Treatment Acceptance: The Power of a Life Event

THE FIRST PATIENT VISIT: BACKGROUND
A 56-year-old female was referred to me by her periodontist. She said she wanted to be able to smile at her daughter’s wedding, and this was only 4 months away. After our intake interview, I discovered that she was embarrassed by the color of her teeth (Figures 1 and 2). When I asked her how much it bothered her, on a scale of one to 10 (with 10 being the most), she quickly replied “10.” I then learned that she had tried whitening her teeth under the supervision of her previous dentist; however, the result was very disappointing to her. She also told me that she always disliked being in photos and purposely hid her teeth. She really hated the “overlap” of her bottom teeth (Figures 2 and 3).

After listening to the patient’s goals and taking a cursory look at her teeth and smile, I told her that we could help her, but first we would need to do a comprehensive initial exam and workup to decide how we would proceed with her care. We very briefly discussed some possibilities to accomplish her goals without formally presenting any treatment plans. Fortunately, her daughter was a plastic surgeon’s assistant, and she accompanied her mother to the first visit; she helped her mother understand what we discussed, reinforcing the need for a complete workup, which was scheduled before they left the office.

CASE REPORT
Diagnosis and Treatment Planning
At the next patient visit, visual and digital oral cancer screening and subsurface evaluation using VELscope (LED Dental) were performed. Her temporomandibular joints were palpated, teeth examined, and periodontal pocket depths probed with a Perio-Wise probe (Premier Dental Products). Full-mouth digital radiographs were taken using SuniRay 2 sensors and Prof. Suni Software (both from Suni Medical Imaging). Detailed impressions for diagnostic models were taken using a quality alginate substitute material (Status Blue [DMG America]). The patient was shown a variety of photographed smiles (The Smile Catalog [LVI Global]) to determine what smile design appealed to her. We also looked through A Collection of Ceramic Works: A Communication Tool for the Dental Office and Laboratory (Quintessence Books) together, so I could learn the type of characterization and level of translucency that she desired for her new smile.

Figure 1. Pre-op smile.	Figure 2. Note the shade of the teeth and the overlap involving the lower incisors.

A tentative final shade was selected and would be confirmed again later. Her photo series was shot with a Canon G10 Powershot (PhotoMed International), using a close-up lighting attachment (PhotoMed International) for diagnostic and case presentation purposes. Finally, a very quick mockup for additional length on the upper incisors was done using a flowable composite resin (G-ænial Universal Flo [GC America]) (Figure 4). The patient liked the mockup, and additional photos were shot of the mockup and the position of the upper incisal edges with the lower incisors (Figures 3 and 4).

Prior to presenting any treatment options to the patient, 2 treatment planning consultations were planned. One was with the orthodontist to whom she would be referred (if she agreed) and another with my laboratory team at Killian Dental Ceramics (Irvine, Calif). I needed to know the orthodontist’s thoughts about treating the lower incisor crowding (Figure 4), and what my laboratory team believed would be the best materials to use in view of the serious tetracycline problem (Figure 5), given the patient’s desire for a very light shade. The orthodontist thought he could strip and realign the 4 incisors, but I did not like this option. Why? Because he would have to strip enamel on canines and bicuspids (in addition to the incisors), and move these teeth, potentially disturbing the patient’s harmonious occlusion. Stephen Killian, CDT, and I agreed it would be better to crown the bicuspids since these teeth had been weakened by previous restorative work, and because we were bringing the ceramics far out to the facial to widen the smile by reducing the buccal corridors.

Figure 3. Mockup length with 2 mm added to Nos. 8 and 9.	Figure 4. Overlap and upper incisal edge level after mockup.

Figure 5. Patient’s dark preoperative shade.

After gathering the information, I prepared a total of 4 different treatment plans. Each plan included veneers on the upper 6 anterior teeth and full-coverage crowns on all the upper bicuspids, which were in palatoversion and had old amalgam restorations. For the lower arch, I suggested the removal of one lower incisor and, for orthodontics, to move the other 3 to more favorable positions for space management with veneers.

The orthodontist said he would need 6 months, so regardless of which ortho option the patient chose for her lower arch, there was insufficient time to accomplish the necessary movement prior to her daughter’s wedding. The only way to achieve a fast change in appearance on the lower arch was through restorative treatment.

Diagnostic wax-ups were created using White Inlay Wax (Corning Wax) on models made with Pink Die Stone (ETI Empire Direct) (Figure 6a). The lower wax-up illustrates what could be done restoratively after extracting one incisor without orthodontics (Figure 6b). The patient objected to the gap between her 2 lower incisors at the gingival aspect on the model even though it would not have shown in her mouth unless she pulled her lip down.

