Dental Tribune U.S. Edition No.11, 2017

A2 C L I N IC A L Dental Tribune U.S. Edition | November 2017 ‘Growing Enamel’ — Revisited By David L. Hoexter, DMD, FaCD, FiCD Dental tribune US editor in Chief One of the dental field’s biggest esthetic prior- ities, after restoring and preserving health, is enhancing the smile. In 1995, Dentistry Today published an article I wrote about a technique I developed, which I called “Growing Enam- el.” The phrase is erroneous, of course, because, after enamel is formed, it does not grow. But this technique creates an image of it doing so. In the years since the article was published, the concept has been copied in articles and books on cosmetic treatment techniques without reference or recognition. However, imitation or replication is a great form of flattery. When I wrote the article “Growing Enamel,” it was during the early days of a groundswell of esthetic awareness of the mouth, which resulted in the adop- tion of various oral esthetic techniques and treatments. As a periodontist, I concentrate on the background of a smile to enhance the desired foreground — the appear- ance of a glowing smile. Even, symmetrical and ahhealing The maxillary anterior teeth are the most visual and the crux of the smile. First impressions are formed here. What we want to see is bright, white, symmetrical teeth; but most teeth fall somewhat short of this de- sired illusion. When viewed closely, the natural incisal edges are obviously not even. The lateral incisors’ edges are usually slightly shorter than the central incisors’ edges. The cuspids’ shapes are not entirely level to the incisors and typically of a different shape altogether. The technique “Growing Enamel” helps create the im- age of an even, symmetrical and appealing smile. There are many causes of an imperfect smile. Perhaps there was an accident that resulted in the breaking of an incisal tooth. Perhaps an anterior tooth changed color. Perhaps incorrect shading was used with an an- terior restoration. Virtually anything that changes the desired illusion of a clean, bright, symmetrical flow, might be the culprit. We need to remember that the actual average natural size of the central incisor is 11.5 mm gingival-to-incisal height with an average 9 mm mesial-distal distance. ‘Growing Enamel’ The “Growing Enamel” technique is the manipulation of the periodontia when the tissue is such that it dis- torts the visual appearance of the visible teeth. There must be no loss of supporting alveolar bone, and there must be a healthy zone of keratinized gingiva. Of vital importance is the preservation of the inter- ” See ENAMEL, page A3 355-0004 or drdavidlh@gmail.com. AD Using the “Growing FICD and Pierre Fauchard. He has a practice in New York City limited to periodontics, implantology and esthetic surgery. Contact him at (212) proximal tissue. The keratinized interproximal tissue may be manipulated vertically, but the interproximal tissue must be preserved. There is no new blood supply interproximally, so the area, if removed, will show an undesirable dark interproximal space referred to as a “black diamond.” The resulting final image should end with a healthy zone of attached keratinized, pinkish- white gingiva forming a background to the desired size and shape of the anterior teeth. Using a form of the apically repositioned flap, with healthy tissue as the esthetic goal, the “Growing Enamel” technique serves as a vital approach to achieving a maintainable smile desired by both the patient and the practitioner. What it’s not The technique “Growing Enamel” should be part of the esthetic surgeon’s choices of techniques. Techniques such as “crown lengthening” imply the exposure of more tooth structure by removing surrounding tissue and bone. “Growing Enamel” relates to the exposure of only the anatomical crown, which too often is covered by hyperplastic or excessive gingiva, preventing natu- ral esthetic properties from being emphasized. Terms such as “gingivectomy” or popular words such as “sculpting” are just references to removing hyper- plastic tissue. There is no definitive desired goal except removing excess tissue, and there is inconsistency when there is no uniform and desired goal. Sometimes the removal of tissue can result in root exposure or in- consistent proportions of tissue that distort the smile. A definitive surgical technique such as “Growing Enamel” avoids the recession possibilities and adds predictability to the desired symmetrical background. Case study In this example case, a 19-year-old woman wanted a beautiful smile she could be proud of (Fig. 1). Initially, she presented with bleeding gingiva, but after a series of non-surgical treatments, which included oral hy- giene instruction, the bleeding ceased. Fig. 1: Before, patient wanted a nicer smile. Photos/ Provided by Dr. David L. Hoexter Fig. 2: Periodon- tal tissue reposi- tioned sutured with sling suture technique. Fig. 3: Healed periodon- tia. Enamel exposure full and natural. Tooth #7 restored. Fig. 4: Patient loves and is motivated to care for her new, bright, symmetri- cal smile. Her #7 appeared to not look clean, with a worn, stained restoration labially. It also appeared short in height. The centrals had a square appearance, not the length of a normal ap- pearing incisor, but short- er and not streamlined. The cervical line was ir- regular, the cuspids being higher and the centrals ir- regular and lower. DaviD L. Hoexter, DMD, FiCD, FaCD, is director of the International Academy for Dental Facial Esthetics and a clinical professor in periodon- tics and implantology at Temple University, Philadelphia. He is a diplo- mate in the International Congress of Oral Implantologists, the American Society of Osseointegration and the American Board of Aesthetic Den- tistry. He lectures throughout the world and has published nationally and internationally. He has been awarded 12 fellowships, including FACD,

Dental Tribune U.S. Edition No.11, 2017

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