Dr Gurs Sehmi http://drsehmi.co.uk Cosmetic Dentist, London Sun, 25 Feb 2018 07:47:08 +0000 en-GB hourly 1 https://wordpress.org/?v=4.9.5 117750108 How to Make Dental Implant Treatment Quick and Accurate http://drsehmi.co.uk/make-dental-implant-treatment-quick-accurate/ http://drsehmi.co.uk/make-dental-implant-treatment-quick-accurate/#respond Mon, 27 Mar 2017 14:13:31 +0000 http://drsehmi.co.uk/?p=5307 Dental implant treatment is one of the best ways to replace missing teeth. The dental implant itself is a little metal ‘rod,’ which is placed in the bone (as your normal teeth are) and this is used to support one or more teeth. The problem is that this sounds like the most horrible procedure known…

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Dental implant treatment is one of the best ways to replace missing teeth.

The dental implant itself is a little metal ‘rod,’ which is placed in the bone (as your normal teeth are) and this is used to support one or more teeth.

The problem is that this sounds like the most horrible procedure known to man – “as if going to the dentist wasn’t bad enough, now they want to cut me open and drill holes!!!”

The truth is that in the vast majority of situations, there is very little pain and discomfort afterwards, and even during the treatment, you should not feel a thing. But this is easy for me to say right!

I want this treatment to be over as quickly as possible for my patients.

And I also want the placement of this dental implant to be in the most ideal position, allowing for the best tooth placement on the implant, and I want to be sure I am a safe distance from anything like a nerve, other teeth and air sinuses.

There is a really predictable way of doing this, and I have made a short video for you to help explain this.

I hope you enjoy it!

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How To Fix A ‘Wonky’ Smile http://drsehmi.co.uk/fix-wonky-smile/ http://drsehmi.co.uk/fix-wonky-smile/#respond Tue, 14 Feb 2017 19:45:21 +0000 http://drsehmi.co.uk/?p=5174 The post How To Fix A ‘Wonky’ Smile appeared first on Dr Gurs Sehmi.

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What do you do if when you smile, all your teeth on one side are showing, but on the other, they are all hidden?

No-one is perfectly symmetrical, but the last thing you want is to draw more attention to this!

I’m going to tell you the story of someone who I recently helped to correct this exact problem. Before I do, let me tell you how this is affecting my patients life.

So, he has a job where he is constantly in front of very important people, where a very professional appearance is critical, and he feels that although he can control the clothes he wears – his smile is letting him down.

This is making him feel very self conscious.

So far, he has tried to fix it with invisalign treatment (this is a form of brace treatment done with a near invisible brace).

The problem was that he started this treatment with a dentist in another country, because its cheaper but they didn’t take into account what he was trying to achieve. Hence, the results were not what he wanted, and we are back to square one!

Lets look at doing things properly now!

Lets look at the problem

This is what my patients smile looks like after the attempted Invisalign treatment.

There are two things that he doesn’t like about this smile right now, the first is that its ‘Wonky,’ you can see a lot more tooth on (his) right, than you can on the left.

img_41419942Also, there is a tooth on his left that is out of place, and is really ruining the overall appearance of his smile.

Now, when you have a situation where you don’t like one thing about your smile, chances are that you will fixate on this!

So let me take a minute to show you how this can be improved, and all the areas I think need some level of improvement.

The Cosmetic “Problem List”

img_41419942problem-list

There are lots of things that make smile look great, but above I have just highlighted the main ones that bothered Peter, and the things that we focusing on for his treatment.

Visualise the end result

The only way to achieve excellent results is to plan for them.

In this case, we planned the cosmetic appearance of the smile, by drawing on what I thought was a great smile outline. Super technical – right! 😉

img_41419942-design

So this now gives us a blueprint of what the end result should look like.

For those who have been paying attention, you will notice that we can only see the bottom of the teeth. It is important to design the top of the teeth as well.

This is because when you feel better about your smile, you will show more gum!

Here is the full design.

In this situation, we have areas of recession (where the gum has gone higher), these are tricky to cover up. There are procedures that you can do to bring the gum back, however in this case, we decided to shape the gums a little, and use a special design in the veneers to give the illusion of the tooth shape being correct.

 

The Trial Smile

When you are considering this kind of treatment, then would you want to try out your smile before having it fitted?

This is exactly what how I do my smile designs (veneer treatment).

We prepare the teeth for the veneers and build up the new smile in hard provisional material.

This is the trial smile, and initially I thought the teeth looked a little too long, but the truth is that these photos were taken when Peter was numb, so they look deceptive.