Her husband came to the case presentation visit. After explaining the various options to both of them, the patient asked what I thought was best. I suggested that she treat the upper arch and wait until after the wedding to treat the lower arch by removing one incisor and repositioning the remaining 3 teeth. The reason for the proposed delay on the lower arch was the orthodontist’s 6-month treatment time, and we only had 4 months to accomplish any work prior to the wedding. I suggested that we could opt to bleach her lower teeth before the event, but the change would be limited and we would still not be addressing the overlap. In the end, after hearing the options, she decided to do the upper arch and delay treating the lower till after the wedding. Her husband and I also agreed that it was the best way to proceed. Before leaving, her husband said, “She wanted to do this for so many years, but it took the wedding to finally push her [to do it].” This comment illustrates how timing and the power of life events can motivate patients to treatment.

Clinical Protocol
The patient was anesthetized and teeth Nos. 6 to 11 were prepared for aesthetic feldspathic porcelain veneers. The bicuspids were prepared for lithium disilicate all-ceramic crowns. All the teeth were prepared using a split prep guide (Sil-Tech putty [Ivoclar Vivadent]) to confirm adequate reduction (Figure 7). To prepare teeth Nos. 6 to 11 for the ceramic veneers, a KaVo high-speed air-handpiece (KaVo Kerr Group) was used with No. 834.FG.021 depth cutter diamonds (Komet USA) and No. 6844.FG.016 preparation diamonds (Komet USA). The preparations were designed with enough depth to allow the ceramist to create veneers that would block the severe tetracycline stains and still look lifelike. To prepare the bicuspids for crowns, No. 856-021C Piranha round-end taper diamonds and No. 379-018C Piranha football diamonds (SS White Dental) were used. Photos of the prepped teeth were taken so that the ceramist could see the tetracycline bands and colors that needed to be blocked out (Figure 8).

Figure 7. A Sil-Tech Putty (Ivoclar Vivadent) prep guide was used to achieve correct prep depths.

Retraction cords (Ultrapak No. 000 [Ultradent Products]) moistened with Hemodent (Premier Dental Products) were gently placed using a 45° Fischer Ultrapack Packer (Ultradent Products). After 4 minutes, the cords were removed and the preparations rinsed well and dried. An impression was made using an Originate (Kerr Dental) impression tray with our final impression material (Identium Medium [Kettenbach USA]) dispensed from an automixer (Pentamix 2 [3M]) as Identium Light light-bodied impression material was being injected into all sulci. Identium is a Vinylsiloxanether material (Kettenbach USA), which combines the best properties of polyether and vinyl polysiloxane impression materials. It is extremely accurate with excellent flow characteristics, easy to remove from the mouth, and is odorless and tasteless.

A bite registration (O-Bite [DMG America]) was taken and the midline position was captured using a Microbrush (Microbrush International) positioned vertically (embedded in the bite registration). An opposing arch impression was taken using Status Blue in an Originate tray.

Temporaries that replicated the wax-up were made using a putty/wash matrix (Precision Heavy Body Putty, Wild Berry [DenMat]) (Figure 9a). The teeth receiving crowns were lubricated so the bis-acryl temporary crowns (Luxatemp Ultra [DMG America]) could be removed and cemented. The veneer temporaries were allowed to fully cure on the prepared teeth. This is similar to the shrink-wrapping process wherein a tough clear plastic film is warmed and shrunk over a product to create a tightly fitting package. The temporary crowns were removed, cleaned, and then cemented with GC TEMP ADVANTAGE (GC America). Figure 9b shows all the temporaries in place.

All necessary materials were sent to our laboratory team with detailed instructions and photos of the patient. In the author’s opinion, the addition of photos for the lab team will result in a higher level of artistry from the ceramist compared to sending only models and impressions. The laboratory team created the restorations using a SAM 3 Articulator (Great Lakes Orthodontics). The feldspathic porcelain veneers for Nos. 6 to 11 were fabricated with Vintage Halo (Shofu Dental), incorporating a 0.3-mm thick first layer of opacious dentin to block out the dark underlying shade. The bicuspid crowns were fabricated from lithium disilicate (IPS e.max LT BL4 ingots [Ivoclar Vivadent]) layered with IPS e.max Ceram (Ivoclar Vivadent) (using the cutback technique) to ensure that the final shade would blend with the veneers. All restorations were returned with the intaglio surfaces acid-etched and ready for insertion.

Delivery of the Restorations
After anesthetizing our patient, the temporary veneers were removed in sections. They were sectioned (Figure 10) with a Revelation 858-014 medium-grit needle diamond (SS White Dental) because, in addition to shrink-wrapping the veneer temporaries, spot-etching of the prepped teeth was done to help retain the temporary veneers. The bicuspid temporary crowns were left in place to ensure excess veneer cement would not encroach on the first bicuspid preps when the canine veneers were inserted.

