Veena Sidhu talks to Dr. Sim Tang Eng, Founder President of the Malaysian Association of Aesthetic Dentistry, and one of his foreign patients, about the journey they took together to produce the perfect smile.

In this aesthetic age, most are fussed about whether their nose is too large, their jaw too square, or their chest too flat. Yet, whether many realise it or not, there is one feature that is neglected more often than not – our teeth.

But while one may not necessarily think about their teeth, the aesthetic dentistry field is growing by leaps and bounds, to the extent that our Malaysian expertise is drawing thousands of foreign visitors to local shores to get their teeth fixed.

For a much cheaper price than in their own Western countries, coupled with excellent dentistry, many foreigners are choosing to have their dental work and tropical holiday bundled into one package.

One such patient is John* (not his real name) who came to Kuala Lumpur in November 2005 through a medical tourism operator to have his teeth fixed. For as long as he can remember, English-born John says he never had attractive teeth, and to make matters worse, bruxism (the clenching and grinding of teeth in his sleep) wore down his teeth to a very bad extent.

He recalls, "My teeth have always been bad and I suffered from many abscesses. My teeth were also badly damaged particularly after a hockey accident I had some time ago. I was hit with the hockey stick and lost my two front teeth. I did get crowns to replace them – but they weren’t very aesthetically pleasing.

"All my family have good teeth. Unfortunately, I did not inherit this and my teeth were really bad prior to treatment. I always seemed to develop abscesses – I suppose I must put it down to not looking after my teeth correctly," states John.

How It All Began

"In 2005, I was on holiday in Kuala Lumpur and I met a lady from the United Kingdom who was getting some dental work done. She came to Malaysia through a medical tourism operator and they arranged for her treatment with an aesthetic dentist.

"I obtained the necessary contacts from her, and made an appointment for a consultation with the same operator. Initially, I was introduced to another dentist who suggested dentures to fix my problem. I did not want to have dentures that have to be removed each night. Also, dentures seemed like a quick-fix (I knew my dental state was quite extensive) and so I wasn’t happy with the dental plan put forward. I asked the operator to find me another dentist and they recommended Dr. Sim," says John.

He continues, "On the first consultation, Dr. Sim explained the full options available to me and the time frame involved (which would be months rather than weeks) due to the work needed on my teeth. He explained the procedures in detail and even worked on models to come up with a detailed plan of attack, which would be spread over a year."

Dr. Sim, consultant aesthetic dentist and implantologist, recalls their first meeting, "John’s first visit with me was in November 2005. He had severely worn and attrited teeth due to his grinding habits. As a result, both his upper and lower teeth were very short and that gave him an aged appearance as well as a smile he didn't like. Besides that, John also had some missing teeth that required implants and bridges.

"After exhaustive consultation, examination and treatment planning, it was decided that a full mouth rehabilitation or reconstruction was needed to restore his teeth to optimal function and aesthetics. A combination of porcelain veneers, crowns, bridges, root canal therapy and implants were required to restore the whole mouth."

According to Dr. Sim, the dental work to be done on John was very extensive and needed to be broken down into stages to allow healing between treatment sessions. The reconstruction was so elaborate that all teeth had to be worked on – this included cutting the gums and drilling pits in the jaw to place implant screws and bone grafting (using artificial bone substitute) to reconstruct lost bone matter, a consequence of leaving a missing tooth untreated for too long.

Dr. Sim continues, "When he first came to see me, we were concerned whether or not he would agree to the treatment because it involved so many trips and procedures. But I was surprised that he agreed to the treatment plan, even though it involved multiple trips for him. But John is a smart patient and was very receptive to the treatment plan even though it was to be extensive – he understood what the process involved."

The Case Put Forth

Dr. Sim tells us what the process entailed, "All of John’s front teeth were very short due to his constant grinding. He had also lost two of his front teeth and three back teeth in the past – I had to replace these with implants.

