Rehabilitation

Beyond Cosmetics -- The Esthetic Rehabilitative Patient

Jacinthe M. Paquette, DDS and Cherilyn G. Sheets, DDS

Copyright 2002 Journal of the California Dental Association.

Authors:

Jacinthe M. Paquette, DDS, is a prosthodontist who maintains a private practice in Newport Beach, Calif. She is an associate clinical professor at the University of Southern California School of Dentistry and is co-executive director of the Newport Coast Oral Facial Institute.

Cherilyn G. Sheets, DDS, maintains a full-time private practice emphasizing esthetics and reconstructive dentistry in Newport Beach, Calif. She is the co-executive director of the Newport Coast Oral Facial Institute and a clinical professor of restorative dentistry at the USC School of Dentistry.

The evolution of the esthetic movement has been sustained over time because it touches a base psychological need for most people to feel they are attractive, youthful, and a vital part of society. Through well-organized team diagnosis and treatment planning, patients can benefit from a solid diagnostic and pre-restorative foundation that can more predictably produce consistent optimal treatment results. As the chief diagnostician and treatment supervisor, the restorative dentist must continue to advance his or her knowledge and training to provide the other team members with a concise treatment vision for the patient. With a newly developed synergy between the disciplines of dentistry for team treatment and with tremendous advancement in dental markets and equipment, it is possible to create natural-looking, esthetic rehabilitative treatments.

The esthetic implications of dental treatment have always been important, but the popularization of esthetics as a prime motivator in treatment is a more recent phenomenon. This esthetic movement -- which, in a large part, has been created by the popular media -- has continued and evolved because it touches a base psychological need most people have to feel they are attractive, youthful, and a vital part of society.¹ Dental manufacturers also quickly recognized the growing importance of esthetics and have supported its development with a variety of new esthetic materials and products.

Other articles in this issue of the CDA Journal highlight the areas of objective and subjective projections of beauty and esthetics and how each specialty can contribute to an appropriate and comprehensive esthetic evaluation. Through well-organized team diagnosis and treatment planning, patients can benefit from a solid diagnostic and prerestorative foundation that can more consistently produce optimal results.²

This article will highlight some of the restorative techniques and approaches available for esthetic rehabilitative dentistry and their impact on beauty. It will also illustrate the collaborative results possible from using a multidisciplinary team approach to care.

Meeting patients’ esthetic expectations can have many benefits for today’s clinicians, including:

* The ability expand the services provided to an existing patient base

while empowering them to improve their oral health.

* A renewed passion for dentistry that results from learning new techniques and working with new restorative materials.

* The development of a stronger, more synergistic working relationship with co-specialists to form an interdisciplinary team approach to better meet the patient’s esthetic, functional, mechanical, biological, and psychological needs.

* An opportunity to treat a new pool of esthetic-oriented patients who otherwise may not have sought dental treatment.

Empowering the Patient

New patients are often motivated to seek treatment for esthetic reasons alone, while unaware of pre-existing dental problems. Their desires are typically simple, often revolving around the twin goals of having whiter and straighter teeth. With these patients, comes the opportunity for the dental practitioner to educate them not only in the more sophisticated esthetic choices available, but also in the benefits of good oral health for their total well-being. For pre-existing patients, exposure to sometimes very simple esthetic options such as tooth whitening can help them develop a positive attitude toward maintaining their oral health. For both classes of patients, the opportunity created by their desire for improved esthetics allows dentists to improve their overall dental health.³

A simplified checklist for comprehensive esthetic care is as follows:

* Comprehensive diagnosis and treatment plan.

* Specialist evaluations and recommendation, when indicated.

* Adjunctive questionnaires for smile analysis.

* Diagnostic wax-ups and consultations with laboratory technicians.

* Phase I: In-house treatment including oral health education; behavior modification; more detailed esthetic analysis; and simple esthetic procedures, i.e., bleaching, bonding.

* Interdisciplinary specialist treatment.

* Finalization of restorative treatment plan.

* Definitive restorative treatment.

* Follow-up patient education on maintenance of results, including protective appliances.

