Audition: A Better Way to Treat and Communicate

Cosmetic dentistry is fulfilling the previously unrealized demand for dental services. The market exploded when media exposure created awareness of the treatments available. Patients dissatisfied with their smiles began to seek out solutions. Yet, awareness alone does not lead to more cosmetic dentistry.
Patients interested in cosmetic dentistry may still be deterred from pursuing treatment by a number of factors such as price or fear of pain. While we often assume price to be the stronger objection, this may not be the case. The primary age group to express interest in cosmetic dentistry is the 31- to 50-year-old age range.¹ This is the same age group (35 to 50 years old) who underwent the most minimally invasive cosmetic surgery procedures in 2004.² 
For some patients, whitening toothpastes alone or in combination with in-office whitening may satisfy the change desired. However, many crave dramatic smile improvements that necessitate a restorative approach. Such situations may include significant tooth color discrepancies, small spaces between the teeth, chipped teeth, slightly rotated teeth, or teeth that are unattractively shaped or undersized.
LUMINEERS BY CERINATE (Den-Mat Holdings, LLC), a noninvasive porcelain veneer system, allows us to provide patients who are hesitant to have tooth structure irreversibly removed with an alternative, evidence-based, successful treatment modality.
Offering a conservative approach is just the first step, and with the new Audition (Den-Mat Holdings, LLC) provisional smile patients can now witness the possibilities. Using Audition, the clinician can help change a patient’s curiosity to desire. Patient understanding then shifts from what can be done to what can be. The Audition preview is a powerful tool for patient acceptance of treatment.

THE TRULY CONSERVATIVE WAY

Accurately meeting patients’ wishes for conservative treatment requires a clear definition of the term itself. From the perspective I have gained in my clinical experiences, I propose that an approach may be considered conservative if it provides the least possible harm to natural tooth structure, not simply less harm. For those patients who require porcelain veneers to fulfill their aesthetic treatment needs, we cannot identify an absolute conservative preparation measurement such as 0.3 mm. Conservative treatment is an abstract principle contingent upon the indications of each case. However well-intentioned techniques to prevent overpreparation^3,4 may be, these are inherently flawed, as they are founded upon predetermined porcelain thicknesses (often due to a given porcelain’s physical properties). Relying on a standard removal of healthy tooth structure will ultimately subject some patients to more harm than necessary. Just as other aspects of the diagnosis are based upon the individual, so must the selection of restorative materials and clinical technique being used. Thus, we must also seek to select restorative materials with optimized physical properties to provide for successful clinical treatment.
The LUMINEERS BY CERINATE porcelain veneer system is well-researched and designed to fit this conservative model. LUMINEERS can be created as thin as 0.2 mm to treat patients when there is the need for little or no tooth reduction (enameloplasty only). The thickness of Cerinate porcelain can be adjusted to accommodate any case. When clinical conditions require a more invasive tooth preparation, Cerinate porcelain will meet those needs as well. The clinical evidence supporting the reliability and longevity of thin porcelain veneers fabricated with Cerinate porcelain is well-reported in the clinical literature.^4-10 Any technique that imposes arbitrary guidelines requiring a minimum porcelain thickness, without scientific rationale and evidence, compromises the quality of care our patients receive.
Patented Cerinate porcelain is a leucite-reinforced, pressed feldspathic porcelain with an unparalleled combination of strength and beauty. Its physical properties match the thermal expansion of natural tooth structure when placed with the complementary adhesive materials (Tenure and Ultra-Bond Plus [Den-Mat Holdings, LLC]) in the LUMINEERS system. This total system provides the strength for a highly successful, aesthetic, stress-resistant, nonmicroleaking restoration.

CONGRUENCE AND CONVERSION

To practice conservative dentistry as defined by a customized diagnostic approach justifies the trust patients place in our judgment. It enables us, as clinicians, to consider all the possibilities for effective treatment and prevent a reliance on past experiences that might not be completely applicable to our current patient. In fact, we may be surprised by the opportunities available. Not only are patients more accepting of conservative treatment plans,but we will likely discover just how limiting our previous parameters were. Yet merely offering a conservative approach is not a guarantee for more cosmetic dentistry. The procedural benefits and implications must still be adequately explained to the patient.  We must use all the tools available to educate our patients when presenting the treatment plan. Most importantly, we must believe in our own recommendations.
Clear communication can be difficult in any realm of life. It becomes increasingly complicated when the subject is technical and the parties involved have quite divergent knowledge of the subject. The time and effort spent to clarify the discussion is quite justifiable as the consultation will shape not only our actions but the patient’s expectations.

