Cosmetic/Esthetic - A Quarterly Newsletter on Dental SpecialtiesJADA

Achieving patient satisfaction, step-by-step

The template calls for the image at 225 by 175 but adjustments can be made within reason

It’s not uncommon for cases that start out with low esthetics to be accompanied by high patient expectations.  Researchers publishing in the summer 2014 issue of The International Journal of Esthetic Dentistry described how to manage such circumstances using the case of a 27-year-old woman with amelogenesis imperfecta.

Caused by protein mutations involved in enamel formation, the genetic developmental disorder causes light and dark discolorations and atypical crown shapes. The subject’s chief complaint was dark and white opaque staining. However, she was also bothered by teeth that overlapped and an asymmetrical gingival margin. Researchers hoped to sacrifice as little healthy enamel as possible, while still meeting high expectations for an improved appearance.

The initial clinical examination did not reveal the true depth of the staining, so in agreement with the patient, a step-by-step treatment plan was adopted.

The first treatment step consisted of a home bleaching process. The patient noticed a positive change and was motivated to seek further improvement.     
Step two was a microabrasion technique. Only the most superficial enamel layer was etched and removed with an abrasive paste and a rubber cup. Again, in the follow-up visit, the patient noticed improvement and wanted to continue treatment. This time the goal was to correct the position and shape of her front teeth.

All conditions were ideal for step three, a plan to restore the maxillary incisors and canines with ceramic veneers. At the outset, corrections were performed digitally, and foreseen changes were transferred into a wax-up. The dentist used the resulting mock-up to serve as a communication tool and discuss the prospective outcome with the patient.

Both were satisfied with the result during a try-in session, when veneers were inserted with glycerin gel in order to improve color assessment. All involved with the treatment plan were “very satisfied with the final treatment outcome,” authors reported.

“The patient was heavily involved in the process of decision-making and, therefore, her esthetic expectations could be integrated into the final treatment,” authors commented about the success.  “For the predictability of the treatment, a meticulous prediagnostics and a stepwise treatment protocol is crucial; otherwise the outcome may be compromised.”


How patients, clinicians define esthetic success

The template calls for the image at 160 by 160 but adjustments can be made

Patients and clinicians may prioritize different features when judging the esthetic outcome of root coverage treatment, research published in the March/April 2014 issue of the Journal of Esthetic and Restorative Dentistry reported.

The literature shows that appearance is the patient’s primary concern, and esthetic judgments are essentially subjective. Yet the relationship between an esthetic post-treatment evaluation by a clinician and a layperson had not been established, and few studies examined patient satisfaction, scientists in South Korea found.

Does background knowledge of root canal procedures create different expectations? Do objective and subjective measures of evaluation yield the same conclusions?

Aiming to evaluate the objective and subjective esthetic outcomes as assessed by patients and clinicians, the researchers conducted a retrospective study of 31 patients who had undergone root coverage procedures for the correction of esthetic problems created by 58 buccal gingival recession defects. The patients were treated at Kyungpook National Hospital between 2000 and 2010 and subsequently analyzed in 2011.
Both dentists and patients used two measurements for objective analysis:

For the subjective analysis, patients were asked about their esthetic satisfaction after root coverage procedures and instructed to score their satisfaction on a 1-to-5 point scale. Clinicians used preoperative and postoperative photographs to determine esthetic outcomes.

Results showed that clinicians’ objectively measured ratings increased in proportion to the percentage of root coverage, RES and patient satisfaction. Patients’ objectively measured ratings showed their satisfaction was in proportion with RES scores, but not with the percentage of root coverage.

One of the associated factors studied as potentially influencing clinician and patient assessments of esthetic success was initial recession depth and width. The study showed patients’ satisfaction increased with initial recession depth, whereas clinician ratings decreased.  Authors surmised that in cases of deep gingival recession, partial root coverage might be viewed by patients as a positive outcome if communications between patients and surgeons moderated patients’ expectations before surgery.

The results also showed that patients’ objective ratings of cosmetic results are more favorable than professionals’ evaluations. Clinicians seem to consider the percentage of root coverage as a larger portion of a successful outcome, and the inconsistency in satisfaction between professionals and patients may be due in part to the different perceptions regarding the importance of percentage of root coverage.

