46
Dentistry
1 September 2016
Clinical
Bulimia sufferer’s smile
transformed for wedding day
Thomas Sealey describes how he quickly restored a patient’s badly eroded teeth with minimally invasive techniques
Figure 1
Figure 2
Figures 1 and 2: A 39-year-old patient came to see me eight weeks before he was due to get married, as his front teeth
were chipped
regimes necessary. The patient understood that to restore
the teeth back to their original shape would require
opening his bite to create sufficient space for the palatal
restorations of his upper teeth.
The patient chose to have the damaged teeth rebuilt,
repaired and reshaped with composite material. This
minimally invasive treatment option satisfied both the
patient’s limited budget, and the short time frame he had
until his wedding. He understood that these techniques
would involve maintenance and repair in the long term.
However, he weighed this against the reduced financial
impact, and that there was no requirement for injections,
and decided that this treatment option best met his needs.
He was made aware of the implications for ongoing
maintenance and monitoring of his occlusion. Although
broader and more comprehensive treatment options
were available, the patient felt that these minimally
invasive techniques would provide him with the smile
that he wanted, without further damage to his already
compromised teeth.
Treatment process
Figure 3: After examination, it became clear he had
extensive erosion to all the palatal and occlusal surfaces of
his upper teeth
Figure 4: He had extensive erosion to all the occlusal
surfaces of his lower teeth
Figure 5: The tooth pulp could almost be seen through the
eroded palatal aspects of his upper teeth
Figure 6: The patient was given a course of overnight tooth
whitening, using a combined regime of 10%, followed by 16%
carbamide peroxide, which improved his shade from B2 to BL4
A 39-year-old patient came to see me eight weeks before
he was due to get married because his front teeth were
chipped (Figures 1 and 2). After examination, it became
clear he had extensive erosion to all the palatal and
occlusal surfaces of his upper teeth (Figure 3), and all
the occlusal surfaces of his lower teeth (Figure 4). We
discussed his social history, diet and occupational factors,
which may have had an effect on his dentition.
The patient had a history of bulimia, an illness that is
caused by low self-esteem and poor body image. Sufferers
usually overindulge when they eat and then follow this with
self-induced vomiting. Fortunately, the patient had resolved
these issues but the effect of the acidic vomit on his teeth was
obvious. The tooth pulp could almost be seen through the
eroded palatal aspects of his upper teeth (Figure 5).
I contacted his general medical practitioner to arrange
for further testing, to ensure he was not suffering from
ongoing gastric reflux or similar conditions.
Treatment options
The patient’s general oral hygiene was good, but clinical
examination showed advanced generalised erosion. The
amalgam restorations were prominent within the teeth
where the dentine had eroded around them. Some teeth
had also fractured. All his teeth had a normal periapical
appearance on radiographs. Each tooth was responsive to
both the electric pulp tester and to cold.
I showed the patient pictures and examples of all the
types of dental treatment available to him, including
orthodontics, crowns and veneers – both ceramic and
composite. We discussed in depth the durability of each
technique, and the differing hygiene and maintenance
The patient was given a course of overnight tooth
whitening, using a combined regime of 10%, followed
by 16%, carbamide peroxide, which improved his shade
from B2 to BL4 (Figure 6). This was completed over a
four-week period. During this time, a face-bow record
was taken and a provisional diagnostic wax-up was made,
opening the patient’s bite enough to allow the eroded
palatal surfaces to be rebuilt.
The patient attended for fitting of a trial smile. This
essential step allows the patient to visualise the final results.
It is crucial for the consent process, as well as providing
the opportunity to assess the aesthetics of the teeth in
relationship to the patient’s face and smile. I use Memosil 2,
which is an accurate and clear silicone impression material
to take impressions of the wax-up teeth. The silicone stent
can be easily removed from a non-perforated tray. The
stents are filled with a temporary crown acrylic material in
the desired shade and immediately placed over the patient’s
own teeth. This creates an exact replica of the wax-up teeth
worn by the patient and allows me to observe the occlusion
and aesthetics (Figure 7). Changes can be made to the waxup at this point.
This minimally invasive treatment
option satisfied both the patient’s
limited budget, and the short time
frame he had until his wedding
In this case, composite bonding of almost every
tooth was completed in two stages under rubber dam
isolation. First, the lower teeth were restored and then
the upper posterior and premolar teeth. This opened the
bite sufficiently to allow for the palatal restoration of the
upper anterior teeth. The stents were used as guides to
help develop the correct occlusal height and relationships
of all the posterior teeth.
