December 1, 2006
by Elliot Mechanic, DDS
Clinicians must make choices on a daily basis. Treatment planning, experience, knowledge of dental materials and procedures allow us to provide our patients with the best we have to offer.
We are living in the age of the extreme makeover and the public seems to be bombarded with the message that a beautiful smile is essential. The cosmetic dental revolution is proving to have both a positive and negative impact! There has never been as high a public awareness and positive image for dentistry and the evolution of dental materials and proliferation of continuing education has been phenomenal. On the other hand, the “make a buck” attitude of those wishing to capitalize on the dental boom has resulted in considerable amounts of unnecessary dentistry. Patients often choose to allow their teeth to be mutilated irreversibly and then regret their decision.
A 22-year-old female presented for an esthetic consultation (Fig. 1). She did not like the look of her teeth and desired porcelain veneers. She had read articles about esthetic dentistry in numerous fashion magazines and was led to believe that veneers were quick, painless, long lasting and did no damage to the natural teeth. Consultations at two other dental offices had recommended six and eight laminates respectively. As the patient was confused by what she sensed was an aggressive sales approach, she desired a third opinion.
Visual and photographic examination displayed a caries free dentition in class I occlusion with a healthy periodontum. The central incisors were small and misshaped and a gummy smile existed.
Periodontal probing determined this to be due to altered passive eruption where the gingiva does not recede normally leaving a facial sulcus of 3-4mm (Figs. 2-5). In our patients case, the gingival level were easily correctable by simple laser gingivectomy.
Every patient is entitled to a complete description of their oral condition and alternative treatments. I explained how healthy her young dentition was and how many long years her teeth needed to function and be preserved. Natural teeth are virtually maintenance free and although I recognized her esthetic concerns, I recommended that as little as possible be done to alter the integrity of her teeth.
Pointing out the discrepancy in gingival levels and the lack of shape of the central incisors I used a photo of her smile and with a pen drew in changes I would make to the gingival levels and to the shape of the central incisors (Fig. 6).
From the drawing, the patient was able to visualize the benefit of what just two porcelain veneers could achieve. It became clear to her that a conservative approach did have numerous advantages and she asked what the next step would be. Although, her only concern was her front teeth, she was scheduled for a new patient examination to include X-rays, study models and a face bow registration. We must perform elective esthetic dentistry in a totally healthy environment and a complete examination is essential to ensure that no other dental problems are present.
Computer generated imaging allowed her to further visualize the possibilities (Fig. 7). She immediately scheduled an appointment for the procedure.
A diagnostic wax-up was created at the lab as per our instructions (Fig. 8) and the patient signed a consent to treatment form (Fig. 9). As dentistry purely for esthetic reasons is completely elective, it is imperative that the patient acknowledge that they were given a clear choice and that they accept responsibility for their choice.
The patient was anesthetized and a diode laser was used to alter the gingival levels (Fig. 10). The teeth were conservatively prepared (enamel only), impressions were taken, and the teeth provisonalised with Luxatemp (Zenith/DMG, Englewood, NJ) (Fig. 11). Postoperative instructions were given and the patient was scheduled to return two weeks later for any esthetic modifications to the provisionals and to choose a final color.
When she returned a few weeks later, it appeared as if nothing had been done and that the teeth had been this way all along. The gingiva and shape of the teeth were in harmony with the existing dentition and the patient’s face (Figs. 12 & 13).
Photos and a model of the temporary were taken and a final color chosen. The lab was instructed to create feldspathic porcelain veneers to the exact form of the temporary prototype. They were instructed to create the same texture and detailing as the adjacent teeth. At the seating appointment, the provisionals were removed and the final case luted with the Vitique esthetic cementation system. (Zenith/DMG, Englewood, NJ). Our patient was instantly delighted by the result (Figs. 14 & 15).
When evaluating an elective esthetic case, it is imperative for a dentist to gain perspective of the patient’s desires and to be able to visualize the final intended result before beginning treatment. Planning, experience, knowledge of restorative materials and a complete explanation to the patient of all options are the key to patient satisfaction.
Dr. Elliot Mechanic received his Bachelor of Science (1975) and Doctor of Dental Surgery (1979) degrees from McGill University. He is esthetic editor of Oral Health.
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