April 1, 2010
by Les Rykiss, DMD
I think that most practitioners agree that in this day and age, we are all trying to do ideal cosmetic dentistry. We attend the seminars by the talented cosmetic dentists that advocate minimal or no prep veneers such as Lumineers, (or whatever lab they are using), and we see beautiful veneers that are usually placed from 2nd bicuspid to 2nd bicuspid for optimal esthetics. This is “ideal” but is this the type dentistry that most patients are willing to do? More and more patients are coming in more aware of what modern dentistry can offer due to television shows, newspaper and magazine advertisements, but are they willing to spend the money to achieve that goal? Most patients are very conscious of the fact that veneers are not a covered service under their dental plans, and therefore are reluctant to spend thousands of dollars of their discretionary income to achieve maximal esthetic results. So when patients are unwilling to do the extreme makeover, what can we do to enhance the appearance of their smile? At this point we must take a step back and realize that cosmetic dentistry outside of Hollywood can sometimes be just as much of a challenge.
The importance of treatment planning is essential to the overall outcome. For instance, if the patient only wants tooth 21 restored, it is still important to bring forth the message to the patient that there is an underlying problem that will not disappear by simply matching the adjacent central incisor. Perhaps full mouth rehabilitation is essential to allow for harmony during function, and of course giving optimal esthetic results. Failing that, what we see mostly, as dental practitioners, is single tooth replacement. I find that this is ultimately one of the biggest challenges that I face, and therefore pre-op record taking is essential. Full photos will not only help you to find a perfect solution, but in this day and age essential for communication with the laboratory esthetic expert technician. A simple true light photo will allow the technician to gain that much more information about the true degrees of hue, chroma, and value, than simply picking a shade tab. A full series of photos will show the degree of translucence, how the light reflects off the natural teeth, the surface texture, and degree of characterization. That is, are there blemishes, decalcification marks, frostiness from mouth breathing? Multiple photos from slightly different angles will allow the light to reflect differently off the facial surface of the tooth, and show more surface detail. All this will allow the experienced technician the ability to build all this into the ultrathin veneer at a thickness of 0.5-0.75mm. As well, by taking a photo with the shade tab selected in the photo (also during preparation for stump shade), colour correction of your photo can be achieved. Again, this depends on the true abilities of the lab technician (artist) that we choose to do the work.
Proper mounted diagnostic casts are also essential for case presentation, as well as communication with the lab prior to the procedure appointment. My philosophy on record taking is that you can never have too much information. Do more now and save time later. It is essential to take either a stick bite, or full face bow records when doing any anterior reconstruction. We have the ability to see the patients’ symmetry and defects when they are in our chair, but trying to convey that to the lab, who does not have the same luxury, is the most important thing.
It is essential that we as practitioners deliver all the information to our patients at any time. This is especially true in a situation where they are looking for a full cosmetic makeover, yet are only willing to do minimal work. We are only matching the existing situation, not changing it. Make sure that the patients’ expectations are realistic. Failing this, no matter how wonderful the results are that we achieve, it will never be enough for an unrealistic patient. This is where a comprehensive treatment plan will help tremendously. You will be able to deliver treatment options to the patient from the most conservative to the most ideal, explaining them thoroughly, and allow the patient to make their own educated choice knowing full well all the possible ramifications of each choice.
This case is a perfect example of the type of dentistry that most general practitioners face on a day to day basis. This patient presented for a new patient examination, stating his chief complaint being “the discolouration of my front tooth”. Upon examination, it was discovered that tooth 11 had a large old restoration that had been there for about 15 years. It was stained, and worn, and definitely had seen better days. As well, the patient had some crowding issues with his lateral incisors. I explained that we could “reface” as few as six anterior teeth to get a wonderful cosmetic result, which would eliminate the crowding of his upper teeth. His response after hearing what the cost would be, was “Will my insurance cover this?” Of course the answer led to further questions about whether or not anything would be covered by his insurance. The fact that a veneer would be covered on his 11 almost 100% made his decision for him. He chose to do only what would be covered by his insurance.
