J O U R N A L OF ESTHETIC DENTISTRY

PROFILE

Ronald E. Goldstein, DDS

current occupation Private Practice, Atlanta, Georgia

Education Emory University School of Dentistry

Academic Affiliations Clinical Professor of Oral Rehabilitation, Medical College of Georgia Adjunct Clinical Professor of Prosthodontics, Boston University Visiting Professor of Oral Maxillofacial Imaging and Continuing Education, University of Southern California School of Dentistry Adjunct Professor of Restorative Dentistry, The University of Texas Health Science Center

Mice8 President. International Federation of Esthetic Dentistry (1997-Present) Co-founder (1975) and Past President I1977-19781, American Academy of Esthetic Dentistry Eo-Editor-in-Chief, Journal of Esthetic Dentistry f 1993-1998)

Yonorr/ Awarda %st recipient of the Charles L. Pincus 4ward. American Academy of Esthetic lentistry, 1992 Zosmetic Dentistry Award for htstanding Contribution to Esthetic !antistry, American Academy of -osmetic Dentistry, 1992 4chievement Medal Recipient, Alpha )mega International Dental Fraternity, 1997 >micron Kappa Upsilon, 1990 :ellow of both American and nternational Colleges of Dentists

’ublicatiom juthor, “Change Your Smile” Quintessence Publishing) 4uthor. “Esthetics in Dentistry,” 2nd kdition (B.C. Decker)

nnovated first esthetic techniques for :omposite resin bonding (1967-1968) hthor of first complete textbook on sthetic dentistry “Esthetics in Dentistry,” 1976 :o-founder of the first academy on sthetic dentistry (AAED)

%ributiom to D.nthtry

Masters of Esthetic Dentistry

CONSIDERATIONS FOR SMILE-GENERATED LONG-RANGE TREATMENT PLANNING: Thoughts and Opinions of a Master of Esthetic Dentistry

Ronald E. Goldstein, DDS*

electing the optimal treatment S plan for a patient’s subjective esthetic needs often requires much more than satisfying the patient’s supposed main complaint.’ In fact, the patient who says, “I want my crowns replaced,” usually is expressing a perceived desire to fulfill his or her emotional esthetic need, when the actual treatment plan may be more complex.

The first requirement for successful treatment is to determine what the patient’s main complaint infers. Is it really to enhance his or her overall appearance or simply to replace crowns? If the answer is the former, then the next step is to establish what choices exist to improve the patient’s overall appearance. Per- haps the most difficult job is to make a judgment as to how far that treat- ment should go: Does the patient just want to improve an existing smile slightly by a crown replace- ment, or is the objective to enhance his or her total dentofacial appear- ance? Is the patient perhaps even contemplating plastic surgery to further enhance an aging face? If so, the plan should encompass all the choices available to help the patient with that overall goal. This may involve selecting a lighter

shade for the crowns and bleaching, bonding, or veneering other teeth in the smile. Then ten or twelve teeth may need to be included in the treatment plan, instead of just the four or six that the patient deems necessary (Figure 1). And don’t for- get the opposing arch. Bleaching can lighten teeth in the opposing arch to match the patient’s desired veneers or crowns in a lighter shade.

A smile is affected by the spatial arrangement of the individual gingi- val profiles of the teeth within the framework of the lips. Therefore an orthodontic, plastic surgical, or orthognathic consultation should be included in treatment planning if it might improve overall patient satis- faction. Many times, 4 to 6 months of tooth repositioning or a tissue sculpting procedure can make a critical esthetic improvement in the dentofacial harmony, expanding the range of restorative options. In each case the smile line needs to be fully analyzed and the tissue-to-tooth ratio evaluated. Gingival raising may improve the framework of the final product (see Figure 1) .2

LONGEVITY

A primary consideration in treat- ment planning must be to forecast

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Figure 1 . A, Believing that it would make her smile ideal, a SCyear-old woman requested replacement o f her anterior crowns. Computer imaging helped the patient visualize how much better she would look with treatment to raise the periodontal tissue plus crown or porcelain veneer restoration of all the teeth that showed during the widest smile. B, Post-treatment photograph showing the esthetic improvement achieved with the combined restorative treatment.

for the patient approximately how esthetic life exceeds the functional as well as the replacement forecast. long their restorations will last life, so it is only fair that practitioners For example, a patient who wishes esthetically and when they will need prepare patients with specific rec- to have composite resin bonding as to be Many times, the ommended maintenance procedures an economic alternative can be told

Figure 2. A, To achieve a prettier smile, this 57-year-old woman sought whiter, straighter teeth. B, Composite resin bonding was chosen for the maxillary teeth, whereas orthodontic treatment was planned for the lower teeth. C, Following composite resin bonding of the maxillary teeth, a dual-cured acrylic nightguard was fabricated to help protect the bonded teeth from fracture. D, Twelve years later the patient was still pleased with her smile owing to the durability of the restorations and the absence of fractures or repairs.

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that the average range of life expect- ancy is between 3 and 8 years.2 If the restorations last longer, the patient will be favorably impressed with not only the treatment rendered but also the economic savings.

The patient presented in Figure 2 was told that the bonded restora- tions might need some maintenance each year or so, in anticipation of possible chipping or staining. The average range of life expectancy was given as 5 to 8 years. After 12 years, during which there had been no maintenance, with the exception of quarterly prophylaxis appointments, repairs were performed on the restor- ations. The patient was extremely pleased not only that the composite bondings had lasted considerably

longer than forecasted, but also that no repairs had been required during that time. Minor orthodontic treat- ment helped to create a more favor- able occlusal relation, and a com- fortable dual-acrylic nightguard helped to avoid potential damage due to clenching or grinding habits. Consistent conscientious home care on the part of the patient also helped to maintain these restorations.

