Creating a More Youthful Appearance: Multidisciplinary Treatment Planning

Thomas E. Dudney, DMD
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INTRODUCTION
If Ponce de Leon failed to discover the fountain of youth, it was not for a lack of trying. Nor have people ceased in their quest throughout time to seach for ways to rejuvenate their appearance or “turn back the clock.” Today, many people are living longer lives and are therefore looking for ways to reverse the effects of aging and to improve their appearance. In these times, dentists play an important role in helping them to achieve their goals. Together with orthodontists, oral surgeons, periodontists, and plastic surgeons, restorative dentists can, through a coordinated multidisciplinary team approach, address many of the aesthetic issues that concern their patients.

According to Dr. Richard Erlichman, a member of the American Society for Aesthetic Plastic Surgery, statistics show that the number of cosmetic surgery patients older than age 65 years has grown more than 350% in the last 5 years. In another survey, of 5,053 American females 55 to 64 years of age, 85% said that they were unhappy with at least one body part. It is not surprising that—with the increasing role that social media plays, the information that is readily available on the Internet, the less invasive and more conservative nature of many procedures, and the marketing by healthcare professionals to the general public—the number of people requesting cosmetic enhancement continues to rise. Statistics show a 39% increase in cosmetic procedures during the last 5 years (2011 to 2015), with surgical procedures up 17% and nonsurgical procedures up 44%.1,2

As people age, there is often a disconnect with how they feel about themselves on the inside and with what they see in pictures of themselves or in the mirror. Frequently, an unattractive smile is one of the first things that they will notice. Conversely, an attractive smile can play a significant role in increasing self-confidence and self-esteem. An independent study3 conducted by the American Academy of Cosmetic Dentistry discovered the following:

  • 99.7% of people interviewed believed the smile is an important social asset.
  • 96% of adults believe that an attractive smile makes a person more appealing to members of the opposite sex.
  • 74% of adults feel an unattractive smile can hurt a person’s chances for career success.

And, in response to the question, “What would you most like to improve about your smile?” the most common answer given was, “Whiter, brighter, straighter teeth.”3

As is often the case with older patients, multiple procedures may be necessary to achieve the desired outcome; therefore, a multidisciplinary treatment approach is often indicated. That is why it is so beneficial for the restorative dentist to be part of an interdisciplinary team that can work together to satisfy the highest of patient expectations.

The following case report will illustrate how a coordinated multidisciplinary treatment plan was developed and executed to address a patient’s concerns and to achieve the desired outcome.

CASE REPORT
Diagnosis and Treatment Planning

A 62-year-old female was referred to the author for a restorative consultation by the orthodontist who was coordinating a multidisciplinary treatment plan. Previously, the patient had been referred to the orthodontist by another dentist for evaluation of her Class II malocclusion as well as other appearance-related concerns.

It is important in multidisciplinary cases that one member of the team assume the role of “quarterback” in order to ensure a well-designed treatment plan and to lead a coordinated effort. Just as the quarterback of a football team must see the whole field and understand everyone’s role, so must the interdisciplinary team quarterback. Furthermore, this dental quarterback must have an understanding and the working knowledge of what the other specialists do and how each professional’s role contributes to the success of the case. The other members of the team, in addition to the orthodontist and restorative dentist in this case, included an oral surgeon and facial plastic surgeon.

Figure 1. Pre-op full-face smiling.
Figure 2. Pre-op maxillary occlusal view. Figure 3. Pre-op mandibular occlusal view.
Figure 4. Pre-op profile, showing mandibular deficiency. Figure 5. Pre-op lateral ceph, showing Class II relationship and constricted airway space.
Figure 6. Pre-op smile, showing flat smile arc and insufficient incisor display. Figure 7. Pre-op retracted, showing unaesthetic tooth size, shape, and color.
Figure 8. Pre-op full-face, showing loss of skeletal support, drooping eyelids, deep nasolabial folds, and “marionette lines” (corner of the mouth to chin) and “jowling.”

The orthodontist, serving as the quarterback, had utilized digital imaging software to demonstrate choices to the patient with realistic outcomes, and after the patient had expressed an interest in proceeding, had begun to develop an overall treatment plan with input from the other team members.4,5 The agreed upon sequence of treatment was as follows:

  • Orthodontics to position the teeth for orthognathic surgery and aesthetic finishing (Figures 1 to 3).
  • Oral surgery to move the mandible forward in order to improve jaw relationship, soft-tissue support, and airway space (Figures 4 and 5).
  • Restorative dentistry to improve smile aesthetics (Figures 6 and 7).
  • Facial plastic surgery including a rhytidectomy (facelift), blepharoplasty (eyelids), lip augmentation, and a platysmal lift (neck) for facial rejuvenation (Figure 8).6

After completion of the orthognathic surgery and aesthetic tooth repositioning, the patient was ready to begin the restorative treatment (Figures 9 to 11).

At the consultation appointment for the restorative phase, the patient stated that she was unhappy with the appearance of her smile, specifically the shape and color of her teeth (Figures 12 to 14).

