April 3, 2019
by Douglas L. Lambert, DDS, FACD, FASD, FASDA, FICD, ABAD
Esthetics is still one of the key driving forces in dentistry today – whether it is one tooth or an entire mouth. The persona created by a beautiful smile is seen as a true asset to one’s personality. Meeting the needs and expectations of the patient continues to be the driving force for successful outcomes. The patient’s access to “dental knowledge” has grown exponentially over the past decade due mainly to the plethora of information available at the touch of a key stroke. The myriad of esthetic and cosmetic procedures available to patients continues to grow as a result of rising demand for these services by a health-conscious society seeking to maintain or recapture their youthful appearance.1
Our desire to satisfy a patient’s esthetic and restorative goals can pose a multitude of challenges for us as dentists. Incorporating a comprehensive approach to care is paramount to the planning and final outcome. In many cases, enlisting the expertise of our specialist colleagues throughout the treatment planning process can create a pathway yielding superior results. Decisions regarding a direct or indirect approach for the restorative phase must be considered. Material selection and the techniques to employ them are at the highest level we have ever experienced as a profession. Even with the best planning and execution, the potential for falling short of success can still occur as a result of numerous unforeseen circumstances. These can include various technical issues, operator error, laboratory mistakes, and patient compliance just to name a few. However, perhaps the most subjective factor in the restorative process can be patient expectations. In order to minimize the chance for a negative outcome, the foundation of success comes from proper communication between dentist and the patient, as well as the ceramist when indirect methods are incorporated. Beauty is truly in the eye of the beholder. When evaluating a smile, it can be very tempting for the practitioner to impose his/her own vision of the “ideal” onto the patient. Listening attentively, showing images of other smiles as illustrations, and guiding the patient with open-ended questions are effective tools in defining a route to success. One of the main tools we can champion is the diagnostic preview or “mock-up” as a visual stimulus for discussion and refinement of the esthetic and restorative goals.
The concept of the diagnostic preview or “mock-up” is not new to dentistry and articles extolling the virtues of its use are ubiquitous within the dental literature. Techniques to create the mock-up vary considerably and may include the use of photographs, pre-mock-up study models, laboratory fabricated wax ups, putty and plastic stents, bisacryllics, PMMAs, flowable resins and paste composites. Recently, many advancements in the field of computer-generated smile design have exploded onto the dental marketplace. Digital smile design (DSD) platforms assist in formulating a restorative treatment plan based on an analysis of the patient’s dental and facial proportions. Through the use of videos, photographs, and temporary mock-ups, digital smile design can offer a virtual sense of the relationship between the lips, gums, and teeth, as well as how they work together to create the patient’s smile. All of the visualization techniques reported in the literature have strong merit as they allow the operator and the patient to visualize what is esthetically and functionally possible. Many of these approaches lend themselves to one or more additional appointments to fully evaluate the results or require additional financial investments and/or the manipulation of software and computer-generated images.2-15
The basic tenants of the diagnostic preview/mock-up are predicated on communication and apply regardless of method utilized or whether the final restorative process involves a direct or indirect approach. The numerous benefits include, but are not limited to:
The use of a free-hand, direct composite mock-up in the patient’s mouth can yield all these benefits, plus be a quick and simple way of establishing the initial grounds for the final esthetic vision that both the patient and dentist seek. Taking this “low tech” approach to the mock-up allows the dentist to meld the information gained during the patient interview and create an immediate reference point at the time of the initial consultation. The ability of the patient to visualize the end result at the first appointment can have a very positive impact on case acceptance.
Consultation and Mock-Up
A 33-year-old female presented for a new patient consult regarding her smile as she neared completion of clear aligner therapy with her orthodontist. Her chief complaint is, “I do not like my short lateral.” Medical and dental history were noncontributory. Periodontal status, soft tissues and oral mucosa, occlusion and joint evaluation were all within normal limits. Current radiographs were evaluated with no significant findings. The consultation progressed with dialogue relating to specifics of her esthetic concerns and goals. A series of digital photographs were taken and utilized during the review session to assist the patient in identifying specific shortcomings her smile. A portion of those images are presented in this article (Figs. 1-5).
While one can certainly appreciate the patient’s personal view of the short maxillary left lateral incisor (2-1), we must look beyond that limiting scope and apply our smile design principles in order to properly review her case. Consideration of the gingival architecture, width-to-height ratios, Golden Proportion, smile line, incisal embrasures, buccal corridor, axial inclination, contact points, and incisal display are just a few of the many boxes to visit on your smile design checklist. During our smile design evaluation, a slight discrepancy in the gingival heights of the two central incisors (1-1, 2-1) was measured, as well as a lack of interdental papillae which created a black triangle between them. In addition, the two laterals (1-2, 2-2) had essentially the same mesial-distal width as the central incisors, thus creating an obvious proportional discrepancy. These additional findings were not revealed to the patient at this time (Fig. 6).
