A Shared Understanding: Managing Aesthetic Treatment Imperfection

INTRODUCTION
We are so hard on ourselves. Our nature as dentists is to focus on what went wrong instead of celebrating what went right. We dwell on and beat ourselves over that one patient, that one case, that one tooth that didn’t turn out as well as planned. The pain from failure is often greater than the happiness from success. Why do we do that to ourselves?
We take a single patient complaint or small compromise in a case and magnify it so that we end up convincing ourselves that we don’t measure up to others in the profession. We convince ourselves that we are the only dentist who has treatment disappointments. The truth is that we all have similar struggles. Certainly, any conscientious practitioner tries hard to do quality, patient-pleasing work. Striving to become better is what keeps the spark and passion alive in our practices. We learn from our failures. We all want to become more skilled, have more clinical success, and have happier patients. To get maximum happiness and reward from our professional lives, we must learn how to plan for and deal with an imperfect outcome.

Thorough planning and communication with the patient and lab team are key. Listening to the patient, knowing patient expectations, identifying limitations, and dwelling on the positive are all important steps for reducing tension later. There must be a shared understanding between the dental team and the patient. There are steps that can be taken to improve this shared understanding (Table).

Understanding Starts at the Patient Consult
A female patient with the desire for a better smile came to our office for an aesthetic consultation (Figure 1). Often, the road to success centers around effective photography. A few digital photos were taken by the chairside team and put up on a 35-inch monitor in the operatory and reviewed with the patient. The assigned office team member does an interview while going through each image:

• What can we do for you?
• What don’t you like about your smile?
• What are the 2 most important things that you want us to correct with your smile?

These are the first steps to a shared understanding. Active listening, empathy for patient desires, and accurate documentation will help lessen disappointment later. The patient is shown the images and a list is made of what he or she does not like. Most likely, patients have never seen their teeth enlarged on a monitor; it often accentuates what they already did not like and points out flaws that they never considered.

Figure 1. At the consultation appointment, our patient stated that she wanted her smile improved.

In this case, the patient wanted her teeth to be in better alignment, to have the shade of her teeth improved, and to have a more youthful smile. The chairside team reports what they have learned to the doctor while the photo that best exemplifies most of the identified features that the patient did not like stays on the monitor for the patient to focus on while the doctor is briefed. Internally, we refer to this step as dwelling on the ugly.

The dentist then reviews the pictures again in front of the patient, pointing out things from the doctor’s perspective. The patient will often describe his or her desires differently to the doctor than to the clinical staff. This is where the tempering of expectations starts—to begin to curb patient expectations with regard to biologic, material, and technique limitations. It’s where desires meet reality.

Understanding Compromise
In this case, there was a missing left central incisor (tooth No. 9). A PFM bridge had been done to replace tooth No. 9, and the patient had a history of previous periodontal therapy. Her midline was off about 4.0 mm (to her right) and there was a slight cant in the PFM bridge (Figures 2 and 3). The composite veneers were leaking, with recurrent and interproximal decay on several teeth.

She had been missing tooth No. 9 for many years and had significant buccal plate and horizontal resorption. We offered the option of grafting and implant placement, and the patient declined. The pontic site would be compromised without ridge augmentation. If the patient should decline to accept recommended procedures, those compromises must be explained, understood by the patient, and documented.

After reviewing and agreeing that her gum tissue did not show in the photos, a compromise was agreed upon (this was the first compromise).

Tooth No. 7 was facially inclined and flared. We pointed out that the tooth may be a limiting factor in keeping the new restorations from looking bulky. The choices were extraction, an additional pontic, or implant placement. We agreed that leaving it in place, reducing what we could, and then evaluating the bulkiness of the temporary would be our plan. Another potential compromise.

When patients want whiter teeth, the challenge becomes what we will do with the lower teeth. She could not afford to veneer them, so bleaching was discussed. Promising the patient that we could predictably bleach her lower teeth to match her goal of 0M2 on the maxilla, a shade she chose with the assistant, would be misleading. Therefore, with her understanding, a slightly darker shade on the maxilla, 0M3, was chosen in case bleaching was not effective or maintained on the mandibular teeth. This was one more compromise chosen by the patient.

Figure 4. Lab team involvement with a detailed and shared understanding of the case is vital to success. A wax-up, reduction guide, and temporary matrix are all important communication tools.	Figure 5. The lab team also provided a soft-tissue modification plan that was created according to model/photographic analysis.
Figure 6. The diode laser (Picasso Lite [AMD LASERS]) was used to increase symmetry and to create more aesthetic soft-tissue contours.	Figure 7. Decay removal, composite buildups, and consistent preparations are the basis for long-term success.
Figure 8. The preparations were checked using the lab-fabricated reduction guide. In this case, the position of the laterals were a potential aesthetic compromise if left in place.	Figure 9. Preps were completed and a shade photo taken for the lab team.

