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Cosmetic Case Presentation by Timothy Burke, DMD

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We have all had new patients that call and, when asked what type of appointment they would like, say they are due for a cleaning. In fact they might actually need one, but because they don't know what else to ask for, it's where they start. They may already be aware of dental problems-periodontal disease, broken or decayed teeth, or the need for orthodontic treatment, but assume that we will find these problems and ask them about it. Sometimes it is just a way to get a second opinion or, they might know they dislike something about their smile, but are not even sure what it is. They want to come in for bleaching or veneers because that's what they are familiar with. They've seen the advertising. Likewise, we get calls about Invisalign because they don't want to spend years in brackets, not even realizing that short-term orthodontics even exist. In reality, they are often open to other options, but are unaware of what is available.

When dealing with cosmetic treatment, broaching the subject is more delicate than telling patients they need a crown to repair a broken tooth, or endo for an abscess. Most people get that, and they often know what we're going to tell them when they walk in. Pointing out fault with a patient's appearance, however, can have disastrous consequences if not handled properly. Even when they are aware of shortcomings with their smile, they may want to keep it that way, because it's a sign of individuality. Even if they are aware, and don't like what they see, they may not wish to hear about it from someone else. Broaching the subject can present a dilemma for the entire staff. A range of non-threatening questions serves to open the conversation and allows patients to express their feelings. Inquiries regarding spaces catching food, rotated teeth that are difficult to floss, or asking about chips and fractures that result from parafunction or bad habits often allow them to open up, giving you permission to discuss ways to resolve their problems.

Our job is to look into the crystal ball and figure out which one is sitting in our chair, and proceed accordingly. Sometimes, though, our life is made easier. Patients come in who already know they have a problem, that there is a variety of options, have some idea what they are and want to hear everything we have to say.

Case Presentation

This patient had recently moved to the area and was seen for a recall, during which she mentioned that she was not happy with the appearance of her smile and was considering veneers to fill in the spaces. The dental history was otherwise uneventful – regular hygiene visits and a few posterior restorations. As a recent graduate from nursing school who had started her first job, she had done some research online, and was moderately knowledgeable as to what each option involved.
Her primary complaint was the presence of the multiple anterior maxillary diastemas, and the shape of #10. When asked about the mandibular diastemas, she said she was aware of them, but they were secondary in importance (Figs. 1-5).

We discussed her current condition and the range of treatment options: orthodontics, both referral and Invisalign, gingival contours, direct and indirect veneers, crowns, etc., in order to get a feel for what result she anticipated, and what treatment she was willing to consider.

She felt that she did not want traditional ortho, and though cost was a factor, this was primarily because she was interested in anterior cosmetics, because of the time involved, and her wish to avoid bracketing if at all possible. I started by discussing the nature of the spaces and tooth morphology, and how the restorative phase could be made easier and with far less tooth preparation by reducing the flaring of her anteriors prior to the restorative phase. She had heard about "instant orthodontics" and liked the idea of having everything completed quickly, but once she understood that repositioning would decrease the final tooth size, the amount of tooth reduction and the possibility of endodontic treatment, she thought that orthodontics sounded like a pretty good idea. We did discuss the pros and cons of full orthodontics, but decided on Invisalign to align the mandibular anterior, and position the maxillary teeth in order to better redistribute the spaces and help minimize preparation depth as much as possible.

At this point Invisalign records were taken: an FMX, PVS impressions, a bite registration and clinical photographs. The prescription was submitted and ClinCheck reviewed together.

Invisalign treatment was generally uneventful, but as there was some persistent lagging, we decided at aligner #6 to increase the time to three weeks between aligner changes, which resolved the issue.

Upon completion of the Invisalign treatment, new study models, photographs, bite and prescription outlining our restorative plan were collected and sent to the laboratory, where a waxup and temporary stent were fabricated. A Cosmetic Aligner (Cosmetic Aligner LLC, Little Silver, New Jersey) was used to record the mid-line and horizontal plane, and a photograph taken to show relationship between the horizontal plane and interpupillary line (Figs. 6-8).

The wax model was used to create a mock-up of the intended shape and position of the veneers. As #11 had not rotated as far as we would have liked, we also discussed placing direct composite or veneers on the canines. When doing the mock-up, however, we only included seven to 10 to see how it how much of a deficit it would create. She wore these temporaries for two weeks in order to evaluate speech and aesthetics, during which we made slight changes to the length and contour. She was very happy with the result, but decided she wanted to veneer the canines as well to correct shape, position and eliminate the hypo-calcified areas present on the incisal third of both (Fig. 9).

