In an earlier article, I went over the importance of creating beautiful anterior temporaries to help build your practice and inspire confidence in your patients. Like many procedures, there can be times when a patient comes back because they are unsatisfied and want the temporaries modified. In this situation you can always remove the temporary and make the necessary adjustments but it's much easier to adjust the length and contour intra-orally.
The patient that I'm going to use as an example is pictured above. He suffered a traumatic bike accident that left his anterior teeth fractured, and they needed to be lengthened for proper esthetics. My treatment plan for him included extending the length of both centrals and laterals to make them level with the occlusal plane. In addition, this patient's centrals and right lateral were endodontically treated prior to my treatment and he was being treated orthodontically to address an occlusal issue with the lower anteriors.
Once the orthodontist had the lower anteriors in position, I was able to prepare the teeth and place the temporaries. As you can see in the second photo, the temporary lines up with the occlusal plane and the canines beautifully.
However, he immediately started experiencing phonetic issues, particularly with his "s" sounds. When this happens I typically don't adjust anything for at least four weeks since there is typically a rapid phonetic adaptation to alterations in anterior tooth position. After four weeks the phonetic issue, a lisp, hadn't subsided and the patient kept mentioning that he felt the teeth were "too big."
When a patient is having speech issues it is important to identify if the problem is from the incisal edge position or lingual contour, in his case it is due to tooth length. It will now be necessary to reduce the length and test phonetics as they are shortened. The challenge is to reduce the length and maintain a pleasing incisal plane as it is easy to make mistakes in the amount of reduction, especially when sitting behind the patient as the teeth are being adjusted. I like to use a black marking pen to preview the adjustment by blacking the incisal edges on one side of the mouth, leaving the other side as a visual control.
Once I'm satisfied with the length on that side, I repeat the process on the other side. Then it is a matter of reducing the teeth so the reduction just removes the black line. I generally perform the reduction with a straight handpiece and large coarse porcelain polishing wheels to remove the black marks, followed by using discs to refine the form and embrasures.
In this particular case, I didn't only shorten and reshape the centrals and laterals, but the canines and premolars as well to maintain an esthetic contour. During the final shaping phase, I prefer to stand in front of the patient while they are seated in an upright position. Using this trick allows me to look directly at the patient and get a much better visual of the patient's esthetics compared to sitting behind them.