Co-Diagnosis in Smile Design: Involving Patients in the Ownership of Their Outcomes

Aesthetic or cosmetic dentistry, along with implant dentistry, is one the fastest growing areas of dental treatment today.1 The popular buzzwords smile makeover have become part of the standard lexicon in contemporary culture, and dental patients are now more aware than ever of the treatment options available to them to improve the aesthetics of their smiles. Dentists who want to enter this area of dental care must not only be able to accomplish results that are generally accepted as competent, but they must also understand and fulfill their patients’ expectations.2 To do this effectively, it is important to educate patients considering such care in all of its details and to involve them in the decision-making process inherent to such treatment at each step of its course. This article will describe such a case that I recently completed, where my patient took control of this procedure under my guidance to achieve just the smile she had envisioned.

Figure 1. The patient’s upper anterior teeth. Note the marginal breakdown and recurrent decay.

The patient was a 35-year-old wife of a young professional who had deferred definitive oral healthcare through her husband’s education and then until after his student loan debt was retired. She presented to our office the next month after her husband’s final student loan payment was made. Upon initial examination, she was found to be missing several lower posterior teeth, and her remaining dentition, including her upper anteriors (Figure 1), was filled with extensive direct restorations that were deteriorating due to leakage and recurrent decay. Her periodontal condition, however, was reasonably stable considering the time she had gone without professional care, and she did not have significant occlusal pathology. Aesthetically, while No. 7 was somewhat labially malposed, her gingival heights, facial midline, buccal corridor, and lower lip line were all well-positioned.3 Phonetics was not an issue. At that visit, she was referred for an endodontic consult to save several pulpally involved teeth and to the oral surgeon for extraction of a partially impacted lower third molar and placement of 3 endosseous implants to replace the previously mentioned missing teeth on the mandible.

Figure 2. Some of the tooth contour profiles from which the patient can choose for his or her new smile.

While specialized treatment proceeded, I gave the patient a copy of a CD we have in our office that illustrates the protocol we use to return a patient’s smile to a state of normal, healthy function and pleasing aesthetics using indirect restorations. I asked her to study it in detail and return for a consultation with any questions she might have about the steps and techniques ex-plained on the CD or the results of actual cases done in our office that it depicted. Included on the CD is a description of the stages involved in smile design as well as their sequence and the variable parameters of contour and shade that can be chosen. The CD lists several different tooth forms to choose from as well (Figure 2). I also asked her to tentatively select the contour profile she found most appealing from among the several shown on the CD and to think about how she would like the shade for her upper anteriors to be determined. Did she want to match the shade of her lower anteriors, which were to be bleached before some conservative composites would be placed, or did she want to go in a different direction?
At the consultation, she indicated the contour set she had settled upon and that she wanted to match the bleached shade of her lower anteriors. This visit is extremely important, and sufficient time should be allotted to it so that the patient’s understanding of and desires for the proposed treatment can be fully explored. Further discussion elicited the statement that, “I don’t want them to look so absolutely perfect that they stand out.” With this in mind, I began to visualize a smile design for this patient where the ideally mesial inclination4 of its tooth orientation was eased and slight rotation of some teeth were introduced to avoid flawlessness of these relationships, as the patient desired.
After her endodontic treatment and implant surgery were completed while basic preventive care was rendered, all of her posterior teeth were restored with full-crown coverage. Her lower teeth were then lightened, and thereafter a few small composites were placed. Now that all other preprosthetic and restorative treatment had been carried out, we were ready to achieve the smile she had come to me for in the first place.
Before a burr touches tooth in smile design, a proper plan must be finalized. A review of the aesthetic parameters noted above must be undertaken and then correlated with the tooth contours that the patient has decided upon along with any specific desires that he or she might have. A laboratory wax-up on articulated study models is the next step to ascertain whether the golden proportion can be attained in a functionally correct occlusion under these circumstances.5 This wax-up can be used to demonstrate to the patient the kind of result possible and to gain approval for the anterior case to begin. Alternatively, a cosmetic imaging service (Smile-Vision.net, SmileArt.com, Digident.com) can provide a graphic illustration to the patient of the potential outcome.

Figure 3. The wax-up used to assess the case form and function. Note where the red marker outlines the preparation template margins.

