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Inside Dentistry

January 2013, Volume 9, Issue 1
Published by AEGIS Communications


Minimum Dentistry, Maximum Results

Conservative treatment options for appropriate patients based on patients’ lifestyle and budget as well as esthetic concerns.

By Aria Irvani, DDS

Those who have practiced dentistry long enough know that the less valuable tooth structure is removed, the more predictable and durable the results will be.1,2 While this holds true at the single-tooth level, the implications of conservative treatment are more profound on a larger (full dentition) scale.

This becomes particularly important in treatment-planning decisions in esthetic cases. As all dentists know, the easiest way to treat an anterior case is to treat every tooth that shows in a patient’s smile (frequently from the first bicuspid to the first bicuspid or the second bicuspid to the second bicuspid). In this manner, a uniform smile can be easily achieved, but it will be at the expense of removing tooth structure and a higher cost to the patient. This form of treatment was advocated and frequently justified during the extreme makeover craze that swept the nation several years ago. Most of those patients did not care or were not informed about replacing these restorations 5 to 10 years down the line or what they would do once these restorations failed and required re placement with more extensive restorations. As every practicing dentist knows, even the finest of restorations have a finite service life, which depends upon the amount of enamel removed, the type of the restoration, the skill of the laboratory technician and the dentist, and ultimately the environment in which that restoration will need to function3,4 (ie, the patient’s occlusion, dietary habits, and parafunctions).

While finances should never dictate treatment, the fact is that today’s economic climate is significantly different than before. Patients are much more educated about the types of treatments available, and they are more concerned about durability of their restorations and what happens when they need to be replaced. In some ways, this is a blessing for the profession, because it forces clinicians to be much more diligent in treatment planning.

At some point in clinicians’ professional lives—once enough experience is gained, with the exception of complex multidisciplinary cases—most procedures become simple and repetitive; done enough times, most become second nature. With a paradigm shift toward more conservative dentistry, the cognitive aspect of the profession really comes into play. Dentists need to be much more creative in treatment planning to achieve the best result with minimal manipulation or removal of patient’s tooth structure.

This requires using all of the disciplines of dentistry in the treatment-planning arsenal. Creative use of orthodontics, bleaching, enameloplasy, and composite resins in anterior esthetic cases can achieve longer-lasting and better results than using full or partial ceramic restorations to correct cosmetic defects.5

It is imperative that dentists listen carefully to patients’ concerns, because often times what the clinician thinks they need is completely different from what they think they want. Spending enough time with the patient prior to any treatment is valuable because it gives the dentist the opportunity to fully understand the patient’s wants and expectations in order to determine whether it is possible to deliver the desired results within the patient’s budgetary and time constraints. One of the most valuable tools in treating such cases—as well as any esthetic dental treatment—is the use of photography.6 Patients often tend to forget what their dentition looked like prior to treatment, and photography serves not only as an excellent marketing tool but also is immensely useful in the informed consent process.

Rare is the patient who presents with an open checkbook and the willingness to give the clinician the freedom and permission to do whatever is needed to give him or her a great smile. Today’s consumer is much more educated, technically savvy, and generally has a budget allocated to dentistry. Therefore, spending enough time during the cosmetic consultation can pay huge dividends in meeting and exceeding a patient’s expectation once the treatment is completed. When the dentist’s clinical ability intersects with the patient’s expectations, the result is a happy patient.

One of the easiest, most conservative procedures in cosmetic dentistry that can also produce profound results is enamel reshaping or enameloplasty. This procedure—when combined with tooth bleaching, composites, and indirect restorations on selected teeth—can give the patient dramatic results with minimal expense and virtually no damage to the teeth. As people age, the teeth tend to accumulate chips and wear patterns that, over time, make teeth look misshapen and unattractive. With selective recontouring of teeth followed by whitening, dentists can restore patients’ smiles and turn back the clock.7

It is important to note that the success of this multifaceted approach depends on careful case selection. The severity and type of wear, the amount and quality of available enamel, existing restorations, and the patient’s smile line all help to determine the viability of this type of treatment. A consultation along with photographs and digital simulation can reveal if the patient an appropriate candidate.

These cases illustrate how dentists can use the concept of minimally invasive dentistry through the creative use of enameloplasty combined with other restorative procedures to achieve superior results.

