The ‘Smile Trial’ by Dr. Tom Hughes

Categories: Cosmetic Dentistry;
The ‘Smile Trial’ 

Temporary mockups let patients “test-drive” your suggested cosmetic dentistry treatment

by Dr. Tom Hughes

Years ago, in the mid-1980s, my wife confided in me that she was unhappy with the way her smile looked in photos. In some lighting conditions and at certain angles, it appeared as if her upper right lateral incisor was missing. It was only a shadow, the result of a slight lingual position of her tooth, but it made her self-conscious, and I thought I could fix it. But before we jumped in with a porcelain veneer, I suggested we preview the effect it would have on her smile.

I made a temporary composite veneer that advanced the tooth labially just enough to see if a porcelain veneer would make her happy. She immediately liked the composite preview and two days later we took impressions for my very first porcelain veneer procedure. On my wife, and my very first porcelain veneer. So, no pressure!

Ten days later, I bonded on the porcelain veneer: She was thrilled and our marriage survived. It was obvious that her trial composite veneer made it easy for her to accept treatment. It was much like her trying on new clothes or test-driving a new car. Before-and-after smile photos of other patients are helpful. Computer simulations are helpful. But I immediately recognized that nothing could replace the chance for a patient to test-drive their own new smile in real time.

At the time I tried this concept on my wife, cosmetic dentistry was in its infancy. Patients were understandably full of questions. Yet no amount of me patiently answering questions and showing photos of other people’s postoperative successes could fully address their concerns. (“That’s great, Dr. Hughes, but how will it look on me?”)

I wanted out of this uncomfortable role of new-smile salesman. The hard sell is inappropriate, presumptuous and ineffective; an honest depiction of the likely outcome of the treatment works far better. I decided to resume the test drive concept that had worked so well with my wife.

I soon learned how to quickly create single or multiple temporary composite veneers and full crowns to show patients in accurate detail what their new smiles would look like. This smile simulation method avoids overpromising what can be done, and without exception gets seriously interested patients to “yes” and ultimately to a happy conclusion.

This was one of the biggest “aha!” moments of my career. A composite smile simulation allowed serious patients to preview their outcomes with accuracy and gain approval from family and friends. Along with the preview of the result, the process allowed them to also form an opinion of the dentist’s skill. After that approval, they soon committed to treatment with confidence and found ways to make it happen. Not bad for a small amount of temporary composite quickly placed on a few teeth! From that moment on, I referred to this technique as the “smile trial,” and have had success with it hundreds of times for more than two decades.

The temporary smile preview does the persuading, but it also provides important information for me. I now understand three crucial things before treatment: I know my patient’s desires, I know my patient’s expectations and I know if I am capable of delivering what they want.

Perhaps the easiest smile trial is the single-tooth problem. In this first case, a dark tooth caused by trauma and subsequent root canal requires a porcelain veneer for proper aesthetics and function (Fig. 1). This temporary smile preview was accomplished with a 3-mm gel-etched “bond spot” etched on the labial of the tooth. The opaquer and flowable composites were then applied directly and sculpted to create the temporary veneer.

Because the bond spot provides adequate retention for the temporary, there’s no need to place bonding agents on the tooth; it is only a temporary composite veneer to enable the patient to evaluate and show it to family and friends for one or two days (Fig. 2). The patient is also advised not to bite into anything harder than a ripe banana or the veneer may pop off. When his family and friends became excited about his smile trial, the patient was confident that I could meet his aesthetic expectations. He called our office two days later to schedule the porcelain veneer procedure.

The next example involves a similar process, but on four worn and badly chipped upper incisors (Figs. 3 and 4). This smile preview (Fig. 5) was also accomplished with the direct placement of a flowable composite adhered to a 3-mm gel-etched bond spot on the labial of each incisor. This patient told me that she had rejected all previous proposals for any dental treatment on her front teeth because of undesirable results she had seen on other people. She said, “I don’t want to take any chances that my smile could end up looking worse than it does now.” Her concluding remark has stuck with me: “This is not about my teeth—this is about my face!”

Creating a smile trial may be simple, but the dentist must have a comfortable knowledge of the materials and techniques needed to create what is essentially a small temporary prosthesis. When a patient is happy with the preview, the dentist has already demonstrated skill and care in the creation of this temporary dental sculpture. The patient is then reassured, knowing that you are up to the task and will be able to deliver the final result they desire (Figs. 6–8).

The ‘Smile Trial’
Fig. 1
The ‘Smile Trial’
Fig. 2
The ‘Smile Trial’
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The ‘Smile Trial’
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Next up is a more complicated smile trial evaluation for a patient who was reluctant to have any dentistry performed to correct her smile. She considered the cosmetic result provided by her previous dentist to be “ugly” and completely unsatisfactory since day one (Figs. 9 and 10). She had been embarrassed to smile since she was in high school, and was concerned that any additional dental treatment could make things even worse. She had lost confidence in dentistry and didn’t believe that any dentist could ever correct her “ugly” smile.

