Meaningful Mini-Makeovers in the New Economy

INTRODUCTION
Most clinicians receive promotional literature and/or e-mails about how to attract more patients with large cases or do more smile makeovers. These marketing techniques often come with testimonials of great success by clinicians using a particular method that increased their case acceptance and income. Much of this sounds great. Stories about doing more large veneer cases or full-mouth rehabilitations can stimulate thoughts of greater practice growth and increased profits.

It’s no secret to most dentists that the economy we are now practicing in is more challenging than it’s been in a long time. Many people remain unemployed or underemployed. Those who are working are often under financial pressures that now make dental visits a lower priority. People who want to improve their appearance with smile makeovers with anterior veneers seem to be fewer and farther between. Cosmetic dentistry, as we once knew it, has morphed into a different form in this new economy.

There are still many patients who want to do “something” to their teeth to improve their appearance. Developing treatment plans to help them satisfy their desires while they are on a stricter budget can be challenging. I am not advocating that we disregard our responsibility to present ideal treatment plans based on patients’ wants and needs. I am, however, suggesting that there are ways we can help these patients accomplish meaningful changes in their dental appearance that can go a long way toward satisfying their goals, even if not completely. This article will present several cases in which patients opted for mini-makeovers and were very happy we found a way to help them improve their appearance in this challenging economy.

CASE REPORTS
Case 1
Diagnosis and Treatment Planning—Elizabeth was unhappy with her smile. She worked with senior citizens in a residential facility. She was embarrassed about the way her teeth looked and rarely smiled, which she explained impacted negatively on her ability to maintain a happy attitude at work. When questioned further, she said, “I don’t like the way one tooth is dark and inside the others; my side teeth fall in; my teeth have stripes in them; and my bottom teeth are crooked.” This can be seen in Figure 1.

After a comprehensive exam that included looking at the hard and soft tissues, an extra- and intraoral oral cancer screening with a subsurface screening (VELscope [DenMat]), full-mouth radiographs, and study models, I came up with a comprehensive treatment plan to rectify all Elizabeth was concerned with. I did not prejudge her ability to afford complete treatment. I felt she was entitled to hear a full plan that would satisfy all the issues that bothered her. At our treatment planning conference, it became clear that the full treatment plan was beyond Elizabeth’s means, so we talked about which of her concerns was most important. She said, “The dark tooth that’s inside the others is what bothers me the most.”

I thought if we could improve the color and position of tooth No. 7, aligning it with her other incisors, we would address her paramount concern and accomplish a lot toward helping her smile. Perhaps at a later time we could revisit possibilities for the other issues. After going over the fee for this proposed mini-makeover that included only one veneer, Elizabeth agreed, saying, “I can handle that. Let’s do it!”

Figure 1. Preoperative photo of Elizabeth’s teeth.	Figure 2. Depth cuts.

Clinical Protocol
Tooth No. 7 was very dark as a result of endodontic treatment completed many years ago. In order to give us the best chance for success in bringing this tooth to the required shade, the old palatal composite restoration was replaced with a very light shade (XBW, KALORE [GC America]). Using a reduction bur specially designed for porcelain veneer preparations (Laminate Veneer System [Brasseler USA]), depth cuts were made (Figure 2) and then the preparation was completed (Figure 3). Using a dual-arch impression tray (Anterior Triple Tray [Premier Dental Products]) coated with a polyether adhesive, a polyether impression material (Impregum Penta Soft Quick Step [3M ESPE]) dispensed from an automixer (Pentamix 2 [3M ESPE]) was used to make an impression for the veneer. A sectional bite over tooth No. 7 was made with O-Bite (DMG America). It would be used to confirm the articulation of models in the dental laboratory.

Upon return from the lab team, the veneer was tried in for fit, and several shades of cement were evaluated using a try-in paste (RelyX Try-In Paste [3M ESPE]). After determining the best shade, the lab-etched inner surface of the veneer was washed, dried, and silanated (RelyX Ceramic Primer [3M ESPE]). A layer of adhesive (Adper Single Bond [3M ESPE]) was applied to the veneer and thinned with oil-free air and, next, a light-cured resin cement (RelyX Veneer Cement [3M ESPE]) was applied. Then, the veneer was stored in a protective light-blocking case (Resin Keeper [Cosmedent]) until insertion. A small piece of knitted retraction cord (Ultrapak [Ultradent Products]) was placed in the gingival sulcus of tooth No. 7. Matrix strips were placed at the proximals of tooth No. 7 to ensure that the adjacent teeth did not get acid-etched (Figure 4). When a Mylar strip did not pass easily between teeth Nos. 7 and 8, a dead-soft metal matrix (Dead Soft Metal Matrix [DenMat]) was used. The metal, although dead soft, does not deform as easily as Mylar would when placing it interproximally. Phosphoric acid etchant (Caulk Tooth Conditioner Gel [DENTSPLY Caulk]) was applied for 15 seconds, rinsed off, and then dried. Two coats of adhesive (Adper Single Bond) were applied with gentle agitation. The adhesive was air-thinned to evaporate out the ethanol solvent, and a proper glossy surface was observed after light-curing (Figure 5). The veneer was removed from the light-protective box and bonded into place.