The patient illustrated in Figures 1 and 2 is an excellent example of an esthetic desire leading to improved oral health. She is a cancer survivor and wanted to celebrate her renewed health with an esthetic makeover of her mouth. Her desires were to correct the slight palatal positioning of the maxillary right bicuspids and to eliminate the grayish hue cast in her mouth due to her pre-existing alloys and old fillings. She went through a comprehensive examination, an extensive in-house periodontal therapy program, combined with educational sessions on the care of her mouth, and ultimately was reconstructed (Figures 3 through 6). The most dramatic result in this patient’s treatment was that although her primary motivation for treatment was esthetic enhancement, her most treasured result was that she had established oral health in the process and felt empowered to maintain the result. She is now a vocal proponent of the value of comprehensive esthetic care, including the establishment of individual responsibility for daily maintenance of oral health.

New Restorative Materials and Techniques

The techniques and materials introduced into the marketplace during the past decade have provided restorative dentists with a broader array of treatment options for their patients.^4-6 The most significant of these is in the area of porcelain/resin adhesive dentistry. These esthetic conservative treatment options require knowledge of the best choices for the presenting clinical situation, i.e. preparation design, material selection, functional requirements, and the inherent esthetic properties of each material.

Initially, porcelain veneers were considered a treatment option for simple cosmetic corrections. Today, these ultrathin ceramic restorations continue to evolve into a frequently used treatment option to achieve goals for which enamel replacement is required. Additionally, porcelain veneers and their porcelain-bonded variations (inlays, onlays, veneer/onlays) continue to serve as not only esthetic, but also conservative options to idealize the functional and occlusal requirements in the more complex esthetic rehabilitative patient.

A 50-year-old female patient illustrates these points. She presented with a classic example of a dentition with many years of traditional dental treatments. Her occlusal and restorative stability was compromised due to the complicating factors of parafunctional activity creating uneven wear, breakdown of restorations placed over various periods, marginal leakage, and esthetic compromises. Figure 7 illustrates the wear and breakdown of the anterior dentition that were bothering the patient esthetically. A complete comprehensive examination was performed, and a diagnostic wax-up was initiated to help in the finalization of the treatment plan (Figure 8). The patient’s treatment included an assortment of the varied porcelain bonded restorative designs to restore esthetic, functional, and occlusal harmony (Figures 9 and 10). The patient was able to reach her esthetic goals and achieve a more youthful, attractive appearance, while improving all parameters of her oral health, including her periodontal health (Figure 11). The maxillary and mandibular occlusal views illustrate the combinations of porcelain veneers, porcelain inlay veneers, porcelain onlays, and porcelain-fused-to-metal restorations utilized as part of a coordinated treatment plan (Figures 12 and 13).

Maximizing Results With the Co-Specialist

The various specialties in dentistry have also benefited from the development of esthetically oriented techniques and materials, just as the restorative dentist has benefited. This is especially true in the field of periodontics. Microsurgical esthetic techniques to provide gingival augmentations, gingival papilla regeneration, and esthetically placed endosseous implants are becoming more common.⁷ The level of periodontal surgical sophistication available can "turn back the clock" for many patients with periodontal defects. Without the periodontist’s ability to recreate a harmonious tissue framing of the dental complex, esthetic objectives will frequently be compromised or impossible to achieve.⁸

The female patient illustrated in Figure 14 was in her mid-30s and wanted a "normal smile." Her request was simple to verbalize, but very complex to meet. The preliminary photographs illustrate the impossibility of the challenge to correct the esthetic compromises through restorative care alone (Figures 14 and 15). Her pre-existing fixed partial denture, from the maxillary right central incisor to the maxillary left cuspid was removed and a provisional bridge was fabricated as a surgical template for the periodontist. Preparation margins were placed where the final ideal preparations would be completed. The pontic for the missing maxillary left central was matched in height and contour to the maxillary right central incisor to act as a surgical template of the desired restorative contours. The periodontist performed several microsurgical treatments to cover the exposed roots, build up the labial tissue contours, and create an ovate concavity for the future fixed partial denture pontic. A final microabrasion session with the periodontist smoothed out the contours and blended all grafted areas into the pre-existing gingival tissues. Once the periodontist gave approval for the definitive restorative care, a porcelain-fused-to-gold fixed partial denture was created to finalize the esthetic and restorative correction (Figures 16 through 18). This patient treatment example illustrates the dramatic change that can be achieved through the synergistic efforts found in a team approach to esthetic treatment.

