Success Through Systems by Dr. John Nosti

Categories: Cosmetic Dentistry;
Success Through Systems 

A 10-step guide for predictably outstanding cosmetic dentistry


by Dr. John Nosti


Cosmetic cases elicit a great deal of emotion and energy in a general dentist’s practice. With a positive experience and outcome, patients will be forever grateful for the services you have provided; they will be excellent referral sources to your practice and many will even have an emotional connection with you. The effect on your team is that often they develop a higher sense of purpose and self-satisfaction, and team culture improves greatly in providing this level of dentistry. Overall, the positive energy given and received from these experiences become long-reaching in many areas of your practice (especially team culture).

Negative outcomes and experiences from just one case, however, can have long-term effects on your team culture, your reputation and especially your willingness to take on these cases in the future. The negative energy associated with these outcomes tends to spread throughout the office into many areas (again, one of the most important being team culture).

We all want positive experiences and outcomes when it comes to cosmetic cases. Personally, I like systems because they’re step-by-step processes to apply each time to ensure the results are predictable and successful. A system allows you to communicate with your team so you’re on the same page about where you’re starting and where you’re going to finish. It’s the road map that helps you navigate to success and helps your team know which turns are coming up before they occur.

When a patient first enters the practice, even if they’re ready for a “smile makeover,” we begin with a complete examination—a full-mouth series of radiographs, full periodontal examination, examination of muscles and joints, and aesthetic analysis. If the patient has instability in any of these areas, a general rule of thumb is to clear these conditions before performing any aesthetic treatment.


Step 1: Understand the patient’s goals and desires.

One of the most important aspects of cosmetic dentistry is performing a new-patient interview. It’s vital to listen to your patient during the interview process and understand fully what their goals and desires are. Do they want to have their treatment done because they’re attending an event, like a wedding? Is there a deadline to when they want their treatment completed? Do they want to complete their dentistry just because “it’s time”? Do they want their teeth to appear straighter, whiter or longer? Are they hoping to correct wear, attrition or erosion, or to close black triangles or spaces, to replace old dentistry, etc.? Are they someone who wants all the details? No matter the answers, it’s important for dentist and patient to be on the same page throughout the process. The best way to communicate existing conditions and discuss the goals of treatment is through photography.


Step 2: Photograph and communicate goals and expectations.

When performing cosmetic dentistry, photographs are required for proper documentation. High-quality DSLR photos are excellent, but at times even high-quality cellphone photos can suffice.1 The American Academy of Cosmetic Dentistry photographic documentation series2 illustrates an excellent way to document a case and allows full communication with not only your patient but also the lab performing the case (Fig. 1). This allows you to understand the patient’s goals, desires and expectations. It is critical to judge whether the patient’s goals can be achieved with direct or indirect dentistry alone, or if a multidisciplinary approach is required.

A patient presented to my practice unhappy with her recently performed cosmetic dentistry, requesting that all of her ceramics be replaced. Photos were used to communicate with the patient exactly what she was unhappy with and what she wanted to accomplish (Fig. 2). Although there were issues with the axial inclination of the lateral incisors, the patient’s main complaint was her gingival tissue display. Using the patient’s clinical photographs, it was communicated that her complaints required a surgical solution, not just a replacement of her existing ceramics.

Cosmetic Dentistry
Fig. 1
Cosmetic Dentistry
Fig. 2


Step 3: Create proper diagnostic and treatment records.

It’s important to provide the lab with high-quality records to start your patient’s treatment. These records include patient photographs, maxillary and mandibular PVS impressions, facebow record and centric-relation bite record. For the lab to perform to the best of its abilities, photos are important to illustrate where the teeth fit in relation to the patient’s facial features. Tooth display, midline, occlusal and incisal cant and tissue display all can be communicated with photographs where the lab would otherwise have to guess.

Providing the lab with PVS impressions, versus using alginate or similar irreversible hydrocolloid impression material, allows the lab to pour the models in the most accurate way possible, as well as allowing model duplication.

A facebow record should be considered the standard of care in treatment when performing cosmetic dentistry. It transfers the patient’s maxillary model to the lab articulator; this transfer is in three dimensions relative to the rotational axis of the condyle. The end result is the ability to move the articulated casts in a way that mimics as closely as possible the movements of the condyle in the fossa. Along with allowing the lab movements to match the patient’s movements, it transfers the smile line, midline, incisal and occlusal plane to the lab.

A properly performed facebow (EZ Bow System: Advanced Dental Designs) is the best way to correct an incisal/occlusal cant, as well as prevent these from occurring in final ceramics (Fig. 3). One of the most common postrestorative cosmetic errors I see in my office is patients who present with an incisal/occlusal cant (Figs. 4–6). This is a preventable error with the use of a facebow. In each case shown, this catastrophic error is what drove the patients to seek correction.

