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22 cosmetic section DENTAL TECHNOLOGY, JULY-SEPTEMBER 2023

CREATING DENTAL AND FACIAL HARMONY

Cyntia Galvão Gomes de Medeiros and Karoline Leão present a case of oral rehabilitation
of a young patient with severe dental wear using the 4D protocol of planning

Performing an aesthetic and functional rehabilitation requires pre- Composite resin is a material that allows teeth to be restored
cise planning and diagnoses, as well as an operational technique. with an additive – a reversible and safe technique, and, besides
To aid this, the ‘golden ratio’ was one of the first recognized sys- being aesthetic, meets the patients’ requirements and is easily
tems to properly plan a smile design (Fradeani and Corrado, 2006; repaired (Baratieri and Guimarães, 2008; Medeiros, 2018;
Levin, 1978; Lombardi, 1973; Preston, 1993). Currently, waxed Mondelli, 2003; Pashley et al, 2011).
models and digital protocols are the most popular in tooth prepa-
ration (Coachman and Calamita, 2012). TABLE 1: CRITERION TO CLASSIFY DENTAL WEAR (BARTLETT ET AL, 2008)
The ‘rule of 20’ has also been suggested as a simple and accurate
method for defining the anterosuperior segment for dental meas- Score Criterion to classify dental wear
urements (Medeiros, 2013; 2018).
In this case, the central incisor measurement is used as a refer- 1 No surface loss
ence to define lateral incisor measurements (Medeiros, 2013;
2018), alongside other variables observed at the first appointment. 2 Incisal loss of surface texture
The concept of aesthetics is subjective. Several articles have been 3 Loss of tooth tissue with less than 50%
written and reviewed to find a standard to be followed in all cases of dentin surface area
(Frese et al, 2012). Getting to know the patient’s particularities, 4 Loss of tooth tissue of over 50% of dentin
and respecting their wishes and expectations, are the first things to surface area
be considered in the 4D protocol.
The dynamic and static analysis of the facial and dental compo-
nents are to be considered in the appointment, too.
Taking measurements and respecting the proportions between TABLE 2: TOOTH DIMENSIONS (REAL VERSUS IDEAL)
the features associated with a smile when related to facial dimen-
sions and functions of the stomatognathic apparatus justifies the Real Ideal
need for an interdisciplinary approach for better treatment (Levin,
1978; Lombardi, 1973; Medeiros, 2013; 2018; Mondelli, 2003). Tooth Height Width Tooth Height Width
The chemical and physical degenerative processes need to be
UR1 7mm 8mm UR1 10mm 8mm
detected and treated since they compromise the aesthetics, func-
tion and structure inside the teeth. UL1 7mm 8mm UL1 10mm 8mm
Bruxism and acid erosion also affects the vertical dimension
UR2 7mm 5.5mm UR2 8mm 6mm
occlusion (Medeiros, 2018).
The causes may be multifactorial and could be associated with UL2 7mm 5.5mm UL2 8mm 6mm
meal patterns, lifestyle and physiological changes, such as gastroe-
sophageal reflux (Barron et al, 2003; Bartlett et al, 2008; Hamasha
et al, 2014; Harpenau et al, 2011).
However, dental structure is being lost earlier in life, as observed That being said, this article aims to present a case report of oral
in students aged 14 in England (Alfadda, 2014). Therefore, effec- rehabilitation of a young patient with severe dental wear using the
tive diagnosis and prevention measures need to be part of the first 4D protocol of planning. Also, use of the tailored basic erosive wear
appointment protocol (Bartlett et al, 2008). examination (BEWE) (Bartlett et al, 2008) index was used to doc-
When looking at cases where people have been losing their teeth ument dental loss due to acid erosion, presenting the step-by-step
not by dental caries, but by disruption of oral cavity homeostasis, even aesthetic and functional rehabilitation with composite resin
in younger patients, use of conservative procedures is important. throughout the oral cavity.

CASE REPORT and planning.
A 32-year-old male patient, MPC, came to the clinic complaining
about severe bruxism and darkened dentition (Figure 1). During 3. Nano-aesthetics (Figure 1) – analysis of the tooth itself,
the initial examination, an anamnesis was performed as well as a considering aspects related to optical properties, such as translucen-
clinical examination capturing all dental measurements. Extraoral cy and opalescence, which may be altered in patients with acid
and intraoral photographs were taken, in addition to the request for erosion. In this patient, the teeth were darker due to the loss of
a radiographic examination to perform the case planning. enamel.
Under the 4D protocol, clinical evaluation follows the model In the dental analysis, the ‘oral care always unique program was
below of dental and facial aesthetic analysis: used to diagnose and show the patient a clinical report of the teeth
affected by infectious diseases, caries, and gingivitis, as well as
1. Macro-aesthetics (Figure 2) – analysis of the relationship degenerative, physical wear, chemical wear, and gingival retraction.
between the teeth and the face by anterior view, 45° and lateral Out of the 32 teeth shown, 14 were compromised with physical
view. In this case, we could see a reduction in the lower third of the wear, which represents a total of 43%. The analysis of dental erosion
face, reflecting the loss of dental structure and disharmony in rela- was based on the adapted BEWE Index (Table 1).
tion to the teeth and bones of the jaw and mandible. In this case, it was observed that of 32 teeth present, 12 were
grade 1, eight were grade 2 and four grade 3. A total of 24 teeth
2. Micro-aesthetics (Figures 1 and 3) – analysis of each tooth were affected with dental erosion. Severe acid erosion was an
and the lips and gums. Teeth were aligned, small and darkened with important factor in the loss of vertical occlusion dimension
little gingival exposure, confirming the patient’s complaint. At this (Figure 8).
point, dental measurements were collected to be used for diagnosis