Among conclusions, authors said, “The inconsistency in satisfaction between professionals and patients might be due to the fact that for clinicians, percentage of root coverage is considered a larger portion of the success.”

They called for future studies with a prospective approach and a greater number of patients.

The template calls for the image at 160 by 160 but adjustments can be made

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Using wax-ups as blueprints for change

The template calls for the image at 180 by 180 but adjustments can be made

Being able to envision the end result of treatment is especially important for patients when the shape, size and proportion of the front teeth will be changed.

Fortunately, just as architects and engineers have blueprints, dentists and dental laboratory technicians have wax-ups, researchers publishing in the summer 2014 Issue of The International Journal of Esthetic Dentistry commented.

Wax-ups can be tested in the mouth with a resin mock-up so the patient can visualize the outcome and request adjustments prior to treatment. The dentist/dental laboratory technician team made a case for how using the wax-up/mock-up approach they described simplifies the challenging planning stage that dictates the decision-making process and helps the dentist, laboratory technician and surgeon throughout the entire course of treatment. In addition, the patient’s approval of the mock-up prior to treatment is a way of obtaining a “true informed consent.”

Intended to be approached as a single workflow, rather than a sequence of isolated procedures, authors explained the case presentation and treatment plan, diagnostic wax-up, mock-up-guided crown lengthening, second wax-up and teeth preparation, the alveolar model, ceramics and cementation throughout the course of their research.

The importance of giving patients appropriate time to decide if they like the mock-up and submitting proper photographic work to the laboratory were among authors’ advisements for preserving the value of the wax-up. 

“Once the mock-up has been accepted as the simulation of the final restoration, it can be copied, either by taking an impression or just correcting the wax-up. In this way, the wax-up/mock-up binomial takes a leading role from the diagnostic phase all through the surgical and prosthetic phase as the blueprint.”


Diagnosing and managing the ‘eagle’s talon’

The template calls for the image at 160 by 160 but adjustments can be made

The talon cusp, so described because of its resemblance to an eagle’s talon, is a cause of consternation for both patients and dentists. When the accessory cusp is visible on the facial surface of a tooth, its appearance is likely a patient’s first concern. For the dentist, finding out if the cusp is close to pulp or contains pulp is critical to diagnosis and treatment planning.

In addition to diminished esthetics, talon cusps can cause chewing difficulties, fractures, caries susceptibility and speech impediments. Clinical management of the anomaly depends on the size and shape of the affected tooth and the problems it causes, so it differs drastically from patient to patient.

Scientists at Istanbul University studied the case of a 21-year-old female referred for treatment and used their findings to outline a practical esthetic treatment option for the conservative management of a talon cusp. The Journal of Esthetic and Restorative Dentistry reported on the research in the April 23, 2014, online edition.

After discovering an accessory cusp of approximately 2 millimeters in diameter separated from the rest of the crown on the facial aspect of the subject’s maxillary right central incisor, the researchers used panoramic and periapical radiography to further investigate.

Composed of normal enamel, dentin, and varying extensions of pulp tissue, the composition of a talon cusp is typically difficult to determine because of its superimposition on the main pulp chamber.

In this instance, radiographs indicated a “V”-shaped radiopaque structure and three radiolucent globe areas but did not indicate a connection to the pulp chamber or a clearly defined form.

To clarify and establish a definitive diagnosis, scientists referred the patient for a 3-D cone-beam computer tomography scan. CBCT confirmed that the pulp chamber was distinct from the globes, and a diagnosis was made.
Two-dimensional radiographs are not sufficient to understand the complex anatomy of the crown in such an anomaly, researchers reported. However, with the advent of CBCT, diagnoses and correct treatment have become possible, they said.

         In discussion researchers said, “Too many clinicians do not use cone beam because they don’t have one, although there is access to a dental computed tomography scan technology in other dental offices/specialty practices,” authors said. “In the present case, CBCT made it possible to observe a cusp that was not communicating with the pulp.”

         Among their conclusions, authors advocated for early diagnosis and treatment to avoid complications and to maintain a healthy pulpal and periodontal status. “CBCT not only can help in diagnosis but can also serve as an important aid in treatment planning and in ensuring successful results,” they said.

