Managing Esthetics and Economics in the Older Patient: A Case Report

The uncertainty of the current economic climate and sudden rise in everyday living expenses are impacting patient choices regarding their oral care needs.^1,2 Patients who once might have chosen to improve their appearance with a full smile makeover are now asking their dentists to develop treatment plans that balance their esthetic needs with their budgetary constraints. This is especially true for patients who are 65 years or older and living on a fixed income.

According to the U.S. Census Bureau, the number of adults living in the U.S. who are aged 65 and older numbered 61.5 million as of June 2025 and represented 18% of the total population as of 2024.³ Because Americans are living longer, the 65-plus age demographic represents the fastest growing in the U.S. and in years to come will likely become an ever-growing segment of the dental practice patient base.⁴ 

The positive outlook for dentists is that older patients are retaining more of their natural teeth than previous generations, and based on their rate of dental visits plan on keeping them as long as possible. Over the past 20 years the rate of edentulism in adults 65 years and older fell from 32% to 17%, and among those 75 years and older fell from 32% to 22%, according to a report from the National Institute of Dental and Craniofacial Research.⁵ Tooth retention in these age groups may be due to the fact that a majority (63.7%) of this population visits the dentist at least once a year, most likely in hopes of maintaining their good oral health and decreasing any causative factors of tooth loss.⁶

For dentists treating older dental patients, understanding their motivation as well as their financial limitations is critical to treatment acceptance. Spending extra time to create and discuss a range of treatment options that meet the patients’ treatment goals and walk them through the cost and the ramifications of accepting or rejecting each of the proposed restorative options demonstrates a commitment to helping them achieve their desired outcome.

Case Report

A 75-year-old female retiree on a fixed income presented with a chip on the incisal edge of central incisor No. 9 (Figure 1). Her expressed goal was an esthetic restorative solution that appeared natural and would also close the black triangle between tooth No. 8 and tooth No. 9. She was adamant that the treatment plan offer a minimally invasive approach that would destroy as little healthy tooth structure as possible.

As an existing patient, she had been made aware of the misalignment of the teeth in her lower arch and advised on the potential problems the misalignment might cause. Scans of both arches (iTero, Align Technology, Inc.) had been presented to the patient to help her visualize the tooth wear and extent of misalignment (Figure 2 and Figure 3). However, until this event the patient had believed straightening the teeth in her lower arch was a discretionary treatment expenditure and had opted out.

It was explained how the additional years of tooth wear on the lower arch had exacerbated her constricted chewing pattern (Figure 4), resulting in the chipping of tooth No. 9. Aligner therapy would open up her bite and provide the space needed to restore tooth No. 9 and prevent further tooth wear in the lower arch as well as protect restored teeth Nos. 8 and 9 and natural teeth Nos. 7 and 10 from future damage. The patient readily agreed to aligner therapy. Intraoral scans were taken for creation of aligners (SureSmile Aligners, Dentsply Sirona) to straighten the teeth in her lower arch.

With aligner therapy complete (Figure 5 and Figure 6), the patient returned for a consultation discussion concerning restorative options that would provide her with the esthetic and natural-looking treatment outcome she desired. Her upper arch exhibited a host of patchwork dentistry that was exposed in her broad smile. One treatment option proposed to the patient was to restore teeth Nos. 5 to 12 to achieve the symmetry and seamless esthetics of a natural smile. However, because of her age and financial constraints, the patient rejected any treatment plan that moved beyond simply restoring teeth Nos. 8 and 9, which would meet her desire to slightly lengthen her central incisors and give them more natural translucency as well as close the interdental space between the two teeth. The full treatment plan after alignment therapy was to restore teeth Nos. 8 and 9 with minimally invasive veneers.

Retracted and non-retracted photos of the patient with Facial Reference Glasses (Kois Center) (Figure 7 and Figure 8) as well as macro and micro photos (Figure 9 through Figure 13) were sent to the laboratory to communicate the patient’s goals for fabrication of a digital diagnostic waxup of the proposed final treatment outcome.

Preparation and Temporization

After approval of the diagnostic waxup, the patient was scheduled for the preparation and temporization appointment. In order to successfully ensure closure of the interdental space between teeth Nos. 8 and 9, the distance from the gingival margin to the alveolar bone must measure 5 mm or less in order for the interdental papilla to successfully fill the space postoperatively.^7-9 Sounding to bone resulted in a measurement of 4 mm.

The patient was anesthetized and teeth Nos. 8 and 9 were prepared. Retracted polarized photos were taken of the prepared teeth with and without a stump shade guide for reference (Natural Shade Guide, Ivoclar) to aid in communicating the value of the stump shade and shade of adjacent teeth to the laboratory (Figure 14 through Figure 16) for fabrication of the veneers. The laboratory delivered a putty matrix of the patient-approved diagnostic waxup for chairside fabrication of temporary restorations. Using the shrink wrap technique,¹⁰ the preparations were spot etched for 15 seconds (Ultra-Etch, Ultradent Products Inc.) and rinsed and then a self-bonding agent applied (All-Bond Universal, BISCO) and cured (Valo X, Utradent Products Inc.). A self-curing bis-acryl composite temporary material (ExperTemp A1, Ultradent Products Inc.) was injected into the putty matrix and the putty matrix inserted into the patient’s mouth. The margins were trimmed with the embrasure between Nos. 8 and 9 slightly exaggerated to allow space for the papilla to drop down and close the space prior to seating the final restorations. After one week, the patient approved the provisional restorations, and a full complement of photos of the temporized patient was taken to communicate with the laboratory (Figure 17 and Figure 18).