"John has a grinding problem, and the dentist that he was seeing at the time, did not tell him so. Nobody told him he had bruxism and that he needed to get a nightguard to protect his teeth while he slept – so his teeth were just getting shorter and shorter as he was constantly grinding in his sleep."

According to Dr. Sim, John had attempted to fix his smile prior to seeking treatment in Malaysia. He had crowns fitted in the past to correct his broken front teeth, but the dentist fitted crowns that were just as short as his worn down teeth! "I don’t know why it didn’t dawn on his dentist that it is not normal for teeth to be that short," states Dr. Sim.

He adds, "Because John’s teeth became shorter, his face became shorter too. The length of our teeth determines the length of our face and as your teeth become shorter, your face will too."

The Experience

Today, John has a flawless smile, one that he is finally proud and happy to have – but not without a price. The price of pain and patience, that is.

Whenever John was in Kuala Lumpur for treatment, he’d spend hours at a stretch on the dentist's chair while Dr. Sim diligently worked to perfect his teeth.

"The process was worse than I expected. On more than two occasions I was in the office for over eight hours, with intermission for rests, toilet breaks and lunch break. I can remember being uncomfortable and the prepared but yet to be protected teeth (with temporary crowns) were very sensitive, but Dr. Sim was always very reassuring and kept encouraging me to hang in there," recalls John.

"Dr. Sim was always cheerful, even after working on me for so long. I could see he was tired but he always kept at it. I must also praise his staff, as they were really good to me throughout the whole process. I did at times tell myself when it got too unbearable that I should give up and go home, but I did see it through.

"The final result is great and all those long days and nights in the chair have been worth it. I think I have been Dr. Sim’s most challenging case and that he was more impressed with the results than me!

"It has been a few months now since the completion and it is really good to have a healthy mouth and no pain from bad teeth. But to be honest, if I had known how uncomfortable it would be and how much pain I would experience I mightn’t have gone ahead with the procedures! But now, I am thrilled with the results and it was all worthwhile. The service I received was excellent and I love my new smile!"

What John Had Done

Porcelain Veneers
Porcelain veneers are very thin shells of acrylic or porcelain that are attached to the front part of the teeth to enhance their appearance and repair damage. An extension to the bonding technique (which employs a white plastic paste known as composite resin to cover the tooth), veneers can be used to cover badly stained, chipped and uneven teeth, correct mild crookedness without braces, and cover up large fillings.

Dr. Sim says: "In John’s case, porcelain veneers were placed on his four lower front teeth to restore them to their original length and to achieve maximum aesthetics. Veneers were preferred over crowns in this situation because they were more conservative and to also avoid unnecessary trimming of sound tooth structure."

Cost: Between RM600 to RM2000.

Crowns
Dental crowns are artificial replacements (tooth-shaped ‘caps’) that are placed over the original tooth to protect and restore the shape, size and appearance. Crowns can be used to protect a badly decayed tooth, broken or chipped tooth, worn down tooth, to hold a dental bridge in place, to cover misshaped or a severely discoloured tooth as well as to cover a dental implant. Crowns can be made from all metal, porcelain-fused-to-metal, all resin, or all ceramic – all serving different aesthetic uses and functions.

Dr. Sim says: "In John’s case, I had to do porcelain bonded to metal crowns and bridges (with gold alloy) on the back teeth for strength to support his bad grinding. Full porcelain crowns for upper front teeth would be ideal as they are more natural looking since they don’t have the metal backing. However, John needed a bridge for his upper left lateral incisor and I couldn’t do a full porcelain bridge with the existing porcelain system available in KL. Therefore, to compromise this, porcelain bonded to a metal bridge was fabricated for his upper front bridge. To match the optical properties of the upper front bridge, porcelain bonded to metal crowns were indicated for the other upper front teeth."

Cost: Between RM500 to RM2,000 for a crown.

Bridges
Dental bridges, as the name implies, bridge the gap created by one or more missing teeth, where a false tooth is held in place between the adjacent teeth (which are crowned). Dental bridges can be supported by natural teeth, implants, or both.

