A Restorative Challenge Meets Patient Readiness…20 Years Later

A patient’s readiness to accept our treatment plan proposals is often not when he or she enters our practices. In order for patients to go along with our recommendations, they have to be able to fit the treatment that we propose into their lives emotionally and financially. Sometimes this occurs many years after their first visit. While some patients come in asking for elective aesthetic/cosmetic procedures, for the multitude of people who enter our practices for nonelective care, a time delay between their entry and comprehensive treatment plan acceptance happens more frequently than we might think.

BACKGROUND

Figure 1. Preoperative retracted view. Figure 2. Preoperative full-face view.

The patient in the following case presented to my office 20 years ago. I performed a comprehensive examination, including oral cancer screening, full-mouth x-rays, diagnostic models, and periodontal probing. He told me he was not happy with the appearance of his 2 front teeth. I asked Al about some of the other things I saw that could be improved aesthetically, but he said he wasn’t interested. Ultimately, I completed basic restorative treatment on several teeth with caries and composite resin bonding on the upper central incisors (image not available). He then disappeared from my practice. After about 20 years had passed, he called for an appointment, saying that he wanted to discuss “some new crowns on my 2 front teeth.”
As strange as it might sound, nothing a patient does surprises me any longer. We gave Al an appointment, and a few weeks later we met and got reacquainted. I asked about his family and what he was up to, and I learned a lot. I also asked him what brought him back to see me. He said, “I trust you… You did a good job on my 2 front teeth 20 years ago.” Well, I was flattered and at the same time wondered, “If I did such a good job, why did you leave my practice?” I chose not to ask this question at this time; rather, I interviewed Al as if he was a brand new patient about why he came to see me.
After getting a medical history, I asked what his chief concern was. He replied that he wanted to get new crowns on his 2 front teeth, saying, “I don’t like how they look.” The crowns he had on his upper central incisors are shown in Figure 1. I asked Al if it would be okay for me to give him a mirror and ask some questions about a few other things. He consented, and I asked how he felt about the unevenness of his smile, how the side teeth fell in a little, and other aesthetic issues that were obvious to me. Al replied, “Well, they could be more even…and I guess they’d look better if the ones on the side were more in line with everything else.” His pretreatment smile was strained and restricted (Figure 2). Using a patient-centered treatment-planning approach,1 I asked open-ended questions and followed them with other questions or silences that allowed Al to tell me more. When Al finally said he would like to discuss what else could be done for his smile, I knew I had reached him on an emotional level, which is where most of our patients’ decisions originate.2,3

CLINICAL EXAM AND LABORATORY CONSULTATION

A comprehensive examination including a visual oral cancer screening was performed. Today, a subsurface soft-tissue exam using the VELscope Oral Cancer Screening System (LED Dental), which was not yet available at the time we treated this patient, would be included. GC EXAJET Fast Set (GC America), a heavy-body vinyl polysiloxane impression material, and Originate impression trays (Axis Dental) were used to make impressions for study models. X-rays were taken using the innovative Tru-Align positioning system (Interactive Diagnostic Imaging), and full-face and smile images were made using a Canon G5 system (Photo-Med International). Using Zenith/DMG O-BITE Bite Registration Material (Zenith Dental) for bite registration, the Kois Dento-Facial Analyzer System (Panadent), and the Panadent No. 1701 AR Model PCH Articulator (Panadent), the diagnostic models were then mounted for study purposes.
A treatment plan consultation (TPC) with the dental technician who will perform the laboratory phase is very important4 in a complex case like this. Having a TPC with the technician prior to case presentation will serve to facilitate the case presentation to the patient and make technical aspects of the case go more smoothly. Minimizing any surprises that would otherwise occur during treatment is in the best interests of all parties involved.

Figure 3. Preoperative right lateral view. Figure 4. Preoperative left lateral view.

