March 1, 2005
by Michael Soloway, DMD and Robert M. Sorin, DMD
Jane Doe makes an appointment in your office as a new patient. She is a 51-year-old business professional. She has had the same dentist, Dr. Smith, since she was 28-years-old. She has had a pot-pouri of dentistry over the years: several PFM crowns, multiple large composites on her anterior teeth, several teeth have been endodontically treated.
She has had her teeth whitened with trays at home and with a machine in the office. Her bone levels are good, and she has her teeth cleaned every six months. Lately she has noticed that her front teeth are looking shorter and are not smooth on the edges anymore. They have become a concern to her when she looks in her magnified makeup mirror every morning. She is not projecting the smile that she wants. She has read enough in fashion magazines to know some of the commercial answers so she went to Dr. Smith to have some “bonding” done. Dr. Smith replaced her incisal edges with composite resin. Within four weeks it was chipping, so she returned to Dr. Smith who explained that there were newer and stronger bonding agents and he replaced the bonding at no charge. Three weeks later, after it chipped again, she lost confidence. She had read a recent article in the New York Times discussing porcelain veneers as the solution to her esthetic concerns.
Now, based upon a referral from a close personal friend, Jane presents in your office requesting “veneers” on her front teeth. Because she has read the article carefully and realizes that fees vary, she is asking at the outset how much do you charge per veneer?
Is this a familiar scenario? Is it a good thing? Where do you go from this point?
In 2003, Americans spent 9.4 million dollars on cosmetic procedures.1
Jane Doe is in the middle of that population bulge known as the post-war baby boom.
“For the majority of general dentists in private practice, the biggest portion of their patient pool is made up of Baby Boomers — the most demanding consumers in the North American economy. Baby Boomers have been coddled, cajoled and spoiled by every consumer industry trying to market to this huge spike in the population curve. Their expectations are extremely high and they are very accustomed to having their whims met.”2
Jane Doe, of course, is a fictitious patient, but she is a reasonable facsimile or composite of the types of people that we see on a regular basis in our practice. She has taken the trouble to seek us out to solve her esthetic problem with a cosmetic solution. But what, truly, is her problem? Jane is arriving with a preconceived solution already evolved from a combination of her personal cosmetic beliefs and desires, and her knowledge gained from the media marketing so prevalent today.
It is our belief that many patients seeking correction to cosmetic problems have been led astray in how easily their problems can be solved. We believe that the emphasis needs to be first on how the problem evolved, then on how it should be solved. A biofunctional approach to esthetic patient care attempts to evaluate the science of what we are dealing with, and to manage it in a way that can solve our patient’s esthetic problems. Too often, the etiology is ignored at the expense of the treatment. We see the chips on anterior teeth, we see the wear on incisal edges, we see the restorations on the corner of maxillary incisors that have broken multiple times, but we need to more fully evaluate the reasons these conditions have occurred before attempting to solve the problem.
So what then is ‘Biofunctional Esthetic Dentistry’ and how does it actually interface with these cosmetic concerns? Biofunctional Esthetic Dentistry is our philosophy of care that fuses beauty with function, comfort and health in an effort to minimize risk and maximize longevity of treatment. It integrates the biologic and functional components of diagnosis for the esthetically concerned patient and dentist. It involves the assembly of a carefully selected array of personal and diagnostic documents, records and tests. It involves the understanding of a patient’s history: biology in terms of supporting structures, disease processes, chemistry; function in terms of mandibular motion, envelope of motion, anatomy and functional biomechanics; and esthetics in terms of art, tooth position, size, form, alignment, facial balance and harmony.
It is an esthetic solution to a problem that has been scientifically evaluated before the treatment solution has been determined. It is using scientific analysis to determine why Jane got the way she did before we accede to her request for “veneers”. As popular culture brings more and more of these people to our door, we find that the nature of their problem is increasingly more complex than the media has led them to believe. These problems require a different and more investigative approach before instituting what could be an overly simplistic solution.
