A very interesting case for you to see, please see the change and let me know what you think

Two years ago I had a consultation with this patient. he wanted to improve his smile. We discussed numerous treatment options and we decided to first of all straighten his teeth with clear braces. the product chosen was invisalign. After about 15 months of wearing these, the teeth were looking better and the overjet reduced.
The next stage was to carry out some in surgery bleaching to lighten the teeth and new impressions to make a diagnostic wax up.
A diagnostic wax up is when study models are made from the impressions and wax is used on the teeth to have treatment. In this case, we were deciding on porcelain veneers in both the upper and lower arches. This would span from the upper second premolar to the other second premolar. Which in total would be 20 veneers.
For such a large case, I would always recommend a wax up, so that the patient is aware of exactly what is going to be done and how the work will look at the end of the treatment. And even with explaining and seeing the diagnostic wax up, it is common for patients not to fully realize what a huge job they are about to embark on!

 Pre operative photo of my patient two years ago

 Diagnostic wax up to show the patient how the teeth will look after crowns and veneers are fitted.

This shows the patient how the teeth will be trimmed 

 The actual preparations in the patient's mouth

 Below are the temporary crowns and veneers that were fitted for 10 days, whilst the permanent work was being made in the lab.

As you can see this is the end result. The patient wanted quite a light shade, in reality the teeth took a few weeks to settle down. he had some post operative sensitivity and getting used to the feel of his new teeth.
I finally made some upper and lower retainers to protect the work and so far so good!

Hope you enjoyed reading this case and do let me know if you have any comments.

Mouthguards: Do they help or not?

All sports activites do have a certain risk of orofacial injuries. This can be from falling over, to collision with a hard ball or surface. So there is  a very strong argument for wearing a mouthguard to help distrubute forces and protect the teeth and jaws. Mouthguards are made from a type of plastic which allows them to be fairly elastic and this will in turn distribute the forces throughout the mouth.

How does a mouthguard work?

The plastic helps to distribute the impact energy, how this is done will depend on the direction of the impact. If the impact is on the base of the lower jaw, called the mandible, the forces are going upwards through the jaw then the mouthguard will help by acting as a cushion and stop the upper and lower teeth from hitting each other and thus preventing crown and root fractures. 

If the injury is from the front, the material will help to distribute forces but this may still not be enough to prevent the teeth from fracturing but will certainly help the situation.

Types of mouthguards

There are three types of mouthguards available to children and adults.

1. Stock ones made in three sizes. The advantage is that it is low in cost, but rarely worn due to poor fit!

2. Mouth formed one, which are made of hard plastic on the outside and soft on the inside. The material is placed in hot water and then when slightly cooler this is placed in the patients mouth and moulded to their mouth. This is better at protecting the patient but not with high impact sports and the fit can also be a problem. The advantage would be low cost.

3. Custom made mouthguards are the most effective in protecting with all contact injuries and the fit will be very good. These mouthguards can be made when a patient is wearing orthodontic braces and will be made to fit over the brackets. There are lots of different colours and designs, which is fun for the children to choose. They are straightforward to make, which involves taking impressions of the teeth and sending this to the appropriate lab.

From my experience I would advice mouthguards from an age when contact sports are being played. They should be custom made to fit to the patients mouth with comfort and this will provide maximum protection to the patient.

I made this mouthguard for my nurse's son.

Please contact me if you would like anymore information on this or would like one made.

On a separate note, we have exciting news for the practice! We have just been nominated for practice of the year and our hygienist has been nominated for staff of the year too. 

Trauma case this week

Trauma case this week

I had a very sweet 9 year old boy attend this week with a fractured upper right central incisor.

He had been playing on a see saw in the playground, when the metal part of the see saw hit him in the mouth causing half of his tooth to fracture. This happened whilst on holiday in Wales and his grandmother tried to make an appointment to get his tooth seen to.

Unbelievably not one dentist in the area had an emergency appointment that day and some even stated the next available NHS appointment would be in 6 months! A dentist did see him the next morning and put a temporary covering on the tooth.

I then saw him a few days later and after establishing the tooth was healthy, his medical history was clear, I restored this tooth.

Due to the size of the fracture I did administer local anaesthetic to make sure there was no sensitivity for him. Then I restored the tooth using a layering technique of a solid and liquid type of white filling material. This is called Venus heavy bodied composite and tetric flow light bodied. The tooth was polished and post operative instructions were given.

Impressions were also taken to make a sports guard for him to wear when running around or playing sports to try and protect this restoration, as this is almost half the tooth now.

Long term treatment plan for this boys will involve routine radiographs as he gets older to check the vitality of this tooth ( to see if this tooth is still alive ). Unfortunately restorations do not last forever so as an adult I suspect he will require a crown to protect this tooth.