READY, SET, AUDITION

The LUMINEERS Audition smile does just as the name implies. This removable prosthetic smile allows patients to evaluate a trial of their new and improved smile before committing to a LUMINEERS procedure. It can be inserted during a consultation and given to patients to try on their own at home. Patients should be cautioned that the Audition should be removed before eating and is not recommended for long-term use.
The Audition is fabricated by the Cerinate Smile Design Studios and is composed of a high-strength composite resin system. A full-mouth impression made prior to any tooth reduction is sent to the Cerinate Smile Design Studios. From the impressions, the studio technicians will evaluate the case for any tooth modification that may be needed. A prep-guide model, wax-up, stint, and Audition smile will be received back for the next appointment.
An experiential method such as the Audition provisional smile bridges the communication divide in a manner greater than any amount of words or images can achieve. Digital imaging provides patients with a 2-dimensional preview of the planned treatment. Yet for many, it is still difficult to imagine the final outcome. The Audition enables patients not only to see the change, but to experience it as well. Patients can feel how the LUMINEERS will fit within their mouths and witness the reactions of friends and family. In my own experiences, patients wearing the Audition have become resolute about proceeding with LUMINEERS. My case acceptance has improved dramatically.
The LUMINEERS Audition smile is also useful in the diagnosis process. As an accurate representation of LUMINEERS, the Audition smile allows the practitioner to evaluate a patient’s occlusion, tooth sizes and shapes, pronunciation, and overall appearance.

CASE STUDY 1

A 40-year-old female presented with a history of bruxing and a desire for a whiter smile (Figures 1 to 3). Chipping was evident on the incisal edges of the maxillary central incisors. An intraoral examination further revealed a diastema between teeth Nos. 6 and 7. Tooth No. 10 also had a mesiofacial overlap of tooth No. 9. In a treatment plan for using LUMINEERS there were no periodontal or occlusal concerns. From the available options presented to the patient, she ex-pressed interest in noninvasive LUMINEERS.

An impression of the maxillary arch was made using a polyvinyl siloxane impression material. Bite registrations and an opposing mandibular cast were also made and sent to the Cerinate Smile Design Studios with instructions to the laboratory. When the Audition materials were returned by the laboratory, the patient was brought in for a second appointment. Included with the Audition materials were recommendations from the Cerinate Smile Design Studios for slight tooth modification and recontouring for teeth Nos. 6, 10, and 11. The prep-guide model provided instruction for these modifications, which consisted of no more than enameloplasty (Figures 4 to 6). The tooth modifications noted by the laboratory using the prep-guide model were such that even if the patient did not accept the LUMINEERS treatment, they would improve her smile. Reshaping teeth alone is one conservative treatment we should offer to improve the appearance of a patient’s smile.

As illustrated in this case, the tooth modifications suggested would reshape the 2 maxillary canines and maxillary left lateral incisor for an immediate improvement. After these slight tooth modifications were made using the prep-guides notations, the Audition provisional smile was inserted (Figures 7 to 9). The patient was ecstatic over the immediate change she saw in her smile. “I can’t believe how much younger I look and feel. There is no way I can go back to the old me. How soon can I get the actual LUMINEERS?” she asked.

The “wow” factor of Audition was evident. In fact, as much as she was wowed by the provisional, she was even more impressed with the final result when 8 LUMINEERS were placed on teeth Nos. 5 to 12 without any additional reduction (Figures 10 to 12).

CASE STUDY 2

Figure 13. A 38-year-old female wished to correct the appearance of her front teeth and the overall “dinginess” of her smile.