Pre-op records and photos were taken at a separate appointment. Prior to prepping the tooth, a diagnostic wax up was done for this tooth, and a provisional VPS stent was fabricated, for ease of temporization. A pre-op photo was taken with an approximate shade as a guide for my dental technician, so that he could make any colour correction required from the photo.
On prepping the tooth, we were able to be very conservative. A minimal amount of facial enamel was removed (0.5mm), and after removal of the restoration, most of the incisal prepping was already done. Care was taken to ensure a smooth preparation, leaving the margin no more than 1/2mm supragingival. As you can see, a rubber dam was used in this case and it is my opinion that wherever a rubber dam can be used, it should be for ease of retraction, fluid evacuation, and preparation.
After prepping was complete, a stump shade photo was taken again to help the technician decide how much if any opaque layer was required. The greater the difference between the desired shade and the stump shade, will require a deeper preparation. In this case, the difference was minimal, but if the tooth was any darker, I would have had to remove anywhere from 0.7-1.2mm of facial tooth structure.
Again, because the lab does not have the luxury of seeing the patient in person, in the case of an out of town lab, taking as many photos, and from different angles will allow the experienced artist the ability to fabricate the most natural restoration possible. It will show the degree of light reflection and transmission, surface anatomy, and imperfections. Take as many photos as time will allow so that if anything, you have too much information.
A provisional restoration was fabricated with spot etching of the enamel, unfilled resin, and Perfect-temp (Discus Dental), using the VPS splint made from the diagnostic wax-up. Provisional restorations made from a diagnostic wax-up can help in detecting potential future problems for your final restoration. That is, could occlusion or parafunctions become a problem later. How will speech patterns be affected? As well, this allows the patient to leave your office with some insight into what the final outcome will be.
For the most part, anesthesia is not generally required for cementation, unless either you have a nervous patient, or the preparation was deeper, perhaps slightly into dentin. In this particular case, no anesthesia was necessary. The tooth was cleaned and pumiced so that there was no residual resin which could effect the fit of the
veneer. The try-in is usually done with a drop of water only to simulate clear cement later. If the colour needs correction, then a tinted try-in paste would be used. The advantage of water only is that there is no cleanup required prior to cementation.
The importance of an experienced lab artist is seen from this photo. The vitality built into a restoration only 0.5mm thin is readily visible. Many thanks to Robert Passaro from the Passaro Center for Ceramics at the Nash Institute in Charlotte, NC for his attention to detail.
The restoration was approved by the patient and the veneer was bonded with Onestep (Bisco) and Choice2 veneer luting cement (Bisco). As you can see, no colour changes were required. Finishing and polishing was immediately performed and a follow up appointment booked to ensure no residual cement or any other potential problems.
The patient was seen one week for his follow-up appointment, and I wanted to disk off the mammelons of both 11 and 21, as well as get rid of the tiny chip on the mesio-incisal corner of the 21, but the patient wanted everything to remain unchanged.
One week healing shows almost complete gingival health and acceptance of the restoration.
While elective cosmetic dentistry is what a lot of dental practitioners would agree as “ideal” dentistry, with the economy being what it is today, more and more patients are not too eager to stray away from their dental insurance and use discretionary income. In most cases, this means that instead of choosing to accept more complex treatment plans which the patient is completely aware that they would “love to have”, they opt to choose the most cost effective route to make their smile look better. This presents several challenges for the dentist as it is often more difficult to match one tooth in the anterior esthetic zone than it is to do two teeth or more. Every case has its inherent challenges, and for the most part, when the result is exactly what you have envisioned, the satisfaction is enormous. This however takes the combined efforts of the practitioner, the patient, and the dental lab technician. OH
Dr. Rykiss maintains his private practice in Winnipeg, MB. He is a graduate of the University of Manitoba as well as a graduate and Mentor at the Nash Institute for Dental Learning in Charlotte, NC.
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