Communication
Simple Tools to Facilitate Communication in Esthetic Dentistry
Krikor Derbabian, DDS, and Winston W.L. Chee, DDS
Authors:
Krikor Derbabian, DDS, maintains a practice limited to prosthodontics. He is the principal of the Center for Prosthetic Dentistry, a prosthodontic group practice with locations in Burbank and Pasadena, Calif.
Winston W.L. Chee, DDS, is the Ralph W. and Jean L. Bleak Professor of Restorative Dentistry, director of Implant Dentistry, and co-director of Advanced Education in Prosthodontics at the University of Southern California School of Dentistry. He also maintains a private practice limited to prosthodontics in Pasadena, CA.
Copyright 2003 Journal of the California Dental Association.
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Communication is a critical element to obtaining satisfying results with esthetically driven treatment. Communication must first be established with the patient then among all the clinicians and technicians involved with the treatment to achieve the esthetic goals of the patient. This article will review methods to communicate esthetic parameters to allied specialists and the dental technician.
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Communication is a critical element to obtaining satisfying results with esthetically driven treatment.1-7 Communication must first be established with the patient then among all the clinicians and technicians involved with the treatment to achieve the esthetic goals of the patient.
The first step toward this communication is for the restorative dentist, who will ultimately be responsible for the outcome, to establish what type of restoration will be required. Based on this decision, it can be then decided if any adjunctive procedures will be needed to improve the patient’s anatomic presentation.
For example, a patient with a low lip line may not require procedures to align the gingival margins or augment deficient ridges (Figures 1-3). Conversely, a patient with an active lip may require both hard- and soft-tissue augmentation to accommodate the esthetics demanded by the patient.
This article will review methods to communicate esthetic parameters to allied specialists and the dental technician. The more information that the restorative dentist can provide, the better the patient can be served.1,4-15
Digital Photographs
Digital photography is a simple and quick way to communicate an overview of esthetic parameters: facial form, profile, lip activity, gingival marginal relationships, incisal length, degree of translucency, size and shape of incisal mamelons, and other characteristics. A few digital photographs can provide much of this information (Figures 4-6).
More detail on the shape of teeth and approximation of shades can be made with larger magnifications, along with shade tabs held next to the natural teeth for comparison (Figures 7-11).
It is beyond the scope of this article to describe ideal requirements and processes for shade selection. This topic -- which includes optical properties of the shade tabs and ceramics, light sources, and effects of various backgrounds -- has been well-described by many authors.1,2,4-15 However, photographs are only two-dimensional depictions; and more information can be garnered with three-dimensional aids, which will be described in this article.
Modified Shade Tabs
Since teeth are seldom uniform in color, a perfect shade match often cannot be found in a single commercially available tab. A novel approach to accurately communicating color is to send a modified color tab to the laboratory technician. In these situations, a tab with a color higher in value and lower in chroma should be selected.1,15 An abraded tab of the selected color can be modified with surface colors to match the tooth. This modified color tab can be sent to the laboratory technician to be used to aid color matching. This method is especially useful to communicate unique characterizations that some teeth exhibit, such as enamel crack lines, proximal discolorations, or white decalcification patches (Figures 12-16). A useful container for this modified tab is a film canister in which the shade tab can be suspended to avoid disturbing any surface modifiers applied (Figure 17).
Surface Texture and Luster
In addition to color, surface texture and gloss can have a dramatic effect on the appearance of final restorations.15,16 The failure to duplicate these properties is the primary reason many restorations appear unnatural, even when an excellent color match is achieved. Photographs do not provide this important information, and gypsum models do not reproduce the fine surface texture of teeth; therefore neither can be used as a base for matching the surface texture and gloss.15,17 An easy method to transfer this information to the laboratory technician is to have a selection of denture teeth with varying degrees of surface texture and gloss. The denture tooth with a similar pattern of surface texture and luster can be selected and sent to the laboratory technician for matching purposes (Figures 18 through 21).
Achieving the proper surface texture and gloss with this method is convenient, will complement the correct color selection, and will enhance the natural appearance of the restorations.
The Lip Impression
In an esthetically driven treatment plan, a three-dimensional aid such as a lip replica can be very helpful.1,13 It can be made with commonly available materials in the dental office. The lip replica represents a three-dimensional frame that is placed directly on the mounted casts with which one can evaluate and modify the smile line, the occlusal plane, the buccal corridors, and the tooth and gingival display. The lip replica is especially critical when contemplating significant repositioning of maxillary incisal edge position. In addition to being an important diagnostic tool, it can also be a useful to facilitate communication with the patient and to put the diagnostic wax-up into a more realistic perspective when evaluating it on the articulator. For immediate denture situations, the lip replica can be used to prepare an esthetic denture setup because it can include important information such as smile line, lower lip position, buccal corridors, and midline (Figures 22 through 26).