Peter really liked the look of them, so we then proceeded to make the final veneers from high gloss porcelain.

 

The Final Result

The final result looks like they are his own teeth – the look he was going for!

The porcelain veneers have been shade matched to his natural teeth, they are a slightly different colour at the neck of the tooth, then blended to a brighter tip colour – in the same way as normal teeth are!

img_516611450mod

The final veneers are designed to be textured, just like natural teeth.

If veneers are made very flat, they appear dark and dead!

Texture on the surface helps to scatter light, and if you look at the natural teeth in the photo, you can see they are textured – so it makes sense to copy this!

Its really important that the bite pattern is respected here. This means we needed to adjust the lower teeth slightly so that he wouldn’t break the upper veneers.

Find out more about this treatment

Request a call back from a treatment coordinator to find out more about improving your smile

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Lingual Braces, Peg Laterals and Porcelain Veneers! http://drsehmi.co.uk/lingual-braces-peg-laterals-and-porcelain-veneers/ http://drsehmi.co.uk/lingual-braces-peg-laterals-and-porcelain-veneers/#respond Mon, 21 Nov 2016 11:01:20 +0000 http://drsehmi.co.uk/?p=5073 The post Lingual Braces, Peg Laterals and Porcelain Veneers! appeared first on Dr Gurs Sehmi.

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So here is another cool little case that I just finished, here is the before/after shot of the smile.

Cosmetic Dentist London, Dr Gurs SehmiCosmetic Dentist London, Dr Gurs Sehmi

Here are the pre-ops:

Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi

Ortho Assessment

So in this post, I am not going to go into a lot of detail about the ortho – because thats easy bit!

Right side Class 1 canines, Left side1/2 unit class 2, with mild lower crowding, and a little upper spacing. With the lowers, once they are straightened, the incisors will probably tip forward, so some IPR there might be a good idea.

The plan is to level and align, not aiming to correct the left canine class 2.

With the uppers, the peg laterals need addressing, so we discussed either porcelain or composite – the patient was undecided at the beginning of treatment.

Lets listen to the patient for a second!

The main reason the patient called the clinic was that she didn’t like how big her front teeth are. She felt that braces would help her, and she had done some research, so she knew about linguals.

 

Cosmetic Dental Problem List

For the upper teeth, there are several things that are making the front teeth look big, and destroy the harmony in the smile.

  1. The gingival margins are not symmetrical
  2. The tooth width proportions (golden proportion) is all wrong! The laterals are too small, and canines look wide
  3. The height width of the centrals is not the same
  4. The midline is canted
  5. The incisal edges are not parallel to the lower lip

If I overlay what I am imagining in my head to the pre-op, then these things look more obvious.

img_6486-copyNow I know that all the cosmetic problems can be addressed with ortho and veneers, the plan is taking shape!

The only thing I will not correct fully, is the proclination, however this will improve with the ortho. The patient is fine with this, so I took impressions and photos, and sent the whole lot to Sue at Wired Orthodontics.

You can find out more about Wired Orthodontics, and they do a whole bunch of really good ortho courses aimed at people with a little ortho knowledge.

 

The Set Up

For those of you who are not familiar with lingual braces, first you have a kesling set up done, then from that the brace is made. This means the brace is 100% customised for the patient, and the anticipated outcome.

For this reason, its really important that Sue sets the laterals in a little (which she did). This means that I don’t need to do any prep – just in case the patient chooses porcelain veneers after the ortho.

Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi

For the set up, the right side is now in class 1, and this can be replicated in the mouth (with the use of the right mechanics). I didn’t actually end up doing this because we ran out of time, the patient told me that she was leaving the country – so we had to cut the ortho a little short.

This case was still levelled and aligned, but not finished in class 1, and the space mesial to the LL6 still remained (although reduced)

To keep things simple, the steps to the ortho were:

  1. Get the brackets on
  2. Work up the wire sequence
  3. Debond and retain

Okay, it was a little more than that, but not that much more!

And now for the fun bit

Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi

She decided that she would prefer the porcelain veneers, so the process of doing this is:

  1. Prep. In this case, it was non prep, there is a clear path of insertion, and because the teeth are set up a little lingual, there is no need for labial prep.
  2. I did actually prep the UL1 incisally, to get the edges level
  3. Take the impression (having removed the fixed retainer)
  4. Build up the laterals using flow, and shape to look right. Paying extra attention to the line angles. This is what the lab is going to copy.
  5. Replace fixed retainer
  6. Take an impression at the veneer review, having made any changes that the patient wants.

For these veneers, I used Densign. Because they ‘get’ what I want… well, usually!