Moving out of fictional illustration and into an actual case study — Daniel is a 37-year-old, single man who has recently moved to Manhattan. He was told by a dentist in Florida that he has the teeth of someone twice his age. He climbs mountains in Antarctica as a hobby and his general health is excellent. He is unhappy with his flat, worn smile and his assumption, on initial presentation is that he needs to purchase veneers to solve his problem. From this point on, does the solution to his problem rest solely on clinical details such as preparation style and depth, impression technique and the type of porcelain to use? Is that all there is to fulfill his needs and to create a predictable durable result? Is this, or is there simply a cosmetic dental solution to this case that we can deliver in one to two weeks (or 24 hours)?
If not, then how do we proceed from here? This patient needs an esthetic solution to his unacceptable smile, but in order to accomplish this with predictable results, we need to investigate more fully what has occurred here. Let us take a look at Daniel and begin to explore the process — a Biofunctional Esthetic approach to diagnosis and treatment.
Initially we ask our patients to do some writing for us regarding their past dental history (as they see it), as well as their goals, expectations and feelings. Most are happy to comply with this assignment. Getting this in writing gives us a clearer understanding of the patient’s perspective and enables us to listen more intently to what the patient is saying during the interview process. Often a tape recorder is also used with the patient’s permission. Further, they are asked to bring in “historical” photos such as a high school graduation photo, or wedding photo so that we gain some perspective of the problem over a period of time.
Other diagnostic records include a full mouth series of radiographs and 3 sets of identical study models poured in die stone and mounted on a Panadent 1701 AR PCH articulator. Because these become central to our functional analysis, we will put them aside for now and return to the model routine further into the discussion. Also included is a standardized photographic survey of 16-18 shots. These have become an increasingly useful tool in every aspect of our discovery process. They are now used as routinely as we have normally used radiographs. Figures 1-6 show the first six of these photos.
This patient’s past medical history was non-contributory.
Periodontal examination revealed tissues that were healthy with no abnormal pocket depth. This patient was classified as a low risk periododontal patient and it was felt that the long-term prognosis was good.
Evaluation of clinical photographs and intraoral examination of the teeth and existing fillings revealed some interesting findings.
Looking at his preclinical photographs we can see that biomechanically, he has many compromised teeth: cupped out amalgams in the posterior, thinning enamel, multiple erosive lesions. Where does all of this erosion come from? We have to use deductive reasoning and start playing Sherlock Holmes to put all of the pieces of this puzzle together.
It turns out that this patient had a daily candy habit, and liked to suck on lemons and limes. All of this contributes to a low pH erosive environment in his mouth, which is consistent with the clinical findings.
Gaining control of these problems will, indeed, be a driving factor prior to any conclusive treatment. As the enamel is penetrated by the chemical erosion, it exposes dentin that wears at an exponentially faster rate and accelerates the mechanical wear. Prescription fluoride products were dispensed along with behavior modification counseling until we reached an understanding that the destructive habits had ceased and we were able to consider proceeding in a safer environment. In this case, the on-going responsibility of the patient for maintaining a passive oral environment is emphasized.
From figures 1-6 we can see the wear across the maxillary anterior teeth. This patient’s central incisors measure 6.5mm long and are ragged. He has most likely lost at least 3.5-4.0mm of tooth length from these incisors. We can see the normal sequelae of horizontal wear whereby his lower anteriors have erupted above the plane of occlusion, and his mandible has moved forward — both events to compensate for the wear and keep his anterior teeth coupled. Thinking ahead we know that these biologic and functional facts are going to complicate our esthetic goals on several fronts — the first and most obvious being the space required to develop the desired length for his maxillary incisors.
But at this point we still do not know how he got this way, nor the extent and nature of the anterior destructive processes. Is this a simple matter of parafunction (i.e., night time bruxism)? There was a time when that would have been our first and only conclusion, but now our experience suggests other possibilities. Kois suggests several other etiologies in his development of functional diagnoses.
Nevertheless, to engage in a firm differential diagnosis, we chose to test positively for night-time bruxism by using a balanced flat plane orthotic splint. The patient was asked to wear it at night for three to four months so that we could study it for characteristic lateral wear patterns in the acrylic.3 This was done and we observed no significant wear patterns indicative of a night time grinding problem (Figs. 9 & 10).