Delivery

The final restorations were received from the laboratory and the patient scheduled for a try-in appointment. The patient was anesthetized, and a lip and cheek retractor was placed (OptraGate, Ivoclar). The provisional restorations were carefully removed and excess debris on the preparations removed. A translucent try-in paste (Choice 2, BISCO) was applied to the veneers and the restorations seated. Once seated it became apparent the veneers were too bright in value midfacial to incisal. Although the patient initially approved the finals, the clinician insisted they be sent back. The veneers were returned to the laboratory along with images of shade tabs of the temporary material and polarized images taken to communicate the value of adjacent teeth (Figure 19 through Figure 21). Temporary restorations were once again fabricated chairside and placed. A week later the second set of final restorations arrived from the laboratory and the try-in protocols repeated (Figure 22).

Both the clinician and patient approved the color match of the final restorations. The bonding protocol was repeated and the second set of final veneers seated. After a month of wearing the final veneers, the patient returned to the practice for a final assessment. Tissue health around the two veneers appeared excellent, and the black triangle between Nos. 8 and 9 was closing as expected. The patient was thrilled that her central incisors blended so well with surrounding dentition and appeared natural (Figure 23 and Figure 24).

Conclusion

The U.S. Census Bureau projects that by 2035 the United States population of adults 65 years and older will, for the first time in history, outnumber those who are 18 years old and younger.¹¹ As the population of older adults increases, so will the demand for oral health services from prevention and risk management to restorative care. However, the cost of care along with other factors such as medical history, living arrangements and other factors may be primary drivers for the types of dental treatment they choose.

Fortunately, dentistry offers a full range of treatment options that can be tailored to meet patients’ esthetic desires as well as financial concerns. Using a personalized approach to help patients navigate oral health options that offer the best esthetics with the fewest risks, the greatest longevity, and most affordability will help patients make informed decisions about their oral health needs.

About the Author

Dimple Desai, DDS
Private Practice,
Newport Beach, California

Figures and Images

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Dimple Desai, DDS

Figure 1

A 75-year-old patient presented to the practice with a small incisal chip on tooth No. 9.

Figure 2

An intraoral scan taken at a previous appointment and shown to the patient to advise her of potential problems the misalignment may cause in the future.

Figure 3

An intraoral scan taken at a previous appointment and shown to the patient to advise her of potential problems the misalignment may cause in the future.

Figure 4

An intraoral scan taken at the appointment illustrated to the patient how additional years of tooth wear had constricted her chewing pattern and was a causative factor in the chipping of tooth No. 9.

Figure 5

Intraoral scans after aligner therapy.

Figure 6

Intraoral scans after aligner therapy.

Figure 7

Full face retracted and unretracted photos of the patient were taken with Kois Reference Glasses for communication with the laboratory for fabricating the final veneers.

Figure 8

Full face retracted and unretracted photos of the patient were taken with Kois Reference Glasses for communication with the laboratory for fabricating the final veneers.

Figure 9

Macro and micro photos of the patient were sent to the laboratory along with the patient’s expressed esthetic goals.

Figure 10

Macro and micro photos of the patient were sent to the laboratory along with the patient’s expressed esthetic goals.

Figure 11

Macro and micro photos of the patient were sent to the laboratory along with the patient’s expressed esthetic goals.

Figure 12

Macro and micro photos of the patient were sent to the laboratory along with the patient’s expressed esthetic goals.

Figure 13

Macro and micro photos of the patient were sent to the laboratory along with the patient’s expressed esthetic goals.

Figure 14

Retracted polarized and non-polarized images with and without stump shade guide were taken of the patient’s prepared teeth No. 8 and No. 9 for communication with the laboratory.

Figure 15

Retracted polarized and non-polarized images with and without stump shade guide were taken of the patient’s prepared teeth No. 8 and No. 9 for communication with the laboratory.

Figure 16

Retracted polarized and non-polarized images with and without stump shade guide were taken of the patient’s prepared teeth No. 8 and No. 9 for communication with the laboratory.

Figure 17

A retracted image of the temporized patient with Kois glasses to communicate midline was sent to the laboratory for fabrication of final veneers.

Figure 18

Temporary restorations with shade tabs used to communicate to the ceramist the desired shade for the final restorations.

Figure 19

Retracted and non-retracted views of the seated veneers were sent back to the laboratory for refabricating the restorations. Figure 20 is a polarized image; Figure 21 is not polarized. The second set of final restorations arrived from the laboratory and the try-in protocols repeated.

Figure 20

Retracted and non-retracted views of the seated veneers were sent back to the laboratory for refabricating the restorations. Figure 20 is a polarized image; Figure 21 is not polarized. The second set of final restorations arrived from the laboratory and the try-in protocols repeated.

Figure 21

Retracted and non-retracted views of the seated veneers were sent back to the laboratory for refabricating the restorations. Figure 20 is a polarized image; Figure 21 is not polarized. The second set of final restorations arrived from the laboratory and the try-in protocols repeated.

Figure 22

The second set of veneers was seated and matched esthetically with adjacent teeth. The patient was thrilled with the outcome.

Figure 23

The second set of veneers was seated and matched esthetically with adjacent teeth. The patient was thrilled with the outcome.

Figure 24

The second set of veneers was seated and matched esthetically with adjacent teeth. The patient was thrilled with the outcome.

Dimple Desai, DDS

Private Practice Newport Beach, California