In recent years, the public has been exposed to an intense media barrage that has educated them about cosmetic dentistry, periodontal and facial plastic surgery, and implant dentistry. Television shows, infomercials, and dental-product advertisements in print and electronic media have placed beautiful people with fantastic smiles in front of current and potential patients. Patients associate attractive smiles with success and new beginnings. Because of this publicity, offices that provide such services have shifted their emphasis from educating patients about available procedures to educating patients who ask for specific cosmetic procedures about how those procedures are performed and what expectations they can achieve.
Office staff involvement
As these newly educated patients contact your office, they expect to encounter staff members who can answer cosmetic and restorative questions. Accordingly, all staff members should understand and communicate all information necessary to educate patients about cosmetic procedures. To ensure that all staff members have appropriate levels of knowledge, expose each person to basic cosmetic, restorative, and implant procedures from start to finish. Many patients ask any member of the staff complex questions about these procedures. If all staff members have complete, basic knowledge of these procedures, patient confidence and their perceptions of the office will rise.
If any staff members are candidates for cosmetic restorative or periodontal procedures, the procedures should be accomplished with the understanding that they will allow patients to view them when asked. More often, these staff members will receive unsolicited compliments from patients.
Philosophy
Incorporating porcelain veneers as an option for routine cosmetic makeovers must begin with the establishment of a philosophy held by the dentist and staff. Everyone in the office must agree on a treatment philosophy for bonded porcelain veneers so you can achieve the finest results. You must understand and trust the materials involved in the fabrication of veneers as well as the systems used for luting them. Porcelain veneers are more clinically predictable and stable over time than composite resin restorations or composite resin veneering.
Understanding your patients’ desires and expectations is crucial to optimal patient acceptance and satisfaction. Porcelain veneer preparations are not reversible and should be extended to include any part of the tooth structure that, if exposed, would lead to an unacceptable esthetic result. All-porcelain veneer margins should be established on sound tooth structure. This might necessitate preparation design that could include anything up to full-coverage porcelain veneering. Porcelain veneers are ideal for restoring teeth that are chipped, discolored, or that contain multiple composite resin restorations. Using porcelain veneers to close diastemas or to straighten malpositioned teeth should be carefully evaluated case by case. If a thorough analysis of the final restorative result is not carefully anticipated, wider or thicker-than-normal teeth may result. When appropriate, advise patients that orthodontic tooth movement coupled with bleaching can achieve the desired results without subjecting sound tooth structure to irreversible alteration by accomplishing porcelain veneer preparations.
Patient education
The patient must be fully aware of the process and anticipated final result of the porcelain-veneering procedure. Provide the patient with a thorough explanation of the steps involved in esthetic analysis of the patient’s dentition as well as the surrounding gingival and osseous components of the smile and how they impact treatment planning. Also, inform the patient about tooth preparation, successful impression technique, and veneer temporization prior to initiation of treatment. Photos of previously treated cases are useful in establishing a complete understanding of patient expectations as well as educating the patient about potential results of his or her case. Preoperative bleaching is employed frequently to establish an esthetic baseline shade prior to veneering. The patient must be made aware of the time commitment necessary to obtain an optimally bleached dentition.
Patient expectations
The doctor must establish a thorough and comprehensive method of collecting information to learn the patient’s expectations. Use a written form to gather information from the patient followed by separate interviews by the doctor and a staff member (preferably the assistant involved in the case). These interviews coupled with information written by the patient can establish a comprehensive list of patient expectations. A comprehensive archive of previously treated cases can determine the look that the patient desires. Digital morphing can allow the patient to see a side-by-side comparison of his or her teeth and supporting tissues before and after anticipated treatment results are achieved.
Treatment planning
Diagnostic casts, radiographs, and digital photos are required to fully assess the preoperative condition of the patient. Diagnostic casts can be duplicated and altered by mock preparation to establish a diagnostic wax-up. This wax-up can be used to see the result before you start the case. It can also create a matrix to be used in the fabrication of temporary or trial veneering. Photos can be digitally or manually altered to simulate changes in tooth shape or positioning when communicating with the patient. A digital-imaging program can be used to visualize possible results while changing multiple aspects of form, color, and gingival architecture. Using all of these techniques will allow for the treatment of the case in four ways: in your mind, in wax, in acrylic, and in porcelain.
Laboratory communication
The laboratory technician must be given preoperative photos, photos of the veneer preparations, diagnostic casts, diagnostic wax-ups, and a complete list of patient expectations. The dentist must be familiar with types and esthetic or visual effects of porcelains prior to determining a specific set of shades or translucencies needed in fabrication of the veneers. A cast of the patient’s dentition with trial veneers in place will allow the technician to mimic what the dentist and patient have established as the desired esthetic and functionally correct shape.
Delivery routine
A specific, unaltered, proven routine of porcelain veneer delivery must be employed each time porcelain veneers are delivered by the dentist. Variation from a specific routine allows for potential error in the steps necessary in long-term, successful, porcelain-veneer retention. Veneers returned from the lab with an etched internal surface should not be touched until an initial application of silane bond enhancer is applied. This simple, important first step will ensure that the etched surface will not be contaminated by oils and other debris on fingers and casts. Each member of the clinical team should be aware of all steps in the delivery process, and all materials and instruments needed for the entire process should be present prior to initiation of the delivery appointment.
Summary
As the public’s awareness of cosmetic dentistry procedures increases, their interest in and desire to have porcelain veneer restorations also increases. Dentists and all staff members must become educated about the planning, preparation, temporization, and delivery of bonded porcelain veneers. There must be an established understanding of expectations between the dental laboratory technician and the dental office to ensure that all esthetic parameters are achieved on every case without fail. The staff must know the reason for each step in the delivery process so that none of the steps are altered or omitted and won’t result in premature failure of any of the restorations.
If all of the previously discussed recommendations are adopted, the incorporation of bonded porcelain veneer restorations into the treatment options presented to patients will result in a successful and fulfilling transformation of patients’ smiles. Your patients will receive attractive smiles and may also achieve new personal beginnings.
Dr. George T. Knight’s emphasis is in cosmetic and restorative dentistry with an interest in removable prosthodontics. He has conducted research in bonded porcelain restorations and the resin/dentin bonding interface. He recently joined Dr. Little’s San Antonio practice.
Dr. David A. Little specializes in cosmetic and full-mouth restorations, including dental implants. He is an internationally respected speaker and consultant on dental materials, leadership, and management. Reach either dentist via e-mail at [email protected].