The Acrylic Veneer Overlay
The acrylic veneer overlay can provide information regarding the display of anterior teeth both gingivally and incisally.1,13,18 An additive wax-up is made from a diagnostic casts to ideal form. and a labial veneer is made from the wax-up. This veneer can be tried in for patient approval, used as a surgical template for crown lengthening, and used as a guide for fabrication of the definitive restorations.
The following presentation describes the use of this type of overlay. The patient depicted was referred with the chief complaint of “I don’t like the appearance of my front teeth” (Figures 27 and 28). During the patient interview and after analysis of anterior tooth display, it was determined that the incisal edges were aligned well and in harmony with the smile line of the lower lip as was proper for teeth without wear. The gingival margins, however, were found not to be in harmony, which resulted in a less than ideal display of the incisors. The teeth were unrestored, and the most conservative treatment was offered to the patient -- a combination of crown lengthening and bleaching of the teeth. A crown lengthening guide was fabricated and placed intraorally (Figure 29). At this time, the patient was able to preview the intended changes and provide feedback (Figure 30). With the patient’s approval, the crown lengthening procedure proceeded with use of the surgical guide (Figure 31). Once the treatment was completed, the teeth were lightened with home bleaching (Figure 32). In situations where there is severe wear and the teeth require restorations, the gingival margins are aligned for esthetics and the incisal edges are corrected with restorations (Figure 33). Besides being representative of the use of the acrylic overlay for communication to patient and allied specialists, this case is an excellent example of conservative treatment. It cannot be overemphasized that the longevity of the dentition must be taken into account with each esthetic procedure undertaken. This is especially the case when performing elective procedures on healthy dentition.19
Soft-Tissue Casts for Implants and Ovate Pontic Sites
Provisional restorations are commonly used to shape and form pontic sites or peri-implant mucosa.20-23 The shape and form of the soft tissue should be transmitted to the dental technician so that the restorations made will conform to the soft-tissue contours intraorally (Figure 34). The soft tissue cast formed with the use of provisional restorations will provide three-dimensional information to the dental technician.
An intraoral overimpression is taken of the provisional restoration and adjacent teeth. A soft-tissue cast material can be extruded around the ovate pontics to replicate the shape and form of the ridge area formed intraorally (Figure 35). The edentulous area of the master cast is reduced, and the dies are removed to facilitate seating of the index with the provisional restoration (Figure 36). The soft-tissue model can then be used to fabricate the definitive restorations (Figures 37 and 38). Note the form of the tissue with and without the use of this technique (Figure 39).
Summary
A few simple techniques to aid clinicians with communication have been described; visualization in three dimensions is most helpful in transferring information with respect to esthetics.
Acknowledgments
The authors thank Dr. Tina Siu, San Marino, Calif., for the orthodontic treatment and Dr. Mark Handelsman, Tarzana, Calif., for the periodontic treatment for the patient in Figures 27 through 32.
References
1. Derbabian K, Marzola R, Arcidiacono A, The science of communicating the art of dentistry. J Cal Dent Assoc 26:101-6, 1998.
2. Nevins M, The periodontist, the prosthodontist and laboratory technician: a clinical team. In, Perspectives in Dental Ceramics (Proceedings of the Fourth International Symposium on Ceramics). Quintessence Publishing Co, Inc, Chicago, 1988, p 407.
3. Kessler JC, Dentist and laboratory: communication for success. J Am Dent Assoc (special issue) December 1987; 97E–102E.
4. Rivers JA, Schmidt GA, Improving laboratory performance through effective dentist/technician communications. Quintessence Dent Technol 7:51-2, 1983.
5. Shavell HM, Dentist-laboratory relationship in fixed prosthodontics. In, Perspectives in Dental Ceramics (Proceedings of the Fourth International Symposium on Ceramics).Quintessence Publishing Co, Inc, Chicago, 1988, pp 429-437.
6. Tanaka A, Successful technologist-dentist teamwork. In, Perspectives in Dental Ceramics (Proceedings of the Fourth International Symposium on Ceramics). Quintessence Publishing Co, Inc, Chicago, 1988, pp 439-444.
7. Shannon JL, Rogers WA, Communicating patients’ esthetic needs to the dental laboratory. J Prosthet Dent 65:526-8, 1991.
8. Clark EB, The color problem in dentistry. Part I. Dent Dig 37:499-509, 1931.
9. Martin D, The dental technologist’s role in the clinical team. In, Perspectives in Dental Ceramics (Proceedings of the Fourth International Symposium on Ceramics). Quintessence Publishing Co, Inc, Chicago, 1988, p 421.
10. Preston J, The metal ceramic restoration: the problem remains. Int J Periodont Rest Dent 4(5):9, 1984.
11. Wolf M, Teamwork and communication in implantology: dentist-technician-implant surgeon. Int J Dent Symp 2(1):12, 1994.