This level of effectiveness with periodontal therapy to enhance esthetics can be illustrated in numerous cases. A dramatic example of enhancement of restorative results through a multidisciplinary approach is shown with the patient in Figure 19. Even though her deficient pontic-to-ridge adaptation could have been corrected by restorative means alone, the esthetic implications of tooth length, compromised lip support, and lack of papilla were complicating factors. By utilizing a microsurgical augmentive procedure, the dental practitioner could restore the deficient ridge appropriately in all three dimensions. The significant change in tissue volume provided the underlying architectural framework allowing normal harmonious tooth contours, embrasure spaces, tooth lengths, and a more hygienic prosthesis (Figures 20 and 21).^9,10

Even with best-intentioned efforts by the co-specialists, the more challenging esthetic final compromises may sometimes require modifications by the restorative dentist to achieve esthetic goals. Prior to presenting to the authors’ office, the patient in Figure 22 had endosseous implants placed into congenitally missing maxillary right and left lateral sites. This patient had already undergone orthodontic treatment and placement of implants by the oral surgeon, and was seeking periodontal surgery for augmentation of the compromised papillae at the implant sites. Figure 23 was photographed by the periodontist at the time of the surgery designed to augment the deficient papillae. The patient was subsequently referred to the authors’ office for care. She was dissatisfied with the previous restorative attempts to provisionalize the dental implants in the maxillary lateral positions.¹¹ Figures 24 and 25 illustrate a number of factors that were esthetically displeasing to the patient. The overall tooth symmetry was compromised predominately due to the angulation of the implants and the tooth size discrepancy. The facial exit of the implants required the buccal positioning of the provisional lateral incisors to cover the exit hole of the screw-retained provisional. In a young, attractive female, the lateral incisors should take on a less dominant role to that of the central incisors and have more delicate contour.¹² Figure 26 illustrates the buccal exit of the implants due to the thin bone anatomy in that region from the congenitally missing laterals. Modified surgical techniques sometimes allow the correction of these surgical limitations.

The treatment objectives for this patient were to reduce the lateral incisor space through either direct bonding or porcelain veneers on the four adjacent teeth. Also, the implants were to be restored with custom-milled implant abutments to correct the angulation problem and mimic the ideal gingival margin placement, providing an ideal environment for the final cement-retained porcelain-fused-to-metal crowns (Figures 27 and 28). A full-mouth series of radiographs of the completed treatment show mesial composite resin bonding of the maxillary cuspids, porcelain veneers on the two central incisors, and the completed custom-milled gold abutments and porcelain-fused-to-gold crowns on the implant-supported lateral incisors (Figure 29). Figures 30 through 32 show the final photographs of this anterior esthetic treatment restoring the patient to an esthetically pleasing and functionally sound state.

Improving Oral Health While Meeting Esthetic Desires

Of all the dental specialties that can assist in reaching esthetic goals, orthodontics provides one of the most beneficial long-term treatments. Frequently, orthodontic corrections can either eliminate or minimize the need for restorative treatment to reach esthetic goals. Routinely, patients should be directed for an orthodontic evaluation prior to restorative treatments, when indicated.¹³ The orthodontic treatment of the adult patient can eliminate crowding, more properly load the dentition, improve periodontal health, and create appropriate spacing for idealized contours of the future restorative treatment. The patient in Figure 33 initially presented with some simple esthetic desires. Her primary goal was to have a lighter, brighter, smile; and she requested porcelain veneers to achieve that goal. Attempts at tooth whitening by prior dentists had not met the patient’s expectations. A complete examination revealed crowding, and the patient was referred to an orthodontist for an evaluation. Complete orthodontic treatment was recommended, and the tooth arch to tooth size discrepancy required the extraction of one lower incisor (Figure 34). Bonding onto the interproximal surfaces of the lower incisors was done to provide interim esthetic correction of the resulting diastemata. Tooth size discrepancies in the maxillary arch also resulted in slight diastemata between the incisors.

The post-orthodontic restorative treatment plan included porcelain veneers for the maxillary and mandibular anterior teeth to eliminate the interproximal diastemata and provide the patient with the tooth color enhancement she desired. Figure 35 represents the epoxy resin master cast of the porcelain veneer preparations of the maxillary incisors. Note the palatal extension of the interproximal margins in the preparation design to enable the laboratory technician to recreate the appropriate contours for diastemata closure. Figure 36 is the frontal view of the porcelain veneers in place on the master model prior to the final insertion. Following the patient’s esthetic approval of the porcelain veneers, the veneers were bonded into place and a protective occlusal appliance was constructed for future protection of the restorations and retention of the final orthodontic results (Figure 37).

