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Table of Contents
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 77-80

Smile transfiguration - A conglomeration of contradistinctive disciplines

1 Department of Prosthodontics, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India
2 Department of Prosthodontics, College of Dentistry, Majmaah University, Al Zulfi, Kingdom of Saudi Arabia
3 Department of Periodontics, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India

Date of Web Publication30-May-2018

Correspondence Address:
Asif Ebrahim Rangoonwala
Department of Prosthodontics, SDM College of Dental Sciences and Hospital, Dharwad - 580 009, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_49_16

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A multidisciplinary approach has often been utilized for esthetic rehabilitation of compromised dentitions. A thorough treatment plan is a prerequisite for achieving longevity in these conditions. This case report describes the management of a case of dental fluorosis with unesthetic gingival contours due to excessive vertical skeletal discrepancy in the maxilla, prognathism of maxillary anterior dentition accompanied with a short upper lip, by surgical intervention, followed by fixed orthodontics, endodontic treatment, gingival reshaping, and final restoration of the maxillary anterior dentition with porcelain restorations.

Keywords: Dental esthetics, periodontics, prosthodontics, rehabilitation

How to cite this article:
Rangoonwala AE, Shaikh SA, Padakannaya IP. Smile transfiguration - A conglomeration of contradistinctive disciplines. J Interdiscip Dentistry 2018;8:77-80

How to cite this URL:
Rangoonwala AE, Shaikh SA, Padakannaya IP. Smile transfiguration - A conglomeration of contradistinctive disciplines. J Interdiscip Dentistry [serial online] 2018 [cited 2023 Mar 28];8:77-80. Available from: https://www.jidonline.com/text.asp?2018/8/2/77/233616

   Clinical Relevance to Interdisciplinary Dentistry Top

  • This case report highlights the importance of a holistic approach to achieve functionally and esthetically satisfying results when rehabilitating a case of dental fluorosis coupled with anterior vertical maxillary excess.

   Introduction Top

Endemic fluorosis resulting from high fluoride concentration in groundwater is a public health problem in India.[1] In general, the treatment plan involves an amalgamation of two or more faculties to ensure successful management of such situations. Along with the esthetic reconstruction, the functional harmony is of utmost importance for a definitive treatment outcome.[2]

   Case Report Top

A 26-year-old female patient complained of a forwardly placed upper jaw and excessive gum display [Figure 1]. Extraoral examination in frontal view showed increased lower face height, lip incompetence, short upper lip, hyperactive mentalis, and full maxillary incisor exposure. The profile view was convex, lips were protrusive, and mentolabial sulcus was deepened. Intraoral examination showed a full complement of teeth, short clinical crowns in relation to maxillary incisors, end-on molar relationships, presence of 5 mm overjet, and 4 mm overbite. Confluent pitting was seen on most of the surfaces of the teeth. A diagnosis of moderate dental fluorosis was made, based on history, clinical findings, and Dean's index.
Figure 1: Pretreatment intraoral photograph of the patient

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Radiographic examination involved oral pantomograph showing endodontically treated maxillary incisors and left maxillary and mandibular second molars. Cephalometric analysis revealed dentoalveolar proclination of maxillary and mandibular anterior segments with anterior vertical maxillary excess of 4 mm [Figure 2].
Figure 2: Pretreatment lateral cephalogram

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Treatment plan

Orthodontic consultation indicated an orthognathic surgery to correct the skeletal excess followed by fixed orthodontic treatment. The patient consent was taken before surgical intervention. Following which, maxillary anterior teeth were built up using composite resin (Ivoclar Vivadent, New York, USA) and the patient was undertaken for conventional fixed orthodontic treatment. Nine months later, the debonding of brackets was done, and the patient was referred for prosthodontic rehabilitation.

The pretreatment photographs and facebow record were made [Figure 3]. The diagnostic wax-up was done, and a silicone index (Aquasil Soft Putty, Dentsply, York, Pennsylvania, USA) was made for fabrication of temporary restorations. Postspace preparation followed by subsequent composite core build-up (ParaCore, Coltene, Ohio, USA) was done. Tooth preparations were carried out ensuring equigingival placement of margins after which temporization of maxillary anterior teeth was performed. The patient was locally anesthetized, and 2 mm of gingivectomy was performed in the maxillary anterior region using diode laser (EZLASE 940, Biolase, California, USA). The gingival margins of the maxillary central incisors and cuspids were kept apical to that of the lateral incisors [Figure 4].
Figure 3: (a-c) Composite build-up done following surgical intervention

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Figure 4: Crown lengthening

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Temporary crowns were taken off and final tooth preparations were carried out. Both cuspids were involved along with the maxillary incisors, and a subgingival finish line was opted for to ensure a natural emergence profile. Final temporization was done, and anterior group function was established along with uniform tooth contact in protrusion. The final wax patterns were carved in accordance with the adjusted temporaries [Figure 5]. The definitive restorations were CAD-CAM processed (Dentcare Zirconia, Kerala, India) [Figure 6].
Figure 5: Diagnostic wax up