A centric-relation bite record (Fig. 7) allows the lab to mount the case in the centric-relation position and to evaluate the difference between centric occlusion and maximum intercuspation. By starting from a centric occlusal position, it is possible— through a combination of equilibration, removal of closure interferences and additive waxup to the maxillary anteriors—to satisfy cosmetic principles and achieve anterior guidance of the final case. This is one of the first steps to functionally design cosmetic cases and reduce parafunctional forces on the final ceramics.3–5

Cosmetic Dentistry
Fig. 3
Cosmetic Dentistry
Fig. 4
Cosmetic Dentistry
Fig .5
Cosmetic Dentistry
Fig .6
Cosmetic Dentistry
Fig. 7


Step 4: Design the smile (waxup).

An imperative step to cosmetic case success is the diagnostic waxup. Along with the diagnostic waxup, reduction guides and putty matrix are fabricated to assist with the case (Fig. 8). This is important for several reasons:

  • It allows the dentist to place a mockup and to reduce the patient’s teeth only where necessary to achieve the final result. (This will be discussed in Step 5.)

  • It also allows the treating doctor to place provisionals that match the diagnostic plan. This part of the process allows you to test both the functionality and cosmetics of the plan. If the diagnostic waxup is not performed, and a functional and cosmetic “test drive” of the proposed design is not performed in provisionals, then the “test drive” of the desired plan happens only when the final ceramics are inserted.
It cannot be stressed enough that you should not skip this step! Nearly all issues can be overcome by performing a diagnostic waxup. If records were performed improperly and an occlusal cant exists in the diagnostic waxup, a new facebow record can be performed, or the cant corrected in the provisionals. The cosmetics are also adjusted until the patient approves the plan.

Cosmetic Dentistry
Fig. 8


Step 5: Place a mockup and prepare through it.

With a combination of additive waxup and the lab reducing the preoperative model only as necessary to add wax, the doctor performs the same initial enamelplasty to place the mockup (Fig. 9). With the mockup in place, the practitioner reduces and prepares directly into the mockup (Figs. 10 and 11). This prevents over- or underreducing the preparations and allows for the proper amount of reduction to achieve the desired end result.

By conserving as much enamel as possible, bond strengths are increased in final ceramics and long-term success of the case can be increased.6–8 This technique also allows for a uniform thickness of the ceramic, which helps prevent shade variants.9 Once the preparations are completed, a photograph is taken with a preparation shade guide to provide the lab (Fig. 12). This is a necessary step so the lab can understand what effect the color of the preparation may have on the definitive ceramic. This will affect the lab’s decision on ingot selection for the ceramic.

Cosmetic Dentistry
Fig. 9
Cosmetic Dentistry
Fig. 10

Cosmetic Dentistry
Fig. 11
Cosmetic Dentistry
Fig. 12


Step 6: Create provisionals.

Several continuing education training programs and doctors state that provisionals are an unnecessary process in cosmetic cases, especially with minimal or no preparation cases. I believe that by not placing provisionals, the practitioner is missing an integral part of the restorative/cosmetic case.

As stated earlier, provisionals allow the practitioner to test drive the occlusion and functionality of the case as well as the aesthetics. Patients can go home and see their new “trial smile” and offer criticism or suggestions as to what they like or don’t. With the trial smile in place, any functional or cosmetic changes can be made before fabrication of the definitive ceramics. This prevents any surprises or disappointments on ceramic delivery day. The provisionals should be a reasonable representation of what the final ceramics will look like.

[Editor’s note: For a step-by-step technique in fabrication of provisionals in all ceramic cases, visit the “Shrink Wrap Temporary Technique” in the cosmetic forum of Dentaltown here.]



Step 7: Create follow-up corrections and patient-approved provisionals.

The patient returns to the office one week after placement of provisionals to discuss any functional or cosmetic concerns. The patient’s smile can be evaluated at this visit, free of the anesthetic influence that typically is present at the preparation appointment.

During this visit, any corrections or adjustments that are needed are performed and a PVS impression is made of the patient-approved provisionals (Fig. 13) and sent to the lab to match for the definitive ceramics. If functional concerns arise, adjustments are made and the patient is scheduled for another follow-up visit one week later to ensure no further corrections are necessary. This process is continued until functional concerns have been addressed and the patient is stable in the provisionals. In my office, I do not proceed with fabrication of the definitive ceramics until the patient has approved their provisionals.

The EZ Bow facebow is performed on the patient’s approved provisionals, because this will be the first model mounted in the lab. The opposing mandibular model is mounted to the maxillary provisional model, and finally the preparation model is mounted to the opposing mandibular model. After this process, all models are interchangeable with one another.

Cosmetic Dentistry
Fig. 13


Step 8: Get the ceramics to match (lab communication).

Once the patient has approved the aesthetics of the provisionals, it’s time to have the definitive restorations fabricated.

Photography of the patient before treatment (Figs. 1 and 14), the patient’s preparations (Fig. 12), and the patient in the approved provisionals (Fig. 13) are sent to the lab for communication of the definitive ceramics. The practitioner and the lab can discuss which material should be chosen to achieve the desired results both cosmetically and functionally, dependent on the preparation design, preparation color and desired final shade of the ceramics. If any cosmetic or functional changes are made from the diagnostic waxup, the practitioner should provide an impression of the provisionals, which will allow the lab to duplicate the shape and dimension of the provisionals to the final ceramics with the ceramist’s added artistry.

