Cosmetic Dentistry: Avoid costly missteps

Simple esthetic missteps can lead to complex reworks that cost you time and money.

As dental professionals, we are entrusted with the opportunity to grow and evolve our care for patients every day. It’s our responsibility to be our patient’s primary advocate in the recommendations that we make for their treatment. These recommendations need to represent our sincerest assessments that support the most conservative treatment modalities possible in achieving this goal. Assessments that are based upon the forensic evidence that exists clinically that indicate the need for treatment.

New to the scene in the last two decades has been the demand for dental esthetics. The media has brought directly to the public terms like, “No Prep Veneers,” “Bleaching” and “Invisalign.” Patients arrive at our door step asking for these procedures. What we need to help our patients understand is that these are simply products and procedures potentially available in every dentist’s toolbox, available to assist in the restoration of a healthy smile. The key aspect in this patient education process2 is the understanding that esthetics are really only a mirror of the relative health of the system. If there exists a disfiguring or unwanted blemish in someone’s smile, there is typically a biological, structure or functional reason why this deterioration has developed. Failure to completely identify and address this etiology significantly compromises our opportunity for predictability.

When providing esthetic dental enhancements for our patients, we are stepping into an advanced level of treatment planning. From this perspective, we are beginning with a vision of the end in mind, but with a focused discipline and an omnipresent understanding of the engineering of the system at large. We need to follow a protocol that will ensure predictability in all aspects of our health belief model: biology, structure, function and esthetics. This protocol allows the restorative dentist the opportunity to maximize the esthetic reveal, yet modulate the design depending upon the idiosyncrasies specific to the patient. Our options for treatment begin with the most conservative techniques and progress depending upon the needs of the situation. Our options involve reshaping teeth, repositioning teeth, restoring teeth or repositioning bone.3 Dentists who responsibly manage these design parameters will quickly separate their practices based upon the predictability that they are able to provide for their patients based upon clinical needs and the concepts of responsible esthetics.

The tipping point is the ability to remain committed to a comprehensive approach. External influence from the media or an emotionally motivated patient can cause a departure from this discipline and result in unpredictable outcomes. These mercurial situations are when services are provided, without diligent planning and analysis, and we wonder why the treatment falls short of expectations. Dr. Dawson teaches us that 90% of failures aren’t due to the material or technique, but the failure to plan.4 Failures may be defined as fractures, sensitivity, periodontal architecture effects or criteria related to esthetics.5 In the end, the patient’s confidence has been lost and the reputation of our profession is tarnished. Retreatment of these cases after critical failures is unfortunately initiated from an emotionally charged situation due to the iatrogenic compromised clinical condition.

This patient presented emotionally distraught and disappointed in her “new” smile. With positive motivation, she had sought the esthetic improvement of her smile and had Lumineers placed just 2 months prior. Since the delivery of her restorations, two of the veneers had fallen off or broken. Her tissues had increasingly become inflamed and floss shredded and got stuck when she attempted to clean her teeth. She began to lose confidence and experience “buyer’s remorse.” The restorations were inconsistent in chroma and value. The criteria related to global and macro esthetics did not harmonize to create a pleasing appearance.6 In some ways, she began to blame herself. At this point, her smile was better before she started then it was now. Initially, it seemed like an obvious choice to seek treatment. It was fast, it was easy, it required little to no preparation of her teeth and it was reasonably inexpensive compared to other alternatives. How did things begin to fail?

As with every case, decisions for treatment planning begin with a comprehensive exam. Our responsibility is to study the forensic data and make recommendations for treatment based upon the signs and symptoms of dental disease that exist. The complication in retreatment however, involves the mitigation of the newly introduced restorations and the resulting irreversible iatrogenic consequences. The protocol involves 4 stages:

• 2D Treatment Planning. An assessment of the biological, structural, functional and esthetic components of the smile creating a vision with the end in mind.

• 3D Treatment Planning. The in vitro creation of a dental blueprint through the use of diagnostic mounted models with the anticipated surface changes to the teeth modeled in wax.

• Prototype Restorations. The in vivo testing of the design of the contours and positions of the teeth in the patient’s smile.

• Definitive Restorations. The delivery of the final restorations.

In our 2D Functional Esthetic Checklist we assess the stability of the joints and complete a tooth-by-tooth evaluation. We begin to create a vision of potential solutions for the esthetic and functional needs of the patient. Our analysis of Smile Design is divided into 3 sections to conceptually assist our evaluation. We begin with the broadest strokes of smile design and progressively narrow our focus to critique the individual characteristics in our attempt to emulate nature. The concepts of Global Esthetics focuses on those criteria that are observed in un-retracted smiles and how the smile orients to the face and the lips that encircle them. As we continue to narrow our study, our attention aims toward the elements of Macro Esthetics. Macro Esthetics identifies the shapes and contours of teeth and their relationship to each other. Our final frame of reference converges on Micro Esthetics, which are those criteria related to the subtle intricacies of shade, textures, translucencies and surfaces effects that make teeth look like teeth. These are the criteria that aid us in fooling the eye and allowing restorations to blend invisibly into the smile.

In 3D treatment planning we have the opportunity to begin to test out our best guess of how we envision the smile to be. This anticipated design can then be virtually tested on the articulator to see if it meets the functional parameters for stability and predictability. Once the contours of the teeth have been defined by this modulation process this becomes our dental blueprint. A specific set of matrices can then be fabricated from this blueprint, to be utilized chairside to allow our preparations to be efficient and conservative. These matrices will also aid in the fabrication of prototype provisional restorations.7

In the next stage of our protocol, the prototype restorations play a far more important role than simply a transitional phase as the lab8,9 fabricates the definitive restorations. These prototypes are a reflection of the anticipated shapes and contours of these final restorations and allow us to verify important criteria related to function and esthetics in the patient’s mouth before the definitive restorations are created. Once the final adjustments to the prototypes are refined, and approved by the patient and the doctor, a copy of these approved provisionals are sent to the lab. In the creation of the definitive restorations, the lab now has the information to produce predictable, beautiful restorations.

Predictable, durable and esthetic dental restoration can only come from the implementation of a reproducible protocol. This protocol must honor the functional and esthetic parameters that are found in nature. In the end, each case is treated 4 times:

• Visually through the tools of 2D Tx Planning and Smile Design

• Virtually through the use of mounted models and a Dx Wax-Up

• Refined through use of Prototype Restorations in the patient’s mouth

• Delivery of the definitive restorations

Esthetics adds an exciting allure in the healthcare market place. The danger is to allow this influence to effect our treatment planning protocols. Providing predictable recommendations for treatment is our responsibility. True esthetics are merely a reflection of the relative health of a system. To ignore this founding concept is to introduce errors of ineptness. Skipping the essential components to predictable care comes at great cost, both emotionally and financially, for the patient and dentist.