12. Drago CJ, Clinical and laboratory parameters in fixed prosthodontic treatment. J Prosthet Dent 76(3):233, 1996.
13. Marzola R, Derbabian K, et al, The art of communicating the science of dentistry. Part I: Patient-dentist-patient communication. J Esthet Dent 12:131-8, 2000.
14. Derbabian K, Marzola R, et al, The art of communicating the science of dentistry. Part II: Diagnostic provisional restorations. J Esthet Dent 12:131-8, 2000.
15. Derbabian K, Marzola R, et al, The art of communicating the science of dentistry. Part III: Precise shade communication. J Esthet Restor Dent 13(3):154-62, 2001.
16. McLean JW, Reproducing natural teeth in dental porcelain. In: The science and art of dental ceramics. Vol II. Quintessence, Chicago, 1980:21-44
17. Sorensen JA, Torres TJ, Improved color matching of metal-ceramic restorations. Part II: Procedures for visual communication. J Prosthet Dent 58:669-77, 1987.
18. Cho GC, Donovan TE, Chee WWL, Clinical experiences with bonded porcelain laminate veneers. J Cal Dent Assoc 26:121-7, 1998.
19. Heymann HO, Swift EJ Jr, Is tooth structure not sacred anymore? J Esthet Restor Dent 13(5):283, 2001.
20. Chee WW, Donovan TE, Treatment planning and soft tissue management for optimal implant aesthetics. Annals of the Academy of Medicine Singapore 24:113-7, 1995.
21. Chee WW, Cho GC, Ha S, Replicating soft tissue contours on working casts for implant restorations. J. Prosthod 6:218-20, 1997.
22. Chee WW, Provisional restorations in soft tissue management around dental implants. Periodontol 2000 27:139-47, 2001.
23. Chee WW, Cho GC, et al, A technique to replicate soft tissues around fixed restoration pontics on working casts. J Prosthod 8:44-46, 1999.
To request a printed copy of this article, please contact/Krikor Z Derbabian, DDS, 2625 W. Alameda Ave., Suite 326, Burbank, CA 91505-4822.
Legends
Figure 1. Anterior view of implant restoration from tooth No. 9 through No. 12.
Figure 2. Implants in position for restoration in Figure 1.
Figure 3. Anterior view of implants with lips retracted.
Figure 4. Preoperative view of patient with high lip line and discolored resin composite veneers on teeth Nos. 8 and 9.
Figure 5. Closest shade tabs at normal exposure to aid technician.
Figure 6. Closest shade tabs at lower exposure by 1 f-stop to aid technician.
Figure 7. Postoperative view of patient in Figure 7 with porcelain veneers in place.
Figure 8. Intraoral view of veneers post cementation on teeth Nos. 8 and 9.
Figure 9. A shade tab lower in chroma and higher in value should be selected.
Figure 10. An abraded shade tab of similar shade can be altered with surface modifiers.
Figure 11. The modified shade tab next to the originally selected shade tab.
Figure 12. The modified shade tab can be sent to the laboratory in a film canister and used for the final shade matching of the restoration.
Figures 13 through 16. A selection of denture teeth can be modified with different levels of surface texture and surface luster. These tabs can be used to better communicate these two surface characteristics.
Figure 17. The smile replica can be made in the dental office.
Figure 18. An impression is made over a custom bitefork.
Figure 19. The impression/bite assembly is loaded with putty impression material and seated on the articulated models.
Figure 20. The completed smile replica on the articulated models.
Figure 21. The smile replica provides valuable information -- such as midline, smile line, and buccal corridors -- to complete the diagnostic wax-up.
Figure 22. Patient presentation on referral from orthodontist prior to debanding. Note proper alignment of incisal edges and uneven gingival margins.
Figure 23. Patient in Fig 22 with lips retracted.
Figure 24. Acrylic overlay in place for patient preview and operator assessment.
Figure 25. Intraoral view of teeth Nos. 6 through 11 after crown lengthening.
Figure 26. Patient’s smile after crown lengthening and bleaching.
Figure 27. Patient ready for restorations after orthodontic treatment. Note alignment of gingival margins when there is wear of incisal edges.
Figure 28. Occlusal view of ovate pontic receptor sites.
Figure 29. Putty index with provisional restoration in place; soft-tissue cast material is being placed.
Figure 30. The index with provisional restoration and unset soft-tissue cast material is placed onto the master cast to form the ovate pontic receptor sites -- note the removal of the dies from the master cast to facilitate seating of the index and to prevent damage to the dies.
Figure 31. The formed ovate pontic receptor sites to the provisional restoration.
Figure 32. The provisional restoration in place with putty index removed after setting of the soft-tissue cast material.
Figure 33. Occlusal view of the uncorrected master cast pontic area.