Cosmetic Dentistry
Fig. 14

Step 9: Verify everything on delivery day.

The delivery day should be an exciting day for your patient, your team and you. The first tip for proper cosmetic case insertion is to deliver the anesthetic palatally, instead of traditionally into the muccobuccal fold for the maxillary arch. This is performed by placing topical first, then delivering the anesthetic bilaterally between the first and second premolar, and halfway between the hard palate and the gingival margin (Fig. 15).

If you deliver the anesthetic palatally, the patient will be comfortable during the try-in and insertion while still having full movement of their lip to evaluate the ceramics and aesthetics.

After the anesthetic has taken effect, the provisionals are removed and each ceramic is first tried in one at a time to ensure marginal integrity. After verification of the margins individually, the ceramics are tried in simultaneously, starting from the centrals and moving distally to the second premolars.

During this step, contacts are verified and margins are examined again to ensure proper fit. If an open margin is detected, the appropriate contact is adjusted until the ceramic fits as it did when it was individually seated.

Before showing the patient the result, the ceramics are tried in simultaneously with try-in paste. This step is necessary to hydrate the ceramic and to demonstrate its true color and shade. If the ceramics are tried in while they are dehydrated, they will look more opaque and brighter, compared with the hydrated ceramic (Fig. 16). This is a critical mistake often made in cosmetic dentistry and the reason why many practitioners believe that they see a “color shift” in ceramics once cemented.

[Editor’s note: For a step-by-step technique in inserting all ceramic cases, click here to be taken to the “Inserting the Maxillary 10—‘Tac and Wave Technique’ ” discussion thread in the Cosmetic forum on Dentaltown.]

Cosmetic Dentistry
Fig. 15
Cosmetic Dentistry
Fig. 16


Step 10: Enjoy a postoperative celebration.

The patient is scheduled for their postoperative insert visit about two weeks after delivery day. At this visit, any fine-tuning to the occlusion is performed and postoperative photos are taken.

This is a prime opportunity for a team member to request consent from the patient to use their photography as part of the office’s before-and-after marketing. If the patient shares any stories or reports a positive experience, a team member can also request a testimonial from the patient to use in marketing in conjunction with their photographs. The patient is congratulated and their smile celebrated (Fig. 17).

Cosmetic Dentistry
Fig.17


Conclusion

Each of the steps outlined is a critical component for cosmetic case success in your office—from listening and connecting to your patient before treatment, to designing trial runs of the smile, all the way to cementation. Following this process, you will build more confidence in your treatment, your patients will have an outstanding experience resulting in more referrals, and the office culture surrounding cosmetic cases will soar. 


References
1. Hardan, Louis. Mobile Dental Photography with Auxiliary Lighting. Quintessence Publishing (2020).
2. Photographic Documentation and Evaluation in Cosmetic Dentistry: A Guide to Accreditation Photography. American Academy of Cosmetic Dentistry, Copyright 2009–13.
3. Dawson, Peter E. Functional Occlusion e-Book: From TMJ to Smile Design. Elsevier Health Sciences (2006).
4. Thornton, Linda J, “Anterior Guidance: Group Function/Canine Guidance. A Literature Review.” Journal of Prosthetic Dentistry, Vol. 64, Issue 4, 1990, Pages 479–482.
5. Kerstein, Robert B., and Radke, John. “Masseter and Temporalis Excursive Hyperactivity Decreased by Measured Anterior Guidance Development, Cranio, 30:4, 243–254, DOI: 10.1179/crn. 2012.038.
6. Fradeani, Mauro, Redemagni, Marco, and Corrado, Marcantonio.” Porcelain Laminate Veneers: 6-to 12-Year Clinical Evaluation—A Retrospective Study.” International Journal of Periodontics & Restorative Dentistry 25.1 (2005).
7. Horn, Harold R. “Porcelain Laminate Veneers Bond To Etched Enamel.” Dent. North Am. 27 (1983): 671–684.
8. AlJazairy, Yousra H. “Survival Rates for Porcelain Laminate Veneers: A Systematic Review.” European Journal of Dentistry (2020).
9. Pop-Ciutrila, I.S., Ghinea, R, Dudea, D, Ruiz-López, J, Pérez, M.M., Colosi H. “The Effects of Thickness and Shade on Translucency Parameters of Contemporary, Esthetic Dental Ceramics.” J Esthet Restor Dent. 2021 Jul; 33(5): 795–806.


Learn more from Dr. John Nosti and earn CE credits!

Dr. John Nosti has created more than a dozen video CE courses for Townies about restorative dentistry, implants, occlusion, cosmetic dentistry, prosthodontics and more. To check them out, click here.

Author Bio
Dr. John Nosti Dr. John Nosti practices in Mays Landing and Somers Point, New Jersey, with an emphasis on functional cosmetics, full-mouth rehabilitations and TMJ dysfunction. Nosti is a member of Dentaltown’s editorial advisory board and the clinical director of the Clinical Mastery Series, geared toward advancing knowledge in occlusion, aesthetics and restorative dentistry.

 

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