Treatment planning for patients who require a slower transition into veneers.
Every day dentists have patients who are able to recognize how the transformation of a smile can change a life. They know that it will help them or their loved one to land that job, find that special someone, or just give them that extra edge in business and networking. Patients are additionally motivated by what they see on television, in the movies, and on the pages of magazines. They can appreciate how a beautiful smile can take years off of one’s appearance, increase self-confidence, and make that person more approachable and distinguished. In fact, often, family members, friends, and co-workers have undergone similar smile rejuvenations, which only serve to motivate patients even more.
So, given that patients have an understanding of how a beautiful smile can impact the way others perceive them and the way they feel about themselves, why might these esthetic treatments get delayed? What happens when the desire is there, but one’s apprehension or finances get in the way? And what can dentists do to keep patients motivated and committed? Dentists may consider employing ways that enable patients to see how they could look (digital imaging, wax-ups, temporaries, reshaping, bonding, Snap-On Smile® [Den-Mat, http://www.denmat.com], etc). Additionally, dentists need to be careful when walking that fine line knowing that patients may lose interest if things drag on too long, but a hard sell may create a negative experience that could risk losing that patient and their referrals forever.
This article explores how to work up, stage, and execute a smile makeover on an individual who is just slowly testing the water, but not yet ready to take the plunge.
When a patient brings in a photo of a supermodel and says, “I want to look like this,” is that being realistic? The reason models are so photogenic is because their faces are perfectly symmetrical. However, 95% of people have faces that, when bisected, have a left and right side that do not match up. Even among esthetically pleasing faces, asymmetry is a typical finding.1 Cosmetic dentists are taught to make teeth that are symmetrical and of golden proportion. But unless a patient has a perfectly symmetric face, the dentist would be doing that patient a disservice in giving him or her perfectly symmetric teeth. Otherwise, the dentist is just placing something completely symmetrical within an asymmetrical frame, which would have the adverse effect of making the teeth stand out.
This is where excellent communication with the dental laboratory comes in. Clinical results are directly proportional to the communication skills dentists have with their laboratories.2 Digital photographs, preliminary impressions, a proper bite and facebow registration, and custom shade all help to convey the necessary information to the laboratory. An esthetic wax-up serves as a template for temporary restorations, and doubles as a selling tool to help convince the patient to move forward with the proposed treatment. This wax-up should function only as a guide for the final restorations, because a perfectly symmetric smile created on the wax-up most likely will not serve all of the patient’s esthetic needs. Any asymmetry in the smile relative to their face will need to be modified in order to create harmony when that patient smiles, so that the layperson does not recognize any discrepancy.3 For example, one must take into account an occlusal cant, which is a form of asymmetry that is apparent when a person smiles but not perceived on intraoral images or study casts.4 Another form of asymmetry that may need to be modified is the amount of buccal corridor space that is visible on either side; its minimization is a critical smile feature.1, 5-8
There are different ways to compensate for this asymmetry. One method is to add a flowable bisacrylic or composite to the temporaries made from the wax-up. Another way involves adding flowable bonding material directly onto the teeth themselves, and then using the additive/reductive method to achieve harmony between the symmetry of the teeth relative to the symmetry of the face. Either way, once the desired result has been achieved in the mouth, an impression should be taken so that the final restorations can be modified accordingly.
Additionally, esthetic dentistry based on the patient’s facial features may dictate the need to include different shapes, inclinations, and rotations of teeth. Some people just may need more prominent canines or more prominent centrals. Perhaps the laterals need to be rotated to catch the light in just the right way. Use old photographs and listen to the patient to find out what characteristics he or she liked and disliked about the original smile. Then, when appropriate, give the patient back something to make the teeth feel like his or her own.
Four years ago, a 57-year-old woman first presented herself to the author’s office with the chief complaint, “I just broke my front tooth on an olive pit. I am also really unhappy with the looks of my teeth and would like veneers at some point” (Figure 1 View Figure, 2 View Figure, 3 View Figure, 4 View Figure, 5 View Figure). The patient had previously seen an orthodontist to straighten her lower anterior teeth, and was planning on having veneers done for her maxillary teeth, but said she “missed the financial window of opportunity.” The patient was aware that the linguals of her maxillary front teeth were substantially eroded, but denied any history of bulimia. She said that she wanted to have a more natural appearance for her teeth, with softer and rounder edges.