Ivoclean and the intraoral try-in
By Dr. Ron Jackson
Middleburg, Va.

Ideal for use after intraoral try-in, Ivoclean is a universal cleaning paste that effectively cleans the bonding surfaces of all types of restorative materials. The intraoral try-in step confirms proper restoration fit before final placement and remains an essential component of predictable restorative techniques.

During the try-in step, the surfaces of the restoration can become contaminated with blood and/or saliva, creating a barrier that prevents primers from physically bonding to the surface of the restoration. Traditional methods for removal—including rinsing, brushing, steaming or phosphoric acid application—can only remove some, but not all, of the contaminants.
However, thoroughly cleaning the bonding surface of restorations with Ivoclean ensures optimum surface conditions, setting a foundation for strong and durable bonds between the adhesive luting material and the restoration.
Ivoclean is suitable for all types of restorative materials, including glass-ceramics, zirconium-oxide ceramics, aluminium-oxide ceramics, precious metal and base metal alloys, and laboratory fabricated composite restorations. It removes any excess contaminants that can inhibit bonding. It’s active ingredients contain zirconium-oxide particles suspended in a gel, which, once applied to the surface of the restoration, attract residual phosphate contaminants found on the internal surface of the restorations. Ivoclean absorbs the contaminants like a sponge, and after 20 seconds, the gel and contaminants can be rinsed away. By removing any contaminants present on the internal surfaces of a restoration, Ivoclean provides the ideal surface to maximize adhesive bonding and longevity. Unlike traditional methods, Ivoclean ensures complete removal of contaminants, offering increased predictability and adhesive strength for final restorations.

A step-by-step demonstration

The Ivoclean bottle was shaken well before dispensing. After the monolithic zirconia crown was tried-in, Ivoclean was applied to the intaglio surface of the restoration. The cleaning action of Ivoclean was allowed to take effect for 20 seconds, after which the paste was thoroughly rinsed with water spray.

After rinsing, the crown was dried with oil-free air. A restorative primer was applied to the clean surfaces and allowed to react for the appropriate time. Excess primer was dispersed with a strong stream of air. The resin cement was loaded into the monolithic zirconia crown and bonded to place, according to manufacturer’s directions.

The patient needed a new crown on tooth #18. A monolithic zirconia crown was fabricated and returned from the laboratory. The crown was tried in to confirm fit, occlusion adjusted and crown repolished.

On removal of the restoration, the Ivoclean bottle was shaken well before dispensing, and the restoration was rinsed with water and dried with oil-free air. Ivoclean was applied to the intaglio surface of the restoration using a microbrush. After 20 seconds, the restoration was thoroughly rinsed with water and dried with oil-free air.

A restorative primer was then applied to the clean surfaces and allowed to react according to the manufacturer’s instructions for use. Any excess primer was dispersed with a stream of air. After the prepared tooth was cleaned, a bonding agent was applied. The resin cement was loaded into the restoration, and the monolithic zirconia crown was seated with light pressure. The cement was tack cured, excess peeled away and final cured, according to the manufacturer’s directions.

A 1972 graduate of West Virginia University School of Dentistry, Dr. Jackson has published and lectured extensively on esthetic, adhesive dental care.

ADA offers brochure on veneers

The template calls for the image at 160 by 160 but adjustments can be made

A patient brochure titled “Dental Veneers” (W288) can be ordered through the ADA Catalog using the promo code 14354E.

 The ADA is offering members a 15 percent discount on all catalog orders placed with the promo code through July 15.

A colorful 6-panel educational resource, the veneers brochure is available in packs of 50, 100, 500 and 1,000. They can be ordered at or by calling the ADA Member Service Center at 1-800-947-4746.

“Dental Veneers” features before-and-after photos and explores the benefits of treatment using both porcelain and resin veneers.

The template calls for the image at 160 by 160 but adjustments can be made

Smile to the Max with IPS e.max
The new Smile to the Max application for smartphones and tablets provides patients with a wealth of information about the benefits of transforming their smiles with IPS e.max, the leading all-ceramic, metal-free material for today’s dental treatments.  It’s a great tool for educating patients about the benefits of IPS e.max.  The app is now available for download at iTunes and Google Play.


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