Our ability to rule out parafunction as a reason for his anterior wear still left us with the question of how this wear developed. Functional analysis may bring us into the largest potential area for controversy; but we believe that it is essential in a biofunctional esthetic diagnosis and treatment plan. It is not our intent to indulge in this controversy, but to emphasize the requirement for thorough diagnosis and clarify the evolution of our current belief system.
Now let’s revisit our three sets of models. The upper casts are mounted using a Kois Facial Analyzer giving us a standardized mounting parallel to the horizon. The first lower model is mounted in MIP, i.e. maximum intercuspal position. The second lower cast is mounted in CR in the orthopedic position of the mandible. Suffice to say that set one is mounted in a functional dental closed position and set two is mounted in a condylar-based position. Set three is used for appliance development.
The appliance that we use with increasing frequency is the Kois Deprogrammer (Fig. 11). This is a very useful appliance that consists of a Lucia jig just behind the upper incisors incorporated into a Hawley appliance for support. The beauty of this appliance is that it allows complete access to the occlusal surfaces of the teeth. This appliance has become central to the development of our diagnoses, treatment plans, and implementation of therapy. It has a single central bearing point as close to center as possible behind the central incisors. It holds the teeth apart in the posterior by as small a margin as is comfortable–usually 1-2mm. In cases where posterior occlusal prematurities exist, this appliance is instrumental in determining where those centric occlusion (CO) tooth contacts are located and in eliminating these contacts during occlusal equilibration.
Our patient was instructed to wear the appliance for 3-4 weeks day and night except when eating. This removes the engrams or habitual closing patterns of the mandible, allowing the condyles to seat in the fossae and the mandible to close into centric relation (CR).
After the patient was deprogrammed, he reported that when he closed, he was first hitting in the back area, i.e. his CO tooth contact. Kois speaks about a normal functional occlusion as having an envelope of function that creates an efficient use of closing and opening muscles, that does not create premature loading of teeth and therefore will not create wear or mobility. It has an MIP position that the brain can easily find with no slide, and terminal closure that is compatible with harmonious TMJ function. He discusses ‘occlusal dysfunction’ as one category of abnormal masticatory function. In the dysfunctional patient, there is no ‘home’ position, the mandible is not closing with equal, simultaneous, bilateral contact and the condyles are forward. For these reasons, in the dysfunctional patient their envelope of function is enlarged such that the mandibular teeth are not coming in cleanly and safely behind the upper teeth during chewing. This results in destructive friction in function and hence increased wear. This proved to be the case with Daniel.
After Daniel was deprogrammed, an occlusal registration made with the appliance in place (Fig. 13). You can see the central bearing point that is the only point of contact, and how convenient it is to register an accurate bite with the appliance remaining in the mouth. After many years of bilateral manipulation, we are finding this technique highly accurate, repeatable, and functional. This confirmed that the patient was, indeed, closing on a prematurity in the posterior and so the final pieces of the puzzle began falling into place. Our conclusive diagnosis was, indeed, occlusal dysfunction.
Several problems could now be solved at once. First we have the problem of insufficient room to lengthen his incisors to achieve a more esthetic result and restore more normal tooth anatomy. Second we have the problem of the occlusal dysfunction that will continue to cause wear or to destroy whatever porcelain restorations we use to restore his anterior teeth. We now knew that we could equilibrate Daniel and position his mandible into CR where the condyles would seat posterior to where they were currently seated in maximum intercuspal position (MIP). If we could give him a “home”, where all his posterior teeth contacted bilaterally and simultaneously with equal force, and give him a way to find his way comfortably into that home, it would relieve the dysfunction, the enlarged envelope of function, and stop the frictional destruction in the anterior region. With the distal movement of the condyles, we could create just enough space in the front to deliver the desired esthetic solution safely. That is precisely what was done.