Figure 3. Completed preparation.	Figure 4. Phosphoric acid (Caulk Tooth Conditioner Gel [DENTSPLY Caulk) with adjacent teeth protected.
Figure 5. Bonding agent (Adper Single Bond [3M ESPE]) was light-cured and a proper shiny surface verified.	Figure 6. Elizabeth, immediately post-op.

The immediate postoperative result can be seen in Figure 6. Tooth No. 7 now appeared to be in line with Elizabeth’s other incisors, and the veneer shading blended in very well with her natural teeth. Elizabeth was thrilled with the result, confirming my thought that, even if we couldn’t create the ideal smile for her, we could find a meaningful way to improve her smile within her limited budget.

Case 2
Diagnosis and Treatment Planning—Kelly was troubled by the white spots on her front teeth, “…especially my 2 front ones,” she said. A conversation about options to improve the appearance of her front teeth included direct composite bonding and porcelain veneers. These options were not affordable for her, so we discussed other options that would be meaningful.

Various techniques for eliminating hypocalcified spots have been developed. Enamel microabrasion has been used, sometimes followed by home treatment with casein phosphopeptide-amorphous calcium phosphate complexes (CCP-ACP).¹ I have seen the regular application of CCP-ACP (MI Paste Plus [GC America]) alone, without other treatment, be successful in many cases. However, patient compliance is mandatory, and this is not always easy. Of course, restorative treatment including removal of the white spots with a bur and subsequent restoration with bonded composite always works; however, this involves the removal of tooth structure.

Figure 7. Preoperative photo of Kelly, demonstrating her hypocalcified white spots.	Figure 8. Obtaining clean tooth surfaces.
Figure 9. Application of etching gel (Icon-Etch [DMG America]).	Figure 10. Application of a drying agent (Icon-Dry [DMG America]).
Figure 11. Application of the Icon (DMG America) resin infiltrant.	Figure 12. Kelly, immediately post-treatment.

A technique utilizing infiltration of a resin through the enamel surface was developed and introduced in Europe about 3 years ago; this resin infiltrant, known as Icon (DMG America) is now available in North America. The technique allows for maximum preservation of tooth structure and can give a patient immediate improvement. Additional benefits are that the clinician does not have to rely on patient compliance with home application, and, the infiltrant method is minimally invasive with no removal of any tooth structure. In a recent article in the Journal of the American Dental Association, researchers from Oregon Health and Science University and the University of Washington said, “Resin infiltration significantly improved the clinical appearance of white spot lesions (WSLs), with stable results seen 8 weeks after treatment.”²

While Icon has multiple purposes, including the arrest of incipient caries on the proximal surfaces of posterior teeth, this case will demonstrate its use on smooth surface white spot lesions on Kelly’s incisors (Figure 7). When I began this case, I informed the patient that while we could eliminate or greatly minimize the white spots, I was not sure if the darker brown areas would change.

Clinical Protocol
In order for infiltration to be successful, it is important to start with a clean surface. Using flour of pumice (using an Ultrapro Tx Prophy Angle [Ultradent Products]) in an RDH handpiece [DENTSPLY Professional]), all the surfaces to be infiltrated were cleaned, rinsed, and dried (Figure 8). Icon-Etch (DMG America) was applied selectively to the spots to be treated, left on for 2 minutes (Figure 9), then thoroughly rinsed and dried. The process was repeated and Icon-Dry (DMG America), a liquid dessicant, was applied to ensure a perfectly dry surface (Figure 10). Icon resin infiltrant was applied in accordance with the instructions (Figure 11) and light-cured.

At the end of treatment, the patient and I were both excited to see that not only were the white spots gone, but the brown areas were also nicely subdued (Figure 12). Since Kelly was from out of town and had very limited time, she decided to have the defective restoration in tooth No. 7 replaced by a dentist where she lived.

There are not that many modalities we use in clinical practice that give us this type of immediate satisfaction with such minimal intervention. Kelly was thrilled with the results and expressed her gratitude for this meaningful change with a beautiful thank-you card.

Case 3
Diagnosis and Treatment Planning—Betty, a nurse, was referred for a smile makeover by another patient. In our initial interview, she talked about many things related to her smile that bothered her. When asked to smile for preoperative photos, it was clear that she strained her facial muscles and was not smiling easily (Figure 13). Among her issues were the “stripes and unevenness,” along with “high gums and crookedness” (Figure 14). She knew her lower front teeth had worn edges and were misaligned but said, “This doesn’t bother me as much as the top teeth do.”

