Creating consistent results with cosmetic dentistry is certainly the ultimate goal that every practitioner wants to achieve. However, achieving this result and patient satisfaction can be elusive at times. Because cosmetic dentistry is artistic in nature, there is much subjectivity in fabricating the final esthetic look. In providing indirect cosmetic dental restorations and prosthodontic services such as porcelain and resin veneers, crowns, etc., there is much to consider prior to delivering the final product to the patient (Fig. 1).
What the clinician may consider as esthetic may not coincide with what the patient views as esthetic. In the eyes of the patient, inconsistent success can cloud the positive aspects of cosmetic dentistry. Ultimately, remaking the cosmetic restorations can lead to lowered confidence by the patient, wasted time by the clinician, and unnecessary remakes by the laboratory. In order to consistently be successful with each cosmetic dental patient, it is important that the dentist have a tool that will help remove the subjective nature of esthetics. The key to consistent success with cosmetic dentistry is the esthetic transitional restorations.
There are many elements to consider in properly delivering cosmetic dentistry. From the diagnostic phase, to the fabrication of the cosmetic restorations, to the final adhesion of the restorations, there are many details in restoring teeth cosmetically. Although each step is important, the esthetic transitional phase is one step that is essential in creating a predictable result. Interestingly, this step is one of the most underutilized in clinical treatment. Many times the provisionalization phase is considered a chore to most dental offices, and therefore delegated to dental auxiliaries who may not be properly trained . Without proper consideration of this phase, achieving optimal esthetics is like trying to shoot a target in the dark.
In using the traditional methods of the past, the esthetic aspect of the new restorations are relied purely on the artistry of the laboratory technician in creating the esthetic restorations. Unless there is an in-office technician working with the dentist, this haphazard approach provides very little guidance and leaves a tremendous amount of guess-work by the technician. What is the ideal length and width of the central incisors such that optimal facial proportion and facial balance can be achieved? What contours and textures are appropriate for this patient? Where should the incisal edges be placed such that the smileline will perfectly complement the lips and facial features of the patient? These are some of the same questions the laboratory technicians must ask themselves as they work on each cosmetic dental case.
The result of guesswork can lead to aggressive clinical adjustment of the porcelain restorations to such a degree that much of the surface glaze and esthetic characterizations would need to be willfully removed. The outcome to this haphazard method is a compromised end result both esthetically and functionally.
Historically, provisional restorations were made to merely cover the teeth preparation in order to keep the prepared dentition safe from the oral environment. Exposure of dentin can lead to unwanted decaying of the dentition, tooth sensitivity and overall uncomfortableness. In the past, acrylic provisional restorations provided a means to cover the teeth with very little focus on the esthetic implications. The definition of the term “provisional” is one that “is provided for a temporary need.” In providing effective cosmetic dentistry, the purpose of the temporary restorations should go beyond the need to just provide a temporary cover for the teeth. Thus, more appropriately, this phase of treatment should be looked at as transitional rather than just provisional. In creating a transitional prosthesis, the ideals of esthetics, health and function can be effectively worked out prior to fabricating the final restorations (Figs. 2-6). Once this phase of treatment is implemented and not just looked at as a change in semantics, a new plateau for the clinician will be achieved.
THE HUMAN FACTOR
In the world of art there is much subjectivity to how one views the quality of work. What would be revered as a masterpiece by some, may look less than sane by others. In the same way, “esthetics” in cosmetic dentistry is also very subjective in its assessment. Excluding the patients who are having cosmetic dentistry done just to restore a few teeth in their mouth; the profile of the individual who seeks esthetic enhancement is usually one who is very meticulous about their appearance. Their concern for creating the “right look” for themselves places much demand on determining the correct length, width, shape and color of the final esthetic appearance.
In addition, the type of patient who generally invests in cosmetic dentistry is one who wants to stay in control of their destiny when it comes to their appearance and/or health. Thus, the enhancement patient is possibly a person who may be considered a perfectionist. For these reasons, it is important to implement the esthetic transitional restorative procedure in order to satisfy the most discriminating patient and to create a predictable final cosmetic dental result.
In creating esthetic transitional restorations, the practitioner must take the time to first study the esthetic needs of the patient. A proper esthetic diagnosis and diagnostic records should be taken prior to starting any cosmetic case. Facebow mounted diagnostic models, retracted and unretracted dental photographs and proper bite registration are needed prior to starting the cosmetic dental evaluation. Once done, a comprehensive study of the patient’s face and smile needs to be completed.