Examination revealed a fractured porcelain-fused-to-metal crown on tooth No. 8 and recurrent caries at the crown margins of teeth Nos. 8 and 9, but no additional caries. Al’s periodontal condition was surprisingly good, except for gingivitis, and there was no osseous involvement. His soft-tissue exam was negative. He had moderate crowding in both maxilla and mandible, gingival heights were not where they should be, and tooth widths were not in proper aesthetic proportions. Lateral views show both upper posterior sextants were linguoverted (Figures 3 and 4) with multiple cross-bites on the right side (Figure 3). X-ray analysis did not reveal any other problem areas but did show that both upper central incisors had previously had endodontic treatment. While diagnostic models showed a malocclusion, he was functioning well in his maximum intercuspal position (centric occlusion [CO]).

CASE PRESENTATION

After a thorough discussion of what could be done for him, Al decided to treat his smile from upper right second bicuspid to upper left second bicuspid. He decided not to include the upper first molars in the aesthetic rehabilitation even though he would show these teeth in a very full smile. We talked about getting a “more even” look, which was one of his goals. After discussing the issue of gingival positions, Al elected to accept the existing gingival heights.
I explained that there were unknown issues that could only present themselves after removing the crowns on teeth Nos. 8 and 9. I told him I didn’t know if restructuring these teeth with posts and cores would be needed until after the old crowns were removed. Tooth No. 28 would have to be reduced in height; there was the possibility that the reduction could cause sensitivity in that tooth and the very remote possibility that if that occurred and did not resolve, root canal treatment could become necessary.
The treatment plan we agreed on was placing porcelain veneers on the teeth from upper right second bicuspid to upper right lateral incisor and the same on the contralateral side. Equilibration to level the occlusal plane would be done, and the central incisors would have new crowns. Gingival heights were to remain where they were. Any questions that Al had were discussed so he had a complete understanding of what we would be doing. Financial arrangements were made, and several appointments were scheduled.

TREATMENT BEGINS

Figure 5. No. 29 equilibrated, No. 28 still to be done. Figure 6. Applying Super Seal to No. 29.
Figure 7. Central incisor crowns removed. Figure 8. Caries excavated.

The occlusal heights of teeth Nos. 28 and 29 were reduced to eliminate the crossbites. Approximately 2 mm were removed on No. 29, but No. 28 required only a reduction of about 1 mm (Figure 5). Since a small amount of dentin was exposed, Super Seal (Phoenix Dental) was applied to the occlusal of No. 29 to prevent sensitivity (Figure 6). This product “reacts with the calcium hydroxyapatite to form a fine granular calcium oxalate precipitate. This precipitate is an acid-resistant liner that is biologically and chemically complexed with the underlying substrate of the vital dentin.”5
Using a GENTLEsilence LUX 6500B high-speed air handpiece (KaVo America) and an Razor 1557 Carbide (AXIS Dental), the existing crowns on teeth Nos. 8 and 9 were resected and removed (Figure 7). The Razor burs are designed with a blade geometry that allows for rapid and smooth cutting through most restorative materials. All decay was carefully removed under magnification with Dimension-3 Dental Loupes (Orascoptic, A Kerr Company) and a SS White Burs’ Great White Gold Series pear-shaped bur No. GW 330 (Figure 8).

THE CENTRAL PLAYERS

The central incisors required much more treatment than the other teeth to be treated. The remaining coronal tooth structure consisted of thin fragments on the proximal aspects of teeth Nos. 8 and 9. I felt that posts were needed to help retain the cores in both teeth. There is much confusion and controversy about which posts are the best to use. Much research is devoted to this area and centers on fiber posts versus metal posts. However, each category has many subcategories: fiber posts can consist of either quartz or glass, and metal posts can be cast, stainless steel, or titanium. We also have the issue of parallel posts versus tapered design. The question as to which post is best is far more complex than asking “metal or fiber?”
While there has been much discussion in the literature and among clinicians about the use of prefabricated fiber posts, the studies have not truly isolated an answer as to which post is best. One reason for this is that the use of a post cannot, and should not, be viewed as an isolated entity without considering the condition and overall treatment plan for the tooth involved. The amount of root structure removed to place the post, the preparation design for the crown, specifically the ferrule, and how a post is cemented are more significant than the type of post used. Several studies have shown that the presence of an adequate ferrule on the tooth, and leaving as much radicular dentin as possible, are more significant factors for success in teeth treated with posts.6,7 In summary, root fractures are less likely to occur when a proper ferrule design is employed. If sufficient exposed tooth is not available for a ferrule, crown lengthening should be considered, when possible.
It is this author’s opinion that metal posts still retain a long and successful track record of success and should definitely not be abandoned. In a study done at the Universitätsmedizin Berlin in Germany, authors compared the clinical outcome of prefabricated rigid titanium posts to glass fiber endodontic posts when luted with self-adhesive universal resin cement and used in conjunction with composite cores. They concluded the following: “Both titanium and glass fiber-reinforced composite posts result in successful treatment outcomes after 2 years. The material combination used seems to be appropriate in the short term for cementing endodontic posts, irrespective of the post material.”8 Another study concluded “Prefabricated titanium posts with composite cores, zirconia posts with heatpressed ceramic cores, and cast posts and cores yield comparable survival rates and fracture strengths for the restoration of crowned maxillary incisors with moderate coronal defects. Survival rates and fracture strengths for zirconia posts with composite cores are significantly lower, so this combination cannot be recommended for clinical use.”9