Figure 9. Orthognathic surgery and aesthetic tooth positioning completed. Figure 10. Maxillary occlusal view, post-orthodontic treatment.
Figure 11. Mandibular occlusal view, post-orthodontic treatment.
Figure 12. Patient ready for aesthetic finishing and facial plastic surgery.
Figure 13. Smile post-orthodontic treatment. Note the improved smile arc and incisor display. Figure 14. Retracted post-orthodontic treatment view, ready for restorative phase.

Like so many patients with worn and discolored teeth, she said that she wanted a whiter, brighter smile. This, once successfully completed along with the soft-tissue procedures, made her feel that she would then have a more youthful looking appearance. The patient, having already been prepared by the orthodontist as to what to expect,6 accepted the proposed treatment plan of 12 maxillary restorations (teeth Nos. 4 to 15) and 8 mandibular restorations (teeth Nos. 21 to 28), and the first appointment was set up to begin the restorative phase of treatment.

Clinical Protocol
At the first appointment, diagnostic information was gathered and forwarded to the dental laboratory team with instructions to fabricate a diagnostic wax-up, prep guides, and a putty matrix for provisional fabrication.

The patient returned 2 weeks later for the preparation appointment. Since there was an existing PFM bridge on teeth Nos. 13 to 15, and because tooth No. 13 was in the aesthetic zone, it was decided to include the bridge in the treatment plan. The restorative work would include: lithium disilicate crowns (IPS e.max Press [Ivoclar Vivadent]) on teeth Nos. 4, 5, 6, and 12; lithium disilicate (IPS e.max Press) veneers on teeth Nos. 7 to 11 and 22 to 27; lithium disilicate (IPS e.max Press) onlay veneers on teeth Nos. 21 and 28; and a zirconia bridge (IPS e.max ZirCad [Ivoclar Vivadent]) layered with a fluorapatite glass ceramic (IPS e.max ZirPress [Ivoclar Vivadent]) on teeth Nos. 13 to 15.

Figure 15. Full-face smile after restorative phase and plastic surgery.
Figure 16. Smile after aesthetic finishing. Figure 17. Retracted after aesthetic finishing.
Figure 18. The 1:1 photo of the completed maxillary restorations. Figure 19. The 1:1 photo of the completed mandibular restorations.
Figure 20. Postoperative profile showing improved jaw relationship and soft-tissue support. Figure 21. Lateral ceph, showing improved occlusion and an increase in airway space.
Figure 22. Full-face view after plastic surgery showing soft-tissue improvements in the eyes, face, lips, and neck. Figure 23. Final result. Combined effort equals happy patient.

Lithium disilicate is a proven and excellent restorative material due to its strength (400 MPa when pressed) and fracture toughness, aesthetics (especially when cut back and microlayered), and versatility. It can be used for veneers, thin veneers, onlays, crowns, anterior 3-unit bridges, and implant abutments, making it ideal for these types of cases when a variety of restorations are required.7

Before beginning tooth preparation, some minor gingival recontouring was done with a diode laser (Picasso Lite [AMD LASERS]) to create ideal gingival height symmetry. Before taking final impressions, this diode laser was also used for troughing of the soft tissues around the margins of the crown and bridge abutment teeth. After removing the PFM crowns on teeth Nos. 4, 5, 6, and 12; the PFM bridge on Nos. 13 to 15; and any existing old filling materials or recurrent decay; buildups were done using a universal adhesive (ALL-BOND UNIVERSAL [BISCO Dental Products]) in the self-etch mode and a flowable composite (BEAUTIFIL Flow Plus [Shofu Dental]); then the tooth preparations were completed. Next, teeth Nos. 7 to 11 and 22 to 27 were prepped for veneers, and teeth Nos. 21 and 28 were prepped for onlay veneers. Full-arch polyether impressions were taken (Impregum [3M]), and provisionals (Tuff Temp Plus [Pulpdent]) were fabricated using the putty matrix that had been previously provided by the dental laboratory team. Additionally, an occlusal record, stick bite, face-bow, preparation shades, central length measurement, and impressions of the provisionals were taken. This information was then forwarded to the laboratory team, along with a detailed written prescription requesting the materials and shades for the final restorations with instructions to follow the provisionals as a guide for size, shape, and contour. It is important to note that well-done provisionals are critical in smile design cases. This is because they serve as an important communication tool with the patient and, once approved, also give the laboratory a blueprint to follow.

The patient returned 2 days later for a postoperative evaluation to check the occlusion, to discuss the appearance of her smile (including the shade), and to make any changes, if required. After patient approval, photographs of the provisionals were taken and the files were emailed to the laboratory team along with the preoperative and prep shade photos.

