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Dental Tribune United Kingdom Edition

Making Digital Dentistry Happen Objet Eden260V 3D Printer 3D Printing Solutions for Digital Dentistry • Print stone models, veneer try‑ins and delivery trays, surgical guides, denture try‑ins, orthodontic appliances and more • Produce parts faster with superior accuracy and resolution • Eliminate manual work and improve efficiency Find out how Objet 3D Printing can transform your dental business today. www.objetdental.com • dental@objet.com Clinical desperation for a solution and thus time is needed at consulta- tion to clearly discuss all the is- sues as expectations are naturally very high. This is why the most important phase is the consult and consent phase as all cases are different and some will (as it is a soft tissue procedure) have more relapse than others. This is an important point to remember as post-surgery the patient will have the smile they dreamt of but some may relapse, which may in turn lead to disappointment even if it is still much better than the original situation. For this reason it is highly advised to keep pho- tographic records. Colleagues should also be aware that the desire to help desperate patients can cloud case judgment, and cases with especially bowed up- per lips on hard smiling due to very strong musculature are very prone to relapse and the patients must be pre-warned. Even at rest the patient exhibited 5mm of gingivae (Fig 9) and when smiling hard (Fig 10) she showed why this is often more reconstructive than aesthetic surgery. This also shows why it is important that we straighten and whiten these cases as patient’s teeth are always on show and thus need to be an asset. After consent we can then proceed with the surgery and al- ways begin with a chlorhexidine mouthwash. The distal buccal corridors are packed with gauze to prevent blood seeping back and with a scalpel (number 15 blade) start with the incision on the mucosa of the inner surface of the lip first using a brushing stroke so as to merely cut the sur- face. Starting at the frenum and making an ovoid shape to the canine area (we used to go back further but now see benefits of making a shorter deeper ovoid) then make the second incision at mucco-gingival margin back to the frenum. The surface mucosa then may be peeled off (Fig 11, another case) and then repeated on the other side until you have the full ovoid removed (Fig 12). This is then sutured together finely yet tightly using 5.0 silk interrupted sutures, remember- ing to always start at the centre to assure correct assimilation of the borders. The patient must not use any excessive lower facial expres- sions in the two weeks healing period following the treatment. After this point the remaining sutures are then removed (some fall out after 10 days). The patient is then shown the result and it is recorded and again asked to re- frain from smiling for another week. After six months the patient returned and whilst the rest po- sition was the same (Fig 13) as it always is the hard smiling ex- hibited a pleasing improvement (Fig 14) but there was still not ideal balance. After a detailed dis- cussion with the patient, includ- ing careful periodontal probing and assessment, it was decided to lengthen the crowns as well without any associated dentistry due to the shape of the teeth and position of the enamel cementum junction. A flap was then raised from 3 to 3 (Fig 15) and a small amount of bone removed with a round bur prior to the flap being re-sutured closed with Prolene. Electro- surgery was then used to remove the excess gingival tissue to the correct level (Fig 16) and the scar from the lip surgery can be seen. After a further three months the patient came in for a follow- up (she lived 200 miles away) and further photographic records were taken to show the case at nine months post the initial sur- gery. The rest position now had balance (Fig 17) and on hard smil- ing (Fig 18) the patient was very contented with the outcome and even consented to a full-face pho- tograph (Fig 19) which she had declined prior to the surgery. She felt her expectation had been met, and the case was a satisfying re- sult with very low trauma and no long-term side effects to the pa- tient. Her new, more confident ap- proach to life was also particularly pleasing. Conclusion Being a soft tissue procedure, re- lapse can always be an issue es- pecially in cases with very hyper- active musculature. More than 360 cases in the last eight years it is felt that the vast majority of them have fulfilled the patients expectation but follow-up is com- plicated by the distance most pa- tients have to travel. Case assessment and selec- tion as well as careful consent procedure is critical in under- page 26DTà November 12-18, 2012United Kingdom Edition 25