Case 1

The patient in this case was a 40-year-old woman with a very high dental IQ (Figure 1 and Figure 2). Her peg lateral incisors had been bonded 15 years previously and the restorations were in need of replacement. She wanted minimal removal of any tooth structure. The treatment plan was to do indirect porcelain restorations on teeth Nos. 7 and 10. Because tooth No. 6 was in lingual version and noticeably affected her smile, a no-preparation veneer on the tooth was suggested. “No-prep” veneers, also known as “prep-less” veneers, are very predictable restorations.8 Some selective enameloplasty to correct the buccal inclination of teeth Nos. 5 and 12 would give her a much more harmonious result without the need for any restorations. The patient was sent to the laboratory for a custom shade match after preparation and temporization along with detailed records and photographs. The patient was extremely pleased with the results especially because no tooth structure was removed unnecessarily (Figure 3 and Figure 4).

Case 2

A 35-year-old woman presented with concerns about a discolored crown on tooth No. 9 at the margin and chipped teeth (Figure 5). She was told that she needed replacement of the crown on No. 9 and veneers on teeth Nos. 7, 8, and 10. The patient had financial constraints and was interested in treating the problem with minimal dentistry. The porcelain-fused-to-metal crown (PFM) on tooth No. 9 was replaced with a Lava™ (3M ESPE, www.3mespe.com) crown due to the dark stump shade. Simple enameloplasty on the laterals and the central incisor gave the patient the smile she wanted. Although the result may not be ideal, it exceeded the patient’s expectations while avoiding unnecessary restorations and expense to the patient. Even though the six proposed restorations would have arguably given her a more controlled esthetic result, this conservative treatment provided her with at least 90% of the result of the more aggressive treatment in terms of improved visual impact (Figure 6). Doing one versus six restorations also diminishes the chance of restoration failure in the long run by a factor of six. This type of treatment is the cornerstone of conservative cosmetic dentistry, which ultimately benefits the patient.

Case 3

A 40-year-old man presented complaining chiefly of teeth that were chipped, worn, and disproportionately spaced (Figure 7). The patient was very concerned about preserving as much of his natural dentition as possible. The treatment comprised placing two porcelain laminates on teeth Nos. 8 and 9 to restore the teeth and close spaces and two incisal angle composites on teeth Nos. 7 and 10 to correct embrasures and make the teeth more proportionate. No enamel was removed on the lateral incisors. The teeth were simply pumiced, sandblasted to increase the bond strength and available bonding of the enamel surface, etched, and bonded. The finished case demonstrates a substantial improvement over the unrestored teeth, and the patient was very pleased with the results (Figure 8).

Case 4

A 27-year-old woman, a busy professional, presented with concerns about a rotated cuspid and chipped teeth (Figure 9). She declined orthodontics because of time and financial constraints. Her treatment consisted of one porcelain laminate on tooth No. 6 to align the tooth with the rest of the dentition, and enameloplasty to correct the uneven wear on the central and lateral incisors. The finished case shows acceptable esthetics that satisfied the patient’s requirements (Figure 10). This case illustrates one of the difficulties in making judgment calls, because the clinician must weigh the patient’s desire for quick and inexpensive treatment versus what is professionally sound and acceptable. This type of treatment fit the patient’s lifestyle far better than orthodontics would have.

Case 5

A 29-year-old man presented with fractured upper central incisors and discolored and misaligned teeth (Figure 11). The quickest fix was to do six porcelain laminates on the upper teeth to restore the teeth, improve their shade, and give the illusion of straight dentition. Although using laminates on the teeth would have been the quickest fix, it would necessitate mutilating four other perfectly healthy teeth, which was unacceptable. Instead, through a combination of orthodontics, bleaching (internal and external), and porcelain laminates on teeth Nos. 8 and 9, the patient ended up with a result that is esthetically pleasing and has far greater longevity than preparing and restoring six teeth (Figure 12).

Conclusion

These cases illustrate the importance of using all resources available in presenting patients with options. By shifting the focus from idealism to what is important to the patient and taking advantage of the full range of tools at their disposal, dentists can often tailor treatments to accommodate the patient’s lifestyle. This type of treatment can also be a stop-gap measure until the patient can afford the ideal restorative plan. As with any treatment, the informed consent should be discussed in detail,9 and the advantages and disadvantages of this type of treatment should be communicated to the patient. An intraoral mock-up will often help tremendously in understanding patients’ desires and managing their expectations.10 Meeting patients’ expectations by delivering sound dentistry while being mindful of their financial and time constraints is challenging and rewarding at the same time.

