Before and After
Anatomy of teeth is developed through coalescing of various lobes. For example, bicuspids are generally formed from two lobes and molars from four lobes. When individual lobe coalesces to form teeth, they usually create deep fissures where food and bacteria can thrive and cause cavity or demineralization of tooth structure. This photo shows stains or possibly carious lesion on the fissures of the first molar.
Fortunately, the discoloration on the first molar is deep pitted stain and non-carious. All stains were removed prior to placement of sealants to make certain that nothing is inadvertently left behind. In a 15 year study, sealants have been shown to decrease the development of cavity in posterior teeth by seven-fold compared to those of unsealed teeth. It is by far the most affective way to protect posterior teeth from developing cavity.
Anterior Chipped Teeth
These maxillary and mandibular incisor teeth were chipped from sports accident. It has been estimated that the prevalence of traumatic dental injuries among school children in different parts of the world varies from 3% to 45%, of which 9% involved permanent incisor teeth.
These injuries involving permanent anterior teeth may lead to eating restriction, changes in physical appearance, speech defects and psychological impact that affect the child's quality of life.
Multi-layering of composite along with white tint was utilized to better blend in with the surrounding tooth structure in the maxillary and mandibular incisors. The restorations were then shaped, contoured, and polished to high shine to prevent detection. Mouth guard was recommended and should be worn when playing sports, especially contact sports to minimize oral-facial complex injury.
Patient has history of periodontal (gum) disease resulting in a significant loss of interdental papilla (gum between the teeth) which causes unsightly smile. The periodontal condition has been stable for years, and now the patient wants enhancement of her smile without any additional compromise to her already weakened teeth and gum.
No removal of tooth structure was necessary or required since this is an additive case. Teeth were simply cleansed, and the spaces between the teeth (diastema) were closed by layering composite. In addition, using composite the right central incisor was brought into alignment with the left central incisor onto the same plane to enhance harmonious integration or flow of the incisors.
This 7-year old patient has a condition that causes his to have soft, weak, and incompletely formed enamel on his erupting permanent adult teeth. This hypoplastic enamel condition, for this patient, resulted from inadequate systemic calcium absorption during the formation of adult teeth from lack of Vitamin D. This condition is obviously debilitating to a developing child and requires very conservative cosmetic enhancement considering the age of the patient.
The teeth were slightly roughen and were prepared for bonding. The photo depicted here shows the initial layering to mask deficiencies and to obtain a neutral background from which additional layers of composite can be built and integrated.
Pre-operative: Patient requested replacement of existing amalgam restorations from objections during a jubilant smile.
Even though the existing amalgam restorations were in somewhat good conditions, marginal leakage is observed. This is a common occurrence with amalgam restorations which do not bond to the underlying tooth structure resulting in marginal staining and microleakage.
Patient complains of root sensitivity from this leaky restoration with recurrent caries. Root sensitivity is a common occurrence among adult population, and it is most commonly caused by mechanical abrasion from improper tooth brushing technique causing V-shaped wear in the neck of the tooth which in turn exposes nerve endings resulting in sensitivity to touch and temperature.
Direct Composite Veneers
Pre-operative: This patient's main concern was to replace the discolored composite on her front tooth and to have overall whiter, brighter, and healthier smile without any compromise to her tooth structure.
Post-operative: The nature of this case lends itself to beautify her smile with composite system which can be artistically blended, handled, and sculpted to achieve cosmetic desires of the patient. In addition, the strength of the composite system is utilized to manage and develop proper occlusal scheme to minimize or prevent wear and chipping at the edges of the teeth.
This patient presented with significant tooth wear on maxillary and mandibular canines resulting in the alteration of the occlusal scheme. This tooth wear was caused by nocturnal parafunctional habits as revealed on her existing nightguard. The oral hygiene was meticulous with sound periodontium. Other than the wear on the canines, no other tooth wear was observed.
Treatment plan was simply to restore loss tooth structure and to regain a mutually protected occlusal scheme followed by a new nightguard which the patient must faithfully wear to minimize and prevent further destruction of tooth. A composite stratification technique was used to replace loss tooth structure on the canines followed with proper contouring and polishing of the restorations to obtain seamless integration of the restorations with the remaining dentitions. This replacement also enhances the smile to it's natural appearance and helps to reestablish a mutually protected occlusal scheme. This case shows appropriate use of composite in replacing loss tooth structure and at the same time reestablishing functional deficiency.
Single Anterior Porcelain Veneer
Anterior Porcelain Crowns
This patient presented with a severely compromised maxillary central incisors with small lateral incisors resulting in unevenness in tooth ratios of all incisors causing significant distortion and distraction in smile zone.
