The Aesthetic Revolution
30 years of pitfalls, lessons and successes
The lessons of our past define our future!
By Dr Derry Rogers
Over the last 30 years the research into adhesion, occlusion and preparation design have changed significantly and affected the clinical landscape we deliver. As a result of this, the author has seen the successes and failures of different prep designs, the birth and demise of many ceramic systems and the need to have a clear understanding of occlusion and parafunction in order to provide long term success for our patients.
What have we learnt:
- Patients grind and overload their teeth and our restorations.
- The design of occlusal schemas can assist in the longevity of our restorations, but there are some patients that will continue to grind and we need to manage their grinding forces to reduce the number of porcelain fractures we will have to manage.
- Patient expectations need to be reviewed and discussed before we can assist in their cosmetic smile design.
- The growth of the number of different ceramic systems needs to be constantly reviewed to ensure that we are providing the best strength, ability to manufacture and best aesthetic result for our patients with the ceramics we choose (or our labs choose for us!)
- The aesthetic success of a case is only complete when we have provided long term adhesive stability at the restorative tooth interface, created an occlusal scheme within the confines of the individual stomatognathic system and provided occlusal stability utilizing the strongest, most aesthetic materials for each case we treat.
- The relationship between ceramist and dentist is paramount to the final result and hence the satisfaction of our patients.
We have the responsibility to diagnose and create the treatment plan, but the larger the case or more demanding the anterior case, the more the communication skills between dentist and ceramist defines the success of the end result.
Over 30 plus years, my ceramist and I have enjoyed the best relationship and at times the stress of divorce. The ability to leave egos at the door and resolve our differences has defined the case successes we have enjoyed and more so, the smiles we put on our demanding patients faces.
Aesthetic failure is often related to the incorrect choice of material as well as a failure to understand the patient’s expectations and how those expectations can be housed within the often hostile environment of our patient’s mouths. Poor prep design, when occlusal factors prevent long term success and lead to fractures, as well as poor temporaries (or provisionals) can lead to cases being rushed and compromised.
If you cannot create the result in provisionals, the clinician will struggle to deliver a good aesthetic result.
Over the years we have been requested to retreat cases that did not necessarily consider all of these factors.
The difficulty in these cases is not just recreating a new smile but also managing the often bruised psyche and compromised cosmetic expectations that the patient may have developed after a failed aesthetic case.
Often the simple use of pre treatment wax ups and the transfer to the patient’s mouth during case discussion can highlight issues related to unrealistic expectations.
The attending clinician then has the choice to recommend referral to another clinician rather than find themselves dealing with unhappy patients who just want their old smile back.
The proliferation of different ceramic systems that have come and gone over the last 30 years is a concern.
We need to be clear on the expectations we place on these materials to stand up to the compressive and tensile forces of bruxers and parafunctional activities they manifest.
We have used PFM systems for many years with great success but the demands of “aesthetic success” have moved us towards all ceramic systems – but at a price! The beauty of layered porcelain will often win over monolithic systems even though one will provide strength and the other beauty.
We need to be mindful of these differences and also develop our communication skills to be able to explain these types of limitations to our demanding clients.
They often forget the disclosures we provided at case discussion when porcelain fractures become an issue; so the need to provide written advice and relevant warranties are a requirement of the modern day clinician as well the ability to understand how to communicate to different personality styles.
Records required for complete treatment planning and case presentation include:
- Full photographic records
- Hard and soft tissue examination
- Full periodontal charting
- Occlusal examination with TMJ screening
A full set of photographic records enables the clinical team to overview all aspects of its design, including specialist referrals and ceramist consultations.
Ultimately when final restorations are delivered, the relevance of the team process can be seen.
Not all cases are going to require the use of specialists but many exclusively anterior aesthetic cases will require a clear understanding between the dentists and ceramists as to the expectations of treatment and the restrictions imposed by material selection in the sometimes hostile environment of the mouth.
The Digital revolution:
The last five years have been exciting in the development of CAD/CAM systems and their integration into modern day practice.
These developments have reduced the regular need for ceramists, especially in the creation of restorations in low level aesthetic cases. The author has seen monolithic systems deliver excellent results that have satisfied both patients and clinicians alike.
The exceptions to this rule are the demanding clients that want perfection and demand aesthetic results that challenge even the most disciplined and creative ceramist / dentist teams.
In these situations, the relationship and artistic skills of the ceramist / dentist team are required to deliver “wow” .
In overview, we are living in one of the most exciting times in dentistry. We have to be careful not to expect too much of our new materials until we have trialled them in the clinical situations that warrant them.
The choice of a monolithic high strength anterior single crown in a bruxer may not provide the ability to achieve a natural result. And the choice of a refractory layered posterior crown with a patient demanding high level aesthetics potentially can lead to cohesive porcelain failure in a 3-5 year period.
We need to ensure we carry out a full and thorough examination spending time to listen, quantify and qualify exactly what our patients expect to have at the end of the clinical treatment and then choose the appropriate materials on the basis of aesthetic expectations and the risk profile of prevalent parafunctional behaviours.
Our catch cry since the advent of cosmetic dentistry in the 80’s has been: “You don’t have to be born with a beautiful smile to have one.”
We need to fully understand our patients’ expectations and disclose the limitations we have when asked to deliver a beautiful smile.