Considerations for Successful Esthetic Smile Design

The Roundtable is a forum for debate on key topics, trends, and techniques in dentistry. For each edition, a panel of experts examines a subject to help expand your knowledge and improve your practice. This month, our panel discusses esthetic dentistry, focusing on patient expectations in the esthetic zone, preparations, restorative options, and recommendations for bonding success. To watch the whole conversation, go to: insidedentistry.net/go/roundtable-indirect

Inside Dentistry (ID): How do you successfully navigate patient demands and expectations with your clinical protocol, and is it you or the patient who is ultimately answerable for the smile design?

Dennis Wells, DDS (DW): Successfully navigating patient demands and expectations with my clinical protocol, even after 35 years, is still a difficult process. At my practice, we approach every case using "prototypes," a word I borrowed from Jimmy Eubank, DDS, years ago. We want our patients to test-drive and approve their smiles before we move forward with ordering the case from the ceramist. Swatches, computer simulation, and photographs are helpful, but for patients, nothing can compare to having their new smile in their mouth, under their lips, and being able to test it phonetically, functionally, and esthetically. As for the design, it's a co-effort between the dentist and patient. Dentists have the responsibility to use their expertise and knowledge of teeth and the chewing system, as well as their knowledge of esthetics and their own personal taste, and marry that with the patient's interests, tastes, and specific wishes. If we allow the patient to take too much control, they simply don't have enough information. If the dentist has too much control, then many times you're going to miss the arena of patient subjectivity that is inherent in smile design. Beautiful smiles present in a limitless number of looks, feels, and artistic designs, and if we don't create a partnership, then the design is vulnerable to failure. At my practice, we try to be coaches and consultants. We're not dictators in the smile design process, but we sometimes have to explain to the patient what his or her role is, the limits of that role, and where they ultimately do have to trust us. The more that I do this, the more I appreciate just how tricky the communication is and that there is a sweet spot-you just have to know how to get to it.

Peter Harnois, DDS (PH): Dennis is absolutely right. There comes a point when the patient has to trust that we know what we're doing. We allow the patient to become part of the process by introducing them to a trial smile that they can wear inside their lipline and function with for 3 to 4 weeks before the laboratory finishes the ceramic work. We've all been trained by the American Academy of Cosmetic Dentistry to work from patient-approved provisional restorations, and when a patient likes their temporaries, it removes some of my stress. Before that came to fruition, we could hope that a patient would be happy with their new smile, but we wouldn't know for sure. Now, patients have the ability to approve a restoration that the laboratory then reproduces. To ensure success in complex cases, when the patient is chairside, I take off half of the temporaries to see that the lab has actually mirrored them correctly. It's very helpful to get information from the patient about what they want. If a patient brings in picture of a celebrity and tells me that he or she wants to have those teeth, it makes my job quite a bit easier, and the design becomes a co-partnership.

David Hornbrook, DDS (DH):We demand that our patients trust us, but I can guarantee that in the past, when patients have said, "Do whatever you think is right. I trust you," we've had to redo some cases. The trial smile, prototype, mock-up, and provisional restorations address the things that need to be done and how the patient wants to look, but they are also about defining variables. These are things like shape, length, contours, surface texture, and incisal edge characterizations. When I consult my patients, I believe that they are building what I call a "brain smile." They might say that they want white teeth, but I'm not just going to go with that. I'm going to show them examples of what "white" is using shade guides, my own teeth, my dental assistant's teeth, or photographs. My goal is to have them look at that shade tab or another smile and say, "Yes, that is what I meant." Then they'll put that exact shade in their brain smile. I do this with any smile variable because even though they trust me, some of the variables that I like, they may not like. I make sure that I use examples for the different aspects of those variables so they'll put them in their brain smile. They're the homeowner, the ceramist is the builder, and I'm just the architect. My goal is to make sure that everything is done properly so it lasts a long time, but I want to take my patients input, add nuances to make sure it's going to look esthetically pleasing, and try to guide them in the direction that I feel is going to be best for them.

ID: There are many material options available today from feldspathic porcelain, to lithium disilicate, to the ever-popular zirconia esthetic. What are your considerations and go-to materials to satisfy expectations?

DW: I have a personal bias, which is toward feldspathic powder liquid ceramics. I feel pretty strongly that those are the gold standard in terms of pure esthetics and the ability to assemble a restoration in a way that mimics nature like none other. With that said, I think the harder materials that we have now-the zirconias and the lithium disilicates-are gifts sent from the dental gods because there are definitely patients whose muscle forces and parafunctional habits are going to exceed the limits of their own natural teeth as well as feldspathic porcelains. You can set the teeth up as perfectly as you want in their mouths and have the occlusion dialed in, but if patients bite their nails, then they're more than likely going to challenge their ceramics in the same manner as their natural teeth. Lithium disilicate is a material that we go to from time to time without cutting it back and weakening it, but it's always a second choice if we're talking about really demanding esthetics.

PH: I agree with everything that Dennis said. There was a time when the only thing that I wanted to use was feldspathic porcelain. Then IPS e.max (Ivoclar Vivadent) and the lithium disilicates came out. With those materials, you get flexural strength that ranges from less than 100 MPa to more than 400 MPa. I've become a strength person, and I've never looked back. I use lithium disilicate, and Dennis made another great point in that it can't be cut back, or you'll lose the advantage of using it in the first place. There's a process using an Additive-Reductive Template (DenMat) for which I'm now a part of the education team. With this process, you put reduction templates over the patient's teeth and minimally reduce only what is necessary to get an ideal arch form.

You can get lithium disilicate down to 0.3-mm thick and use a bur or rubber disk at the margin, and then you do not have to necessarily prepare a margin in these cases. I've started to combine all of the best elements of minimally invasive dentistry. And yes, I'm giving up some esthetics, but when I make the decision for my patients, the strength allows me to sleep better at night.

ID: Peter, there seems to be fear associated with esthetic bonding. Is there any key advice you can pass along to help others ensure the predictable outcomes that you achieve for your patients?

PH: I may be giving a very simplistic response to this, but my advice is to read the directions and look at the science behind them. Google the components and become a student of the chemistry behind the materials. Once you take some time to research and understand the systems, it takes away the stress.

DH: Well, I think Peter is exactly right-reading the directions is number one. Unfortunately, those are the first things that are thrown out by the average dentist. Fortunately, these can now be retrieved from the internet if thrown away. It's also important to slow down. Everyone wants something that is faster, easier, and cheaper, but it doesn't always work that way. I think newer dentists believe that they need to put these restorations in the mouth in 1 hour or that they need to have four or five hygiene checks during a smile design insertion appointment. Instead of rushing, do everything possible to make sure that you're doing the very best that you can for the patient you're working on. Follow mentors, look at research instead of flashy advertisements, take your time, isolate properly, and read the instructions.

DW: You should also have a very strict protocol that is followed by you, your team, and your laboratory. The entire process should be cinched down tight so that each step runs smoothly. Bonding can be really fun and exciting as long as you're in control.

Dennis Wells, DDS, is a member of the American Academy of Cosmetic Dentistry and maintains a private practice in Nashville, Tennessee.

Peter Harnois, DDS,is the president of the Illinois American Academy of Facial Esthetics and is in private practice in Hinsdale, Illinois.

David Hornbrook, DDS, is the director of education at Utah Valley Dental Lab and maintains a private practice in San Diego, California.