Once my patient had approved of our plan, the next and most important step in her smile design took place. This step was the placement of provisional crowns, constructed on the basis of the previously mentioned wax-up (Figure 3), after initial prep-aration of her upper anterior teeth. I used fused laboratory-fabricated provisionals (Arrowhead Dental Lab) for the utmost in aesthetics, strength, and efficiency. To guide tooth preparation, the provisionals came with a clear reduction template that had strategically placed openings for insertion of a perio probe to measure my progress as I cut the teeth. This minimizes the number of times needed to try in the provisionals and then adjust the preparations for proper seating. Once the provisionals were fully seated and lined with acrylic chairside, I checked the occlusion to make any needed adjustments before I polished and provisionally cemented them.
Provisionalization is the key step in smile design because it allows the dentist to assess the functional aspects of the case as the patient is judging his or her aesthetic prospects.6 While your patient is considering how his or her smile now looks, you can be evaluating how well factors such as occlusion, phonetics, and mastication as well as the aesthetic features planned for the case have been executed. This is the stage where any “bugs” in your treatment plan need to be eliminated, not when the definitive restorations are being tried in, and this is why the provisional stage must not be hurried or pressured.
I dismissed my patient after provisional cementation, instructing her to appraise her new smile carefully and note any changes from this reference point that she might desire. Two-week follow-up in this case revealed a stable occlusal scheme in canine guidance with the only functional discrepancy being a slight interference on F sounds when the patient was asked to count from 40 to 50. Since the patient indicated satisfaction with her lip line relationship in the provisionals and I judged it to be appropriate as well, I shortened all of them by approximately 0.5 mm, and this speech impediment was resolved. Her next follow-up 3 weeks later was uneventful. I dismissed her again, advising her to take as long as she would like to make a decision on the aesthetics of the case before proceeding to the definitive crowns.
Three months later, the patient stated that she was done assessing her provisionals and was ready to go on to her definitive restorations. The only changes she requested from the form of her existing provisionals was to have larger embrasures at the incisal edges and for the labial surface of tooth No. 6 to be slightly less bulky. These changes were expressed in the laboratory prescription for the definitive crowns, referring to the study model poured from the impression taken of the provisionals in place. The preparations were beveled at this visit (I used a shoulder and bevel design for the preparations in this case), and the final impression was then taken. The final shade of the lower incisors was also taken at the same visit with a digital shade matcher (ShadeVision [X-Rite]), and all of these records were sent to Arrowhead Dental Laboratory for production of the definitive restorations using its Elite porcelain application technique.

Figure 4. The definitive restorations at one-week recall.

Figure 5. The patient one year later, showing off her restored smile.	Figure 6. A closer view taken at the same visit.

At her next visit these restorations (Captek [Precious Chemicals Company]) were tried in, and the patient approved them without change. They were then definitively cemented in place. From the time the patient was seated for the insert visit to the time she was dismissed was less than 40 minutes. At her one-week recall appointment (Figure 4), the patient was thrilled with her new smile. Her soft-tissue response was excellent, as were both her speech and occlusion. She commented, “This is just what I was looking for.” At a recall appointment one year later, her restorations were functioning perfectly, and she was as pleased as ever with her new smile (Figures 5 and 6).
Educating and involving your patient in the course of smile design is a key element in its successful outcome, from initial treatment acceptance to satisfaction with the eventual clinical outcome. When patients feel they have a say in and some control over the progression of treatment, they will be more confident in its final result. This confidence created by the patient’s intimate involvement ultimately extends to the dentist as well in his or her knowledge that the decisions made in cases conducted like this one are collaborative with the patient taking a considerable measure of responsibility for the choices made. While a well-trained dentist can have an extensive working knowledge of and definite ideas about what ideal aesthetics are, beauty is still in the eye of the beholder. And when it comes to smile design, the only beholder who really counts is the patient, whose expectations it is your job to satisfy, within the bounds of what you know will actually work.

Acknowledgment

The author thanks Hernan Varas of Arrowhead Dental Laboratory and his talented team of CDTs for their expertise in the fabrication of the restorations shown in this article.

References

Dr. McArdle graduated from Tufts University School of Dental Medicine in 1985 and has been practicing general dentistry on the New Hampshire seacoast ever since. He has served on the active medical staff in dentistry of Concord Hospital in Concord, NH, and on the board of directors of Priority Dental Health (prioritydental.com), the New Hampshire Dental Society’s Direct Reimbursement entity. He is a co-founder of the Seacoast Esthetic Dentistry Association (dentalesthetics.com), which is headquartered in Portsmouth, NH. He is the founder of Seacoast Dental Seminars (seacoastdentalseminars.com), also headquartered in Portsmouth. He has authored numerous other articles both nationally and internationally in major peer-reviewed publications. He can be reached at (603) 430-1010, drmcardle@seacoastdentalseminars.com, seda@dentalesthetics.com, or by visiting mcardledmd.com.