April 1, 2013
by Stephen Poss, DDS
As the dental field rapidly evolves with new materials and digital technology, there are some basic concepts that are consistently disregarded with anterior aesthetic dentistry. In this area of dentistry there are ten basic principles that, when overlooked, can compromise the long-term satisfaction of both the patient and the dentist.
No one would consider building a house without an architectural plan to visualize the end result. This architectural plan allows the construction company to prepare for most unforeseen challenges and to develop a plan to overcome them.
So why is it that when a patient decides to have a smile makeover the clinician leaves so much to chance? This clinician has been practicing 30 years and, during this time, has made every mistake and seen every possible scenario that can make a predictable aesthetic case turn into a nightmare for both the dentist and the patient.
In this brief summary are 10 principles of treatment planning that, when followed, can alleviate many unnecessary headaches.
When the patient’s first contact is made with your office be sure you and your team members are listening to their expectations. Are they realistic? Can you meet or exceed their expectations? We all have had that patient whose case we wish we had not started or wish they would just go away. Recently this clinician had a patient call the office with her twelve upper teeth prepared and in provisionals by another dentist (Figure 1) Her provisionals appeared to be acceptable. After listening to the patient talk about midlines, axial inclinations and embrasures of her teeth, there was shadow of doubt that no one was going to satisfy this patient’s concerns.
Always call the previous dentist to get the full story. The patient was on her fourth set of provisonals. The dentist mentioned that, with the economy hurting his practice, he was eager to start the case immediately, with very little preparation or thought about how he was going to meet her expectations.
Always review the patient’s complete medical and dental history. Do they have any pre-existing muscle pain? Do they have any popping or clicking of their temporomandibular joint? The clinician can create a tempormandibular problem by incorrectly replacing the incisal edges with veneers or crowns. If placed too far lingually the patient can either fracture the dental work or cause jaw pain as the patient is forced to move their mandible too far posteriorly. It would be wise to document that there was a pre existing problem before work is initiated. Improper placement of the incisal edges can also create a phonetic problem as well.
There is another concern to observe at the consultation appointment. Notice the patient’s vertical index. This is the distance from the CEJ of the upper central incisor to the lower central incisor when the patient is in centric occlusion. (Figure 2) Generally if this measurement is less than 15mm the clinician should expect a little more difficulty managing the occlusion. This is especially true if the overjet is less than 2mm.
Determine if any of the anterior centric stops will be removed during preparation of the teeth. There are some indications that may make it necessary to remove tooth structure including the centric stops. If there were any existing restorations that need to be replaced or removed then the anterior occlusion may have to be altered. (Figures 3) The clinician would need to visualize where they are going to place the lingual margins. The margins can be placed above or below the existing centric stops. Preferably the margin should not be at the occlusion stop.
Determine if the case will require a wax-up. Are the changes that the clinician are making significant? If the arch form was going to be changed in any form then a wax-up would be highly recommended. The clinician may also want to consider a preparation matrix to verify that enough reduction is made to achieve the necessary aesthetic results. This would be true especially with midline shifts and any crowding teeth in the arch. (Figures 4 and 4a)
Verify the patient’s satisfaction aesthetically as well as the phonetics in the provisionals. It would be ideal to have the patient return to the office 48-72 hours after the provisionals are placed. Make any desired changes and have the patient verify the changes and their satisfaction before the porcelain work is started. Take the necessary photographs, which is usually a smile and retracted photographs, of the provisionals. The photos and impressions should be sent to the dental laboratory. The clinician should follow up with a phone call to the laboratory to make sure both the clinician and the dental laboratory are on the same page. (Figure 5)
Inspect the dental laboratory restorations at least a few days prior to the patient’s expected return to the office. Make sure the laboratory has the length, shading and contours that were requested. There may also be a path of draw problem that may require the restorations to be placed in a certain order. This can be very common with multiple restorations. This will save the dentist time and anxiety at the cementation appointment.
Try the restorations in to verify the fit first. Then place water or try in gel in the restorations and allow the patient to view the aesthetic work thoroughly before they are placed in permanently. If the provisionals have been verified and approved by the patient initially, then this will not be an issue. Also, make sure if there is anyone who will be making the decision of the aesthetics besides the patient, (spouse or relative) they will need to inspect the work before it is placed as well. Once the dental work has been approved, the patient is required to sign a consent form verifying they approved the shade and shape of the restorative work. This will make the patient at least feel more responsible for their decision to allow the work to be place permanently. (Figure 6 Consent Form) This form will also prevent the patient from considering major changes in their new smile.
Determine the cementation technique prior to the appointment time. This is critical! Adhesion is beyond the scope of this article however there are total-etch systems, self-etch systems and universal adhesive systems. All the systems can be very effective if used accordingly to the manufactures instructions. This may sound elementary but many post-operative sensitivity issues are due to incorrect use of the adhesive system.
Schedule a post operative visit within the first week of cementation. Since most patients are numb when the case is seated, it is wise to verify the occlusion and aesthetics when the anesthetic is no longer present in their lip. Also, this clinician will rarely do any contouring at the cementation appointment because the numb lip can throw off the clinician’s visual acuity. The dental assistant should confirm post-operative instructions on hygiene; what to do and not to do with their new teeth. This would include certain restrictions such as tearing plastics like potato chip bags. This is a more common cause of failure than you might think. Please don’t assume the patient will automatically know this.
Discuss the longevity and warranty of the new dental work with the patient. This can vary in every office. This clinician has many cases that have been in use 15-20 years. Typically most
clinicians and patients would expect at least 4-5 years. This can also depend on the circumstances in which the dental work could fail. All of the details of what the clinician and patient expect can be written in the consent acceptance
form before the veneers are placed. (Figures 6 and 6a)
Dentistry is a demanding profession. There are many challenges that can and will appear. This is especially true with cosmetic work. Having these principles and systems guidelines in place can make this part of esthetic dentistry rewarding for both you and your patient.OH
Dr. Poss has directed numerous live patient continuums at various teaching institutes on restorative dentistry. He is also on the editorial team of the Reality Publishing. This would include writing and evaluating new dental equipment and materials for product development. Dr. Poss maintains a full time restorative practice in Brentwood, TN. Beautifulsmiles@earthlink.net.
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