Figure 10. Temporaries were made from the wax-up matrix in a shade that the patient desired as the final shade. Review was done 3 to 5 days after the preparation appointment, and the evaluation results were communicated with the lab team.

So what can’t we do? Pointing out the limitations of treatment versus her needs and wants must start early. It is important not to use words like permanent, exactly, perfect, and other words that imply that we will meet all the patient’s goals, regardless of biologic or material limitations. Everyone must be on board before treatment as to the degree of non-perfection that may be expected.

Lab Team Involvement
Having input from the dental laboratory team on a case like this is critical to the proper treatment planning of a comprehensive or cosmetic case. Often, the ceramist will come up with ideas to help treatment that the office team and doctor did not think of or consider. Having the lab team involved before beginning the actual clinical work obviously helps to make the treatment appointment more efficient, but even more importantly, there is the peace of mind that the clinician has by getting input from someone else about the case. It’s amazing how often the ceramist will think of something the doctor overlooked.

Alginate substitute (Silginat [Ket­tenbach LP]) was used to make accurate pre-op impressions. These were sent to the lab with a full series of photos, bite registration, and our stated goals for the case. We also supplied incisor measurements and what we thought would be the correct incisal position.

The dental technician then waxed up the teeth, made prep reduction guides (Figure 4), and a soft-tissue modification plan (Figure 5) according to the photos and treatment goals sent. The soft-tissue modification plan provides the clinician a basic blueprint for precise diode laser tissue recontouring without regard to biologic limitations.

Review of Expectations Before Treatment
At a case presentation appointment (or on preparation day), the chairside team reviews the plan. The patient is reassured about making great choices with treatment and how excited the team is to provide treatment as agreed upon. In our practice, we don’t go into a great amount of detail about upcoming treatment, but instead, we do deliver a pleasant and positive outline of what will be done during the appointment. The staff is trained to talk to the patient about how meticulous and thorough the doctor is and that excellence is the goal of the entire team. The tone is that of positive reassurance.

Clinical Treatment
After the treatment review, the patient was given local anesthetic. After bone sounding with a sharpened periodontal probe, it was verified that soft-tissue recontouring could be successfully done using a diode laser (Picasso Lite [AMD LASERS]). The author’s goal is to keep the final restoration margins 2.5 to 3.0 mm from the bony crest to prevent biologic width violations and to prevent chronically red or inflamed gingiva. Other areas were also shaped; this was done according to tissue type, location, and restoration margin extension (Figure 6).

Depth cuts were made and tooth preparation completed. All corners were rounded and the preparations were smoothed (Figure 7). Then the reduction guide was inserted and the tooth preparations were inspected (Figure 8).

Figure 11. A zirconia framework (layered) bridge (Lava Plus [3M]) was made from maxillary cuspid-to-cuspid, with individual layered zirconia crowns (Lava Plus) on the maxillary bicuspids.	Figure 12. After try-in, the restorations were cleaned (Ivoclean [Ivoclar Vivadent]).
Figure 13. The teeth were isolated and cleaned with pumice (Preppies [Whip Mix]) and then 2% chlorhexidine (Cavity Cleanser [BISCO Dental Products]).	Figure 14. Retention to the large composite buildups (Core-Flo DC [BISCO Dental Products]) was increased using air abrasion with 50-µm aluminum oxide.
Figure 15. A dual-cure universal bonding adhesive (ALL-BOND UNIVERSAL [BISCO Dental Products]) was massaged onto the teeth and air-thinned.	Figure 16. Cementation was done with a self-etch self-adhesive dual-cure resin cement (BeautiCem [Shofu Dental]).

Both lateral incisors involved preparation challenges. Tooth No. 7 was too far facial, and to reduce it enough for 2.0 to 3.0 mm clearance was not possible without compromising its strength. Having discussed this issue previously with the patient, this made our decision to leave it under-prepared facially more acceptable, and we would re-evaluate this issue in the provisional restoration phase. Tooth No. 10 was in the center of the proposed contact between it and the pontic. To reduce the tooth so it fit into the proper position, it would have to be prepped into the pulp and reduced to the point of questionable bridge abutment support. The effect of this compromise could result in an incorrect midline or tooth proportions that would not be acceptable. In this case, the compromise was made by the doctor to add another abutment to the bridge and to evaluate this during the temporary restoration phase as well.