Figure 9. IntegraPosts cemented. Figure 10. IntegraPosts cemented, occlusal view.
Figure 11. Coronal dentin etched. Figure 12. Accor Multisized Matrix.
Figure 13. Accor festooned and fit. Figure 14. LuxaCore core buildup.
Figure 15. Great White Ultra Kit.

My current preferred post is Premier Dental’s IntegraPost (Figure 9), a titanium parallel-sided grooved post with a head design that allows the composite core to lock into the post head. The post preparations were etched with 37% phosphoric acid (Gel Etchant [Kerr Dental]), then rinsed and dried. A thin layer of a dual-cure adhesive, Clearfil Photo Bond (Kuraray Dental), was applied on the walls of the post preparations and excess solvent evaporated. IntegraCem (Premier Dental) was mixed, and the posts were coated with the cement, then inserted into the canals (Figures 9 and 10). Light-curing the excess cement for 5 to 10 seconds with the Optilux 501 halogen curing light (Kerr Dental) stabilized the posts.
After reapplying Gel Etchant to the coronal dentin for 10 seconds (Figure 11), rinsing and drying, Clearfil Photo Bond (Kuraray Dental) was applied to the etched coronal tooth structure. The fit of a previously festooned Accor Multisized Matrix (Figure 12) was confirmed (Figure 13), and Zenith/DMG Luxa-Core Dual Blue (Zenith Dental) was injected into the Accor matrix (Figure 14). Both central incisors were prepared with 360° chamfers for porcelain-fused-to-Captek (Precious Chemicals Company) crowns using Great White Ultra bur No. GWU 855-025 (Figure 15). These burs cut smoothly and efficiently with very little chatter in a high-speed handpiece. Captek was chosen as the metal under the porcelain because of its light-dispersing ability, which mimics that of healthy natural tooth structure, as well as its ability to blend aesthetics with strength.

TREATMENT CONTINUED

All teeth, other than the central incisors, were prepared for porcelain veneers using the Laminate Veneer Preparation Kit (Brasseler USA), after removing any old composite resin. This kit has all the burs needed for porcelain veneer preparations and is user friendly. The preparations were wrapped onto occlusal surfaces to ensure maximum strength in occlusion. There was the need to build some veneers out facially to create an acceptable arch form, the need to create the illusion of a harmonious smile with no crossbites, and finally, to properly fill up the buccal vestibule.
After placing Ultrapak Cord No. 000 (Ultradent Products) with a Fischer Ultrapak Packer No. 171 Small (Ultradent Products), the master impression was made using medium body Impregum Penta Soft Polyether (3M ESPE) impression material and a sulcular wash of Permadyne Garant 2:1 (3M ESPE) in COE Brand Disposable Perforated Trays (GC America) previously coated with tray adhesive (3M ESPE). The opposing arch was impressed with EXAJET Fast Set (GC America) polyvinyl siloxane impression material, and the bite registration was made with Zenith/DMG O-BITE.
A one-piece temporary appliance was created with Zenith/DMG Luxa-temp Fluorescence (Zenith Dental) by injecting the material in the preoperative impression and seating the impression over the prepared teeth. Teeth Nos. 8 and 9 were lubricated with mineral oil in order to avoid having the composite cores and composite provisional materials fuse together. After 2.5 minutes in the mouth (as Luxatemp instructions indicate), the one-piece temporary was gently teased off using a Wynman

Figure 16. Temporary cemented with GC TEMP Advantage.