Another Cosmetic case to show you

I want to show you this case of a 17 year old girl that I completed last week.
She attended six months ago complaining of not being happy with the look of her upper teeth. She didn't like the gap between her upper central incisors.
We discussed the options she had available. This would either be a quick fix of upper veneers or clear braces. I was keen for her not to have veneers as I felt she was too young to have teeth prepared and cut for veneers. So we decided to go ahead with clear braces. The type used was a brand called Insignia. These braces tend to just move anterior teeth, so for this case, this is perfect.

The clear aligners were worn for six months without issues. Afterwards I tidied up the upper central incisors with very small anterior composites on the edges.

She was very happy with the result and has now had upper and lower fixed wires placed and also she will wear night time removable retainers.

After teeth are moved it is VERY IMPORTANT to retain these teeth in the new position, if not the teeth will relapse back to the original position within a few months if NO RETENTION is provided. 

Retainers can also be fixed or removable. Both have advantages and disadvantages. The advantage of fixed wires is that they are there permanently and will be consistently retaining the teeth. the disadvantage is that it is not possible to clean the teeth interdentally with floss, so oral hygiene can be compromised.

The advantage of removable retainers is that you can maintain your normal oral hygiene routine and the flip side is you have to be motivated and remember to put these in!

Hope you enjoy this blog and photos. Do contact me if you have any questions or would like a consultation about anything you would like changing in your mouth.

Pre operative

Post operative

Tips on your child's FIRST TRIP to the dentist

A child's first visit to the dentist can be a huge experience, with different people, new surroundings, sounds and sights to deal with. Regular visits to the dentist from the age of 2 and a half to 3 years of age is a good idea to help promote good oral health for the future and to allow six monthly check ups not to be feared by the child!

Here are a few tips to get you and your child started:

1. START YOUNG

In the UK it is deemed that a child should start attending from the age of 2.5-3 years of age or when all the deciduous teeth have fully erupted. This is very important to allow the child to develop a good relationship with the dentist, to have trust and build up confidence. Some people feel that deciduous teeth are not important, but this is not the case and they are there to maintain space for the future adult teeth to erupt into the correct position. If a child just attends when in pain then a bad relationship will occur from a young age and each visit will end up being a stressful one. Caries can be caught early if the child has regular visits and oral hygiene can be monitored.

2. USE THE CORRECT LANGUAGE TO THE CHILD

If a parent is anxious of dentists, this can transfer to a child, as they are keen listeners and will pick up on anything that worries the parent. I think it is good to use simple language about going to the dentist, such as " the dentist will be counting your teeth and washing away all those naughty bugs " 

Try not to mention the words pain or hurt and never say to your child that the dentist is just going to look at your teeth, as this may not be the case once the child is in the dental chair.

3. DO NOT USE THE DENTIST'S VISIT AS A PUNISHMENT

If you threaten your child by saying I will take you to the dentist if you are naughty then this will not do well for their visits in the future! Make sure your child sees the dentists as being somewhere safe and potentially fun.

4. PREPARING YOUR CHILD FOR THEIR DENTAL VISIT

 Before their first dental appointment you can start preparing your child by either carrying out role play and pretending to be the dentist and acting out what will happen in the chair. Count their teeth, perhaps ask your child to show you how they brush their teeth. Books with good illustrations about a trip to the dentist, would be a good idea too.

5. ROME WASN'T BUILT IN A DAY

 Be prepared for your child to be a bit resistant to treatment or even sitting in the dental chair, even after all that great explaining, role playing and reading books before hand! Your child may still not fully understand what is being asked or discussed and get nervous about this. This is okay and trust will be being built at each appointment until they love coming and will just run into the surgery and jump in the chair.

6. MAKE SURE YOUR CHILD KNOWS THAT COMING TO THE DENTIST IS VERY IMPORTANT

 Your child should try to understand, with time, that seeing a dentist is very important to maintain good oral health and that this will always happen every six months.

Veneer case

Recently completed case

I started treating this very nice patient in 2012. His main complaint was that he wasn't happy with his smile and he would like whiter looking teeth and straighter ones.

He thought veneers on all his upper and lower teeth would be the answer, which in some cases this might be the case, but in this instance I suggested this would not be a good long term result due the amount of crowding he had.

The treatment plan was to first straightening his teeth with clear braces. I used a product called Invisalign to do this and due to the amount of crowding, it took over 1.5 years to move his teeth. Once the teeth were in a better position then I started on the cosmetic treatment.