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Figure 6: CAD-CAM imaging

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Final cementation was carried out using resin cement (RelyX U200, 3M ESPE, Bengaluru, Karnataka, India) [Figure 7]. The patient was recalled 3 months later, and facial and dental components of her smile were evaluated [Figure 8] and [Figure 9].
Figure 7: (a-c) Protrusive, right lateral, and left lateral excursive movements with final prostheses

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Figure 8: Three-month recall intraoral photograph

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Figure 9: (a and b) Pre- and post-treatment extraoral photographs

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   Discussion Top

A variety of conditions affect the perception of excessive gingival display. These can be categorized as skeletal, alveolar, muscular, periodontal, and dental in origin.[3],[4]

It was imperative for the patient to understand that deviation from the ideal was significant and it was difficult to fully remedy the problem. Treatment was undertaken only when the patient had realistic expectations.

The endodontic procedure was carried out, and a strategic establishment of length and angulation of the composite cores was done to make sure that the final crown contours conform to the desired anterior guidance of the restored teeth.

The plan of esthetic crown lengthening via periodontal contouring alone was unacceptable, and it was decided to use periodontal contouring to refine results following surgical intervention. For prosthetic rehabilitation, crown lengthening did contribute to both beauty and function since the stability of new restorations relied heavily on the establishment of adequate coronal retention and a healthy biologic width.

Bone sounding rather than direct visualization was used to determine the osseous morphology as it a more reliable method. The major advantages of laser therapy over traditional scalpel and bur treatment was its ability to induce immediate hemostasis, reduced postoperative pain and better soft-tissue healing.[5],[6]

A facebow transfer ensured that the incisal plane was aligned parallel to the interpupillary plane. The lips are important as they create the boundaries of the smile, hence we had to seriously consider the correction of the facial composition, before we ventured into the correction of the dental composition.

Fricative sounds helped to determine the labiolingual position and length of the maxillary teeth. The provisional restorations played a crucial role to help confirm proper placement of the final incisal edge position, establishment of anterior guidance and incorporation of long centric. The right canine tip needed to be rounded off approximately 1 mm above the incisal plane to ensure anterior group function in the right excursive movement. Thus for functional purposes a minor esthetic compromise had to be made.

Strict adherence to golden proportion calculations is known to limit creativity and this may lead to cosmetic failure hence creating harmony and balance was done by eye through proper adjustment and evaluation of provisional restorations rather than utilization of any specific formula.[7]

A key feature included in the shaping of the central incisors was the central dominance. Maxillary laterals are known to influence gender characterization, and hence in this particular case, their distal aspect was rounded off. Finally, the canine was shaped to bring out the soft and delicate personality of the patient and thus its labial prominence, and cusp tip was blunted.

For incorporating a youthful appearance, a defined incisal embrasure was established, and polychromatic shades with low chroma and high value were selected.[8]

   Conclusion Top

This case report demonstrates that the judicious application of oral and maxillofacial surgery, orthodontics and periodontal surgery accompanied by prosthodontic rehabilitation resulted in correction of excessive mucosal display that is predictable and long-lasting.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Kotecha PV, Patel SV, Bhalani KD, Shah D, Shah VS, Mehta KG, et al. Prevalence of dental fluorosis & dental caries in association with high levels of drinking water fluoride content in a district of Gujarat, India. Indian J Med Res 2012;135:873-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
Derbabian K, Marzola R, Donovan TE, Cho GC, Arcidiacono A. The science of communicating the art of esthetic dentistry. Part II: Diagnostic provisional restorations. J Esthet Dent 2000;12:238-47.  Back to cited text no. 2
Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry. Dent Clin North Am 2007;51:487-505, x-xi.  Back to cited text no. 3
Foley TF, Sandhu HS, Athanasopoulos C. Esthetic periodontal considerations in orthodontic treatment – The management of excessive gingival display. J Can Dent Assoc 2003;69:368-72.  Back to cited text no. 4
Magid KS, Strauss RA. Laser use for esthetic soft tissue modification. Dent Clin North Am 2007;51:525-45, xi.  Back to cited text no. 5
Sobouti F, Rakhshan V, Chiniforush N, Khatami M. Effects of laser-assisted cosmetic smile lift gingivectomy on postoperative bleeding and pain in fixed orthodontic patients: A controlled clinical trial. Prog Orthod 2014;15:66.  Back to cited text no. 6
Ricketts RM. The biological significance of the divine proportion and Fibonacci series. Am J Orthod 1982;81:35.  Back to cited text no. 7
Frush JP, Fisher RD. The dynesthetic interpretation of dentogenic concept. J Prosthet Dent 1958;8:558-81.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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