Restorative Dentistry

Strategic Aesthetic Planning

In Tips entitled ‘Relationships’, I suggested that one scenario occurred when the dentist was passive and the patient active, whilst in ‘Effectiveness and Efficiency’ the risks of complying with unjustifiable patient demands were considered.

When we are asked to carry out several crowns or veneers or a smile makeover for cosmetic reasons, patients will have developed certain expectations about the final result. If we fail to meet that expectation then at the very least there will be a complaint, or more likely, litigation. It follows that if we are to meet those expectations, we need to know in considerable detail what is being requested, and more importantly have a system of recording both questions and answers in a comprehensive, clear and unambiguous way in the contemporaneous clinical notes. The computer literate may be able to create a form within on screen records. Alternatively consider using a preprinted paper record.

The next consideration is what questions to ask? Those I used are detailed below, but do feel free to add to them to best meet your own personal circumstances.

Question 1.

How important, on a scale of 1 – 10 is it for you to keep your natural teeth for life?

Here I am looking for a score of at least 8 to demonstrate the patient’s seriousness about long term dental health.

Question 2.

How would you like your teeth to look in 15 years’ time?

A worrying number of patients seem to think that crowns and veneers should last for their lifetime and never need replacing. This question gives the opportunity to discuss the life expectancy of such restorations. Recent medico-legal opinion would expect a well- made crown to last at least 12 years. You can also discuss colour changes that might occur with other teeth and what might be required and when during this period.

Question 3.

Does the overall appearance of your smile bother you?

Here a simple yes answer allows you to move to more detailed questions that focus on each patient’s perception of their needs.

Question 4.

Does the shape of your teeth bother you?

In my experience most patients seemed relatively little concerned about shape before treatment. However, if the final result fails to achieve bilateral symmetry, then shape will most definitely be noticed and be commented upon, usually after a member of the family has seen the final, cemented result.

Question 5.

Does the shade (colour) of your teeth bother you?

This is most definitely a key question. The majority of patients do notice the colour of their restorations, and this is an early question to determine. Some patients ask for teeth so white they look false in relation to their skin tones or biological age. It may become a challenge to agree a colour at this early stage. My rule of thumb (another) – if I thought the patient was demanding an inappropriate shade – I declined to treat them. See Fig 1. Here old white veneers stand out against natural teeth that have darkened with age. Which colour does the patient want? The choices are old veneer colour, natural tooth colour, or something in between.

Sometimes professional whitening of teeth will meet your patient’s expectations for the time being and further treatment involving irretrievable loss of tooth substance can be delayed or prevented.

Question 6.

Does the position of the teeth bother you?

Again write careful notes. It may be that adult orthodontics is indicated rather than crowns. This may be instead of or in preparation for optimally placed crowns/veneers. A tooth may be so far out of position that the process of crowning or veneering would expose the pulp or risk later pulpal death. Elective devitalisation may be indicated. This risk benefit analysis needs careful recording as it may well form a complaint that informed consent was not obtained if the procedure does not go to plan.

Question 7.

For how many years has your smile been of concern to you?

I consider that this is another key question. In these days of instant gratification, I worry that younger patients demanding operative interventions have not thought out the long term consequences. Patients who for example want to change their smile because they are in the public eye or a former patient of mine who wanted to improve her smile as a 60^th birthday present to herself, usually have thought things through.

Question 8.

If you could change your smile would you like to have a Hollywood perfect smile or a natural smile with slight irregularities?

Patients choosing the former option have very high expectations. It follows that you and your technician must have the skills and experience to deliver the desired result. Patients choosing the natural smile, the vast majority of British patients I treated, give more freedom for you to develop your creative talents in designing new smiles.

Question 9.

If you could improve your smile would it boost your confidence?

This question looks at one possible psychological driver for treatment. A good result is very satisfying for both dentist and patient. Conversely, if the result has not met your patient’s expectations a complaint is inevitable.

Question 10.

What would have to change in your teeth for you to be pleased with your smile?

The tip here is to give your patient a hand mirror, and ask them to describe, tooth by tooth, what their concerns are. Record carefully the responses, but beware the ‘I’ll leave it up to you’ individuals.

Photographs, radiographs and study casts are a must. Once you and your technician have the above information you can consider your smile design and prepare a mock up for patient approval using the B set of casts (see tips entitled ‘Model Practice’).

There is much to consider, not least bilateral symmetry, position of the midline, central incisor proportion and dominance, golden proportion, axial inclinations, contact points and shades. Which restorative material will you use? Remember porcelain fused to metal gives significantly poorer light reflection then zirconium oxide reinforced crowns.

By the way, to avoid common errors, contact points are placed in the incisal third at UR1/UL1, mid third at UR2/UR1 and UL1/UL2, and gingival third for UR3/UR2 and UL2/UL3.

I prefer composite rather than wax for any tooth build-ups, not least because it does not deform when suck down clear plastic sheets are used to make temporary crown formers.

Finally I am reminded of Lord Moran (Winston Churchill’s doctor). When asked if surgery was an art or a craft he replied that with experience he hoped surgeons became more artful and crafty. Designing smile makeovers is a fantastic way for dentist to show those attributes.