The cool thing about them is that they scan the model, then scan the patient approved provisional model… Then do some magic, and end up with a really good copy of the provisional that I have painstakingly crafted!

Unfortunately this didn’t work perfectly, this is a photo of the first try in:

Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi Cosmetic Dentist London, Dr Gurs Sehmi

I didn’t like the distal and incisal edges of the veneers, so I explained the issues to the lab, and they fixed this really quickly.

Lets not worry about the contraptions that are going on – on the left side – this was a little experiment 😉

The second time around, the guys at Densign did a fantastic job – take a look!

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So, she was really happy with the result, and as always the main objective to have a happy patient!

The teeth don’t look overly proclined now, we have restored the golden proportion, and she has a really naturally looking great smile.

Patient happy – job done!

If you enjoyed this, like my facebook page to see more cases explained.

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A Simple Class 2 Div 2 with a sectional lingual brace http://drsehmi.co.uk/a-simple-class-2-div-2-with-a-sectional-lingual-brace/ Thu, 01 Sep 2016 16:26:15 +0000 http://drsehmi.co.uk/?p=3612 After my last post, I got so many kind messages so I want to start by thanking everyone who took the time to private message me, to tell me how useful they find these blog posts!   So, that said, lets get on with todays case walk through: I got a simple Class 2 Div…

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After my last post, I got so many kind messages so I want to start by thanking everyone who took the time to private message me, to tell me how useful they find these blog posts!

 

So, that said, lets get on with todays case walk through:

I got a simple Class 2 Div 2 Incisal relationship case here, the canines are 1/2 unit class 2 – this is the kind of case that any GDP who has been on a simple ortho course can tackle.

The overjet is going to increase as the centrals tip forward, and if the patient is happy with this, then thats great!

If your patient is not cool with this idea, then things get a bit more complex. Luckily, in this case, my patient wanted a quick fix before her wedding (she gave me about 9 months to do it), and she didn’t like the laterals. She didn’t want a visible brace, and aligners were not the preferred option, so we did this one with a lingual fixed.

So with a lingual brace, the biggest problem (and a common one) is that the bracket on the UR2 will not bond.

This means the first objective of this mission is to get things aligned enough so that I can bond that tooth up. This is what I did first:

So the photo on the left is the preop, the right is at the first review (around 6 weeks after).

There has definitely been some movement.

For this kind of brace, the brackets are passive for this wire size (12niti). This means that the wire is loose in the bracket, and can easily slide out of one side.

In the area of the UR2, there is excess wire that has been bent into a loop, and there are blobs of composite that stop the wire from escaping through the brackets.

This creates a spring, helping to expose the palatal surface of the UR2.

Anyway, I was getting impatient and bored, so I changed the mechanics at the next visit:

So the picture on the right is the second review.

Instead of composite stops, I have now changed them to crimpable stops (1), and placed them further apart. The overall principle is the same as before.

The bit marked in blue is a powerchain going from the labial of the UR2 to the UR3 bracket (2). This helps to derotate the UR2, while the wire is tipping the centrals forward.

This worked beautifully!

So now, the bracket is on, it should be plain sailing, just work through the wire sequence, and we should end up with a perfect result!

The problem is that I didn’t check the set-up of this case before I bonded up!

Here are pictures of the set up, and the ‘final result’

Now, the clinical result looks like the set up – so there is no problem with the brace! But I didn’t check the keslings, otherwise I could have sent it back for adjustments before bonding up!

So the laterals are still not fully corrected. I have two options:

  1. Debond and finish with clear aligners
  2. Try to be a hero and do some wire bending.

Because I am a hero, I chose option 2. And started to talk to the patient about composite bonding to ‘finish things off!’

The wire bends are in blue, and I have drawn on an exaggerated (blue) wire to show the bends more clearly. I have learned that for a lingual brace, the bends need to be TINY!

The desired tooth movement is in black.

The end result:

As always the end result could be improved slightly with a little gum contouring – but thats the beauty of looking over your cases – you always learn how you could improve things!

These days I talk to my patients a lot more about gum contouring post ortho.

If you liked this, I post all my cases on my Facebook page – give it a like to get more updates.

Gurs

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Treating a Skeletal Class 3 With STO ;) http://drsehmi.co.uk/treating-a-skeletal-class-3-with-sto/ Tue, 23 Aug 2016 04:44:03 +0000 http://drsehmi.co.uk/?p=3572 Okay, I apologize in for the slightly click-bait title to this weeks blog. Just before I get some arsy emails – lets be clear – I cannot treat big skeletal discrepancies with ortho, complex or simple. I can’t even treat with surgery – Ill leave that to the specialists! Here is a case walkthrough of…

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Okay, I apologize in for the slightly click-bait title to this weeks blog.