The veneers were tried in using RelyX Try-In Paste White Opaque Shade (3M). When fit and aesthetics were confirmed, the veneers were cleaned of all try-in paste, then silane (CLEARFIL CERAMIC PRIMER [Kuraray Dental]) was applied to the intaglio surfaces as directed. A thin layer of bonding agent (Adper Single Bond Plus [3M]) was applied followed by an adequate amount of light-cured resin cement (RelyX Veneer Cement White Opaque Shade [3M]). The veneers were placed in a Resin Keeper (Cosmedent) to protect the light-cured cement from light.

Matrix strips (Dead Soft Metal Matrix Strips [DenMat]) were placed between the central incisors and lateral incisors. The central incisors were etched with phosphoric acid for 15 seconds, washed, dried, and then bonding adhesive was applied, thinned, and left uncured on the teeth. The 2 central incisor veneers were seated and tack-cured (Demetron OptiLux 501 [Kerr Dental]) facially and palatally for 5 seconds and then gross excess cement was removed. Before final curing for 60 seconds, a coating of a glycerin gel (DeOx [Ultradent Products]) was applied to ensure a full cure at the margins by preventing an oxygen inhibited layer from forming.

Figure 10. Sectioning of temporary veneers.	Figure 11. Using Traxodent system (Premier Dental Products) prior to bicuspid insertions.
Figure 12. Immediate postoperative photo.	Figure 13. Photo at the one-week post-op follow-up visit.

After the remaining veneers were inserted, the bicuspids were anesthetized. The temporary crowns on the bicuspids were removed, and any residual temporary cement was removed. After aesthetics and fit were confirmed, the internal surfaces of the crowns were cleaned with Ivoclean (Ivoclar Vivadent) to remove salivary contamination, then rinsed, dried, and prepared for insertion by applying Clearfil Ceramic Primer and air drying. This primer contains MDP and silane, which serve to activate the internal surface of the crowns for bonding with resin cement. The tooth surfaces were rinsed, dried, and gently cleaned with a MicroEtcher IIA (Danville Materials).

Sometimes microetching disturbs the gingiva, causing a small amount of bleeding. This is a critical issue since blood will prevent proper setting of the resin cement, leading to multiple sequelae (such as poor adhesion and internal staining, which increases as the compromised adhesive bond disintegrates). To be sure the crowns would be bonded properly, Traxodent (Premier Dental Products)—a Hemodent Paste Retraction System that absorbs blood and crevicular fluid—and anatomically formed Retraction Caps (Premier Dental Products) were left in place for 2 minutes (Figure 11). This created excellent hemostasis and gently retracted the gingiva.

Panavia V5 (Kuraray Dental) cement was chosen for the bicuspid cementation because of its ease of use, reliability, and because it is a dual-cured material. Panavia V5 Tooth Primer (Kuraray Dental) was applied to all bicuspids and left in place undisturbed for 20 seconds, then air dried. Enamel and dentin are prepared for bonding simultaneously with this product. Panavia V5 Paste White was injected into the crowns and seated, then tack cured from the facial and palatal directions for 3 seconds, and then the gross excess was removed. The margins were cured, and isolation was maintained for 3 minutes to allow the self-cure component to contribute to adhesion. An immediate postoperative photo of all restorations in place was taken (Figure 12). The patient was seen for a post-op check a week later and couldn’t stop smiling (Figure 13).

CLOSING COMMENTS
There are many reasons patients do not accept our treatment plans. Sometimes the reason is purely emotional, other times purely financial, and in many situations, a blend of both or the timing of the proposed treatment. Accepting what we propose must fit into our patients’ lives. As you see in this article, the daughter’s upcoming wedding precipitated the patient’s action to do something she had been thinking about for years. I look forward to completing her lower arch one day, when there is adequate time for the preferred treatment plan.

Acknowledgment
The author wishes to acknowledge Stephen Killian, CDT, and his entire team at Killian Dental Ceramics (killiandental.com) in Irvine, Calif, for their input and support in changing yet another patient’s life. A special thanks to David Pixley (also at Killian Dental Ceramics) for his artistry displayed in the final restorations.

Dr. Fier is a full-time practicing clinician and is the executive vice president of the American Society for Dental Aesthetics. He is a Fellow of the American Society for Dental Aes­thetics and a Diplomate of the American Board of Aesthetic Dentistry, and he was honored with Fellowships in the American College of Dentists, the International College of Dentists, the Academy of Dental-Facial Esthetics, and the Academy of Dentistry International. He is a contributing editor for REALITY and is on the dental advisory board of Dentistry Today. He lectures internationally on aesthetic and restorative dentistry, and, since 1997, he has been listed in Dentistry Today’s annual Leaders in Continuing Education directory. He can be reached at (845) 354-4300 or via email at docmarv@optonline.net.

Disclosure: Dr. Fier reports no disclosures.

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