Again, the ultimate beauty of the deprogammer is seen in the equilibration process. Because of the dental access, we were able to equilibrate by reducing the jig sequentially until the posterior contacts began to touch and then eliminated them until we gained bilateral simultaneous equal intensity contact from molars to cuspids. We are able to evolve a treatment plan based upon biology, function and esthetics. We have a patient that is experiencing normal function in CR with his mandible in its orthopedic position, allowing us the room and the safety to design the smile that incorporates the beauty and harmony that we both desire.
Most of our esthetic parameters and decisions flow from a single primary factor — maxillary incisal edge position. From that point, a smile can be bui
lt including occlusal plane development, lip relationships and tooth display. Detailed analysis of the photos becomes critical in this phase. The evaluation of facial anatomy, ginvigal architecture, embrassure form, and desired tooth colour and contour are all factors to be considered in order to successfully create the desired result. Blending all of these factors successfully with the patient’s vision becomes a work of art in itself.
In Daniel’s case, he had a certain esthetic direction and it required, at least, restoring the missing length in his anteriors. Although analysis of his resting lip photos indicated that he is still showing a millimeter of tooth, we knew that to create a great esthetic result we needed to lengthen his maxillary anteriors and create a bolder and more harmonious smile line. The end result speaks for itself.
The execution of the treatment, in detail, is beyond the scope of this article. All of the normal routines of our system were followed. Models mounted in CR were used to fabricate a diagnostic waxup creating the 10.6mm central incisors and leveling the occlusal planes. From the wax-up, a template was made and a bonded resin mock-up was performed in the mouth as a trial of both function and esthetics. (Fig. 13). After the teeth survived the test without any breaking or chipping, Daniel was brought to the complete provisional stage (Fig. 14) as a final test of all parameters. With mounted models of the final provisionals as a guide, the lab work was completed and the case was inserted in sections. The restorations were a combination of bonded porcelain in the anterior and bicuspid areas and metal ceramics in the posterior (Figs. 15-17). As has now become our habit, a final deprogrammer would be made and used post-insertion to spot the occlusion back in from front to back.
We live in a society where appearance is increasingly important in both our social and workplace environment. Patients have become more educated and sophisticated in their expectations through increased media exposure. Many of the Baby Boomers don’t want to look like their parents did at a similar age. Our responsibility as dentists, scientists and clinicians is to provide the esthetic results our patients’ desire without losing sight of the biological and functional components that are so important in determining a result that is beautiful, comfortable and long lasting. Our patients should expect more than just a “cosmetic” solution to their esthetic problems.
Doctors Soloway and Sorin maintain a private practice devoted to biofunctional esthetics in New York City. Among their many professional affiliations, they are founding members of the CRE Metro New York Study Group.
Oral Health welcomes this original article.
1.American Society for Esthetic Plastic Surgery Report Feb. 18, 2004.
2.AGD Impact, January, 1998.
3.Effect of Full Arch Maxillary Occlusal Splinting on Parafunctional Activity During Sleep in Patients with Nocturnal Bruxism and Signs and Symptoms of Craniomandibular Disorders. Holmgren K, Sheikkholesham A, Riise C. Journal of Prosthetic Dentistry 1993; 69:293-297.
4.Evaluation, Diagnosis and Treatment of Occlusal Problems. Dawson PE 2nd edition, CV Mosby Co. 1989.
5.Esthetics of Anterior Fixed Prosthodontics. Chiche, GJ, Pinault A. Quintessence 1994.
6.New Definition for Relating Occlusion to Varying Conditions of the Temporomandibular Joint. Dawson PE, Journal of Prosthetic Dentistry 1995; 74:619-627.
7.TMJ Occlusion and Function, Neff P.A. Georgetown University Press 1975.
8.Limits of Human Bite Strength, Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Journal of Prosthetic Dentistry 1986; 56: 226-229.
9.Symbiosis of Esthetics and Occlusion: Thoughts and Opinions of a Master of Esthetic Dentistry, Miller L. Journal of Esthetic Dentistry 1999; 11(3):155-165.
10.Comparing the Perception of Dentists and Lay People to Altered Dental Esthetics. Kokich VO, Kiyak A, Shapiro PA. Journal of Esthetic Dentistry 1999; 11: 311-324.