see here clearly is close up view. Again, this is something I share with the patient. They’re seeing these photographs just like you are. I believe that patients when they are seriously considering esthetic restorative or restorative direction that they’re interested in the details of this. They want to know if you know what you’re talking about. They want to know exactly what’s going to happen. How much tooth structure is going to be taken away, and how you’re going to do the things you say you’re going to do. For her, another thing that we’re going to have to address is to enhance the architecture of the gingiva and create a bilateral balance between the left and right side and we can do that utilizing diode laser technology in which we will do in this case. Her view with her mouth close is also all the time a nice and revealing photograph in that we can impact sometimes the lip support in the anterior region particularly if were going to build out her smile facially. The thing I always do with patients in our office and we have found it to be extremely beneficial in contributing to our case acceptance and that is that we utilize computer generated image in three different views: a full face, a frontal view and a lateral view perspective for the reasons I’ve already mentioned. And we’re utilizing the Envision A Smile for the reason I’ve already mentioned. And we’re utilizing Envision A Smile which I happened to be a designer of. In these views, the patients are getting a perspective on what our propose results are going to be. Or more importantly or another way of putting that is that we’re showing the possibilities of what is attainable. And we’re doing so in a way that gives me an anatomically correct computer generated image of our proposed result would be. Here you can see a preview of that. And often times we’re able to improve up on the computer generated image in our true clinical and final results. So this gives you an idea. It gives the patient an idea of our direction and how we think that we can help them. And again because these images are produced in an anatomically correct way we know that we’re going to get there and probably you’ll have a better result than that we’re showing.