Restoration of Fractured Tooth
Pre-operative: Existing amalgam restoration composing of metal alloy which expends and contracts with change in temperature within oral cavity results in the fracture of this tooth. Amalgam also contains mercury which is known to be a toxic substance although the amount of mercury ingested during the chewing cycle is unclear in literature. Fracturing of teeth from amalgam restoration is a very common occurrence and it is directly proportional to the size of the restoration (i.e. the greater the volume of amalgam restoration occupied within the tooth, the greater the chance that the tooth will be fractured). At times, the fracture can be so extensive that the tooth can no longer be salvage.
Post-operative: Following removal of the failing amalgam restoration, the tooth was conservatively restored with porcelain onlay. This restoration is conservative because it only requires refinement of the remaining tooth structure, and it is far superior to amalgam restoration because of its physical properties which are similar to tooth but also because of its ability to strengthen the remaining tooth structure through bonding and thereby reestablishing the integrity of the tooth. With today's technology, every step must be taken to increase the longevity of the tooth by being conservative and this type of restoration is not only conservative but it is predictable.
Posterior Porcelain Onlay
Pre-operative: Failing amalgam restoration with recurrent caries requiring replacement of restoration.
Design of the onlay restoration is generated in reference to the anatomical features of the tooth and the opposing tooth.
Restoration is then characterized by creating depth through gradation of colors which blend with the surrounding tooth structure. It is then seated to observe the precision and accuracy of the fit to the preparation.
Single Posterior Porcelain Crown
This tooth has a prior history of root canal therapy with severely broken down existing large occlusal composite restoration. Given that this tooth is nonvital and has lost a significant amount of tooth structure, it would not be predictable to restore this tooth with another composite restoration but instead it will be more prudent to restore this tooth with porcelain restoration which will allow it to regain its strength and integrity.
Every cosmetic dentist understands the difficulty in restoring a single maxillary incisor in order to achieve a seamless integration of the restoration with the rest of the natural dentitions in the smile zone. This patient has a small maxillary right lateral incisor which was enlarged with a composite as a child and is looking for options to have more definitive treatment to obtain better esthetics. He also has significant incisal wears on all canines of maxillary and mandibular dentitions without any wear facets on any of the posterior teeth indicating the possibility of nocturnal parafunctional habits.
In order to develop proper width and length of the lateral incisor, the worn incisal edges of the canines must be restored and the development of proper functional and occlusal scheme must be established. Due to increased longevity of the porcelain restorations, the lateral incisor was restored with porcelain veneer using CEREC Technology. The macro anatomy was developed during the designing phase of the restoration and the micro anatomy involving integration of characterizations from adjacent teeth was obtained through detailed staining and glazing which allows seamless integration of the restoration in the smile zone. The incisal edges of the canines were then conservatively restored with composites to meet both the functional needs and cosmetic demands of the veneer. Finally, occlusal guard was fabricated to protect the newly fabricated restorations from destructive nature of parafunctional habits. This case demonstrated the use of CEREC Technology and conservative treatment with proper diagnosis in achieving a successful functional and esthetic results.
Non-surgical Periodontal Therapy
Patient with existing periodontal disease presented with significant gingival inflammation, mild bone loss, and failing existing bridges.
Notice the presence of spaces between the teeth, also referred to as black triangles, caused by recession of gum from periodontal disease.
Non-surgical periodontal therapy (scaling and root planning), gingival recontouring, and temporization of the failing bridges were carried out to allow proper healing of the gingival tissue.
Notice the appearance of the healthy gingiva compared to that of the diseased. The black triangles were eliminated after the tissue has healed with fabrication of new bridges and veneers on central incisors which follows guided tooth proportions and blends with the surrounding gingival tissue.
Utilization of dental implants for tooth replacements have become increasing popular due to its predictability where an overall success rate of greater than 98% have been reported over a ten year period. With that in mind, this patient wants to replace her first molar, which was lost from caries, with a dental implant.
Also notice the presence of cavity on second molar and loss of first molar space from mesial (forward) drifting of the second molar.
Due to insufficient amount of bony support for implant, bone graft was necessary at the implant site prior to implant placement. The radiograph shows the implant in place. Both bone graft and implant placement was performed by Dr. Jimmy Choi.
Full Mouth Reconstruction
This patient presented with interproximal cavities, failing existing restorations (fillings, crowns and bridges) and history of periodontal (gum) disease which caused her to loose some of her teeth and her supporting bone level.
For simplicity, the treatment goals for this case is to reestablish dental and gingival health, create dental and gingival harmony, establish occlusal stability, and enhance or beautify the overall appearance.