Dr. Sim says: "The missing three teeth on John’s lower left jaw were replaced by a three-unit bridge supported by two implants whereas the lower right missing molar was supported by his two adjacent teeth."

Cost: The cost of the crown multiplied by the units in the bridge.

Root Canal
Root canal therapy is treatment to save a tooth whose pulp, which contains nerves and blood supply, is diseased or damaged. Pulp damage can be caused by bacterial infection through a cavity, injury to the tooth which can then rupture blood supply or damage a nerve, and gum disease, to name a few. Treatment involves removing pulp tissue through a small opening in the tooth to clean the pulp chamber and root canals. When the tooth is cleaned and free of infection, the canals and pulp chamber are sealed with a material that prevents bacteria from re-entering the tooth. A crown is often recommended to protect the tooth from breakage.

Dr. Sim says: "One of John’s teeth (premolar) required root canal therapy and I referred him to my colleague for the treatment."

Cost: Between RM900 to RM1,200.

Implants
Dental implants are the permanent solution to missing teeth. The implants are an artificial root that is placed in the jaw to hold a replacement tooth or bridge in place. An incision is made in the gum and a hole is drilled in the jaw to screw in the implant, made of titanium alloy. There is a waiting period of two to six months to allow new bone to grow around the implant. During this period a temporary crown is fitted, after which, a permanent crown is fixed.

Dr. Sim says: "John had three implants placed; two in the lower jaw and one in the upper jaw."

Cost: Between RM5,000 to RM9,000 for an implant

TOTAL DENTAL COST: ABOUT RM80,000

The Importance Of A Smile

Maybe the pearly whites of Tinseltown have influenced the rest of the world to follow suit to attain the perfect smile, but influence or not, a good smile can do wonders for your confidence, and of course, your looks.

"A smile is a form of body language – it expresses warmth and friendliness. It is also very often the first impression people have of you. If you have a very nice and pleasing smile, people will be naturally more drawn to you, as opposed to a person who doesn’t smile, or has a not-so-pleasing smile," explains Dr. Sim.

But it doesn’t just stop there. A good set of teeth also indicates good health – an important factor in our ever-growing health-conscious society. After all, a smile with rotting or missing teeth isn’t much of a pulling factor, is it?

Fortunately, the field of dentistry has evolved to such an extent that a fix job is easier and less time consuming than what one could have expected 25 years ago. There are a variety of options available: teeth whitening, composite or porcelain veneers, bonding, bridges, implants, tooth contouring and reshaping, dentures, crowns, caps, aesthetic gum dentistry – the list goes on!

John’s Treatment

Sequencing and time frame

11/11/05
John goes in for consultation and examination. Radiographs, study models, bite registration, face-bow records and photographs are taken for treatment planning and diagnostic wax-up (mock-up).

6/3/06
John returns to KL for the surgical placement of three implants. He stays for six days so that his condition can be reviewed. He then returns to his work place in Phnom Penh where a dentist friend of Dr. Sim removes the stitches a few days later.

20/4/06 & 21/4/06
Two full days – one for upper teeth and another for lower teeth – are spent preparing John’s teeth for full mouth rehabilitation. Procedures included trimming the teeth, taking impressions and fabrication of temporary plastic crowns to wear during the interim period while waiting for the porcelain teeth to be made.

On day one, John has a root canal treatment done by a colleague of Dr. Sim’s.

On the second day John leaves the clinic with a completely new set of plastic temporary teeth modelled after the diagnostic wax-up.

19/6/06
Porcelain crowns, veneers and bridges are ready. John spends a day at the clinic fitting new teeth onto the upper and lower jaws. A total of 24 units of new porcelain teeth are involved. In the same visit, an impression is also taken for the implants so that new teeth can be fabricated on them.

1/11/06
The implant-supported porcelain crown and bridge are ready and fitted. To prevent damage to his new porcelain teeth due to his grinding habit, an impression is taken for the fabrication of a nightguard which John will have to wear every night.

3/11/06
The nightguard is fitted. John is pleased with the final results!