Just before I get some arsy emails – lets be clear – I cannot treat big skeletal discrepancies with ortho, complex or simple. I can’t even treat with surgery – Ill leave that to the specialists!

Here is a case walkthrough of a patient who I treated, and finished treatment about 6 months ago. Here are the pre-ops:

If you actually want to learn a little about ortho, you need to look at these photos, and do your analysis. At least look at the canine classes, overjet, overbite and count the teeth!

If I just give you my analysis, you won’t learn anything – trust me, you only learn by doing, not just by listening.

The Salient Features

So, the most obvious issues here are:

  1. Class 3 Skeletal relationship
  2. Full unit class 3 on the left, and almost 1.5 units on the right (canines)
  3. Overjet is negative, and overbite is normal
  4. Upper arch spacing, lower arch mild crowding
  5. Some dento – alveolar compensation for the SK3 base
  6. Upper midline is about 3mm to the right of the facial midline
  7. There is a supernumerary left lateral incisor

The thing you can’t see from the photos is that there is a 5+mm pocket between the UL1/2

Because of this, I recommended he see the periodontist for treatment before we started braces. This is important, because he had seen a specialist ortho before coming to me, and one factor for him taking up treatment with me was that I told him about this pocket, and advised that he sees the periodontist!

What does the patient care about?

Now, from a dental point of view, the most obvious thing here is the SK3 relationship, and the best option is surgery. All the patient cares about is how crooked the teeth are!

So we discussed surgery, we discussed extraction ortho, and compensation, and talked about just straightening them.

It turned out that all the patient wanted was to have them straight. He has lived with the reverse overjet all his life, and its not a concern for him!

We also told him about the supernumerary, and that it is an extra tooth (with a funny kink to the root), so we may not be able to get it perfectly straight, and he was happy with that.

To be honest, the supernumerary was a bit of a gift because it helps to reduce the reverse overjet, and its not massively obvious that its there, the shape and the colour of the tooth is pretty good!

So thats our treatment plan sorted, we stuck on the brace, normal labial brace with 3M Gemini brackets:

These photos are straight away after a perio session – but wait – what is that massive growth you can see on the lower occlusal??!

According to the periodontist who was treating him, this is an epulis, or pyogenic granuloma. It can be safely removed surgically, so this is what I did at the end of ortho.

Okay, now we are happy with that, and more importantly, the patient is no longer concerned with it, we can finish the ortho.

Normal wire sequence, probably something like 14niti, 18niti, 20-20niti.

The End Result

So you can see that I got happy with a scalpel, to remove the overgrowth. Apparently this is the best way to remove it. Its the first time I have had to do this, so lets see how this works!

The upper retainer is from 3-3, but because of the supernumerary, this looks really long!

The reverse overjet is also increased, this is because the lower arch has ’rounded out’ and are much more upright.

The most important thing is that the patient is happy.

Could it have been improved?

Clearly surgery would give the best result here. It is possible to tip the lower back with extractions, possibly two premolars or an incisor (personally I would be inclined to take the premolars).

 

If you noticed, that granuloma didn’t completely go after the initial surgery. I probably didn’t remove it enough the first time around. After the last review, I haven’t seen the patient, but I am sure he will call if this is bothering him. If he does, I will reattempt to remove it surgically.

Any questions/ comments please get in touch as normal!

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Upper arch case with a TAD and premolar XLA http://drsehmi.co.uk/upper-arch-case-with-a-tad-and-premolar-xla/ Tue, 09 Aug 2016 10:12:39 +0000 http://drsehmi.co.uk/?p=3537   Here is a single arch case, where if I had done this without extractions, the patient would have hated the result! So here is my thinking, and treatment planning. Great, so lets do the planning: On the right, she is 1/2 unit class 2 (canine), almost class 1 molars, and on the left, 1/2…

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Here is a single arch case, where if I had done this without extractions, the patient would have hated the result!

So here is my thinking, and treatment planning.

Great, so lets do the planning:

On the right, she is 1/2 unit class 2 (canine), almost class 1 molars, and on the left, 1/2 unit class 2 canine, and again only very mild class 3 on the molar.

The overjet and overbite are normal, and the inclination of the incisors is about normal, so although there is upper arch crowding, I definitely don’t want to round out the incisors, as this will increase overjet, and procline the teeth – a look that very few patients like!

From the occlusal, we can see about 3-4mm of crowding, so if we were to just put a brace on, then the incisors would just tip forward, proclining them, leaving me with an unhappy patient!