The patient returned 3 weeks later for adhesive bonding of the lithium disilicate veneers and crowns, and for the conventional cementation of the layered zirconia bridge. The temporaries were removed and the teeth were cleaned with hydrogen peroxide and an antimicrobial rinse (Consepsis [Ul­tra­dent Products]) in preparation for bonding. All the restorations were tried in to evaluate fit and contacts. Then, after cleaning the intaglio surfaces with a universal cleaner (Ivoclean [Ivoclar Vivadent]) (per the manufacturer’s instructions) to remove any contaminants, the lithium disilicate veneers and crowns were silanated (PORCELAIN PRIMER [BISCO Dental Products]) and set aside, organized by tooth number. The layered zirconia bridge (teeth Nos. 13 to 15) was cemented first using a bioceramic cement (Ceramir [Doxa]) so that the remaining teeth could be isolated with a rubber dam for the adhesive bonding of the lithium disilicate restorations. After isolation, the teeth were prepared for adhesive bonding utilizing a total-etch technique with a universal adhesive (ALL BOND UNIVERSAL) and a light-cure resin cement (eCement Kit [BISCO Dental Products]) for the veneers, and a self-etch technique with the same universal adhesive and a dual-cure resin cement (eCement Kit) for the crowns. Next, the process, with the rubber dam placed, was repeated in the mandibular arch using the total-etch technique and a universal adhesive, and a light-cure resin cement for the veneers (Nos. 22 to 27) and dual-cure resin cement for the onlay veneers (Nos. 21 and 28). After cleanup was done, the occlusion was checked and adjusted with the aid of a digital occlusal analysis system (T-Scan [Tekscan]) and then the restorations were polished with rubber points (Ceramiste [Shofu Dental]).

With the restorative dentistry completed, the patient was ready to begin the facial soft-tissue procedures as the final phase of the multidisciplinary treatment plan.

After sufficient time for postsurgical healing, the patient returned for postoperative photos and stated that she was extremely happy with the results, felt more confident in social settings, and loved hearing from friends and family that she looked younger (Figures 15 to 19).

CLOSING COMMENTS
Cosmetic dental procedures have gained a wide acceptance throughout the years for creating results that can often significantly improve self-confidence and self-esteem. In many cases, conservative dental treatment is all that is needed to achieve the desired goals, but sometimes more extensive procedures with a multidisciplinary approach might be required. That is why it is beneficial for the restorative dentist to have access to, or be part of, an interdisciplinary team that can work together to coordinate complex treatment plans.

This case serves to demonstrate how a well-designed multidisciplinary treatment plan can seamlessly allow members of the team to meet the desired objectives and satisfy patient expectations (Figures 20 to 23).

Acknowledgment
The author would like to thank ceramist Gary Vaughn, CDT (Corr Dental Laboratory in Roseville, Calif), for his great work and attention to detail. The author would also like to recognize the outstanding contributions of the other interdisciplinary team members of this case: Dr. David Sarver, orthodontist; Dr. Jon Holmes, oral surgeon; and Dr. Daniel Russo, facial plastic surgeon.


References

  1. Cosmetic Surgery National Data Bank Statistics. New York, NY: American Society for Aesthetic Plastic Surgery; 2015. surgery.org/sites/default/files/ASAPS-Stats2015.pdf. Accessed July 12, 2016.
  2. Plastic Surgery Statistics Report. Arlington Heights, IL: American Society of Plastic Surgeons; 2015. plasticsurgery.org/Documents/news-resources/statistics/2015-statistics/2015-plastic-surgery-statistics-report.pdf. Accessed July 12, 2016.
  3. Cosmetic Dentistry Statistics. Madison, WI: American Academy of Cosmetic Dentistry Scientific Survey; 2009.
  4. Sarver DM. Orthodontics and esthetic dentistry: mission possible! Journal of Cosmetic Dentistry. 2016;31:14-26.
  5. Sarver DM. Soft-tissue-based diagnosis and treatment planning. Clinical Impressions. 2005;14:21-26.
  6. Pessa JE. The potential role of stereolithography in the study of facial aging. Am J Orthod Dentofacial Orthop. 2001;119:117-120.
  7. Tysowsky GW. The science behind lithium disilicate: a metal-free alternative. Dent Today. 2009;28:112-113.

Dr. Dudney is a 1977 graduate of University of Alabama at Birmingham School of Dentistry. He is a member of the ADA, the Alabama Dental Association, and the American Academy of Cosmetic Dentistry. He is also an accredited member of the American Society for Dental Aesthetics and a Diplomate of the American Board of Aesthetic Dentistry. He has served in the past as the clinical director for the Aesthetic Advantage hands-on programs taught by Dr. Larry Rosenthal at New York University and the Eastman Dental Clinic in London, UK, as well as the clinical director for the California Center for Advanced Dental Studies live-patient hands-on programs taught in the United States, Canada, and the United Kingdom. Presently, he is the clinical director for the newly formed Pacific Aesthetic Continuum hands-on programs. In addition to teaching hands-on programs, he has presented workshops and lectures at dental meetings and has authored several articles on aesthetic and restorative dentistry. He can be reached via email at tedudneydmd@aol.com or via the website thomasdudney.com.

Disclosure: Dr. Dudney reports no disclosures.

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