Carbide Crown Gripper (Miltex). With an H257EF fine-staggered tooth E-cutter (Brasseler USA), the flash was removed from the temporary and the margins refined and polished using Enhance finishers and polishers (DENTSPLY Caulk) and PoGo diamond micropolishers (DENTSPLY Caulk), both with gentle pressure. The temporary was cemented with GC America’s GC TEMP Advantage (Figure 16), and the patient was given instructions about which foods to avoid and how to clean around the temporary.

INSERTION APPOINTMENT

Figure 17. Captek crowns and da Vinci veneers. Figure 18. Laboratory work, occlusal view.

The restorations were examined on the models for fit, arch form, and overall aesthetic harmony (Figures 17 and 18). After removing the temporary restoration with the Wynman Carbide Crown Gripper, the fit of each veneer and crown was evaluated individually. All restorations were then tried in together to confirm that contact areas were properly done and to check the overall aesthetics. When I was satisfied that everything fit together properly and looked well, the veneers were tried in again, this time with various shades of Prevue Clear tryin gel (Cosmedent). It is critical to do this so that chairside shade adjustments, if necessary, may be made to blend the veneers with the crowns. If you cannot achieve shade harmony between veneers and crowns, the crowns may have to be returned to the dental laboratory for shade adjustment after the veneers are placed. It is this author’s experience that when digital images of the prepared teeth, with shade tabs in the images for reference, are sent to the laboratory, and the undershades (stump or dentin shades) of each tooth and desired final shades are conveyed to quality technicians, it is easy to achieve shade harmony in most cases combining crowns and veneers. After Al viewed his try-in and approved what he saw, the veneers were taken out of his mouth and prepared for insertion.
The inner surfaces of the porcelain veneers were previously etched at the laboratory. Ultra-Etch (Ultradent Products) was then applied to the insides of the veneers to remove any debris that accumulated there from the try-in. After thorough rinsing and drying, a silane solution, RelyX Ceramic Primer (3M ESPE), was applied per manufacturer instructions to the inner surfaces of the veneers. A thin layer of Adper Single Bond (3M ESPE) was applied and air-thinned to avoid pooling of the bonding agent and to ensure that all areas were properly covered. Insure, shade Clear, resin cement (Cosmedent), which corresponded to the shade of the accepted Prevue Clear try-in gel, was uniformly applied inside each veneer. The veneers were then placed in a ResinKeeper Mixing and Storage Palette (Cosmedent).
The teeth receiving the veneers were gently cleaned with a Micro-Etcher IIA Intraoral Sandblaster (Danville Materials) filled with a 50-µm aluminum oxide (Danville Materials), then washed and gently air-dried. The crowns for the central incisors were placed, but not cemented. This was done to ensure that all restorations would maintain the same relationship to one another as in the try-in. Secondarily, having the uncemented crowns sitting on the central incisors while the adjacent lateral incisor veneers were bonded would prevent bonding adhesive and resin cement from attaching to uncovered coronal portions of teeth Nos. 8 and 9.
Using a 10-second etch with Ultra-Etch 35% phosphoric acid, rinsing, gentle drying, and a very thin layer of Adper Single Bond Plus on the teeth, the veneers were spot-bonded with a curved, 2-mm light guide in an Optilux 501 halogen curing light. Bulk excess cement was removed, and all facial and palatal surfaces were light-cured for 40 seconds. Contact areas were then checked and any excess resin was removed with Superfine NTI Diamond Finishing Strips (AXIS Dental) and Epitex Finishing and Polishing Strips (GC America). After all the veneers were placed, the internal aspects of the Captek crowns were sandblasted lightly with the Microetcher, then cemented on the central incisors using a resin-reinforced glass ionomer cement, GC Fuji Plus (GC America). The postoperative occlusal image (Figure 19) illustrates how the bicuspids were built out facially to create a proper arch form. It also demonstrates the correct tooth surface planes needed to form proper incisal embrasures.