A direct composite diagnostic preview was proposed and accepted by the patient. Cotton roll isolation was obtained and the maxillary six anterior teeth and surrounding gingival tissues dried with a 2 x2 gauze. No tooth modification or enamel-dentin bonding was used. A light shade of composite (Empress Direct B1 Enamel – Ivoclar/Vivadent – Schaan, Liechtenstein) was applied to the patient’s teeth starting with the two centrals. The composite was manipulated and shaped with instruments and brushes (Figs. 7 and 8). The sequence included application of the resin to the full labial surfaces of the laterals and centrals (1-2, 1-1, 2-1, 2-2) and the mesial of the canines (1-3 and 2-3). Each composite segment added was cured for 10 seconds with an LED light source. The completed direct composite mock-up eliminated the dark triangle, repositioned the gingival height of the right central to that of the left by overlaying resin on the gingival tissue, and reproportioned the dimensions of the anterior six teeth to a more harmonious balance. At this point, we removed the patient’s bib and escorted her from the operatory to a large wall mirror where we stopped 2-3 feet from it and had her evaluate her smile. This has proven to be a very effective method to allow the patient to freely view her proposed smile in a more natural fashion, from multiple angles, and while speaking (Figs. 9 and 10).
As a result of the diagnostic preview, we discussed in more detail the options for both direct and indirect materials, as well as vital tooth whitening prior to any restorative procedure. Subsequently, the patient chose custom whitening trays (Opalesence 10% CP – Ultradent – South Jordan, UT) and a direct composite bonding protocol due to the conservative nature of its approach with full resin veneers on the centrals and laterals and partial coverage on the canines.
The patient declined the use of local anesthetic based on the minimally invasive nature of the proposed tooth preparations and use of composite resins in an additive manner. Preparation of the maxillary six anteriors followed an enamel-only protocol with a 40u diamond (L260.8Z–Premier Dental – Plymouth Meeting, PA) over the facial surfaces of the centrals and laterals (1-2 through 2-2) and mesial half of the canines (1-3 and 2-3). Additional enamel removal of 1 mm on the mesial proximal aspect of teeth 1-2 and 2-2 was necessary to give space to widen the centrals and redistribute the spacing in the anterior segment based on the mock-up. Each tooth was individually restored by first isolating the prepared tooth with a specialized matrix (Margin Perfect Matrix Ultra – Margin Perfect Matrix, LTD – Minneapolis, MN) according to the manufacturer’s directions. This created a sealed system, free of oral fluids, in which to restore the prepped tooth. A total-etch technique was employed with a 30+% phosphoric acid (Enamil Prep – Ivoclar/Vivadent) for 15 seconds, rinsed with water and air dried. Application of a universal enamel-dentin bonding agent (Prime & Bond Elect –Dentsply/Sirona – Milford, DE) was used and light cured for 10 seconds with a LED source (Bluephase Style – Ivoclar/Vivadent). Two shades of composite were chosen for the direct composite bonding, a dentin shade and an enamel shade (Empress Direct Shade B1 Dentin and Bleach Light – Ivoclar/Vivadent), as determined during the mock-up. Both were preheated to 130° F in a composite warming device (Calset – AdDent, Inc. – Danbury, CT) to enhance the placement of the resins. The dentin or gingival layer was placed first and manipulated with various composite instruments as well as those utilized in the mock-up. The initial layer was cured for 20 seconds with two lights – facially and lingually positioned. The subsequent layer of enamel replacement composite was applied and shaped accordingly, then exposed to the LED light for an additional 20 seconds. The matrix was removed and the restoration contoured with 12-fluted spiral-bladed carbides (H48L.31.010 and H379.31.018 – Brasseler, USA – Savannah, GA). After the occlusion was verified, final polish was created with a series of finishing cups and points (Astropol – Ivoclar/Vivadent) (Figs. 11-15).
The ability to communicate and illustrate the options we can provide for our patients is paramount to predictable restorative outcomes. The use of a direct composite mock-up can provide a “low tech” approach to this goal at the time of the initial consultation and yields innumerable benefits regardless of whether a direct or indirect material path is taken. It provides a simple, cost-effective approach as an effective educational tool to convert a vision into a visual concept, resulting in both a clinical success and exceptional experience for the patient.
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About The Author
Douglas L. Lambert, DDS graduated from the University of Minnesota Carlson School of Management and the University of Minnesota School of Dentistry. He is a Fellow in the American College of Dentists, International College of Dentists, Pierre Fauchard Academy, Academy for Sports Dentistry, American Society for Dental Aesthetics, and a Diplomat of the American Board of Aesthetic Dentistry. He has authored numerous articles, presented lectures and hands-on seminars nationally and internationally, and is part of the education team for the Post-Graduate Course in Comprehensive, Esthetic and Implant Dentistry at the University of Minnesota School of Dentistry and the Catapult Education Group. He serves as an independent researcher for many dental manufacturers, and as the team dentist for the Minnesota Lynx of the WNBA. Dr. Lambert’s practice in Edina, Minnesota emphasizes cosmetic, comprehensive, and sports dentistry.