Conclusion

The ultimate goals in esthetic oriented treatment plans are to:

* Meet the patient’s esthetic desires;

* Use the most conservative treatment possible to meet those goals;

* Enhance the patient’s oral health in the process of treatment; and

* Educate the patient in how to preserve their dentition for a lifetime.

These goals begin at the time of diagnosis and represent general guidelines for any esthetic treatment. If a patient’s esthetic goals can be met simply by bleaching their teeth, that would be an appropriate treatment plan. However, if there are structural/biological problems that require solutions concomitant with the esthetic desires, an appropriate esthetically motivated treatment plan could include all of the disciplines of dentistry to provide an ideal resolution to the patients’ problems and desires. The American system of dental delivery is unique in the world, in part due to its advanced specialty educational system. Because of this system, it is possible to draw upon talented practitioners in multiple disciplines as a treatment plan is designed for a patient. The restorative dentist must assume the role of the quarterback of the team. Additionally, as the chief diagnostician and treatment supervisor, the restorative dentist must continue to advance his or her knowledge and training to provide the other team members with a concise treatment vision for the patient. With a newly developed synergy between the disciplines of dentistry for team treatment and tremendous advancement in dental materials and equipment, it is possible to create natural-looking esthetic rehabilitative treatments.

References

1. Goldstein RE. Esthetics in Dentistry. JB Lippincott Co, Philadelphia, 1976.

2. Roblee RD, Interdisciplinary Dental Facial Therapy. Quintessence Publishing Co Inc, 1994.

3. US Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General. US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, Rockville, MD, 2000.

4. Yananoto M, The value conversion system and a new concept for expressing the shades of natural teeth. QDT Yearbook. Quintessence Publishing Co Inc, Chicago, 1992, p 9.

5. Geller W, Kwaitkowski SJ, The Willi’s glass crown: A new solution in the dark and shadowed zone of esthetic porcelain restoration. Quint Dent Technol 11:233, 1987.

6. Rinn LA, The Polychromatic Layering Technique. Quintessence Publishing Co Inc, Chicago, 1990.

7. Nordland WP, Periodontal plastic surgery: esthetic gingival regeneration. J Cal Dent Assoc 17(11):29-32, 1989.

8. Garber DA, Salama MA, The aesthetic smile: diagnosis and treatment. Periodontology 2000 (11):18-28, 1996.

9. Chiche GJ, Pinault A, Smile rejuvenation: a methodic approach. AACD Symposium Edition, PP&A, 5(3):37-42.

10. Kokich VG, Nappen DL, Shapiro PA, Gingival contour and clinical crown length: their effect on the esthetic appearance of maxillary anterior teeth. Am J Orthodont 86(2):89-94, 1984.

11. Chiche FA, Leriche MA, Multidisciplinary implant dentistry for improved aesthetics and function. Pract Periodont Aesthet Dent 10(2):177-186, 1998.

12. Pound E, Personalized denture procedures. Dentists’ manual. Denar Corp, Anaheim Calif, 1973.

13. Kokich VG. Esthetics: The orthodontic-periodontic restorative connection. Seminars Orthodont 2(1):21-30, 1996.

To request a printed copy of this article, please contact/Jacinthe M. Paquette, DDS, 360 San Miguel Drive, Suite 204, Newport Beach, CA 92660.

Legends

Figure 1. Pretreatment photograph of patient’s maxillary arch. She wanted all restorations replaced for esthetic reasons, and that the lingual position of the two maxillary right bicuspids corrected restoratively.

Figure 2. Pretreatment photograph of patient’s mandibular arch. She wanted the older restorations replaced for esthetic reasons.

Figure 3. Patient’s completed reconstruction showing a combination of porcelain-fused-to-metal crowns, porcelain veneer onlays, natural teeth, and porcelain veneers.

Figure 4. Frontal view of patient’s completed dentistry also illustrating the improvement in oral health due to the improved marginal integrity, hygienic embrasures, and advanced oral hygiene training.

Figure 5. Patient’s smile from the left view demonstrating the qualities mentioned in Figure 4.

Figure 6. Photo that the patient sent to the authors’ office with a note saying, "Please tell all of the dentists that you work with how very happy I am with my new healthy and attractive smile. You can’t imagine how much this means to me."

Figure 7. Anterior magnified view of the patient’s central incisors showing the wear and chipping of the incisal edges.

Figure 8. Diagnostic wax-up of the patient in Figure 1 demonstrating the possibilities to the patient and dental team of an esthetic reconstruction.

