The Impact of Aesthetics in Restorative Treatment Planning

David Little, DDS

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INTRODUCTION
Treatment planning remains an essential component in creating highly aesthetic and functional restorations. The first step in treatment planning is to identify the ideal end result, and then to use that as the basis for developing the treatment plan.1 This includes addressing material selection, color, shape, and provisionalization with the final results in mind. In addition to final restorative results, treatment success is also predicated on understanding the patient’s aesthetic desires and effectively communicating those within the context of the treatment plan among all members of the dental team.2

Although the main reason for treatment may be enhanced aesthetics, the goal of associated procedures is to decrease risks and enhance prognosis.3 By addressing risk and functionality, aesthetic components of a case can be appropriately considered and created. Individual risk assessment helps clinicians determine an appropriate plan to address and correct the problems that could ultimately affect treatment longevity and prognosis.4

Therefore, for example, clinicians are encouraged to examine the patient’s biology to ensure that periodontal plastic surgery is possible with laser recontouring, if it appears warranted; and that osseous surgery is unnecessary. It is critical to know, prior to definitive treatment planning, if a patient requires osseous surgery, as the specialist should examine the patient’s condition from different perspectives. By assessing the patient’s condition thoroughly during the planning stage, proposed treatments can be altered to satisfy functional and aesthetic requirements.

This is significant, particularly because aesthetics encompasses many variables and preferences for patients and clinicians alike. Actively listening to and discussing patient expectations avoids over-promising and under-delivering results. Adapting a patient’s current dentition to create a more aesthetic smile includes balancing shade, opacity, shape, and other oral structures. Creating minimally invasive treatments is also essential for successful restorations and requires due consideration when determining ideal aesthetic outcomes for each individual.5,6

Yet, despite these considerations, achieving ideal aesthetics can still be challenging, especially when treatment involves anterior teeth.7 For example, if a patient requires a single-tooth implant in the aesthetic zone, it is important to always ask how the individual wants or expects the end result to look. Frequently, patients say that they want their restorations to look completely like natural teeth, but without further discussion or comments from the clinician, patients can be surprised when the aesthetic outcome doesn’t match their expectations. However, this question and the patient’s answer present an opportunity for discussing additional procedures (eg, bone and soft-tissue grafting) that would improve the likelihood of achieving the natural aesthetics the patient desires and altering the end results in order to meet or adjust these expectations, without additional surgery.

Communication Is Key
Communication between the patient and dentist, as well as among the entire dental team, is key to successful treatments.8 Fortunately, there are a variety of tools available to facilitate detailed and thorough communication. Utilizing digital imaging improves communication with patients by enabling a visual demonstration of the treatment plan. Additionally, creating a mock-up by placing composite on a wax-up to form a putty matrix and then placing it directly over the patient’s teeth to illustrate the manner in which the aesthetics of one’s smile will change provides another form of communication. Both techniques are visual for patients and can motivate them to respond with either their approval or a discussion regarding their specific likes, dislikes, or necessary changes. Some clinicians take impressions and then have the patient return for a consultation after the laboratory completes a diagnostic wax-up. Unless the patient is from out of town or requires urgent and immediate care, this can be a useful alternative.

It is essential that the dental laboratory team be included in the communication process from the beginning, whether by requesting wax-ups, sharing the patient’s aesthetic desires, or discussing initial restorative plans. This helps to ensure that the final restorations are designed and fabricated in a consistent manner with the agreed-upon treatment plan and requirements. Among the beneficial tools to facilitate communication with the laboratory are digital scanning (eg, iTero Scanner [Align Technology]) and digital photographs, both of which help to clearly transfer information about the patient’s current condition and anticipated results. The virtual and digital realm provides a means for cost-effective, accurate, and efficient creation of virtual diagnostic wax-ups, review of aesthetic concerns, and restorative design.

CASE 1
Diagnosis and Treatment Planning

This patient’s chief complaint was an unaesthetic appearance (Figure 1). He felt his teeth were too small, stained, and had disproportional spacing (Figures 2 and 3).

A complete diagnostic workup was performed, including a thorough clinical examination and photographs, as well as bone sounding. This was performed during a close examination of tissue heights due to the need to discuss periodontal plastic surgery options. Detailed and accurate photographs were captured for diagnosis and laboratory and patient communication, after which a treatment plan was developed. A CB scan was not necessary for this case.

