When Less Invasive Is Also Aesthetic

INTRODUCTION
An aesthetically pleasing smile depends on many factors such as tooth color, position, size, and shape, with tooth color ranking the top of these factors, according to surveys.^1,2 With the goal of creating perfect smiles, a common approach is to prepare all anterior teeth for laminate veneers or all-ceramic crowns to provide complete control over these factors. However, many patients are willing to accept a level of aesthetic compromise in their final smile in order to satisfy their preference for a more conservative approach.³
Traditionally, aesthetic choices that were believed to be best have been made solely by clinicians on behalf of their patients. Today, the newly advocated evidence-based approach emphasizes the importance of patients’ preferences, their treatment needs, and the best available scientific evidence in developing appropriate treatment plans; this, in addition to the dentist’s clinical experience and expertise.⁴
As more information becomes available to patients through different forms of media, they become more critical of how their goals are achieved. A common concern expressed by patients is the amount of healthy tooth structure removed in the process of reaching their desired aesthetic goals. Dental professionals have also expressed their concern over the excessive removal of healthy tooth structure for the sole purpose of upgrading a patient’s appearance.⁵ When patients state their preference of more conservative approaches, minimally invasive treatment options can be considered. The World Congress of Minimally Invasive Dentistry bases this model on “a medical model that controls the disease first; and then uses minimally invasive techniques to restore the mouth to form, function and aesthetics.”⁶
Another concern is the predictability of these minimally invasive cosmetic procedures as it relates to achieving successful outcomes. Recently, questions have been posed whether cosmetic dentistry is evidence-based.⁷ The most conservative treatment for discolored teeth, when compared with other cosmetic treatments, is bleaching of teeth; its effectiveness is well reported in the literature.⁸ The advancements in current composite resin materials and techniques have made composite restorations more reliable and predictable and have provided patients with excellent aesthetics in a minimally invasive manner.^9,10
This article illustrates how a patient’s cosmetic goals were reached, while still meeting his preference of less tooth reduction by utilizing a minimally invasive approach of teeth bleaching and composite fillings. These treatment decisions and protocols are supported by available scientific evidence.

CASE REPORT
Diagnosis and Treatment Planning
A 40-year-old male patient presented with anterior teeth that had multiple discolored restorations, caries, and an undesired overall color of the natural dentition; all this significantly diminishing the patient’s satisfaction with his smile (Figures 1a and 1b). The patient had full-coverage crown restorations placed on all his posterior teeth within the last couple of years, and it had been recently recommended that he have anterior indirect restorations done. He had also been experiencing long-term postoperative discomfort after the placement of one of the posterior crowns. Additionally, the color mismatch between the upper right and left posterior restorations had reduced the patient’s confidence in an additional irreversible major cosmetic treatment.

A thorough dialogue with the patient revealed that the dark appearance of his anterior teeth was his main cosmetic complaint; the misalignment of lower anterior teeth was not a concern. The patient expressed his preference of utilizing the least invasive approach to help him realize his aesthetic, comfort, and functional goals while preserving as much natural tooth structure as possible.
Our pretreatment discussion with the patient involved talking about the benefits and risks of multiple cosmetic options, starting from the least invasive and ending with the most invasive procedures. The treatment recommendations were presented with a clear discussion of the possible limitations of our approach, and it even included discussing the possibility of having to alter the treatment plan during the course of treatment. To meet the patient’s cosmetic needs and preference for minimal tooth reduction, the recommended treatment sequentially included: caries removal of the already endodontically treated tooth No. 7; evaluation for nonvital internal bleaching to maximize the results of our minimally invasive approach; external home bleaching of upper and lower anterior teeth; and replacement of all anterior restorations with conservative composite fillings after the patient was satisfied with the color of his natural dentition.