She had a class I molar relationship on both right and left sides, with a 1.5-mm overjet and a reverse curve of Spee. The author gave her the option of seeing her orthodontist to bring her maxillary teeth into better alignment, and gave her a referral to see a periodontist regarding gingival and osseous reshaping, especially in the area of tooth No. 5, which was lingually inclined. The author and the patient also discussed the possibility of gingival grafting, especially in the area of No. 10, where she had 3 mm of exposed root surface. At that time, however, the patient was only interested in whitening her mandibular teeth, and discussing crowns and/or veneers for her maxillary teeth.
One year later, she returned for Zoom!® whitening (start D4, finish B62) (Discus Dental, https://www.usa.philips.com/c-m-pe/dental-professionals/) and to take impressions for Snap-On Smile® because she was between jobs, had interviews coming up, and did not think that she would be hired unless she did something about her smile (Figure 9 View Figure). Her plan was that once she got her job, she would save up, and then have the veneers done. The author gave her the Snap-On-Smile, which did not look exactly the way she had envisioned, but it did help her get a job. Additionally, it photographed well in pictures and allowed her to feel less self-conscious. The author also performed some enamel reshaping so that if she opted not to wear her Snap-On Smile, her teeth would not appear so jagged. Recontouring teeth has been shown to significantly improve the final occlusal and esthetic end result.9
She returned a few months later with a new job, and with it a new resolve to revisit her treatment plan. The periodontist had determined that osseous surgery and crown lengthening for esthetics for teeth Nos. 3 through 14 would be indicated to achieve optimum esthetic results, along with root coverage for tooth No. 10 and a lateral pedicle graft or connective tissue graft in that area to reduce the need for palatal grafting and to give her the best color of soft tissue on the buccal. Her lip curtain did mask the exposed root areas, and she decided that she did not want to spend the money for this and undergo the surgery if these areas did not show when she smiled wide. She was not interested in undergoing any further orthodontic treatment or having any surgical periodontal procedures, but she was open to non-surgically reshaping her gingival tissue, especially around tooth No. 5 where her tooth appeared short and needed to be lengthened.
Preliminary photographs, impressions, and bite and facebow registrations were taken 6 months later (Figure 6 View Figure). After 3 years of preparing for this moment, the patient finally mentioned that she had a relative who was a dentist, who preferred to do only LUMINEERS® (DenMat) and had advised her to go this route, saying he would not charge her anything except the laboratory cost. As someone who wanted to be more conservative and to whom cost was a large consideration, this was a big decision for her to make. The author proceeded to explain the difference between veneers and LUMINEERS, and how in the right circumstances LUMINEERS would be a fine option (eg, when the color of the teeth was not being dramatically changed, or when the teeth being preparing were smaller, lingually inclined, or could afford to be built out while maintaining an even thickness of porcelain). To assist her in her decision, the author set up a meeting with his master ceramist to discuss all of the pros and cons of each option, and to see which path was more aligned with her desires and expectations. After her research and the consultations, she decided that doing veneers with the author was the right choice for her.
Visual, periodontal, and occlusal assessments were performed. The author analyzed her case following the requirements for occlusal stability as outlined by Dawson, including: stable stops in centric relation, anterior guidance within the envelope of function, full posterior disclusion in protrusive movement, and no posterior interferences on the working or non-working side in canine guidance.10 The treatment planning sequence began with one of the most important steps, an appraisal of the maxillary central incisors relative to the upper lip.10 An error in the incisal position can cause restorations to break and a sore musculature from an uncomfortable envelope of function.11 The author strived to create an incisal edge that would contact the inner vermillion border of the lower lip when pronouncing the letters “F” and “V.”12 The author determined the length and horizontal edge position of her maxillary incisors as best as he could, which would be tested and modified during the provisional stage derived from this diagnostic wax-up. The correct position should also allow for the air to flow naturally between the upper and lower incisors when creating the “S” sound.11 In his efforts to create a more youthful smile, the author planned to round the incisal edges, open incisal and facial embrasures, and soften the facial line angles.10 The cuspids, which supported the corners of her mouth, were made to be approximately the same length as the central incisors.13 The ideal smile arc would mimic the curvature of the lower lip from central incisor to canine.14, 15
Once the diagnostic wax-up was created (Figure 7 View Figure and Figure 8 View Figure), buccal and incisal putty stints were fabricated to show where enamel reduction was necessary (Figure 12 View Figure and Figure 13 View Figure). A clear periodontal stint was made to guide the gingival reshaping. Additionally, a putty stint was fashioned from the wax-up to create a matrix for creating an exact replica to be used for the provisionals. The diagnostic wax-up, preparation model, and guides all served as a “cookbook” guide to verify esthetic design, phonetics (while wearing temporaries), and adequate tooth reduction to achieve the restorative needs.