There are many factors that the practitioner needs to take into consideration when developing the new facial appearance for the patient. Understanding that each person is unique in their facial shape, personality, occupation, gender, etc., the idea of smile designing should be expanded to include the study of faces in order to create overall facial attractiveness and facial rejuvenation (Figs. 7 & 8). Achieving “Facial Synthesis” should be the ultimate goal of the clinician. Facial Synthesis is the ability to create facial balance and harmony utilizing cosmetic restorations that are ideally sized, colored, textured and contoured to uniquely enhance the facial features of the patient. The dentist must take the time to study all the diagnostic records in order to create a mental imagery of the final look prior to starting the enhancement work.
With the understanding of how the final cosmetic restorations should be sized to meet the correct facial balance and proportion, the clinician will now be able to reconstruct the esthetic dentistry on the mounted diagnostic model. On the stone model, tooth preparations can be done to simulate the amount of tooth structure needed to be removed. This exercise helps the practitioner to understand, 1) how much tooth removal is actually necessary prior to the preparation appointment, 2) if any gingival surgery may be needed prior to the esthetic/restorative treatment and the extensiveness of the gingival changes in order to create the correct esthetic proportions, and 3) if any specialists may need to be used prior to the final cosmetic restorative treatment. This will help to correctly treatment plan the case and provide a controlled treatment for the patient.
In performing a diagnostic wax-up, the new esthetic contours are created. Keeping in mind the facial and smile requirements, the wax-up should reflect the proposed enhancement based on the individual patient’s facial needs. This esthetic wax-up becomes the new blueprint for all involved specialists and laboratory technicians. This communication device is a tremendous tool not only for treatment, but also to communicate the treatment plan to the patient (Fig. 9). In addition to this diagnostic wax-up, using a cosmetic dental imaging system and/or an esthetic mock-up on the patient’s dentition using composite resin can be done to convey your prospective end-results to the patient (Figs. 10-15). Once the patient accepts the esthetic mock-up, an impression can be taken prior to removal and be used as a template for the esthetic transitional restorative procedure.
Through the diagnostic phase, the initial concerns of the cosmetic treatment can be conveyed by the patient. Modifications on the diagnostic wax-up, the esthetic mock-up and/or the cosmetic dental image of the patient can be done to narrow the esthetic gap between the practitioner and the patient. In order to keep treatment moving forward, it is imperative that the patient be given some control over the esthetic aspect of treatment at this time. Although the clinician is there to advise the patient as to the health and functional necessities of the overall case, the patient should be allowed to take part in the decision-making process as to how they would like to look in the end.
For many years, the powder/liquid acrylics have been the mainstay for custom provisionalization. Although acrylic resins made an acceptable short-term restoration, there were many negative aspects to these materials. The considerable amount of shrinkage along with color instability and a strong, unpleasant odor of acrylic left a lot of room for improvement. With the emergence of the composite provisional materials in 1982, a new level of provisionalization was achieved. The composite-based materials provide a color-stable, odor-less provisional restoration with very low shrinkage. Many generations later, the composite-based material comes in a self (chemical)-cure (e.g. Luxatemp Plus — DMG Zenith, Integrity — Dentsply Caulk, Perfect Temp — Discus Dental, Protemp Garant — ESPE, etc.) and light-cure/dual cure (e.g. Luxatemp Solar — DMG Zenith, R.S.V.P. — Cosmedent, Iso-temp — 3M, etc.) that gives a tremendous number of choices for the clinician.
TRANSITIONAL ESTHETIC PROCEDURE
Prior to starting the direct technique provisionalization procedure, it is important to realize that if the clinician uses the pre-treatment model to make the transitional restorations, the blueprint for proper esthetics, phonetics and function will be very difficult to attain. Thus, it is important that the transitional restorations be fabricated from the diagnostic wax-up. It is through the diagnostic wax-up model that the majority of all the patient’s esthetic/ restorative problems have been worked out. It is important to emphasize that not all the esthetic problems will be worked out until the esthetic transitional restorative procedure is complete.
In the tooth preparation phase of treatment, an 0.020 clear matrix stent made from the diagnostic wax-up should be used as a guide. To create this clear matrix stent, the waxed model is duplicated in stone such that the accuracy of the diagnostic wax-up is not lost. Using this clear stent, the proper amount of tooth preparation can be achieved with minimal amount of tooth removal (Figs. 16 & 17).
After finalizing all tooth preparations, esthetic transitionals can be made using the same 0.020 clear matrix. At this stage, it is important to block out any severe undercuts using utility wax or any other flexible material that will allow for non-binding removal of the resin temporary material after its initial set. In addition, it is imperative to lubricate the tooth preparations and surrounding gingival tissue in order to avoid bonding of the resin temporary material to any resin build-ups and/or resin-based restorations that may have been done on the dentition. A silicone lubricant such as Masque (Bosworth) works tremendously well for this situation.