Shades of the prepared teeth were taken to help the ceramist in choosing opacities and final shades (Figure 9). Full-arch vinyl polysiloxane (VPS) impressions (Panasil [Kettenbach LP]), a bite registration (Futar [Kettenbach LP]) and alignment guides, and an articulation record (Kois Dento-Facial Analyzer [Panadent]) were all taken and sent to the lab team. A temporary was made using the lab-fabricated matrix using a composite material (Luxatemp [DMG America]) in the shade the patient chose for the final restorations.

The Temporary Restoration Phase
One of the most important steps in a complex case is the temporary phase. It allows the patient the chance to preview basic shape, size, color, and incisal edge position based on the lab wax-up. These living and modifiable transitional restorations give the patient a preliminary chance to view the size, shape, and color that we desired for the case.

Five days after the preparation appointment, the patient returned, and the temporary bridge was evaluated (Figure 10). The patient was asked about aesthetics, speech, comfort, length, and color. The patient then signed a shade agreement form of the final shade (the same, lighter, or darker than the temporary/transitional restorations). Any needed adjustments were made, then photos and impressions of the temporary restorations were taken and sent to the lab team along with a brief description of the patient experience/feedback.

Preparation compromises and their aesthetic effect were also evaluated in the temporary phase before the final restorations were made. In this process, there must be a shared understanding among the staff, the doctor, and the patient.

Restorations
A 6-unit layered zirconia anterior bridge (Lava Plus [3M]) was made along with layered zirconia (Lava Plus) bicuspids (Figure 11). The lab made them based on the wax-up and a few corrections we made in the temporaries. All restorations were tried in for fit and aesthetics, cleaned using a universal cleaning gel (Ivoclean [Ivoclar Vivadent]) (Figure 12), and then rinsed thoroughly and dried with oil-free air. The teeth were cleaned using flour pumice (Preppies [Whip Mix]) (Figure 13) and then 2% chlorhexidine (Cavity Cleanser [BISCO Dental Products]). The retention to large composite resin buildups (Core-Flo DC [BISCO Dental Products]) was increased using air abrasion with 50-μm aluminum oxide (Figure 14).

A dual-cure universal adhesive (ALL BOND UNIVERSAL [BISCO Dental Products]) was massaged onto the tooth surfaces and air-thinned (Figure 15), followed by cementation with a self-etch, self-adhesive, dual-cure resin cement (BeautiCem [Shofu Dental]) (Figure 16). (The bridge was cemented first followed by the bicuspids.) After cleanup of any excess cement, the margins were fully light-cured (Elipar S10 [3M]). Finally, the occlusion was checked and adjusted as needed, and then the restorations were polished (CeraMaster [Shofu Dental]).

Celebrating Victory
We emphasize the positive; it rubs off onto the patient. At the insertion and at follow-up appointments, everyone in the office tells patients how great they look. “Wow, that’s one of the best cases the doctor has ever done. You look terrific.” Of course, we listen to any patient concerns and address any identified issues, but the goal is to do our best to not allow patients to control the emotion in the office by dwelling on anything that seems less than perfect to them.

CLOSING COMMENTS
As doctors, it is so important to know that we all share the same issues. The difference is in how each of us chooses to handle them. Plan for success, use all your resources to do the best, and do not beat yourself up over imperfections. If the limitations of biology, materials, and patient expectations are handled from the beginning, tension levels after the case will be lessened (Figures 17 and 18). What makes a happy patient is for the team and doctor to listen, and then to effectively communicate to the patient what can and cannot be done. Then, thorough evaluation of photos, models, and planning with the lab team will reduce stress when the case is delivered (Figures 19 and 20).

If you follow the recommendations woven into this case report article, you will improve your patients’ satisfaction. Furthermore, it will help you be happier dentist who learns to take joy in the successes, dwelling less on the dissatisfaction that is sometimes found in any necessary compromises.

Acknowledgment
The author would like to thank the Pacific Aesthetic Continuum (thepac.org) for the principles used in this case and the Pacific Aesthetic Dental Studios for their excellent case planning and restorations.

Dr. Griffin completed a general practice residency and maintains a general practice in Eureka, Mo. He focuses his clinical efforts on efficiency in almost all phases of general dentistry while providing state-of-the-art care and services for affordable fees. He centers his teaching content on increasing practice efficiency and on predictable restorative dentistry techniques. He can be reached via email at jgriffinjrdmd@gmail.com or via the website eurekasmile.com.

Disclosure: Dr. Griffin reports no disclosures.

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Focus On: Regenerative Dentistry