At the preparation appointment, reduction was completed as conservatively as possible to achieve a good aesthetic result and provide a positive seat. Lingual surfaces were largely maintained intact, other than an incisal wrap. Though minimal, the preps still came out deeper than I wanted, and today I would strongly consider noprep veneers with a slight gingival seat (Fig. 10).

Ultradent Ultrapak 000 (black) cord was placed, followed by Kerr Take1 Heavy body (blue) as tray material covered with a layer with plastic wrap (Invisalign impression technique), and after setting, the light body (orange) as wash material. Again, a Cosmetic Aligner was used to record the mid-line and horizontal plane, this time with the preparations in the maxilla, and a photograph taken with it in place.

Empress aesthetic was used to fabricate the restorations to match the 1M1 Vita 3D-Master shade tab.

At the insertion appointment, the temporaries were sectioned and removed. The preparations were cleaned with a flour of pumice slurry, followed by isopropyl alcohol and water.

Interface was placed on the intaglio of the restorations, followed by Surpass 2 and 3. The teeth were prepared with Surpass 1, 2 and 3. RelyX Veneer Cement was placed per the manufacturers directions, and the veneers seated using the tack and wave technique.

At the one week follow-up appointment, contacts were checked and polished, and impressions taken for Invisalign-style retainers (Figs. 11-14).

So, looking back, what do I think? First, she is very happy with the result. We need to remember that when we criticize the size, rotation or contour of a single tooth, most patients are looking at the improvement to their quality of life; I look at it and think of all the things that could be changed; she looks at it and can't quit smiling.

This is a case where there were some compromises made, but the result was a significant aesthetic improvement, while at the same time mitigating expenditures of time and money. It is certainly not at accreditation level, but then it was never intended to be. This is just bread-and-butter cosmetic treatment, an example of what can be done without a lot of hassle. However, it has made a big change in the patient's life, and at three years' post-op it looks the same as the 21-month photos (except that the gnarly spot on the gingiva of #8 is now healthy) (Fig. 15).

What the patient didn't like about her teeth pre-op:
  • Big spaces
  • Little tooth (#10)
  • White spots
  • Anterior teeth flared

What she didn't like post-op:
  • According to her, nothing
  • When pressed, she admitted that maybe we could have done something to correct the negative space in the buccal corridor. We can always get to that later.

What I like:
  • Tissue over the facial zenith of #9 had been inflamed since the initial visit; this resolved, but took some time. At three years' post-op, it is fine now, but I have no picture.
  • The patient is thrilled!
  • She smiles all the time, where previously she only smiled with her lips closed, or hand in front of her mouth.
  • Other than the multiple visits for the Invisalign, there were not that many office appointments.

Shortcomings I see:
  • Traditional orthodontics would have expanded the posterior maxillary arch, decreasing the aforementioned negative space.
  • Because #11 did not rotate as much as anticipated, the veneer came out larger than I would have liked. Greater buccal reduction during preparation would have resolved that issue, and also with #6.
  • #8 & 9 could have been tipped mesially a bit more to make prepping easier.
  • Because of the small size of #10, I'm concerned about strength of the remaining tooth even with minimal preparation.
  • Would have done bicuspids to correct buccal corridor
  • Somewhat gummy smile; discussed slight intrusion, but she did not want to spend the extra time and did not really mind it.
  • Could have tweaked bottom ortho more, but she's happy with the way things are as-is.
  • If I had known anyone other than me would ever see the photographs, they would look a whole lot better!
  • I used straight A range cement, I wish I had mixed it with translucent to decrease opacity.

In the end, I still had questions:
  • How much did the compromises affect the outcome?
  • To what level would treatment have to rise, in order to make a difference?
  • What would that end up costing in terms of time, money and enamel, and is it worth it?
  • How much does the patient care?
  • How much do I care?
  • Do I care more than the patient does?
  • Are the compromises detectable to the patient, or any other non-professional?

* I would like to thank Bob Brandon and the team at Keating Dental Arts for their help in the planning and fabrication of this case.

Author's Bio
Dr. Timothy Burke graduated from Farleigh Dickinson University Dental School in 1986, where he also pursued graduate study in Human Anatomy prior to joining his father's practice in Allentown, Pennsylvania where he has remained. A 10 year volunteer with Donated Dental Services of Pennsylvania, he is also a founding member of the Empire State Academy of Cosmetic Dentistry and has served the AACD on both the Ethics and Affiliate Relations committees, and is currently a member of the AACD Affiliate Relations Task Force.
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