Using a resin provisional material such as Luxatemp Plus (DMG Zenith), a relatively bubble-free provisional can be achieved (Fig. 18). With the auto-mix gun, the provisional material is mixed and dispensed into the clear matrix stent. Being aware of the working time of the resin provisional material, the material filled matrix stent is placed in the mouth on the prepared teeth. Because of the limited working time, it is imperative that the stent is fully seated such that intimate contact of the matrix stent to the vertical stops (unprepared teeth or soft tissue) are attained. Because the resin provisional material is not as flexible as methylmethacrylate, it is important that the clinical team be aware of the working time of the resin provisional material.
As soon as the initial working time is complete, the provisional restorations should be uniformly removed off the prepared teeth immediately. If it is not removed uniformly, the provisional will be distorted and/or torn. After successful removal of the provisionals, it should be allowed to fully set without disturbance (Fig. 19).
After the setting time of the resin provisional material is complete, it is carefully removed from the matrix stent. Using a high speed diamond bur (Brasseler 6856), the gross excess of resin is removed near the margins (Fig. 20). Then a single sided diamond disk (Brasseler 919P220) is used to open embrasure spaces, properly shape esthetic contours and create anatomical texture (Fig. 21). Carefully the esthetic transitional restorations are placed back on the prepared teeth and checked for proper marginal adaptation. At this time the refinement and margination can be done using composite resin carbide burs (Brasseler OSIF023 — football; H50A010 — fluted carbide). Margin contours, proximal contours and esthetic contours should be designed to promote tissue health and create a blueprint for the esthetics of the final case (Fig. 22). (Note: A nice feature of Luxatemp system is that there is a flowable light-cured resin (Luxaflow — DMG Zenith) that can be used to instantly fill in any porosities or voids that may exist. However, other light cured flowable composites (Permaflow — Ultradent, Flow-It — Jeneric Pentron, Tetric Flow — Ivoclar Vivadent, etc.) can be used to achieve the same purpose.
To approach the esthetic needs of the case, it is important to take this time to properly shape and contour the esthetic transitionals so that facial synthesis can be achieved (Fig. 23). Although the patient may still be residually anesthetized, initial contouring to achieve good facial proportion and balance can be done. Prior to seating the transitional restorations, tints and opaquers (e.g. Tetric Color — Ivoclar Vivadent, Creative Color — Cosmedent, Kolor + Plus/Opaker — Kerr, etc.) can be used to enhance the esthetic value. After sealing the teeth preparations with a dentinal sealant (Superseal — Best Buy Discount Dental Supply) the esthetic transitionals are temporarily luted onto the teeth with a provisional cement (e.g. Tempbond NE — Kerr, Neo-temp — Teledyne/Waterpik, Duralon — ESPE, etc.).
Since the initial template for the new smile was already attained via the diagnostic wax-up, only minor adjustments are necessary at this time. The patient should be allowed to wear the esthetic transitional restorations for several days so that they will be able to critique the esthetics of their new smile. Remember, beauty is in the eye of the beholder; therefore, this stage is one of the keys to finalizing the esthetics of the case. By relinquishing some control of the esthetics of the case, the patient will feel a sense of reassurance. By recontouring the esthetics of the transitional restorations to the patient’s desire, the subjectivity and guesswork is removed so that the final indirect esthetic restorations can be fabricated by the ceramic artist with confidence (Fig. 24).
Keeping the health and functional requirements in mind, the clinician and the patient should work as partners in sculpting out the final esthetic case that will meet everyone’s happiness (Figs. 25-29).
Creating cosmetic dentistry can be an extremely rewarding experience if done correctly or it can be a very miserable experience if done incorrectly. In recognizing the pitfalls of treatment, it is very important that the clinician institute esthetic protocols to meet the demands of the patient. Although the esthetic transitional restorative procedure can be construed as time consuming to many practitioners, it creates the win-win-win situation for the doctor, the patient and the ceramist by reducing the number of remakes of cosmetic dental cases. Understanding and implementing the use the esthetic transitional restorative procedure can eliminate much of the subjectiveness of cosmetic dentistry and ultimately lead to consistent success.OH
Dr. Wynn Okuda is an accredited member of the American Academy of Cosmetic Dentistry, and a Fellow of the International College of Dentists. He is the co-founder of the Pan Pacific Dental Institute. He is also National Vice-President of the American Academy of Cosmetic Dentistry. He has a private practice in cosmetic, implant and restorative dentistry in Honolulu, Hawaii.
The author expresses his sincere appreciation for the beautiful ceramic artistry of Mr. Danny Materdomini of da Vinci Dental Studios of West Hills, CA.
Oral Health welcomes this original article.