Successful Treatment Planning of Mature Patients: Function and Aesthetics

In the last few years reality TV shows have overwhelmed our society with beautiful, fit, sexy, young people with whiter teeth. This trend has resulted in a boom in cosmetic dentistry that has greatly benefitted our profession. These days, patients from all walks of life and age groups are demanding a white  Hollywood smile. However, the patients of more advancing age have perhaps been neglected or taken for granted because of our false assumption that they are too old for bleaching, veneers, crown lengthening, connective tissue grafts, Invisalign, traditional orthodontic treatment, etc.

In the past, we failed to mention any possible aesthetic improvements to an older patient. To fulfill our patients' needs and desires for functional and aesthetic treatment, we as clinicians should not only pay attention to those younger generations but also to the older generations, and thus make a big difference in the lives of people of all ages.

This article will share with my colleagues the tremendous joy we can bring to the more mature patients in our daily practice.

CASE STUDY

Figures 1a to 1d. Preoperative view of maxillary and mandibular region with gingival recession and moderately severe crowding showing in different angle views.

The patient was born in 1923 and presented with severe overbite, moderately severe anterior crowding, and 5 small amalgam fillings in her molar areas. The majority of her natural dentition was intact with low caries indices and some calculus buildup, but it was very sound periodontally (Figures 1a to 1d). The patient had no history of TMD, tension headache, or neck and shoulder pain, but did report having arthritis in her knees, quite normal for an 82-year-old woman. We had been providing her with periodontal maintenance care without any discussion of possible improvements. During the next visit to the office (after being away for about a year), the patient had noticed on the walls our photographs of makeover cases featuring happy patients and beautiful teeth. A cosmetic consult was then requested and scheduled, at which multiple photos were taken, complete aesthetic and functional analyses were performed, and an in-depth discussion of the patient's desires and expectations was conducted.

During this visit, bite registration and impressions were taken for diagnostic models. The patient returned for the next appointment for a preoperative consultation, during which photographs and both original and diagnostic models were evaluated. Orthodontic treatment and periodontal surgery options for function and aesthetics were discussed with and declined by the patient. After looking at the models and comparing them, the patient mentioned, "It would be a miracle if you could do this for me, because most dentists had suggested that there was no hope for aesthetic treatment for someone my age."

Financial details were then presented, accepted, and paid for with a check, not a credit card or third-party financing as often is the case with many of our younger patients.

 

 

Treatment Planning

Figure 2. In-office mock-up model with composite resin serves as a communication tool or template for fabrication of the provisional restorations.

 

 

With a patient in this age group, it would not be appropriate or safe to treat both arches in the same visit. There was some concern of possible pulpal exposure during preparation of tooth No. 8 because of its severe malposition, and this had been discussed with the patient during the previous consultation. Diagnostic wax-ups with resin were fabricated to outline and visualize the final result1 (Figure 2). In this case, no preparation matrix guide was necessary. However, prior to the preparation appointment, 2 custom-made acrylic impression trays were fabricated (Bosworth) as well as a silicone matrix for the provisionalization stage (Kerr Sybron).

Preparation Appointment

After reviewing the procedure with the patient and having all consent forms signed, dated, and witnessed, more digital photos were taken for documentation. Once all vital signs were taken with an electronic monitor and recorded, topical anesthesia was applied, followed by Citanest plain (AstraZeneca) and Marcaine 0.5% (Cook-Waite) with 1:200,000 epinephrine. Teeth Nos. 7 to 10 were prepared for full ceramic crowns (Empress, Ivoclar Vivadent) with 1-mm to 2-mm reduction with 360? full shoulder margins. Teeth Nos. 5, 6, 11, and 12 were prepared for wraparound, indirect pressable veneers (Empress) with chamfer margin depths of 0.5-mm to 1.5-mm reduction to provide structural durability and color matching.2 All preparations were started with facial contour alignment before further reduction was continued. This technique helps remove only necessary tooth structure, thus avoiding excessive prep-arations. In addition, the complete preparations were accomplished at approximately 1-mm subgingival depth.

During the preparation phase, evaluation of reduction and draw angle were constantly monitored at different view angles using direct vision and mirrors, both regular and occlusal. Once all preparations were finished, provisionalization was initiated using the silicone matrix loaded with temporary resin (Integrity, DENTSPLY Caulk). The provisionals were then contoured and adjusted to provide proper fit and function with cuspid-protected occlusion. Working on the provisionals before taking the final impression allows the clinician to correct any misalignment of preparations and any reduction deficiency, and to verify stability of the occlusion and aesthetic parameters of the case.1

Once the provisionals were deemed satisfactory, they were polished with pumice and set aside for cementation. Retraction cords were then placed with Nos. 000 and 00 GingiBraid (Dux Dental). Viscostat (Ultradent) as well as Hemodent (Premier Dental) were used as necessary for hemostasis. Once the cords were in place for 10 minutes, Nos. 00 cords were then removed, leaving only Nos. 000 cords in the sulci. A polyvinyl siloxane impression (Aquasil Ultra, DENTSPLY Caulk) was then taken, followed by an anterior stick-bite and a CR posterior bite. A face-bow transfer and stump shade selections were also recorded.

Figure 3. Retracted view of the maxillary final provisional restorations of teeth Nos. 5 to 12.
Figures 4a and 4b. Final finishing with No. 30 fluted bur and silicone disk.