A 38-year-old female wished to correct the appearance of her front teeth that had been traumatized in a bicycle accident when she was 6 years old (Figure 13). The diagnosis of endodontic staining was made. Radiographically the teeth had not been endodontically treated and the root canals had become obliterated. Endodontic evaluation revealed no problems and no need for further endodontic treatment. When anterior teeth are traumatized at a young age it is not uncommon for the teeth to discolor without the need for endodontic treatment. The yellow-orange opaque appearance of these traumatized teeth is due to a “bruising” of the pulp and bleeding of the “bruise” into the dentinal tubules. The hemosiderin products remain in the dentinal tubules and cause the discoloration. For this patient the intraoral examination confirmed that there were smile deficiencies other than the discoloration of teeth Nos. 8 and 9 (Figures 14 and 15). In addition to the discoloration, tooth No. 9 was slightly shorter than No. 8. The patient was also unhappy with the dingy appearance that her teeth presented when she smiled. She had tried whitening in the past and was discouraged by the result. Treatment options were presented to the patient. She was interested in LUMINEERS for the combination of longevity and noninvasiveness.
It was decided that she would be given an Audition provisional smile so she could evaluate and preview the LUMINEERS option. An impression was made and sent to the Cerinate Smile Design Studios with a request for a 10-unit Audition smile. As with the first patient, a second appointment was scheduled when the Audition materials were received. In this case, there was no tooth modification or recontouring necessary.

With the Audition, the patient saw herself as she had not dared to imagine for 32 years. She had a white smile for the first time with the Audition smile (Figures 16 and 17). “I find myself smiling and laughing so much more. It’s amazing!” She decided almost immediately that she wanted the full set of LUMINEERS. A new impression and the wax-up were sent to the Cerinate Smile Design Studios for the fabrication of 10 LUMINEERS. The LUMINEERS were received, and the wax-up was returned for future patient education use. The LUMINEERS were then placed on teeth Nos. 4 to 13 without any removal of tooth structure (Figures 18 to 20).
The comments from this patient were particularly rewarding to hear as a clinician. With Audition and LUMINEERS I can provide patients with truly conservative and clinically successful treatments that improve not only their smiles but their lives as well. The patient told me, “I thought that when people looked at me, they wondered why I did not fix my smile. It pained me to respond to people when they asked what was wrong with my teeth. When I found out that LUMINEERS could perfect my smile without grinding my teeth away, I was hooked. Now that I have my LUMINEERS, I smile at everyone! My friends and family thought that I had them bleached because they look so natural. I think that people will look at me differently now that I have a bright, white smile.”

CONCLUSION

References

1. American Academy of Cosmetic Dentistry. Groundbreaking survey provides insight into the incredible growth in cosmetic dentistry [press release]. http://www.aacd.com/media/releases/pr2005_05_02.aspx. Published May 2, 2005. Accessed September 24, 2007.
2. Demand for minimally invasive cosmetic procedures rises. AORN Journal. May 2004. http://www.findarticles.com/p/articles/mi_m0FSL/is_5_79/ai_n6074292. Accessed September 24, 2007.
3. Magne P, Belser UC. Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Esthet Restor Dent. 2004;16:7-16.
4. Radz GM. A preparation technique to minimize tooth reduction in porcelain veneers. Oral Health. July 2006;15-19.
5. Strassler HE. Long term clinical evaluation of Cerinate porcelain veneers. Presented at: IADR 83rd General Session & Exhibition. March 9-12, 2005; Baltimore, MD. http://iadr.confex.com/iadr/2005Balt/techprogram/abstract_61652.htm. Accessed September 24, 2007.
6. Yu X, Ouellet D, Ibsen R. Perio evaluation of long-term prep versus non-prep porcelain veneers restorations. J Dent Res. 1998;77(spec issue B):954. Abstract 2583.
7. Jordan RE, Suzuki M, Senda A. Clinical evaluation of porcelain laminate veneers: a four-year re-call report. J Esthet Dent. 1989;1:126-137.
8. Christensen GJ, Christensen RP. Clinical observations of porcelain veneers: a three-year report. J Esthet Dent. 1991;3:174-179.
9. Editor’s Choice: LUMINEERS by Cerinate. The Dental Advisor. 2007;24(1):34.
10. Sapp BB, Sapp HTM. The evolution of the esthetic veneer: a 20-year case study. Contemp Esthet Restor Pract. 2002;6:1-4.
    11. Strassler HE, Ibsen RL. Improving smiles without removing sensitive tooth structure. Contemp Esthet Restor Pract. 2005;9:54-61.

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    Dr. Ibsen is a graduate of and former clinical instructor at the University of Southern California School of Dentistry. He authored the first textbook on adhesive restorative dentistry in 1974 and has led projects resulting in many United States and international patents. In a 45-year career, Dr. Ibsen has delivered hundreds of lectures and published countless articles in the United States and abroad. He is president of Den-Mat Corporation and can be reached at (805) 922-8491, rnoodle@denmat.com, or by visiting denmat.com.