Healthy dental-gingival complex is achieved following periodontal therapy and placement of new restorations including porcelain crowns, bridges and veneers at an established occlusal scheme.
Amalgam Restoration Replacement
Commonly observed with amalgam restorations where marginal leakage and breakdown results in recurrent caries of the existing restorations, and if not taken care of can result in further destruction of tooth structure and eventually may lead to necrosis of the tooth.
Composite system was utilized to replace the failing restorations. Due to the extent of the tooth structure loss, the restoration for the first molar was generated with Cerec CAD/CAM Technology and was adhesively bonded in place. Immediate post-operative photograph above shows natural integration of the restorations with the remaining tooth structure with the added benefit of adhesive bonding which eliminates micro-leakage.
Amalgam Restoration Replacement
Existing amalgam restorations on the maxillary (upper) arch showing signs of marginal wear and breakdown. This patient wants replacement of these amalgam restorations with bonding to minimize and prevent any premature tooth fracture which he had experienced recently on his lower arch.
All amalgam restorations were replaced conservatively with composite restorations through adhesive dentistry. This chemical adhesion of the composite restorative material to the tooth structure not only prevents microleakage at the junction of the filling and the tooth but strengthens the integrity of the remaining tooth structure thereby minimizing the possibility of premature tooth fracture. In addition, anterior porcelain veneers were utilized to enhance his smile and to establish better arch form.
Chipped Tooth Restoration
This 7-year old boy chipped his permanent front left central incisor during a fall, which is the most common type of dental injury among boys. These central incisors are still in the process of eruption and any restoration of choice on these teeth must be conservative to preserve the remaining tooth structure and at the same time must meet or exceed the challenges of restoring anterior teeth.
This photograph was taken 1 year post composite restoration placement. Notice the color stability and the integration of the restoration with the surrounding tooth structure. The choice of composite is ideal for this case due to its conservativeness, its ability to blend and its strength for functional requirements. Also notice that this patient has a significant anterior overbite and both arches (maxillary and mandibular) need to be developed into a better relationship during a Phase I orthodontic treatment.
Invisalign system is ideal for minor tooth movements especially when rotational and extrusive movements are not involved.
As in this case where this patient presented with minor crowding of her maxillary and mandibular dentitions with no prior orthodontic treatment.
The goal of the treatment is to create adequate space through expansion of dental arches to accommodate the tooth mass and to properly align the dentition.
The completed treatment photos show properly aligned dentition with congruent midlines and with a brighter and whiter smile from whitening treatment performed simultaneously with the Invisalign treatment.
Also at the completion of the treatment, a fixed lingual retainer was placed on the anterior of the mandibular arch and clear Essix retainers were fabricated for both maxillary and mandibular arches for the purpose of retention.
Traditional Brackets/Wire Therapy
A traditional orthodontic therapy involving the use of brackets to align dentitions are necessary when rotational movements must be incorporated during the process of aligning the teeth. In general, significant rotational and extrusive orthodontic movements are better managed with brackets and wire than with Invisalign system. This is not to say that one system is more superior to the other; however, recognizing the advantages and limitations of both systems is necessary in order to facilitate and enhance the treatment outcome.
This patient presented with a significantly rotated and distally inclined maxillary canines causing spacings among her maxillary anterior teeth resulting in distraction and imbalance in her smile zone. In addition, missing tooth #29 with retained #T resulted in dental midline discrepancy as seen in pre-treatment photographs.
A comprehensive orthodontic treatment with brackets and wire was carried out along with interproximal tooth reduction of #T to first derotate the canines, second to realign dental midline, third to close all spaces, and at last to obtain improved vertical (overbite) and sagittal (overjet) relationships as seen in post-treatment photographs.
As for retention, a set of clear Essix maxillary and mandibular retainers was fabricated at the completion of the treatment.
Patient presented with discolored and fractured Maxillary right central incisor, chipped Maxillary left incisor, and drift of the Maxillary right lateral incisor. Patient will like to address those issues and enhance his smile.
Maxillary right central incisor with history of trauma was necrotic. Endodontic therapy was performed followed by internal bleaching. A complete healing of the periapical area with bone fill was observed.
A limited orthodontic therapy was carried out on Maxillary dentition to reposition Maxillary right lateral incisor into it's original position to obtain right and left symmetry and to obtain more favorable tip and torque of the maxillary dentitions. A full mouth bleaching was done and gingivoplasty or gum lift was also performed on the central incisors to obtain proper gingival height and symmetry in relation to those of lateral incisors and canines. Finally, the central incisors were very conservatively prepared for veneers which were then fabricated with CEREC technology and bonded in place. This case shows the integration of various disciplines in dentistry in addressing patient's concerns and achieving a successful result.