Diagnostic study models (Xantasil [Heraeus Kulzer]) were developed to create a wax-up for visualizing the proposed results that would be achieved according to the treatment plan. The wax-up provided a tool for communication between the patient and clinician, in addition to allowing the patient to approve the aesthetics prior to treatment.
Based on the clinical examination, the treatment plan, as presented to and approved by the patient, would involve placement of minimal preparation veneers built using stacked porcelain on refractory dies (ie, rather than pressed porcelain) for the anterior teeth. This would provide a conservative and highly aesthetic result. In this case, Bob Williams (ceramist at Synergy Ceramic Dental Studio,  Plano, Tex) planned on using VITA VM7 (VITA North America) for the optimal aesthetic result.

CASE 1
Figure 1. Full-face preoperative image. Figure 2. The patient presented complaining of poor aesthetics in his anterior teeth (Nos. 6 to 11). Figure 3. Retracted view of patient prior to
treatment.
Figure 4. A floss technique was utilized to plan the ideal gingival heights of contour for soft-tissue laser periodontal plastic surgery. Figure 5. Teeth Nos. 6 to 11 were prepared conservatively. Figure 6. After the provisional veneers were seated, the shade was verified.
Figure 7. Retracted view of the final restorations. Figure 8. Full-smile view of the final restorations. Figure 9. Post-op view of the patient with final veneers, displaying a confident smile.

Clinical Protocol
Because the bone sounding revealed hidden cemento-enamel junctions with bone structure in the appropriate location, periodontal plastic surgery would be completed using a soft-tissue laser to even out the gingival heights of contour of upper anterior teeth. Bone recontouring was not necessary. Floss was pulled across the other 2 gingival heights of teeth Nos. 6 to 11 in order to follow those contours, after which a surgical marker was used to indicate where the laser should be applied (Figure 4).

After periodontal plastic surgery, teeth Nos. 6 to 11 were prepared appropriately for the planned final aesthetic restorations (Figure 5). A matrix made from the diagnostic wax-up created ideal provisional restorations (Structur [VOCO America]). To adjust for differences in color and translucency between the provisional and final restorative materials, the provisionals were made slightly darker than the final shade. The definitive restorations would be fabricated with slight color differences to provide a bright, warm, and natural look to avoid a uniform, monochromatic, and otherwise unnatural appearance. The provisionals were seated, and the patient was recalled a week later, after the tissue had settled, at which time the provisionals were evaluated for aesthetics, form, and function (Figure 6). The patient also reviewed the provisionals, discussed what he liked, and then any necessary changes were made. Once the provisionals were satisfactory, an impression (Flexitime [Heraeus Kulzer]) and photographs were taken to update the laboratory regarding the patient’s ultimate aesthetic restorative expectations, as well as to demonstrate the provisionals’ position and fit within the patient’s mouth. This step is critically important, particularly because complications resulting from veneer provisionals have occurred when ideal provisionals are approved but the final veneers feel thick in the patient’s mouth. Therefore, it is important that definitive restorations be fabricated within the parameters of the patient-approved provisionals in order to avoid disappointments.

The final restorations were seated and bonded into place (Calibra [DENTSPLY Caulk]) (Figures 7 and 8). During the final follow-up appointment, the occlusion was verified and patient satisfaction was ensured (Figure 9).

CASE 2
Diagnosis and Treatment Planning

This patient came into our office requesting treatment for a loose tooth (Figure 10). He also presented with dark, stained, and chipped composite restorations (Figure 11) and complained of an unaesthetic smile. Radiographic examination revealed a horizontal fractured root on his left maxillary central incisor (tooth No. 9) (Figure 12). Implant software (SimPlant [Materialise Dental]) was utilized to determine the best approach for treating the fractured root. A CBCT scan was indicated to plan for an immediate and atraumatic extraction, followed by immediate implant placement and provisionalization. Diagnostic impressions were taken along with photographs during this initial appointment as part of the treatment planning process. The treatment plan also involved using the patient’s extracted tooth as the provisional restoration.

CASE 2
Figure 10. Preoperative view of a patient presenting with a loose tooth and discolored and unaesthetic anterior teeth. Figure 11. Retracted view of the teeth prior to treatment. Figure 12. Radiograph of the fractured root on tooth No. 9.
Figure 13. After tooth No. 9 was extracted, an implant was immediately placed. Figure 14. The patient’s original tooth No. 9 was hollowed out and used as a temporary for 3 months while the implant healed. Figure 15. The original tooth helped to maintain the natural gingival contours and margins surrounding the implant.
Figure 16. Retracted view of the patient with his new crown at No. 9 and veneers on teeth Nos. 7, 8, and 10. Figure 17. Smile view of the patient with his newly restored anterior teeth. Figure 18. The outcome, after placement of the final crown and veneers, was a happy and smiling patient.

