Avoiding Patient Disappointment

When a patient describes his or her concept of ideal teeth as "white, natural looking, and beautiful," what exactly does he or she mean? Do these words have the same meaning from patient-topatient as they do for the dentist and the ceramist who will make the teeth? Communication in dentistry is a complex issue, yet essential to a satisfactory outcome. Communication is not a shapeless, subjective entity. There are specific tools and methods that can be used to ensure that a consistent message travels among everyone involved, to achieve the desired restoration, with no surprises for anyone.

In the past decade, the application of porcelain laminate veneers has become one of the most popular esthetic dental modalities because of the conservative nature, increased predictability, and versatile beauty of the restorations. However unlike crowns and bridges, the colors that can be established in porcelain laminate veneers are predicated on several factors, including:

1. Color of the underlying tooth structure;
2. Thickness of the ceramic veneer; and
3. Color and opacity of the underlying luting composite used, in the case of thin porcelain veneers.

Figure 1 A. Preoperative smile of a patient who was unsatisfied with the appearance o f her teeth.:

Figure 1 B. Retracted view following treatment in which
10 porcelain veneers were luted in place.

Figure 1 C. Postoperative new smile with 10 porcelain veneers.

In some clinical cases, the patient's desire is to alter not only the color of the teeth but also the tooth shape, alignment, and surface texture, to improve his or her overall smile (Figure 1). Figure 2 presents a case in which the patient's wish was to close the diastema and keep the shade in harmony with her natural dentition. These types of cases, in which the natural tooth color is of an acceptable shade, can be predictably restored, using the underlying color, by fabricating thin porcelain veneers in a lighter shade combined with a clear composite luting cement. The ceramist can create natural, lifelike veneers (see Figure 1, B). Although the veneers may be lighter than the opposing arch, they still blend in harmoniously, because of the vitality and translucency obtained with the veneers (see Figure 1 C).

Figure 2 A. Preoperative smile of patient who was unhappy with the diastema between her teeth.

Figure 2 B. Retracted view following treatment in which four porcelain veneers were luted into place.

Figure 2 C. The four porcelain veneers maintain harmony with the patient's natural dentition.

How can communication be improved with patients who find their natural tooth color to be acceptable, but who want the overall tooth size enlarged (Figure 3)? In the case presented, the final shade was established with internal characterization and special effects in these unusually thick veneers (see Figure 3, B). This technique is strictly controlled by the ceramist's ability and does not allow the restorative dentist to change and shift the color with composite, as can be done on more translucent veneers that are only 0.5 mm thick.

Figure 3 A. Preoperative smile o f a patient who was unhappy with her relative tooth size and amount o f show during smiling.

Figure 3 B. Postoperative retracted view o f the final porcelain laminate veneers in place, resulting in increased visibility o f the teeth during smiling.

Figure 4 presents a case with a vertical maxillary deficiency that showed when the patient smiled. Her desire was to change the shade, length, and relative shape of the teeth, to create an illusion of a more ideal smile, with visible teeth. To do so, it was necessary to establish the correct tooth length by first fabricating a removable trial restoration (see Figure 4, B) or by applying direct composite material on the natural teeth (see Figure 4, C). The trial restoration was then evaluated relative to the lipline for visibility and harmony. The trial restoration should be fabricated by the same ceramist who will be creating the final porcelain restoration, to enable the patient to see the ceramist's interpretation of their combined preconceived ideas. This final restoration can be altered for length, shape, and color, before becoming the blueprint for the final restoration. The patient can then analyze the teeth for length, width, shape, and even color. To some extent, the patient can actually live with the provisional prior to the ceramist actually fabricating the veneers in ceramic and before tooth preparation. A removable, laboratory-fabricated cold-cure acrylic temporary series of veneers allows
the patient to understand the inherent limitations of lengthening the incisal edges without jeopardizing function. The ceramist is then able to follow this blueprint and layer the internal characterization in the final ceramic veneers, in the correct relative position, without wondering if it is the right length.

Figure 4 A. Preoperative smile of a patient who was unhappy with her overall tooth length, form, and color.

Figure 4 B. Self-cure acrylic laboratory-fabricated provisional restoration for patient's visualization of the final outcome.

Figure 4 C. An alternative method, on a different patient, using direct composite application to demonstrate to patient prior to tooth preparation the clinician's ability to increase tooth size.

Figure 4 D. Retracted view of the laboratory-fabricated cold-cure removable trial restoration acrylic.

Figure 4 E. Patient's new smile line with the removable trial acrylic laminate restoration.

Trial veneers can be used to improve patient communication, in selective cases, at the pretreatment stage. Patients with old veneers or bonded restorations may request new white, but natural looking veneers to improve their smiles (Figures 5 and 6). The conventional method to treat these patients would be to remove the old veneers or bonding,

Figure 5 A This patient was satisfied with her opaque 15-year-old bonded restoration in the maxillary arch but desired porcelain laminate veneers in a whiter shade.

Figure 5 B Trial veneers on the lower arch, for the patient's approval o f the final shade before removing the bonding.

Figure 6. A patient's smile with a series o f porcelain veneers that had been placed elsewhere 3 months previously. She was unhappy with then, unnatural appearance.