Figure 13. Preoperative photo showing Betty’s strained smile.	Figure 14. Pre-op smile close-up.
Figure 15. Marks to reduce cant and create vertical midline.	Figure 16. Depth cuts and deep caries on tooth No. 7.
Figure 17. Preparations completed and knitted packing cord (UltraPak [Ultradent Products]) in place.	Figure 18. Microlase NV (Zila Pharmaceuticals) soft-tissue laser.
Figure 19. Betty, immediately post-op.	Figure 20. One-week post-op photo, showing her more relaxed and natural smile.

Figure 21. Betty’s teeth, shown here 3 years postoperatively.

After a comprehensive exam, a treatment plan was developed addressing all her issues as well as other findings. The full treatment plan included periodontal grafting to eliminate the high gumlines, and 8 veneers on top and 6 veneers on the bottom. The cost of this was more than she was comfortable with, so I suggested that we could give her some improvement without addressing all her issues by placing 4 veneers on her upper incisors. She liked and agreed to this mini-makeover, knowing that certain issues would be left as they were.

Clinical Protocol
Figure 15 shows where the central incisors were marked for reductions that were needed to establish a vertical midline. Depth cuts were made on the 4 incisors (Figure 16) and the deep caries on No. 7 (Figure 16) was excavated and restored with CLEARFIL SE self-etch bonding system (Kuraray America) and CLEARFIL MAJESTY Esthetic composite resin (Kuraray America). After completing the veneer preparations on teeth Nos. 7 to 10, a knitted retraction cord (Ultrapak) was placed (Figure 17) to ensure that the gingival margins would be accurately captured in the final impression. As an alternative, a soft-tissue diode laser (Figure 18) that we have started using in similar cases often eliminates the need to pack any cord. We use the Microlaser NV (Zila Pharmaceuticals), a pen-sized, wireless instrument that we have found to be extremely easy to use.

Feldspathic porcelain veneers for the 4 incisors were returned from the lab team, tried-in individually, and then collectively. For this case, CLEARFIL ESTHETIC CEMENT Try-In Pastes (Kuraray America) were used to determine what shade of cement would be best. The lab team had done an excellent job with the shade, so CLEARFIL ESTHETIC CEMENT Translucent (Kuraray America) was selected. This cement is a dual-cure (light-cured and/or self-cured) composite cement developed for any type of esthetic all-ceramic restorations.

After washing out the try-in paste and drying the etched surface of the veneers, a ceramic primer (CLEARFIL CERAMIC PRIMER [Kuraray America]) was applied to the internal surfaces of the veneers. Two layers of adhesive (Adper Single Bond) were applied to the veneers and, after air-thinning, the preselected translucent resin cement was applied and the restorations were bonded into place. The immediate postoperative result can be seen in Figure 19. At her follow-up visit one week later, Betty expressed joy with her newfound ability to smile without feeling self-conscious (Figure 20). Even though we had not addressed all the issues she originally told me about, she felt like a “new person.” Betty is one of many people that I’ve had the privilege of caring for with meaningful mini-makeovers. She maintained regular visits at our office until she moved away. The last time I saw her, at 3 years postoperatively (Figure 21), Betty was still very happy and doing beautifully with the conservative smile makeover.

CLOSING COMMENTS
The famous song recorded by the Rolling Stones says, “You can’t always get what you want!”

Well, we can develop comprehensive treatment plans, but our patients are not always ready and able to accept all the dentistry proposed, even when the treatment options are based on their desires and needs. There are multiple reasons this happens; some are emotional in nature, but often the reasons are related to their budget. With our current economy, financial concerns seem to be much more prevalent than in the not-too-distant past. Finding a more conservative treatment plan to help a person improve his or her appearance can be emotionally rewarding to both the clinician and the patient. It is my hope that this article will stimulate readers to look for and find meaningful ways to help patients with their smiles using mini-makeovers.

References

1. Ardu S, Castioni NV, Benbachir N, et al. Minimally invasive treatment of white spot enamel lesions. Quintessence Int. 2007;38:633-636.
2. Senestraro S, Crowe JJ, Wang M, et al. Minimally invasive resin infiltration of arrested white-spot lesions: a randomized clinical trial. J Am Dent Assoc. 2013;144:997-1005.

Dr. Fier is a practicing clinician and is the executive vice president of the American Society for Dental Aesthetics, a Diplomate of the American Board of Aesthetic Dentistry, and has been honored with Fellowships in the American College of Dentists and the International College of Dentists. He is a highly respected lecturer in the United States and internationally on multiple topics including aesthetics, restorative dentistry, and practice management. He presents continuing education courses at many dental schools and prestigious conferences internationally. He publishes regularly, and his contributions to the dental literature have been in the areas of esthetics, restorative dentistry, case presentation, hypnosis, and how dentistry affects the quality of life. For the past 12 years, he has been listed in Dentistry Today’s Leaders in Continuing Education. He can be reached at (845) 354-4300 or via e-mail at the address info@smilerockland.com.

Disclosure: Dr. Fier reports no disclosures.