References

1. Opedam NJ, Bronkhorst EM, Cenci MS, et al. Age of failed restorations: A deceptive longevity parameter. J Dent. 2011;39(3):225-230.

2. Magne P, Douglas WH. Cumulative effects of successive restoration procedures on anterior crown flexure: intact versus veneered incisors. Quintessence Int. 2000;31(1):5-18.

3. Land MF, Hopp CD. Survival rates of all ceramic systems differ by clinical indication and fabrication method. J Evid Based Dent Pract. 2010;10(1):37-38.

4. Gonzalez-Lopez S, De Haro-Gasquet F, Vilchez-Diaz MA, et al. Effect of restorative procedures and occlusal loading on cuspal deflection. Oper Dent. 2006;31(1):33-38.

5. Bassett JL. There is more to front teeth than looks alone: diagnosis and treatment. Compend Contin Educ Dent. 2010;31(8):604-612.

6. Dunn JR, Huston B, Levato CM. Photographic imaging for esthetic restorative dentistry. Compend Contin Educ Dent. 1999;20(8):766-774.

7. Davis MW. Esthetic and functional enameloplasty. J Prosthet Dent. 1997;77(6):633.

8. Freydberg PK. No prep veneers, the myths. Dent Today. 2011;30(6):70-71.

9. Puttaiah DR. Essentials of safe dental care. J Contemp Dent Pract. 2011;12(2):i.

10. Kovacs BO, Mehta SB, Banerji S, Millar BJ. Aesthetic smile evaluation—a non-invasive solution. Dent Update. 2011;38(7):452-458.

About the Author

Aria Irvani, DDS
Private Practice
Foothill Ranch, California


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Image Gallery

Figure 1 - This patient presented with discolored direct composite veneers on teeth Nos. 7 and 10. The treatment plan included porcelain laminates on teeth Nos. 6, 7, and 10, along with selective enameloplasty on teeth Nos. 5, 8, and 9.

Figure 1

Figure 2 - This patient presented with discolored direct composite veneers on teeth Nos. 7 and 10. The treatment plan included porcelain laminates on teeth Nos. 6, 7, and 10, along with selective enameloplasty on teeth Nos. 5, 8, and 9.

Figure 2

Figure 3 - This patient presented with discolored direct composite veneers on teeth Nos. 7 and 10. The treatment plan included porcelain laminates on teeth Nos. 6, 7, and 10, along with selective enameloplasty on teeth Nos. 5, 8, and 9.

Figure 3

Figure 4 - This patient presented with discolored direct composite veneers on teeth Nos. 7 and 10. The treatment plan included porcelain laminates on teeth Nos. 6, 7, and 10, along with selective enameloplasty on teeth Nos. 5, 8, and 9.

Figure 4

Figure 5 - This patient presented with enamel wear, chipping on the incisors, and a PFM restoration with a discolored margin on tooth No. 9. The patient was pleased with the enameloplasty on the central and laterals and a Lava crown on tooth No. 9.

Figure 5

Figure 6 - This patient presented with enamel wear, chipping on the incisors, and a PFM restoration with a discolored margin on tooth No. 9. The patient was pleased with the enameloplasty on the central and laterals and a Lava crown on tooth No. 9.

Figure 6

Figure 7 - This patient’s worn and chipped incisors with a diastema were treated by placing laminates on teeth Nos. 8 and 9 and bonding teeth Nos. 7 and 10 to enhance their appearance and restore the teeth.

Figure 7

Figure 8 - This patient’s worn and chipped incisors with a diastema were treated by placing laminates on teeth Nos. 8 and 9 and bonding teeth Nos. 7 and 10 to enhance their appearance and restore the teeth.

Figure 8

Figure 9 - This patient’s chipped incisors with a rotated cuspid were treated with enameloplasty performed on all four incisors and a porcelain laminate on tooth No. 6 to correct the rotation.

Figure 9

Figure 10 - This patient’s chipped incisors with a rotated cuspid were treated with enameloplasty performed on all four incisors and a porcelain laminate on tooth No. 6 to correct the rotation.

Figure 10

Figure 11 - This patient presented with crowding and fractured teeth due to trauma. Orthodontics were performed to correct crowding, and internal bleaching was done on tooth No. 9 and laminates were placed on teeth Nos. 8 and 9.

Figure 11

Figure 12 - This patient presented with crowding and fractured teeth due to trauma. Orthodontics were performed to correct crowding, and internal bleaching was done on tooth No. 9 and laminates were placed on teeth Nos. 8 and 9.

Figure 12