Redefining the Ideal Patient

Admit it. You, too, have fantasized about having a practice full of “ideal” dental patients. Your list of desirable attributes for such a patient is probably similar to my own. Ms. I.P. would have a charming disposition, a flexible schedule, excellent oral hygiene, and a high dental I.Q. She (or he) would also implicitly trust my judgment and accept all treatment recommendations without hesitation. Yes, indeed, Ms. I. P. would display no reservation whatsoever, except perhaps to ask a few intelligent questions that reveal a keen interest and motivation toward maintaining her oral health. Lastly, as she puts it, cost is not a concern when it comes to matters as important as her smile.

While we’re at it, let’s also imagine that our ideal patient, and for that matter our entire patient population, has never even heard of dental insurance “benefits.” Sounds appealing, doesn’t it?

I’ve heard a rumor that there actually is a practice that treats these ideal patients exclusively in some other part of the country. Practically overnight, this “ideal practice” attracted a plethora of perfect patients as a direct result of signing up for a one-weekend practice management course. What’s more, the dentist went golfing while his staff pretended to be entertained by the speaker’s unique combo of standup comedy and dental paradigm shifting. No other effort was required!

Please let me know if you hear of the location of the next “ideal practice” paradigm course. If I can find it, I’m going! Or at least my staff will while I play a round of scratch golf.

Recently, a patient presented to my less-than-perfect practice who caused me to reassess my attitude. My definition of the ideal patient underwent an extreme makeover, as it were. The case report that follows highlights this patient.

Figure 1. Preoperative smile.

A 21-year-old female presented with concerns regarding the appearance of her smile (Figure 1). Her concerns were heightened due to the fact that she was to be married the following week. Unfortunately, the presence of her mother during the consultation did nothing to alleviate the palpable tension in the room.

Figure 2. Preoperative smile, retracted.	Figure 3. Preoperative smile, slightly open.

A clinical exam revealed that she suffered from enamel hypocalcification and mottling. A previous dentist had attempted to correct this deformity in the maxillary anterior with composite resin veneers (Figures 2 and 3). The patient (and mother) reported that she had never been happy with the appearance of the veneers, but she assumed that there were no other options available to her. The proximity of the wedding had motivated them to action, however.

A full-mouth series of digital radiographs were taken using Schick USB sensors Nos. 1 and 2 (Schick Technologies) combined with EagleSoft Digital Integration (Patterson Dental). In addition, digital preoperative photographs were captured using a Canon 10D digital camera fitted with a Canon EF 100-mm F2.8 macro lens and MR-14EX macro ring flash. After careful review of her medical history, clinical photographs, and radiographs, CEREC-milled ceramic veneers from teeth Nos. 5 to 12 and from Nos. 21 to 28 were recommended as the ideal treatment option. By utilizing the CEREC process, the time constraints this patient presented with were no longer an obstacle to treatment acceptance. A final target shade of 1M1 was agreed upon by the patient and her mother.

The patient and mother were then escorted to the consultation room. At this point, I was confident that my skillful staff would answer any further questions, arrange payment options that suited the patient’s budget, and establish a schedule to meet the deadline. After a few minutes, however, I was informed that the treatment plan exceeded the budget by a wide margin and was asked to arrive at an acceptable alternative. With some measure of reluctance, I agreed to attempt to achieve the promised result with composite veneers on all of the proposed teeth except the 4 maxillary incisors, which would be restored with the originally proposed CEREC veneers. The difference in fee in my office for composite versus porcelain restorations afforded the patient the opportunity to proceed with treatment.

Figure 4. Correlation image of mock-up of teeth Nos. 7 and 8.

In the course of a single visit lasting approximately 5 hours, the patient received her new smile. The patient’s maxillary teeth were anesthetized with a combination 2 carpules of 4% Septocaine (Septodont) with 1 x 10-6 epinephrine (Septodont) and one carpule 0.5% Marcaine (Cooke-Waite) with 1 x 10-12 epinephrine. The existing composites on teeth Nos. 7 to 10 were increased in length with composite and recontoured to provide an acceptable mock-up from which to fabricate the new veneers. Correlation images—often termed “optical impressions” (Figure 4)—were then made of the mock-ups for teeth Nos. 7 to 10 using the CEREC acquisition unit and camera. Because the software currently does not allow for virtual models across the midline, the images for each quadrant were made separately.