The preparations were then cleaned with Tubulicid Red (Global Dental), the veneer preparations were spot-etched, and adhesive (Prime & Bond NT, DENTSPLY) was applied to all preparations and light-cured for 20 seconds with the Optilux 501 (Kerr/Demetron). The provisional crowns (Nos. 7 to 10) were cemented with TempBond Clear (Kerr Sybron) and light-cured. The provisional veneers (Nos. 5, 6, 11, and 12) were bonded with flowable (Filtek, 3M ESPE) and tack- cured; any excess material was then removed before final light-curing was completed (Figure 3). The final occlusion was checked again with blue and red articulating paper, and appropriate adjustment was accomplished with No. 30 fluted burs (Brasseler USA; Figures 4a and 4b). Final polishing was done with silicone polishing points and brushes.

The patient was then seated straight and given a hand mirror to look at her new smile. Her emotional expression and joy warmed our hearts and made all staff members realize the special place that modern dentistry has commandedÖ the ability to change someone's life for the better! Because the patient's home was more than an hour away, and considering her age and safety, the provisionals were made in one piece to prevent their accidental loosening.

The patient was then scheduled for a follow-up visit in a week for any refinement of the provisional. Shade selection, photographsóretracted and occlusal views, and accurate length measurement of all provisionals were documented. Alginate impressions of both arches were taken. A diagnostic wax-up, diagnostic models, photos, shade selection, stump shade, length measurements, impressions, bite registration, and face-bow transfer were accomplished for final laboratory ceramic fabrications. (Note: Always keep a set of original models for your records.)

Final Cementation

After anesthesia was administered and the rubber dam placed, the provisionals were sectioned and removed. The preparations were then cleaned with Superoxol (Moyco Technologies). The ceramics were tried in and evaluated for fit, color, and form. All ceramics were etched with hydrofluoric acid (Ultradent Porcelain Etch) for 2 minutes, then rinsed and dried; silane (Kerr Sybron) was applied. The preparations were then isolated with

cotton rolls and split rubber dam technique; No. 000 retraction cords were placed. All preparations were then cleaned, scrubbed with Tubulicid Red, and etched with 37.5% phosphoric acid (Gel Etchant, Kerr Sybron) for 15 seconds. A single component adhesive was applied (Optibond Solo Plus, Kerr Sybron) on the preparations and internal surface of the ceramics. The standard protocol is to cement the 2 central incisors first, followed by the lateral incisors, and then the rest of the restorations. The final restorations were cemented with the luting resin cement Variolink II (Ivoclar Vivadent). Tack-curing for 3 seconds was done to facilitate cleanup of any excess cement in the interproximal and marginal areas, and final curing was accomplished for 40 seconds. All marginal areas were re-etched with 37.5% phosphoric acid, and adhesive was applied and light-cured for 40 seconds. Any excess cement and retraction cords were removed, and the occlusion was checked and finalized with the patient seated.

Figures 5a and 5b. The final result meets all the patient's objectives and maintains equilibrium of the smile.

The excited patient was then provided with a hand mirror to check out her new,  youthful smile. The patient

was delighted with the result. Immediate full-face photos were then taken, and care instructions for the ceramics were reviewed. Closeups and retracted views were photographically documented with a Canon EOS-1Ds Mark II digital camera. This article illustrates the successful treatment planning for function, nonorthodontic tooth realignment and aesthetic treatment of a mature person (Figures 5a and 5b).

CONCLUSION

Cosmetic dental service to patients of more advanced age is not only financially rewarding, but is also very uplifting to those of us in the profession who serve everyday people from all age groups and all walks of life. Being older should entitle one to seek more help to improve his or her quality of life. We believe that a properly executed cosmetic service will bring many years of happiness to anyone, no matter how old he or she may be. This case has put excitement and energy back into my profession. The joy of life of this vivacious, 82-year-old woman has taught me to appreciate the difference in someone's life our profession is capable of making. In fact, this charming "young" lady can hardly wait for the final mandibular ceramic restorations we will provide.


References

1. Nixon RL. Mandibular ceramics veneers: an examination of complex cases. Pract Periodontics Aesthet Dent. 1995;7:17-28.

2. Al-Omari WM, Al-Wahadni AM. Convergence angle, occlusal reduction, and finish line depth of full-crown preparations made by dental students. Quintessence Int. 2004;35:287-293.


Acknowledgment

Special thanks to Tom and Beatrice Dabrowsky, LDT, RDT at B.I.T. Dental Studio, Dillon, Colo.

Dr. Le maintains a private practice in Port Arthur, Tex, with an emphasis on aesthetic, implant, tissue regeneration dentistry and full-mouth reconstruction. He graduated from the University of Texas Dental School in San Antonio in 1987 and completed his undergraduate work at Williams College in Massachusetts with a degree in studio art. He is a fellow of the International Congress of Oral Implantologists and a member of the American Academy of Implant Dentistry, American Orthodontic Society, American Academy of Cosmetic Dentistry, Academy of General Dentistry, and other organizations. He completed the Esthetic Continuum at Baylor College of Dentistry, the preceptorship in oral implantology at San Antonio, and the prosthetic program at the Misch International Implant Institute. He can be reached at (409) 982-7827 or by visiting southeastcosmeticdentistry.com.



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