Clinical Treatment
After the patient’s agreement to his financial obligations, the initial phase of treatment started with making upper and lower alginate impressions to fabricate trays for external home bleaching.¹¹
At the next visit, caries in the upper right lateral incisor (tooth No. 7) was judiciously removed using a caries disclosing agent (Caries Detector [Kuraray America]). Internal bleaching was then initiated in tooth No. 7, using a “walking bleach” technique of sodium perborate (Sultan Healthcare) mixed with water and placed in the pulp chamber.¹² Upper and lower external home bleaching trays were delivered and a carbamide peroxide bleaching gel (Perfecta Tooth-Whitening Gel 21% [Premier Dental Products]) was dispensed. The mere removal of caries from tooth No. 7 through a lingual access while maintaining the integrity of the facial surface created immediate aesthetic improvement in the initial phase of treatment, restoring the patient’s confidence in the minimally invasive approach (Figures 2a and 2b).
Once the patient was satisfied with the color of his natural dentition (Figures 3a and 3b), bleaching was discontinued. Internal bleaching was discontinued after 2 days and external bleaching was discontinued after 4 weeks. A minimum waiting period of one week is recommended before starting the restorative procedures to avoid any compromise in the bond strength of the adhesive system to tooth structure.¹³ This waiting period also allows the teeth to return to a relatively stable color.
Old restorations and any associated caries were then removed (Figure 4), and the remaining tooth structure was re-evaluated for a minimally invasive restorative approach using a universal nanohybrid composite resin material (Tetric EvoCeram [Ivoclar Vivadent]). All composite resin fillings (bleach shade and A1 shade) were placed in a single visit, utilizing a self-etching primer and bonding system (Clearfil SE Bond [Kuraray America]).^14,15 Restorations were finished and polished with aluminum oxide based composite resin polishing systems (Enhance [DENTSPLY Caulk] and Moore-Flex [E.C. Moore Company]) (Figures 5a and 5b).¹⁶

Figure 4. Evaluating the remaining tooth structure of lower anterior teeth, after removing the old restorations.

The patient was very happy with the aesthetic outcome. He was also very pleased that his results were achieved in a minimally invasive manner with less dental chair time, less financial cost, and less psychological anxiety than would have otherwise been associated with extensive dental care.

DISCUSSION
In cosmetic dentistry, one must understand that a patient’s preferences are as important as his or her needs. It is only through an open and a thorough discussion of all available treatment options, including the benefits and the risks, that these preferences can be completely uncovered and clearly addressed. The cosmetic dialogue can start with asking patients 2 simple questions: “Are you satisfied with your smile?” and “Is there anything you would like to change in your smile?” A detailed cosmetic approach can then be customized to each patient’s needs, as perceived necessary by the patient, and as suggested by the dentist. This can eliminate any skepticism associated with today’s public misconception that certain dentists are sometimes attempting to oversell cosmetic dentistry.
There should be no discouragement to adopting a minimally invasive approach whenever it can meet patients’ needs and preferences; the concept of minimally invasive dentistry can be considered relative, depending on teeth conditions. Adopting such a mindset does not mean abandoning veneers and full-coverage crowns, or always recommending bleaching and composite fillings. When teeth are extensively damaged, indirect full crown restorations can be the least invasive approach that will deliver successful outcomes, considering the alternatives of extraction and teeth replacement options.
However, clinicians need to be prepared to manage unrealistic patients’ preferences. Dentists have a desire to always please their patients, yet have an obligation to provide treatments with predictable outcomes. Although patients are at the center of the evidence-based approach, it may not be feasible to meet their expectations if they are unrealistic.
Basing treatment on scientific evidence can increase the chances of predictable outcomes.¹⁷ However, many existing barriers can limit the ability to implement evidence-based dentistry in clinical practice.¹⁸ The ADA policy statement on evidence-based dentistry ranks scientific evidence according to its strength, starting from randomized controlled clinical trials, and ending with the consensus opinion of experts in the absence of scientific evidence.¹⁹ The evidence-based approach calls for searching out and using the best available evidence; which if available would be systematic reviews of the evidence.5 Unfortunately, there are not enough systematic reviews available to address every dental clinical topic yet.20 Additionally, systematic reviews are unable to keep clinicians promptly updated on the latest innovations in dental materials and techniques, such as new cosmetic restorative materials and dental adhesive systems.18 Whenever the available evidence is weak, clinicians may additionally rely on their clinical expertise to make the soundest judgment, taking into consideration the benefits and risks of their approach, discussing them with patients, informing patients of the lack of strong evidence, and guiding them to an informed decision.

CLOSING COMMENTS
Delivering a desired smile in an evidence-based manner while meeting the patient’s preference of a minimally invasive approach can be professionally fulfilling to the dentist and, at the same time, very valuable to the patient. During the course of designing and treating smiles, uncovering patients’ concerns before finalizing any treatment plan, involving patients in the choices made, and basing decisions on the available scientific evidence can create confidence and guarantee more successful outcomes.

References

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20. American Dental Association, Center for Evidence-Based Dentistry. Systematic reviews. ebd.ada.org/SystematicReviews.aspx. Accessed January 10, 2012.

Dr. Alassaad is in private practice in Davis, Calif, with a focus on preventive, restorative, and cosmetic dentistry. He received his dental degree from Marmara University in Istanbul, Turkey, and his California dental license from the Dental Board of California, in 2003. He has previously written for the Journal of the Academy of General Dentistry and oral health columns in the Davis Enterprise local newspaper. He can be reached at sameraldds@yahoo.com.

Disclosure: Dr. Alassaad reports no disclosures.