I firstly made diagnostic wax up of his teeth to show what his teeth would look like with veneers and crowns. then I bleached his teeth with both in surgery bleaching followed by home bleaching, which he did for about two weeks.

Then came the very long 5 hour appointment where I prepared 10 of his upper teeth for veneers and one crown on the upper left central incisor. The veneers spanned from upper left second premolar to upper right second premolar. After treatment, I took impressions which was sent to the lab for the work to be made and the technician also came to visit him. He checked the profile of the patient and also took a shade of his teeth.

Before he left I made a temporary crown and veneers, which were lightly cemented on.

Ten days later, the work returned from the lab and I prepared to fit the work. Local anaesthetic was placed to reduce any chance of sensitivity with the teeth prepared. The temporaries were removed and teeth cleaned and the work was placed to check for the fit and appearance. All looked very good and each veneer was cemented using a cement called Nexsus. Everything was polished and any final adjustments made.

The patient was delighted with the final result and now he has lower implants and a few lower aligners to go to complete his treatment

Recent case to show and techniques used

Recent case to show and techniques used

Last week I treated a very nice gentlman who wanted to replace these amalgam restorations into tooth coloured ones.

I want to show you the procedure I used and should be adopted when removing any kind of restoration. This will provide safety for the patient and good visibility for the dentist.

The pink stuff you can see is called rubber dam.

A rubber dam or dental dam is a rectangular sheet of latex used by dentists, especially for root canal treatment, but also for things like tooth-coloured fillings.  Why use a raincoat for your teeth? (Rubber dam) You don’t have to worry about your tongue getting in the way It protects your throat from little bits of tooth debris If you are prone to gagging, it helps to protect your gag reflex area from being triggered It protects the lips and cheeks by keeping them out of the way It keeps the tooth dry – very important nowadays because many materials need a dry clean environment for tooth-coloured fillings to bond properly It can create a distance between yourself and the treatment:  Many people have a fear of the rubber dam because they are worried that they won’t be able to breathe and/or swallow. In the normal way (with the usual rubber dam design, where the sheet is put on a frame), there is lots of room around the sides, so you will be able to breathe through your mouth:  After the rubber dam had been placed, the old amalgam restorations were removed and underlying caries.

The cavities were then lined with a liquid material called fuji II, this has fluoride and allows to bring strength directly to the dentine for upto one year after placement. This type of material is set hard with a blue light for about 20 seconds. The composite ( tooth coloured material ) is then placed in small increments into the cavity and cured at each stage by the blue light. This allows the material to become hard. The final restorations can be seen below. They were then polished and the occlusion ( bite ) of the patient finally checked after the rubber dam was removed and the teeth were given their final polish.

Recent case to share with you all

Cosmetic case to share with you

I started this case seven months ago and it involves different aspects of dentistry that I want to tell you about. The patient came to see me as she was unhappy with the appearance of her teeth. 

As you can see from the pre operative photo there is a median diastema ( gap in between upper central incisors ) and the upper lateral incisors are small for the rest of the mouth.

We had a consultation about what she was not happy about and formulated a treatment plan. As it was only the anteriors that required movement, I decided to use Insignia, which is a clear brace system from America, which specifically moves upper first premolar to upper first premolar.

Impressions, a bite and full mouth photographs were taken and aligners were made to close the diastema. Each aligner is worn for three weeks, then we would review the progress and move onto the next one. After six months of wearing aligners the gap closed. 

Aligners are made of clear plastic and fit only on the teeth, they are very comfortable and speech and general day to day activities are not affected. They must be worn all the time to complete movement, especially during the night.

Once the gap was closed, the patient had in surgery bleaching, which lightened her teeth by about 8 shades from A3 vita to 0.5M vita. She then topped this up with one week of home bleaching, as you would have read in my previous blog on bleaching, this involves wearing bleaching trays for about two hours per day with 6% hydrogen peroxide gel within them.

Then the fun appointment came! At this appointment, both the upper right and left lateral incisors were prepped on the surface by 0.3-0.5mm to create enough space for the porcelain veneers. Dental impressions were taken of both arches, shade was taken and all of this was sent to the dental lab. The porcelain veneers were made and returned after one week.

The veneers were then fitted with a special cement called nexsus. The teeth are still fragile and prone to moving back to their original position and the gap re-opening, so I fitted a wire to the backs of the upper teeth and made a night time essex retainer.

An essex retainer looks like a hard plastic mouth guard and will help to keep the teeth in the new positiom until the bone has fixed. This could take up to a few years, retention is very, very important.

This is the end result

The patient is delighted, I will review her in a weeks time and it is very important for six monthly check up and cleans as part of her maintenance program.

Few facts about Whitening

Firstly may I wish you all a very Happy new year! Now back to teeth …..