Figure 9. Master cast for the final treatment of the patient in Figure 1 showing a porcelain onlay, three porcelain-fused-to-gold crowns, and a porcelain veneer onlay for the maxillary right quadrant.

Figure 10. Master cast for the patient in Figure 1 showing two porcelain veneer onlays, two porcelain-fused-to-gold crowns, and a porcelain onlay for the maxillary left quadrant.

Figure 11. Final porcelain veneers for the patient shown in Figure 7, which restored the natural beauty and contours to her anterior teeth.

Figure 12. Completed maxillary arch with an assortment of bonded porcelain restorations, and metal-ceramic crowns.

Figure 13. Completed mandibular arch with an assortment of bonded porcelain restorations and metal-ceramic crowns that, together with the restored maxillary arch, established for the patient a functional, esthetic, more hygienic, and more youthful mouth.

Figure 14. Preliminary view of a patient who had "a pretty smile" as her primary request.

Figure 15. The same patient in Figure 14 showing the breakdown in the periodontal architecture, and pre-existing restorations that were unesthetic and unhygienic.

Figure 16. Final photos of the patient showing the results of periodontal esthetic reconstructive surgery and final restorative dentistry on the patient’s natural maxillary right cuspid and lateral, and anterior bridge abutment on the right central.

Figure 17. Final anterior photo of the patient in Figure 16 showing the overall effect of the combined esthetic periodontal microsurgery to gain root coverage and augment the pontic sites in the maxillary left central area and the fixed partial denture from the maxillary right central incisor to the left cuspid. The other teeth have not been restored.

Figure 18. Magnified view of the patient’s maxillary left side demonstrating the healthy tissue subsequent to the grafting and tissue augmentation procedure with final restorations in place.

Figure 19. Patient presented with a concerned for leaking margins on an old anterior bridge. Significant anterior ridge resorption was present.

Figure 20. Master cast for patient with maxillary restorations including the anterior bridge that was made subsequent to periodontal reconstructive surgery of the anterior ridge and the development of anterior papilla.

Figure 21. Final photos of the anterior bridge replacement for the patient seen in Figure 20. Due to the periodontal reconstructive surgery, the patient was able to have a more natural appearance and a more hygienic situation.

Figure 22. Photographs provided by the patient’s periodontist depicting the starting problems with angled implant placement, chronically irritated tissue, and lack of gingival papilla in the areas created by congenitally missing lateral incisors.

Figure 23. Photo taken by the periodontist at the time of tissue augmentation of the right lateral incisor area.

Figure 24. Photo of patient as she presented for treatment. She was dissatisfied with the size and angulation of the lateral provisional crowns and with the black triangles between her teeth.

Figure 25. Lateral profile of patient seen in Figures 22 through 24 showing the labial protrusion of the implant provisionals due to the screw-retained prosthesis limitations.

Figure 26. Master cast of the same patient demonstrating the angulation problem with the implant fixtures. By utilizing custom-milled provisional and permanent abutments, the angulation problems can be mitigated.

Figure 27. Wax pattern post-milling demonstrating the idealized preparation form and the undulating gingival margin replicating the gingival tissue architecture.

Figure 28. Milling of the same pattern as shown in Figure 27 after casting the gold to the titanium collar.

Figure 29. Final full-mouth radiographs of the patient showing the completed implant restorations in the maxillary lateral incisor positions.

Figure 30. Final view of patient’s right side showing the results of conservative mesial bonding on the mesial of the cuspid to increase the width, a custom-designed implant abutment and cement-retained crown, and a porcelain veneer to widen the central incisor.

Figure 31. The same patient as Figure 30 from a frontal view showing a natural appearance to her anterior maxillary teeth.

Figure 32. The same patient as Figure 31 from the left side showing a natural relationship between the veneered centrals, implant-supported lateral incisor crowns, and mesially bonded cuspids.

Figure 33. Patient in Figure 33 at the completion of orthodontic treatment. Note the remaining interproximal spaces, which were more pronounced from a lateral view, and the provisional interproximal bonding on the three remaining lower incisors placed to close the spaces during orthodontic therapy.

Figure 34. Magnified view of the patient’s maxillary cast showing the lingually positioned margins to allow the technician to change the width of the teeth to change the interproximal anatomy. The preparations are precise and delicate.

Figure 35. Final maxillary veneers in position on the master cast.

Figure 36. Final patient smile showing the maxillary and mandibular porcelain veneers placed from cuspid to cuspid creating a more harmonious and healthy appearance.