If a patient is known to have a clenching or grinding habit and refuses to wear a nightguard appli- ance, the life span of treatment ren- dered should not be guaranteed. Such patients rarely will be compli- ant in scheduling the prophylatic treatments that are essential to counteract their destructive oral

habits. Figure 3 shows a patient who refused to wear a bite appli- ance at night and repeatedly frac- tured her composite resin bonded restoration. Indeed, even bonded porcelain veneers should not be guaranteed as being fracture-resistant and fail-safe. Instead, if restoration is the procedure of choice, a full crown may provide the best protec- tion. However, the optimal solution may be to reposition the involved tooth into a more favorable occlusal relation, not only improv- ing the esthetics but also reducing the level of ongoing maintenance (Figure 4). If the patient refuses orthodontic treatment, a final option is cosmetic contouring of the opposing arch to provide incisal clearance (Figure 5 ) .

Figure 3. A, The fractured left ckntral incisor of a 4.5-year-old woman who wanted a conservative approach to repair. B, A 30-fluted carbide bur was used to achieve the final contour of the bonded restoration. C, Multiple repairs were made over a period of 8 years because the patient refused to wear a protective nightguard. Currently, she is considering a full crown restoration.

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These reminders may seem basic, however, at times, I have made the mistake of leaving out or forgetting one of the options, only later having to redo my entire treatment plan.

DO NOT MAKE ASSUMPTIONS

It is a mistake to assume, because a patient has not considered a major correction of his or her smile and does not indicate any desire for a new look, that there is no reason even to discuss the options. One major reason for what may be per- ceived as “dental neglect” may actually be a lack of education of patients who have been dentally “patched” since childhood and do not know that restorative options are available. The teeth may appear dark because of amalgam showing through the tooth, ongoing micro- leakage, adjacent tissue inflamma- tion, or premature yellowing and

chipping. In fact, it is this patient profile that offers the best opportu- nity, and sometimes greatest chal- lenge, to restorative dentistry.

Our learning process should never be discontinued. It is possible to learn something every day from vir- tually everyone--colleague and patient alike. Consultations with specialists and laboratory techni- cians many times enlighten me to a new treatment alternative.

The best approach is to educate the patient in a sensitive manner as to what is possible, and to determine whether he or she is ready to make a major improvement. At some point in the evaluation, the individ- ual begins to see himself or herself more realistically and may begin to envision how he or she could look. The dentist’s role is to provide the

opportunity for the .patient to see how the proposed treatment could affect his or her appearance posi- tively. Esthetic computer imaging is an ideal way to help both the den- tist and the patient visualize the possibilities.

Although a comprehensive approach is what should take place with virtually every patient, there are several reasons why it does not always happen, including:

1. Fear that the patient will think the dentist is “selling” or even “overselling. ’’

2. A perception or prejudgment that the patient cannot afford a broader, more comprehensive treatment plan.

confusing him with too many options.

3. Fear of losing the patient by

Figure 4. A, The left central incisor o f a 41-year-old man needed to be replaced. B, A three-unit bridge and porcelain ueneers were constructed to esthetically replace the missing tooth. However, end-to-end occlusion caused chipping ofthe ceramic restoration. C, The final smile. Orthodontic therapy was used to help correct the occlusal problem. This esthetic restoration bas been fracture-free for many years.

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4. A false presumption that a refer- ral for orthodontics or perio- dontics loses the immediacy of the case and “instant fee”; that is, the dentist concludes that the patient has decided ahead of time that he or she can afford to have “these two crowns replaced” and is now ready to begin.

Some years ago, Burt Press, Past President of the American Dental Association, reiterated what Bob Barkeley had stated: The greatest source of new practice revenue should come from a dentist’s exist- ing patient base. There is no doubt about the validity of this concept, especially when one considers the philosophy of comprehensive oral care. This means that at some point in the next few years, every existing patient should be considered for a

Figure 5. A, Fracture of the anterior bonded incisor of a 50- year-old man who did not wear a bite appliance. B, The right central incisor was repaired, and the opposing tooth was cosmetically contoured. After the repair, the patient began wearing a nightguard appliance to help control his nocturnal bruxism.

comprehensive examination, including intraoral video, which is proactive to determine which teeth may eventually give problems. For instance, by looking at the tooth through either a surgical micro- scope or an intraoral camera, the dentist can better predict which cracks may cause fracture. These defects should be documented by recording the intraoral photograph and brought to the attention of the patient so that he or she can be aware of the potential of fracture as well as the corrective procedures available to prevent such a poten- tially devastating fracture. For example, a mesial or distal crack line in a tooth that has an existing tooth surface consisting of an old amalgam restoration can be a candi- date for potentially dangerous frac- ture if a patient occludes against

something hard that wedges in the microcrack. Restoring this area and protecting the tooth can avoid such extreme and sudden breakage.

The answer is to develop a positive but sincere approach, so that the patient will realize that your desire is to be as helpful as possible in arriving at the best possible esthetic treatment plan. Although in the final analysis the patient may insist on a limited procedure, by offering treatment options, practitioners will be more successful in helping their patients look and feel their best.

REFERENCES 1 . Goldstein RE. Esthetics in dentistry. 2nd ed.

Vol. 1. Hamilton, ON: BC Decker, 1998.

2. Goldstein RE. Change your smile. 2nd ed. Carol Stream, IL: Quintessence, 1997.

9 1 999 B.C. Decker Inc.

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