Space planning

One common goal for treating my patients is to get the canines into Class 1 occlusion, that way I know the overjet is going to be reasonable, in this case, the overbite is normal.

On the right side, the existing space is not where I want it.

But as there is space, it would be silly to extract a tooth to make more space!

The issue is that being so far back, this space will close quickly, without relieving the crowding at the front – which is where we really need the space.

To help with this issue, we need to reinforce anchorage (stop the 6 moving forward).

On the left, there is no space at all! The canine needs to move half a unit distal, so its reasonable to consider an extraction here. The 4 is already filled (and the filling looks terrible!), so this is my choice!

The canine will move 1/2 unit back, and the premolars and molars will come forward to close the space (before de-bond).

After bond up and XLA

To reinforce the anchorage on the right side, I have done two things:

  1. Bonded up the 7
  2. Placed a TAD for direct anchorage

I bonded the 7, so I can start pulling from the 7-4, and as the molars have a greater root surface, and two molars are better than one, I would hope that there is more premolar movement than unwanted molar movement.

To be double sure, I linked the TAD to the 6 bracket. This would hopefully link the 6 to bone, which in theory will not move at all!

On the left side, I just bonded up to the 7 – on this side, I actually want to burn off a little anchorage by bringing the molars forward.

This is a few appointments in and you can see that (even in the previous shots) the incisors have tipped forward! They are now proclined – and the patient hates this look!

This is what the patient would have been left with if I had tried this all non extraction. I could have done some IPR to bring them back a little, but I think you would need to heavily IPR them to bring them back to a decent inclination!

You can also see that once the premolars are back, and the left canine is back, I have used a long tie to lock them all together, and powerchain to tip back the incisors.

This kind of treatment, where you tip the incisors forward, then back is called round tripping.

The finished case

In the end, all the gaps were closed, and the patient is really happy with the results.

There are a few areas that I think it could have been improved:

  1. I could have done some IPR to reduce the black triangles.
  2. I could have used a laser to make the gingival contour more symmetrical.
  3. Whitening would have improved things too.

Did the TAD make a difference?!?

If we look at the molar, then its come forward by about 1/2 a unit. The premolars have come back a little, but at the canine, we have hardly gained any space!

In this case, I didn’t need that much space, so I think I got away with it!

There are ways to distalize the canine from here, but it gets a bit complex, and it was unneeded in this case.

Looking back, there are other ways to reinforce anchorage – and in this case, a Nance appliance would have worked great.

nance

The nance appliance will hold the molars back, by using the hard palate. I think this would have been better in this case.

I hope you got something from this post, for more cases like this, please like my facebook page.


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Ortho, Retainers and Bonding in 5 Quick Appointments! http://drsehmi.co.uk/ortho-retainers-and-bonding-in-5-quick-appointments/ http://drsehmi.co.uk/ortho-retainers-and-bonding-in-5-quick-appointments/#respond Tue, 02 Aug 2016 05:47:25 +0000 http://drsehmi.co.uk/?p=3480 Here is a really simple case, that every GDP should be able to help their patients with! Now, every brace company out there is promoting how fast their system is. The truth is that if you put a force on a tooth, it will move at its own pace, no matter the what shape bracket, or…

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Here is a really simple case, that every GDP should be able to help their patients with!

Now, every brace company out there is promoting how fast their system is. The truth is that if you put a force on a tooth, it will move at its own pace, no matter the what shape bracket, or how its ligated.

I will stress though, that the quality of the bracket, and the appropriate type of wire is very important in achieving a great end result… But I’ll leave this topic for another post.

Let’s talk about this cool little case, and I’ll show you exactly what I did to keep the appointments to an absolute minimum, chair time to a minimum, and still deliver excellent results.

The Case

So the main problems here are:

  1. Crowding (upper and lower arch, both mild)
  2. Tooth wear issues
  3. Asymmetrical gingivae
  4. Uneven colour
  5. Rough edges to the teeth

We can tackle most of these things with simple ortho and bonding!

The Pre Ops (Click to enlarge)

When I do any ortho case, I will still do an ortho assessment, but just so I don’t boar you to death, here is my summary:

Mild upper and lower crowding, on an SK1 base, with right canine 1/2 unit class 2, and left canine class 1. There is a slightly increased overbite, and the lower midline is 3mm to the right.

Bond Up

IMG_7253_1 visualisation

With all ortho, bracket placement is key – this is how I visualise it.

First, imagine the teeth without any tooth wear. The correct height/ width ratio etc. 

Now look at the long axis, and the midpoint of the tooth, if it was not worn. (so mid point with the imagined blue line)

Then just visualise the gingival margins (yellow). In situations where the gingival margin will be visible, I always aim to align the upper gingival margins, then correct the incisal edge with composite or porcelain.