But when I suggested making a composite simulation, she was immediately curious and was more than willing to give it a try, especially when I explained that it was only temporary. Her preview involved making a mock-up in Ultradent’s LC Block-Out Resin (Fig. 11). I like this material because it will not slump and you can easily sculpt, shape and polish it. It is easily removed and highly visible to ensure its complete removal. (Please note, however, that caution must be used when using this material because it is very exothermic when light-cured! Make only small and thin incremental additions at a time.)

This mock-up is much like a wax-up on a plaster model, except that you also have the patient’s face and lips present to help guide you. When this mock-up fulfills the ideal symmetry, size, proportion, shape and smile line requirements for this patient’s new smile, then a PVS impression is taken (Fig. 12). The resin mock-up (Fig. 13) is gently removed from the teeth and safely stored for future uses. The impression is then filled with temporary composite, especially in the voids created by the mock-up previously on her teeth. The impression with the temporary composite is then placed back into the patient’s mouth to cast the temporary smile simulation (Fig. 14). After auto-curing, shaping, polishing and surface glazing with a temporary glaze, the patient now has a smile trial that will permit her to evaluate and show her family and friends the smile that she knows she can have.

Without asking any questions about the cost, her husband took one look at her with the smile trial in place and encouraged her to call our office and schedule the treatment. Her carefully saved mock-up was sent with her to our referral periodontist to guide him in the amount of crown lengthening and the final gingival contours that I specified for her aesthetic treatment.

After healing, she returned to our office for the placement of three full ceramic crowns on #8–#10 and one porcelain veneer on #7 (Fig. 15). The final postoperative portrait (Fig. 16) displays a happy patient with a beautiful smile. She never envisioned a beautiful smile as part of her life. When she looked in the mirror, she began to cry with joy. I was so happy for her that I choked up a bit myself! It was fun for me to help her get what she wanted and see her happy face filled with delight and gratitude. It had been a long road for her, but when I inquired if she would do it all over again, she replied in less than a heartbeat’s time: “Yes!”

The ‘Smile Trial’
Fig. 9
The ‘Smile Trial’
Fig. 10
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Fig. 11
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Fig. 12
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Fig. 13
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Fig. 14
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Fig. 15
The ‘Smile Trial’
Fig. 16

 The final smile trial case involves a patient who wanted to see what her smile would look like if she decided to accept the treatment I had proposed. Her case required 12 porcelain veneers at a cost that exceeded $12,000, and her expectations as well as the cost of treatment were quite high. This case represents the “granddaddy” of all smile previews, but the most intriguing part of this story is what she did once she had it in place. (More on that later.)

The patient presented with a very healthy dental condition, but her smile was indeed unattractive (Figs. 17 and 18). She asked me many questions about how we might transform her present smile into an attractive smile. I met with her for an initial exam, photos and a short consultation. When I realized that her intentions were serious, I asked her permission to create a representative simulation of her new smile. This is much like the time a contractor might invest in providing an estimate of building costs for someone serious about building a custom home. The creation of this smile trial was done much like the previous one, but it was much larger, required one hour of my time, and included Teeth #4–#13.

I again used the LC Block-Out Resin for the mock-up (Figs. 19 and 20), created a PVS impression of it (Fig. 21), cast the composite trial in the PVS impression (Fig. 22), performed some careful flash trimming (Fig. 23) and, finally, affixed the close-ups of her simulation with Fixodent denture adhesive powder (Figs. 24 and 25).

What she did next was a real surprise: With her temporary smile trial in place, she had glamour portraits taken (Fig. 26). She then sent an 8-by-10 enlargement to her husband, who had been deployed to Iraq. He immediately gave her the green light to have the treatment completed.

The patient thought her temporary composite simulation was beautiful and realistic enough to have glamour photos taken, send them to her husband and have the photos do the talking, convincing her husband of the value of the treatment. In her final postoperative portrait (Fig. 27), you can see just how closely her temporary smile simulation mirrored her final treatment results.

The smile trial technique can provide your patients with a realistic simulation of their future smile. It generates high trust, high case acceptance and high satisfaction levels for patients and dentists alike. This is a fun procedure with tremendous impact. Being able to fulfill your patients’ desires and help them get what they want is what makes practicing dentistry rewarding and fun.

The ‘Smile Trial’
Fig. 17
The ‘Smile Trial’
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Fig. 26
The ‘Smile Trial’
Fig. 27

Author Bio
Dr. Tom Hughes
Dr. Tom Hughes learned to work with his hands in his father’s garage. He graduated from the University of Southern California School of Dentistry in 1973, then practiced for 24 years in California and 22 years in Colorado. In 1990, he founded High Impact Image to share his dental images and dental marketing concepts. Hughes recently produced a series of short, professionally produced videos to show the best of what he learned in 46 years of practice. He wants to help dentists simplify procedures, please patients and make dentistry more fun and more profitable.

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