The Restorative Phase
Now 2.5 years after the first Zoom! session, a deep bleaching of her lower natural teeth was performed, starting with a Zoom! Boost (starting shade was C2, finished at D2); the patient was then given whitening trays that she used for 4 weeks (after which she was at a B1 shade), and then a full Zoom! session was performed, finishing at 0.5M1 (Figure 10 View Figure and Figure 11 View Figure).
The chosen shade was 0.5M1 on an A3 foundation; the stump shade was B54 (Figure 15 View Figure). Teeth Nos. 5 through 12 were prepared for veneers and teeth Nos. 3 and 14 were prepared for porcelain-fused-to-metal crowns. Electrosurgery was performed to even out the cervical tissue lines for teeth Nos. 5, 7, 8, and 12 (Figure 14 View Figure). The patient came back a couple of days after this appointment to check her temporaries, occlusion, and envelope of function.
The author took a new impression of the temporaries to communicate with the laboratory what the patient liked and where she was comfortable. The patient wanted to see and approve the veneers before they were glazed and fitted so that she could feel confident that everything was communicated well. After a few slight modifications, she gave full approval and felt confident that the author and his team could give her what she envisioned.
The veneers were tried in to make sure that everything fit well. The preparations were cleaned, then etched using SURPASS® (Apex Dental Materials, https://apexdentalmaterials.com/), because some parts of the preparations were in dentin. Then, using Kleer-Veneer® cement (Pulpdent Corporation, http://www.pulpdent.com) in shade Clear for insertion, along with the Veneer Styx positioning tool (by Cosmetic Innovations Inc), the veneers were predictably seated (Figures 16 View Figure, 17 View Figure, 18 View Figure, 19 View Figure). Excess cement was removed with a Schure 349 Instrument (DenMat) (which does not scratch the porcelain surface), the contacts were flossed, and occlusion was checked in all excursions. The author’s technician made her a nightguard to help protect her investment, because she did have a history of grinding. On follow-up visits, the patient reported that she felt so confident and wonderful, and that she could not stop smiling at everyone (Figure 20 View Figure and Figure 21 View Figure).
Esthetic dentistry is all about creating one’s image and inspiring self-confidence. Patients are a lot more critical of themselves and their appearance these days, and they look to the dental professional to make their smiles more beautiful and youthful. There has been a paradigm shift in dentistry in recent years. A new attitude toward the dentist has emerged, with patients fearing treatment less, and becoming more receptive and excited about doing work that will result in a more esthetically pleasing smile. This generates a whole new level of self-satisfaction among dentists, as they help their patients discover a renewed confidence in themselves as they look in the mirror.
The end result of what cosmetic dentists do is to improve their patients’ self-esteem through the creation of a beautiful smile, but the responsibility does not end there. Esthetic dentists must ensure that these beautiful smiles are built on a strong and healthy foundation. A lack of adequate nutrition and poor home care can be detrimental to the long-term stability of the teeth and surrounding structures. It is the dentist’s job to educate patients so they can maintain what the dentist can give them. A long-lasting, beautiful, and healthy smile will ensure that a dentist’s patients continue to be walking billboards for his or her work for years to come. Once their family, friends, and co-workers see what can be done, perhaps some of their trepidation can be alleviated, paving the way for them to take the plunge themselves.
The author is the founder and president of Cosmetic Innovations, Inc, and the inventor of Veneer Styx, a product used in the presented case.
The author would like to acknowledge both of his master ceramists, Peter Kouvaris and Jason Kim, for their guidance and support throughout the planning and execution of this challenging smile makeover. He would also like to acknowledge his staff for all their hard work and dedication, and for enabling him to achieve these life-changing transformations for his patients.
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