IMG_7257_1

The eagle eyed will notice I got 3M Gemini brackets – these are by far my favorite bracket because of their quality, and ease of debond.

Because this case is really simple, I jumped straight into an 18 niti wire, and left it for 6 weeks.

After 6 weeks

IMG_0435_1

Check it out! Almost done right!

Gingival margins are looking great, and arches are levelling nicely.

Yeah, we got a nice little gap – nothing that a little powerchain can’t solve, so all I did here was: Change to a 20×20 niti wire, and upper powerchain 3-3, and left it for another 6 weeks.

Okay, braces off!

Yes, it still looks crap, but its all good, because the patient knew at the outset that this would happen. This is what I did at this appointment:

  1. Fit fixed retainer
  2. Debond ortho
  3. Composite build ups where needed
  4. Impressions for vacuum formed retainers

I normally stick the fixed retainer on before the debond. This can create a little difficulty when doing the composite, but nothing you can’t handle, as long as you are careful.

Upper retainer is normally 2-2, lower is 3-3.

As you can see, I just separate the teeth, overbuild in composite, then polish down. Any defects (like on the UR1m) are filled in with flow – but this is why you need good magnification.

The composite looks translucent, and you can see exactly where the composite is… Well, the dentist can, not the patient – she loved it at this stage!

After 1 week

Luckily after a little rehydration, the bond up’s look a lot better!

Anyway, at this review appointment, we fitted the VFR, and gave follow up instructions, went through whitening and all that!

I am pretty happy with this case, the UR2 could be improved with a little buccal root torque, and the gingivae on the UR2 could be improved with a laser… But I think I’m getting a little too picky – the patient loved the result!

All questions/ comments welcome 🙂

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Treating a reverse overjet with adult braces… Then veneers! http://drsehmi.co.uk/treating-a-reverse-overjet-with-adult-braces-then-veneers/ Sat, 23 Jul 2016 18:39:23 +0000 http://drsehmi.co.uk/?p=3404 The story for this guy is that he came to see a referring dentist of mine, asking for veneers to improve his smile. Now, its pretty clear that veneers will not be able to give this guy the smile he is looking for. The plan was to ‘jump the bite’ with the upper incisors, and…

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The story for this guy is that he came to see a referring dentist of mine, asking for veneers to improve his smile.

Now, its pretty clear that veneers will not be able to give this guy the smile he is looking for.

The plan was to ‘jump the bite’ with the upper incisors, and make veneer treatment minimal prep.

Anyway, here are the pre – ops:

Analysis

So, we are only really interested in the front teeth, and the patient is only up for single arch ortho – he feels his lower teeth are fine. And to be honest, I cant achieve a lot more by bonding up the lowers.

The important things for reverse overjet cases like this are:

  1. Can the patient posture to an edge to edge relationship?
  2. What is the potential canine relationship
  3. Is the overbite normal or reduced (it normally is in SK3 bases)

The good news is that in this case, the patient can get edge to edge.

On the right side the canines are in class 1.

On the left, its not so clear, but the molars are 1/2 unit class 3, as are the premolars, its reasonable to think that the canine is potentially 1/2 unit class 3 as well.

Taking this into account, its reasonable to think that if we just do levelling and aligning, then one side canine is class 1, and other side is a little class 3, then we potentially have spacing in the upper arch.

This is sometimes quite a tricky thing to visualise, so take your time, think about it and really understand it.

If canines are class 1, and the overbite is normal, and all the teeth are normal sized, then its likely that everything will fit without spaces.

This was discussed with the patient, and its not that big a deal, because we are planning veneers post ortho.

Treatment

The treatment progressed normally, so bonded up, wire sequence was probably 14niti, 18niti then 18ss.

As you can see in these mid treatment photos, the UL3 is pulling the rest of the teeth up (intruding). This is because it has a large root. Because of this, the vertical anchorage of the UL3 is winning against the incisors, so the incisors are intruding.

Because we are in a 18ss wire, over time, the teeth will level out, and the canine will eventually drop.

I think I even went a step further, and used a 18-25 ss wire, just to have a stiffer wire.

One thing to note is we need a bite raiser. As the incisors need to jump the bite, the bite needs to be opened, then the A-P movement can happen, then remove the bite raiser to close the bite again.

The position of the bite raisers is the lingual of the lower incisors.

Bite raiser on class 3

Be careful doing this, as the bite raiser can put an orthodontic force on the lower teeth, causing them to move. You can make a clear aligner to straighten the lowers again, or maybe start with a clear retainer on the lowers to be extra safe.