CONCLUSION

Figure 19. Postoperative occlusal view. Figure 20. Postoperative full-face view.
While I have written much about the techniques used in caring for this patient, I want to reinforce the very important message I stated at the beginning of this article: Sometimes patients are not ready to accept our treatment recommendations when they first enter our practices. For a multitude of reasons, patients may delay comprehensive care until they are emotionally ready and the proposed treatment truly fits into their life. In Al’s case, this happened to be more than 20 years later. We should never view the lack of patient acceptance as a failure, or take it personally. Very often, the rejection of a treatment plan has nothing to do with us, but has everything to do with the patient. If we understand this, we can maintain a consistently positive approach to comprehensive diagnosis and treatment planning. For the patient who needs a large amount of treatment and elects not to do it, we should try to keep him or her in a regular recare schedule and use these visits to gently remind the patient what we had discussed previously. In some cases, the possibility for segmenting treatment into manageable entities rather than “all or none” may apply. This can help those patients who may be ready to do some treatment, but not everything we suggest. If a patient disappears from our practice, goes elsewhere, and then returns to our practice, this also is not a negative. After all, the patient came back, which usually means, “I trust you.” Keeping these concepts in mind can help us to have a noticeable and positive impact on a patient’s quality of life, as exemplified by the great smile Al is so happy to show off (Figure 20).

Acknowledgment

The author would like to thank Daniel Materdomini, MDT, and his entire team at da Vinci Dental Studios in West Hills, Calif, for help in pretreatment planning and for creating the beautiful crowns and veneers for our patient.

References

  1. Fier MA. Patient-centered treatment planning: part 1. Dent Today. Jan 2007;26:56-61.
  2. Bechara A. The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage. Brain Cogn. 2004;55:30-40.
  3. Sierra K. You’re emotional; deal with it. Creating Passionate Users Web site.
    http://headrush.typepad.com/creating_passionate_users/2005/07/youre_emotional.html. Posted July 5, 2005. Accessed April 28, 2008.
  4. Adams DC. The treatment planning consultation: the doctor/technician partnership. Dent Today. July 2004;23:92-95.
  5. SuperSeal product info page. Phoenix Dental Inc Web site. http://www.phoenixdental.com/produc1.html. Accessed April 28, 2008.
  6. Dietschi D, Ardu S, Rossier-Gerber A, et al. Adaptation of adhesive post and cores to dentin after in vitro occlusal loading: evaluation of post material influence. J Adhes Dent. 2006;8:409-419.
  7. Boschian Pest L, Guidotti S, Pietrabissa R, et al. Stress distribution in a post-restored tooth using the three-dimensional finite element method. J Oral Rehabil. 2006;33:690-697.
  8. Naumann M, Sterzenbac G, Alexandra F, et al. Randomized controlled clinical pilot trial of titanium vs. glass fiber prefabricated posts: preliminary results after up to 3 years. Int J Prosthodont. 2007;20:499-503.
  9. Butz F, Lennon AM, Heydecke G, et al. Survival rate and fracture strength of endodontically treated maxillary incisors with moderate defects restored with different post-and-core systems: an in vitro study. Int J Prosthodont. 2001;14:58-64.


Dr. Fier is a full-time practicing clinician who lectures in the United States and internationally on aesthetic and restorative dentistry. He is the executive vice president of the American Society for Dental Aesthetics and coordinates its annual international conference on aesthetic dentistry. Dr. Fier is a Fellow of the American Society for Dental Aesthetics, a Diplomate of the American Board of Aesthetic Dentistry, a Fellow of the American College of Dentists, a Fellow of the Academy for Dental-Facial Esthetics, and a fellow of the Academy of Dentistry International. He is a contributing editor for REALITY and for Dentistry Today, and for the past 4 years has been listed in Dentistry Today’s annual list of leaders in continuing education. He can be reached at (845) 354-4300 or docmarv@optonline.net.

Disclosure: From time to time, the author receives materials, honoraria, and lecture support from many of the companies mentioned herein.

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