Dental Reconstruction Case Study

Published Articles by Dr. Lazare

When a Patient Says “No” to Orthodontics: Navigating Complex Esthetic Reconstructions

What do you do when a patient declines orthodontic treatment, creating challenging restrictions for an already complex esthetic case?

As dentists, we often envision the possibilities for transformation simply by observing our patients. With an artistic eye and clinical expertise, we design smiles that not only enhance appearance but also improve confidence and quality of life. Our training allows us to visualize how a broader arch could eliminate dark buccal corridor spaces, how incisal edges might follow the natural curve of the lower lip, and how individualized tooth form can reflect a patient’s personality. We understand the psychological impact of a whiter, straighter smile and how principles of smile makeover design — from golden proportions to incisal edge placement, width-to-height ratios, and gingival contours — can help achieve these goals.¹˒²

Yet, the art of esthetic dentistry is rarely a solo pursuit. Successful smile makeovers often require collaboration between the cosmetic dentist and trusted specialists. But what happens when a patient refuses recommended adjunctive treatments, such as orthodontics, even after a comprehensive plan has been carefully outlined?

This article explores the planning, execution, and challenges of a smile makeover made more complex by a patient’s decision to decline orthodontics.

Realistic Expectations

Even the most technically flawless smile makeover can be considered unsuccessful if the patient’s expectations are not met. The moment a patient is handed a mirror is often filled with anticipation: the clinician waits for approval, hoping to hear, “I love it!” But sometimes the response is, “This doesn’t look like me,” or complaints that restorations feel bulky, small, or not the right shade.

The key to avoiding disappointment lies in communication. Before beginning treatment, it is essential to understand exactly what the patient likes and dislikes about their smile. Digital photography, mock-ups, and esthetic wax-ups provide valuable previews of possible outcomes. Patients should also be encouraged to bring reference photos and meet with the ceramist for shade consultations. The more information exchanged, the better the clinician can guide the laboratory to produce results that meet or exceed expectations.³

Equally important is documenting the patient’s occlusion and ensuring stability before, during, and after treatment. Temporary restorations can be invaluable for testing occlusion, esthetics, and patient comfort before finalizing the case.

Above all, patients must be informed of the limitations they may face by declining recommended treatments such as orthodontics, laser gum reshaping, or surgery. Thorough documentation and informed consent are critical.

Case Presentation

A 57-year-old woman presented with the chief complaint: “I’m not happy with my smile. I want it whiter and straighter.” Invisalign® and orthodontic treatment were recommended to correct crowding, improve symmetry, and achieve predictable veneer results. However, the patient declined orthodontics and periodontal recontouring.

Comprehensive records were taken, and an esthetic wax-up was created to define achievable goals within the patient’s restrictions. Despite limitations, treatment planning followed Dawson’s requirements for occlusal stability.⁵ Smile design principles guided the provisional stage, ensuring functional harmony with esthetics.

Ultimately, veneers and a crown were placed following whitening and restorative procedures. Through collaboration with a ceramist and other specialists, compromises were managed while achieving a natural, pleasing smile.

Patients seeking esthetic dentistry often have different perceptions of what their “perfect” smile should be compared to the clinical possibilities. It is essential to present all treatment options and explain the consequences of declining recommended procedures. With informed consent, realistic expectations, and careful communication, smile makeovers can succeed even within patient-imposed limitations.

When the boundaries are clearly set and outcomes align with patient expectations, the transformation is considered a success.