On the photos above, you can see the spacing between the UL2/3. This is what we predicted at the beginning – there is a powerchain trying to mesialise the canine, moving the space distal to the canine.

The End Result

So I sent the photos to the referring dentist BEFORE the debond, and we debonded it.

You can see that we have a space distal to the canine – remember we predicted this!!!

We are also 1/2 unit class 3 on the left, like we predicted.

On the right side, the canine has moved a little class 2 – this is because of the powerchain tipping the canines forward to close the spaces created by the rounding out.

Making the veneers easy

Now the teeth are in the right place, the veneer work can be minimal prep – excellent for bonding and long term health.

The pictures above are the trial smile – the veneers are additive, and these are luxatemp veneers, which are customised in the mouth.

This patient lives really far away, and although the final veneers have been fitted the patient has not been back for his veneer review, so we do not have the final veneer photos. yet!

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Lower teeth adult braces http://drsehmi.co.uk/lower-teeth-adult-braces/ Tue, 14 Jun 2016 20:09:08 +0000 http://drsehmi.co.uk/?p=3382 Lower front teeth that need straightening – this is a class 1 canine case, and there is no occlusal room to just tip the incisors forward. The problem is that often (in a class 1 or 3) occlusion, there is little space to tip the lower teeth forward, without addressing the upper teeth. This may mean…

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Lower front teeth that need straightening – this is a class 1 canine case, and there is no occlusal room to just tip the incisors forward.

The problem is that often (in a class 1 or 3) occlusion, there is little space to tip the lower teeth forward, without addressing the upper teeth.

This may mean you need a lot of IPR, or a lower incisor extraction.

Both valid treatment options in the right cases, but here is another which might not be so obvious.

So this lady just wanted the LL2 corrected. The top teeth are fine, its just this one that really bugs her.

As you can see, the bite is slightly deeper than normal, and you will need to take my work that there is almost no room to tip the lower incisors labially.

I just want to apologise for the quality of the photos, I should have taken buccal shots in occlusion, and the lips should be fully retracted. Thankfully the photography gets better!

The Plan

Ok, so I need space. You might be able to see that the lower arch incisors are overerupted. When you intrude the lower incisors, you can get a little room to tip the teeth forward… Here is a diagram to explain this:

Intrusion space planning

The green dot is the initial point of contact, and the blue dot is the final point.

The arrow marked “1” is how much we can now procline the lower teeth, without IPR! suddenly we have some space without IPR! And with fixed ortho, we do not need a lot of space.

The arrow marked “2” indicates the intrusion needed.

Ok, now the treatment is easy right??

I can’t remember if I did this without IPR (probably, as IPR is rare for me), or if I did a minimal amount.

So now, we are into a 18 NiTi wire (the 2 month review was when I placed the 18 NiTi, so this wire still needs to do its job).

My photos are all taken at the end of the review appointment, so if I did IPR, you would be able to see it.

The teeth are straightening out well. I had to place bite raisers for this lady (upper molars) – So I cannot really judge if the incisors are intruded enough – so its all a little guess work at the moment. The teeth are straightening as I would expect but if I reduce the bite raisers and there is a heavy occlusion on the incisors, then this can cause unwanted movement in the upper front teeth.

Having bite raisers on the upper molars also lets passive eruption of the buccal segments (other than the 6’s) and this helps to reduce the deep bite.

A Little Helping Hand

So to this point, we have just let the wire do its work, as the incisors were over erupted, they levelled up nicely… But I want more!!!

So now I started to use some black magic. Also known as wire bending.

It is a lot easier to bend a stainless steel wire, this is an 18SS wire.

You can see the two bends in the wire, between the lateral and the canine. This puts an intrusive force on the incisors.

Now, there is also an equal and opposite force on the canines/ premolars, but from memory these teeth were in occlusion, so there would be no unwanted extrusion there.

Also remember, the premolars and canines have much larger roots, so you would expect more intrusion of the incisors than extrusion of the others with the same force.

The end result

As you can see, we got a really nice result. It took about 6 months and from memory the IPR was either none, or very minimal (I am writing this from memory, not clinical notes…)

What I would change next time…

Next time, I would place the incisor brackets a little more incisal at the bond up. This will avoid (or reduce) any wire bending and intrusion will start from day 1.

Hopefully this change can trim a month or two from the overall treatment.