If this method is used without adequate communication, the patient might decide that the restorations are too artificial and white or too natural in appearance. In this situation the restorative dentist does not have many alternatives: either try to convince the patient to keep the veneers or redo the case.
re-prepare the teeth, and make impressions of the prepared teeth. The impressions would then be sent to the laboratory along with a prescription relating the patient's wishes. Hopefully the ceramist will interpret the written description and meet the patient's concept of what "white" should look like.

For a patient suffering from tetracycline staining and considering porcelain laminate veneers as a treatment alternative, the dilemma is in choosing the appropriate shade (Figure 7). Would very translucent veneers or very white veneers be what was in his or her mind's eye? How can the dentist accept the case and offer the patient an unknown result, taking the risk of having an unhappy patient?

To prevent miscommunication, these types of cases are routinely approached in two stages in a complete trial ceramic, with veneers that are fabricated and used for shade evaluation only.

TWO-STAGE TRIAL CERAMIC RESTORATION PROCEDURE

Stage 1

In the first stage, an impression is made of the natural teeth before the bonding or veneers are removed or the tetracycline-stained teeth are prepared. The ceramist then fabricates several sample veneers with varying levels of translucency and opacity (see Figure 7, B). It is important that the sample veneers be the same thickness as the final restorations will be.

At the next appointment, the veneers are positioned on the natural teeth with try-in paste or glycerin. The patient can see the choices for the final outcome and compare the potential outcome with the old restorations (see Figure 5, B). Thus,
the patient is assured that the new look will be satisfactory. A patient has the opportunity to assess the options, for example, a more translucent veneer or a more opacified veneer, before committing to a treatment plan (see Figure 7, C).

A series of key leading questions should be outlined at the trying-in of these veneers. "Do you see a difference?" If the patient does not, then the ceramist knows that there is greater freedom to do what he or she feels is more attractive. If the patient does see a difference, then follow-up by asking, "What difference do you see?" and then "Which do you like best?" The patient must make this decision, because esthetics is a subjective issue and a matter of emotional feelings, preference, and opinion. Everyone has a different opinion of what is esthetic. If the dentist influences the patient's decision, the patient may return unhappy and say that his or her choice was based upon, or influenced by what the doctor had suggested.

The patient shown in Figure 5, B decided that the trial veneers were still "not white enough." Using a temporary restoration saved the patient and the entire dental team the trauma of going through an irreversible process and certain disappointment with the final result. The case was simply not undertaken.

The patient shown in Figure 7, C felt more comfortable with the more opacified version of the veneers. Although the more translucent veneers often seem more natural to dental professionals, the patient's concept is often quite different.

Stage 2

In cases where tetracycline staining is present or where the teeth will become darker with enamel reduction it is recommended to repeat the evaluative method after reduction. The patient should assess the alternative restoration when it is positioned on the actual darker prepared tooth substance. Obviously this would only be done for the application of six to ten porcelain veneers to change the overall smile, not for one or two veneers that require matching to the adjacent tooth color.

ADVANTAGES AND DISADVANTAGES OF A TWO-STAGE PROCEDURE

Following, are some of the advantages of this type of procedure:

· The patient is involved in selecting realistic and desired shades.
· If the patient does not like any of the shades, teeth have not been reduced and retain their form or the old restorations.
· The dentist and ceramist are not trapped with an unhappy patient and repeatedly redoing the case.
· The dentist and ceramist can detect if the patient has unrealistic expectations before teeth are prepared for restorations.
· There is better understanding of the patient's likes and, perhaps more importantly, his or her dislikes.
· If the patient is not happy with the shade the first time, he or she can consider alternative shade at a subsequent appointment

Figure 7 A. Retracted close-up preoperative view of a male patient who suffered from tetracycline staining.

Figure 7 B. Relative opacity levels were developed with two trial veneers, using the platinum foil technique. Note that on the upper left central incisor the underlying platinum foil bleeds through the ceramic, and it appears to be more gray because o f the increased translucency. On the upper right central incisor, the opacity level is such that it blocks out the platinum foil and so creates the foundation for a brighter final veneer.

Figure 7 C. Retracted view o f the two trial veneers in place, with try-in composite for the patient's selection of the desired final shade.

The disadvantages of this type of procedure include:

· Increased laboratory and chair time, which incurs additional cost to the patient.
· Extra office visits for the patient.
· Not having the accurate tooth substructure shade on which to work.

SUMMARY

The type of communication described makes up a kind of three-dimensional pretreatment communication that leads to greater patient satisfaction and helps to reduce the likelihood of lawsuits from patients who feel that they were promised results that were not met. The method of try-in veneers allows the patient be a part of the outcome in the pretreatment stages. This can lead to a happier, more satisfied patient, which is what all practitioners strive to obtain.

Figure 1. A, B, C, Dentistry by Angela Gribble, DDS; periodontics by Maurice Salama, DMD.

Figure 2. A, B, C, Dentistry by Angela Gribble, DDS; periodontics by Maurice Salama, DMD.)

Figure 3. A, B, Dentistry by David Garber, DMD.

Figure 4. A, B, C, D, E, Dentistry by David Garber, DMD.

Figure 7. A, B, C, Dentistry by David Garber, DMD.