Figure 5. Maxillary preparations.

Next, teeth Nos. 5 to 12 were prepared for their respective restorations. Preparation of the upper teeth revealed that the enamel defects were confined to the superficial layer (Figure 5). Retraction cord was placed into the facial sulci of the prepared teeth. Preparation images of teeth Nos. 7 to 10 were then acquired using the CEREC acquisition unit and camera.

Figure 6. Veneer “virtually” seated.

The veneer for tooth No. 8 was designed and virtually seated (Figure 6) in the CEREC software prior to milling. A shade 1M1 Vita Mark II block (VITA) was inserted in the milling unit, and the milling process started. As the milling process for the first veneer was progressing, the design for veneer tooth No. 7 was completed. The remaining 2 veneers for teeth Nos. 9 and 10 were designed and milled in the same manner. During the remaining time required for the milling processes to complete, the composite veneers for teeth Nos. 5, 6, 11, and 12 were sculpted with 4Seasons (Ivoclar Vivadent), composite layered with bleach light shade in the incisal one-half and B1 shade in the gingival one-half, and light-cured.

Next, the patient’s lower teeth were anesthetized via bilateral mandibular blocks using a combination 4 carpules of 4% Septocaine with 1 x 10-6 epinephrine (Septodont) and 2 carpules of 0.5% Marcaine (Cooke-Waite) with 1 x 10-12 epinephrine. As the anesthesia was taking effect, the CEREC veneers were tried in. They were then stained and glazed with Vita Akzent stains (VITA) using a single application and firing technique, following the manufacturer’s firing parameters.

The firing cycle for staining and glazing the CEREC veneers required approximately 30 minutes to complete, during which time the preparation of teeth Nos. 21 to 28 was accomplished. The composite veneers for these teeth were sculpted in the same manner as for the maxillary teeth. Next, all of the composites were contoured using a single, needle-shaped, fine-grit diamond bur (Brasseler USA). Lastly, the composites were polished using the 3 grits of points and cups included in the Astropol polishing kit (Ivoclar Vivadent) in proper sequential order.

Both the ceramic veneers and the teeth were prepared for bonding by following generally accepted guidelines. First, the bonding surfaces of the restorations were etched for 60 seconds using 8% hydrofluoric acid. The restorations were then rinsed copiously with water for an additional 60 seconds and silanated. A thin layer of Excite (Ivoclar Vivadent) was then applied to the prepared bonding surfaces of the restorations and light-cured. Residual powder was scrubbed and rinsed away from the tooth surfaces. The preparations were then etched with 37% phosphoric acid for 30 seconds, rinsed, dried, and isolated with cotton rolls. A thin layer of Excite was applied to the preparations, further thinned with air, and light-cured. Finally, the restorations were bonded with Appeal light-cured bonding agent (Ivoclar Vivadent), medium value. The excess resin and retraction cord were removed. The patient’s occlusion was checked and harmonized in the patient’s full range of mandibular movement.

Figure 7a. Postoperative smile.	Figure 7b. Postoperative smile, retracted.	Figure 7c. Postoperative smile, slightly open.

Figure 8. Extreme close-up of smile, demonstrating comparable luster and shade of composite and porcelain veneers.

In retrospect, this patient was ideal, inasmuch as her expectations, as well as my own, were exceeded. She had none of the attributes found on the elusive “perfect patient” list. Yet, the opportunity to improve her oral health, self-image, and appearance in an efficient, cost-effective manner is arguably the greatest professional reward one could receive. The materials and techniques available to us today are nothing short of remarkable, and more amazing developments are certainly on the horizon.

Dr. Touchstone graduated from the University of Tennessee College of Dentistry in 1994. Since then, he has practiced general dentistry in Hattiesburg, Miss, with a particular emphasis on aesthetics. He also conducts independent dental materials research and lectures and instructs on the CEREC restorative method. Dr. Touchstone serves on the board of directors of the Academy of Computerized Dentistry of North America. He also maintains memberships in the International Association for Dental Research and several other professional associations. He can be reached at (601) 583-2000 or alextstone@aol.com.