As always – let me know what you think by either leaving a message at the bottom of this page, or get in touch via FacebookTwitterInstagram, Snapchat: gurs.sehmi

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Tips on Reducing a Dental Diastema http://drsehmi.co.uk/tips-on-reducing-a-dental-diastema/ http://drsehmi.co.uk/tips-on-reducing-a-dental-diastema/#comments Sun, 22 May 2016 11:56:33 +0000 http://drsehmi.co.uk/?p=3188 Its surprising how many people call up the clinics where I work, and their main complaint is the gap or gaps between the teeth. Most commonly a nice, juicy midline diastema. Most people will know that this can be reduced or eliminated with composite, porcelain or orthodontics. Without doubt, composite is the cheapest and quickest…

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Its surprising how many people call up the clinics where I work, and their main complaint is the gap or gaps between the teeth. Most commonly a nice, juicy midline diastema.

Most people will know that this can be reduced or eliminated with composite, porcelain or orthodontics. Without doubt, composite is the cheapest and quickest way to do this, however – it can easily look crap!

Here are my tips of what to look for when you are doing this.

Understand the problem.

Most people want a great looking smile, and if you have been doing cosmetic dentistry for a while, you will have a ‘perfect smile’ image tattooed on your brain, and this will tell you that the central incisors need to have a width of about 75% of the height, and the height should be about 11mm, and the visible width of every tooth as you move away from the midline should reduce by the golden proportion.

golden-proportion
As you start to deviate from this, things start looking odd.

Also, the tooth shape should look natural – its so easy to create triangular looking teeth that flare out from the gum line with some un-natural looking emergence profile!

As soon as you add composite to the tooth, you are changing the height – width ratio, and the golden proportion, and the problem with that is – tooth width is never the main problem. In most cases, nature gets the tooth shape/proportion correct, the problem is the tooth position.

To make things more complex, closing diastema’s with ortho is tricky because the position of the teeth is often governed by the soft tissues, and to close a gap can take a disproportionately long time!

Right, lets get back to the point.

In this case, I closed this lady’s lower spaces with ortho – that was easy. Now she wanted a reduction in the upper diastema.

IMG_9745 (1)

Luckily, she just wants a reduction, and not a complete closure!

The most important thing for me is to get the emergence profile right. When you do not pay attention to this, the teeth start to look triangular.

Step 1 : Choose the colour. This is probably less important than you think, I chose a block B1 Venus Diamond, and nothing else.

Step 2: Sandblast, etch and bond the tooth. The important things here is to prepare the tooth right to the CEJ, there is about 2-3mm of free gingivae on the mesial aspects of these teeth, you need to prep all the way down there, because you will need to bond down there too.

Step 3: Create the emergence angle.

To do this, I use a flat plastic, and flowable composite:

IMG_9747 (1)

The left tooth has been prepared, and you can see the flat plastic pushing the gum and I put flow into the space, then cure.

Don’t worry that its not smooth or tidy at this stage, we will correct that later!

Step 4: Build the teeth up, making sure that you build each tooth up symmetrically, and keep the midline parallel to the long axis of the patients face.

Step 5: Polish the crap out of it!

When you are polishing, you have to be careful to keep the line angles of the teeth in the place you want to keep them. You can do this with sof-lex discs (which is what I used here).

Get rid of the step between the composite and the tooth with the most rough disc, and use the other discs at high speed to get the nice smooth polish.

Step 6: Look at the distal line angles. Because you’re making the tooth wider, it is sometimes helpful to bring the distal line angles closer to the middle of the tooth. This gives the illusion of narrowing the tooth. Cosmetically it is very important to keep the line angles symmetrical. Also, it is nice to soften the distal corner of the central incisors if they are sharp and you can also level out the incisal edge at this stage too.

Step 7: Smoothing out under the gum.

For this I used a red flame shaped high speed bur

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The way I use this is to literally go blind under the gum, and make sure its all smooth by using a sharp probe.

IMG_9749 (1)

The end result is very natural, even at close inspection. The mesial line angles could be improved, but are always learning – right?!

The teeth don’t look too wide because the distal line angles were brought into the body of the tooth, as opposed to keeping them distal. Also, the distal edge of the centrals were flared out, and this was adjusted to make them more straight.

The colour and the composite probably doesn’t matter that much. In this case, it was Venus (probably venus diamond – or whatever we had!), and I think shade is B1. Simple right, no layering, no complex shading – this case does not need that!

At the end of the day, this lady wanted a quick solution to her problem, and she left the surgery over the moon with the result. There was no need to increase the time and expense to the patient by doing wax-ups, complex shading.

Let me know what you think, if you found this useful, or what you might have done differently.

You can contact me on Twitter (@gurssehmi), Facebook (search Gurs’s Dental Tips), or Instagram (Gurs_Sehmi)

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