Clinical Protocol
Tooth No. 9 was atraumatically extracted using periotomes and an extraction forcep (Physics Forceps [Golden Dental Solutions]). An implant (ANKYLOS Implant [DENTSPLY Implants]) was placed and the abutment (ANKYLOS Standard Abutment [DENTSPLY Implants]) attached (Figure 13). The patient’s extracted tooth was then hollowed out and lined with a bisphenol A-glycidyl methacrylate composite (Integrity [DENTSPLY Caulk]). It was seated on the abutment to shape and hold the gingival tissue, which was ideal in order to ensure that their contours would be maintained exactly the same as when he presented for treatment (Figure 14).

The implant healed for 3 months, and the patient returned after osseointegration. The temporary was removed, revealing that the contours of the gingival tissue and papilla were well maintained by using the patient’s natural tooth (Figure 15).

The patient originally desired a more aesthetic appearance, so a treatment plan was developed that involved placing veneers fabricated from Initial GCMC porcelain (GC America) on both right and left upper lateral incisors and the right central incisor (teeth Nos. 7, 8, and 10), and a crown restoration fabricated from the same porcelain on the No. 9 implant (left upper central incisor position). The restorations were done by Troy Apparicio (ceramist at Implant Technologies Lab, San Antonio, Tex). An aesthetic workup was completed, and the bonding spaces were stained. After creating the diagnostic wax-up, teeth Nos. 7, 8, and 10 were prepared for veneers, and an abutment level impression was taken. The provisional restorations (Integrity) were created based on the original wax-up and bonded into place using Premier Implant Cement (Premier Dental Products).

One week after the provisionals were seated, the patient returned to evaluate their aesthetics, form, and function. Any necessary changes were made, and the final restorations were fabricated based on the impression of the approved provisionals (Honigum [DMG America]).

To seat the definitive restorations, the provisionals were removed, the preparations cleaned, and the restorations tried in. The crown and veneers were then cemented (NX3 Nexus [Kerr]) (Figures 16 to 18).

IN SUMMARY
Although patients frequently request enhanced aesthetics, additional considerations—including tooth structure and gingival condition, function, form, and communication—also contribute to treatment planning and successful outcomes. While some patients may only desire and require aesthetic alterations, others may require treatments that are more complicated (eg, surgery) in order to achieve their desired results. Thorough assessment and communication between the dentist and patient, as well as among all members of the dental team, prior to and throughout treatment planning, ensures that any problems, conditions, or complications are addressed before or alongside aesthetic concerns. Using visual tools when communicating with patients can help clinicians avoid unrealistic expectations while improving patient satisfaction. They can also help maximize dental team communication and ensure that all components, from the diagnostic wax-up to the final restorations, are completed predictably. By addressing patients’ conditions and functionality first, and then actively listening to their aesthetic desires, clinicians are better equipped to create functional restorations that realistically meet their patients’ aesthetic expectations.


References

  1. Gurrea J, Bruguera A. Wax-up and mock-up. A guide for anterior periodontal and restorative treatments. Int J Esthet Dent. 2014;9:146-162.
  2. Romeo G, Bresciano M. Diagnostic and technical approach to esthetic rehabilitations. J Esthet Restor Dent. 2003;15:204-216.
  3. Bassett JL. There is more to front teeth than looks alone: diagnosis and treatment planning. Compend Contin Educ Dent. 2010;31:604-612.
  4. Bassett JL. Esthetics built to last: treatment of functional anomalies may need to precede esthetic corrections. Compend Contin Educ Dent. 2014;35:118-122.
  5. Radz GM. Minimum thickness anterior porcelain restorations. Dent Clin North Am. 2011;55:353-370, ix.
  6. Bloom DR, Padayachy JN. Aesthetic changes with four anterior units. Br Dent J. 2006;200:135-138.
  7. da Cunha LF, Reis R, Santana L, et al. Ceramic veneers with minimum preparation. Eur J Dent. 2013;7:492-496.
  8. Mechanic E. Aesthetic zone challenges: severe anterior wear, part 3: restoratively driven interdisciplinary treatment planning. Dent Today. 2013;32:86-91.

Dr. Little received his dental training at the University of Texas Health Science Center at San Antonio Dental School and now maintains a multidisciplinary, state-of-the-art practice in San Antonio to provide patients with dramatic restorative treatment results. In addition to being an accomplished international speaker, professor, and author, he is also a respected clinical researcher focusing on implants, laser surgery, and dental materials, and he consults on emerging restorative techniques and materials. He can be reached via email at dlittledds@aol.com.

Disclosure: Dr. Little reports no disclosures.

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