The teeth were prepared by sandblasting the surfaces,
to create micro-abrasion of the enamel surfaces, which
increases mechanical retention. The teeth were then
washed with chlorhexidine to inhibit the matrix
metalloproteinases (MMPs) released from any exposed
and damaged dentine and enamel. These enzymes
degrade collagen over time, which reduces the bond
48
Dentistry
1 September 2016
Clinical
Figure 7: This creates an exact replica of the wax-up teeth
worn by the patient and allows me to observe the occlusion
and aesthetics
Figure 10
Figure 8: Heraeus Kulzer Venus Diamond was used to
restore the posterior teeth
Figure 11
Figures 10 and 11: Venus Pearl was chosen for its inherent strength, the vast array of shades and the excellent natural
aesthetics that can be obtained with a high polish
Figure 9: The upper canine to canine teeth were rebuilt
using Venus Diamond on the palatal aspects and Venus Pearl
on the labial surfaces
The labial surfaces were completed freehand.
The anterior teeth were shaped using Venus Pearl. This
material was chosen for its inherent strength, the vast array
of shades and the excellent natural aesthetics that can be
obtained with a high polish (Figures 10 and 11). I used a
blend of enamel and incisal shades to achieve subtle nuances
on the composite veneers, creating the correct translucencies
and natural aesthetics. To add secondary and tertiary
anatomy, the teeth were shaped with finishing burs and a
three-step composite polishing system (Figure 12).
Clinical consistency in both the handling and the
aesthetic properties of the Venus range make it my
material of choice. If the restorations are well designed
and the occlusion carefully considered, the material rarely
fractures and the incisal edges of anterior teeth can be
restored with confidence (Figure 13).
Clinical outcome
Figure 12: To add secondary and tertiary anatomy, the teeth
were shaped with finishing burs and a three-step composite
polishing system
Figure 14
Figure 13: If the restorations are well designed and the
occlusion carefully considered, the material rarely fractures
and the incisal edges of anterior teeth can be restored with
confidence
Each case should be reviewed on its merits. The aesthetics
would definitely have been improved with some simple
orthodontic realignment of the anterior teeth before
composite placement. However, the patient was not
aiming for perfection, but rather to regain his confidence
in social situations by having improved oral health and
a smile that he would be proud to show at his wedding.
This exceptional aesthetic result has been achieved
without any further damage or loss to his natural teeth,
and all the previously exposed surfaces are protected from
further erosive damage (Figures 14 and 15). The beauty
of using composite material is its versatility, and that it can
be reduced and added to, if necessary, when developing
his smile in the future.
Figure 15
The upper canine to canine teeth
were rebuilt using Venus Diamond
on the palatal aspects and Venus
Pearl on the labial surfaces
Figures 14 and 15: This exceptional aesthetic result has been achieved without any further damage or loss to the patient’s
natural teeth, and all the previously exposed surfaces are protected from further erosive damage
strength of resin-bonded materials. The teeth were etched
and bonded following the manufacturer’s protocol.
Excellent natural aesthetics
Alternate teeth were prepared using the above protocol,
isolating the adjacent teeth with PTFE tape. The teeth were
built up roughly with a blend of uncured Heraeus Kulzer
Venus Diamond composite resin before the Memosil 2 stent
was placed over the teeth. The composite was moulded
into shape by the stent and then it was light-cured through
the stent. By using this technique, the wax-up can be
transferred directly onto the teeth, so that the finished
composite build-ups are placed with precise replication of
the wax-up.
After removal of the stent, I neatened the direct
composites on each tooth by hand. I then removed the
PTFE tape and placed it over the teeth I had just finished,
allowing preparation of the neighbouring teeth in the
same manner. This technique enables very tight contacts
to be formed and prevents the black triangles caused by
using separator strips and wedges.
Figure 16: The patient was extremely happy with the
end result
Venus Diamond was used to restore the posterior teeth
(Figure 8). The upper canine to canine teeth were rebuilt
using Venus Diamond on the palatal aspects and Venus
Pearl on the labial surfaces (Figure 9). The clear silicone
stent was used to guide the shaping of all the palatal
surfaces and the composite was cured through the stent.
The patient was extremely happy with the end result
(Figure 16). At a time when he only had weeks before
his wedding and a very limited budget, his smile was
completely transformed with non-invasive restorative
and cosmetic techniques. This is the future of dentistry.
We are so fortunate to be practising in an era when we
have the material technology to be able to achieve this
outcome without the huge, long-term financial burden
and commitment of the alternative ceramic techniques.
Dr Tom Sealey is a private cosmetic dentist
working in Ingatestone, Essex. He has
extensive experience in all aspects of
dentistry and holds a masters degree in
medical education. Dr Sealey has trained
foundation dentists and lectures on
short-term cosmetic orthodontics, implants and root canal
treatment. He won ‘Best Young Dentist – South East’ at the
2015 FMC Dentistry awards and is the inventor of the Solid
Retention System, distributed by Cfast orthodontics.
FOR MORE INFORMATION, contact Thomas at Start Smiling
by calling 01277 353 456 or emailing
[email protected]. Alternatively, visit
www.start-smiling.co.uk.