More and more people are wanting whiter teeth. Does teeth whitening work and is it safe? 

What is teeth whitening?

Teeth whitening involves bleaching your teeth to make them lighter. Teeth whitening can’t make your teeth brilliant white, but it can lighten the existing colour by several shades.

Who can perform teeth whitening?

Teeth whitening is a form of dentistry and should only be performed by a dentist or another regulated dental professional, such as a dental hygienist or dental therapist, on the prescription of a dentist.

Some beauty salons offer teeth whitening, but this is illegal, so please stay away from these places! 

You can also buy DIY home teeth whitening kits but these may also carry risks. So do be watchful of these products.

What are the different types of teeth whitening available? 

Most dental practices offer two types of whitening:

• Laser / in-surgery Teeth Whitening
• Professional home whitening kits

Both procedures are based on a bleaching process that uses a peroxide-based bleaching gel of varying strength (3%-6% peroxide). 

Laser Tooth Whitening

Laser tooth whitening or in-surgery whitening is a procedure that takes place at the dental practice and uses a light-activated bleaching gel to whiten your teeth. The procedure usually takes approx 1 -2 hours and produces instant whitening results.  I would recommend that laser whitening should be followed up by professional home whitening.

The Laser Tooth Whitening procedure

Prior to carrying out the procedure you would have a consultation with your dentist to make sure that you are suitable for teeth whitening and to explain possible risks and side effects of the procedure. Most dental practices will ask you to sign a teeth whitening consent form to confirm that you have fully understood the procedure and all risks. These days, because the product is heavily regulated, the side effects of sensitivity doesn’t exist anymore. The only real risk is that the gums can become irritate if they are not sufficiently protected during the bleaching procedure.

Before the teeth whitening process is started a dentist or a hygienist will thoroughly clean the teeth, removing any surface stains and tartar. 

The next step will be to make a record of the shade/colour of the teeth before the procedure. This is either recorded using a tooth coloured shade guide/chart or by taking a digital photograph of your teeth. 

The area is then prepared for the procedure.  The dentist will usually place some form of protection around the gums so that only the teeth are exposed to the bleaching gel. This involves covering the gums with cotton wool rolls and a protective gel material that hardens once applied to the gums. A cheek retractor is used to keep the lips and cheeks away from the teeth.

It is very important that your dentist isolates your gums and lips with a protective material in order to avoid any potential damage or burning. 

Eye protection (goggles) is also provided to prevent any damage to the eyes from the laser used or any accidental splashes of the peroxide. 

The whitening gel is then applied to the surface of the teeth and exposed to a light or laser, which activates it. Some systems do not use an activating laser and many dentists argue that the laser doesn’t make any difference to the end result.  During this process if you feel that your lips or gums start to burn then you should let your dentist know immediately. After approximately 15 minutes the gel is removed and the process repeated another 3 times. 

Finally wash off the whitening gel and remove all the lip and gum protection, then a post operative shade/colour is taken. The results are usually quite dramatic and can often be up to 10 shades lighter. Ideally a kit for home whitening should be provided with custom trays and professional whitening gel. 

There is no sensitivity now, due to the fact that the new bleaching gels have a lower percentage of hydrogen peroxige gel and this is combined with calcium. 

Professional home whitening kits provide more permanent results over a longer time scale, whereas laser tooth whitening offers immediate results. A combination of the two provides the perfect solution to both immediate and long-term whitening needs.

Professional home whitening kits

To make a professional home whitening kit, impressions (moulds) of your teeth are taken and bleaching trays are made. Depending on the teeth whitening system, some trays need to be worn overnight while others for only 1-2 hours a day for between 2-3 weeks.

Suitability for whitening

Many people are not suitable for teeth whitening and a dentist will assess your suitability during a consultation. If you have gum disease or other dental health problems, you may not be suitable. The teeth whitening process does not change the colour of crowns, veneers or fillings so it is important to understand that you may need to change these to match the colour of your whitened teeth. This procedure is not suitable for pregnant women or women breast feeding.

Does it hurt? What are the side effects of teeth whitening?

No sensitivity is recorded these days, due to the new bleaching gels on offer. As mentioned before, this is at a lower percentage mixed in with calcium.

Which teeth-whitening brand or system is the best?

There are many different brands of professional teeth-whitening systems, each claiming to provide the best results. The most popular systems are Zoom!®

How much does teeth whitening cost?

This depends on which system is used. Home bleaching is less expensive, as the patient is carrying this out at home compared to in house bleaching. An approximate figure of £250 for home bleaching and £375-550 for in house bleaching I would suggest.

Pre whitening

Post whitening