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The Official Publication of the Canadian Academy of Cosmetic Dentistry
Canadian Journal of
Tooth Whitening: Concepts and Controversies Development of a Functional Occlusion
Vol. 5 No. 2
I
June 2009
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Canadian Journal of Cosmetic Dentistry
Vol. 5 No. 2 • June 2009
Inthis Issue…
features 8
Tooth whitening: concepts and controversies Johnny Fearon
24
Development of a Functional Occlusion Dr. Ron Goodlin
departments 5 6 40
President’s Message — Dr. Steve Hill
42
Career & Practice Transitions — Nadean Burkett
45 46
Announcements
From the Editor — Dr. Edward Lowe Speaking the same Language — Hilary Ford
Product Showcase
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Executive Board and Staff Editor in Chief Dr. Ed Lowe
Canadian Journal of Cosmetic Dentistry
Associate Editor Dr. Ron Goodlin
The Official Publication of the Canadian Academy of Cosmetic Dentistry
President Dr. Steven Hill
This Journal is the official journal of the Canadian Academy of Cosmetic Dentistry. The CACD is a non-profit organization affiliated with the American Academy of Cosmetic Dentistry. Bi-annual publication of this journal with the co-operation of the Toronto Academy of Cosmetic Dentistry occurs twice a year: April and September. There will be one annual Scientific meeting of the CACD each year, and moving to different locations within Canada. The Toronto Academy of Cosmetic Dentistry holds 4 meetings per year, 3 general sessions where leading speakers in the field of Cosmetic Dentistry present various topics of current importance. There is an additional Members Only night open to TACD members and corporate sponsors only. Both the CACD and the TACD membership is open to all Canadian Dentists with an interest in Cosmetic Dentistry. For more information, please contact the TACD or CACD via the Executive Director at 604-669-5550 or online at www.tacd-online.com or www.cacd.net. We encourage the development of regional Academies of Cosmetic Dentistry. For more information contact the CACD via Christine (Executive coordinator) at 604-669-5550, by e-mail at info@CACD.net or visit the website at www.cacd.net
Vice-President Dr. Deborah Cooper-Lall
Director Marek Bedynski, RDT
Director Dr. Robert Knudsen
Director Dr. Alain Methot
CACD Board of Directors Director Dr. Jeffery Norden
Director Dr. Stephen Phelan
Director Dr. Janet Roberts
Dr. Steven Hill, British Columbia – President Dr. Deborah Cooper Lall, Alberta – Vice President, President Elect Dr. Robert Knudsen – Director Marek Bedynski, Ontario – Directors Dr. Stephen Phelan, Ontario – Director Dr. Alain Methot, Quebec – Director Dr. Jeffery Norden, British Columbia – Director Dr. Janet Roberts, British Columbia – Director Dr. Roderick Toms, Ontario – Director Christine Wyatt, British Columbia – Executive Director Telephone: 604 669 5550 Website: www.cacd.net
Disclaimer Director Dr. Rodrick Toms
Executive Director Christine Wyatt
Publisher Ettore Palmeri, MBA, AGDM, BEd., BA
4 I Canadian Journal of Cosmetic Dentistry
Articles published express the viewpoints of the author(s) and do not necessarily reflect the views and opinions of the Editor and Advisory Board. All rights reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner. Publisher: Palmeri Publishing Inc. 35-145 Royal Crest Court Markham, ON L3R 9Z4 Tel: 905-489-1970 Fax: 905-489-1971 Design and Layout: Lindsay Hermsen B.Des.Hon. Printed in Canada Canadian Publications Mail Product Sale Agreement 1033352
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President’sMessage
Dr. Steve Hill, President
A Matter of Trust… The
global financial crisis seems to still be around us – the depth and extent of its impact to all of us seem that it will be in the future. The World Bank lowered its original predictions of growth in most of the world’s economies but just what does that means to us? It depends upon to whom you listen. Who do you trust? In this market, do our patients trust us to make the right treatment recommendations or do they fear we could be financially motivated to promote the more costly options? Trust is as elusive in philosophy as it can be in practice. In The Republic, Plato tells of an argument between Socrates and Glaucon, Plato’s older brother. A lengthy story is told about a shepherd who finds a ring that makes him invisible. Glaucon argues that only the fear of detection and punishment prevents a human being from acting for the sake of his own self-interest. In his discourse, On Trust and Philosophy, Tom Bailey argues, ‘But the heart of trust lies elsewhere… my reliance on others can be ensured simply by their taking responsibility for how their behaviour will influence my decisions about how to act in a particular regard… If I trust the doctor to prescribe me appropriate treatment, I rely on
her because I believe that she has taken responsibility for her role in my decisions about my health. Indeed, I may even allow her to effectively make these decisions for me.’ As dentists, we prescribe procedures for our patients based on a manufacturer’s recommendation? What is the science behind it? Is it objective? Clinically, is this new procedure similar to those we or our colleagues have some history and clinical experience with? These of course are some of the questions we all have to ask ourselves daily. Fortunately, we have many ways to obtain reliable information about the changes and challenges in our profession in order to be responsible for our patients, but to whom will we turn for assuming responsibility for the economic global markets? The challenge the financial markets has in dentistry then is to become as responsible as possible for our clients and patients. Then trust will follow.
References Bailey, T. On Tr ust and Philosophy. BBCi. The Open University. Open2.net
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From theEditor
Dr. Edward Lowe, Editor
If They Don’t Accept Treatment – Who Do We Blame?
I
dropped in to a colleague’s office recently because the doctor had requested some assistance on a challenging case. His reception area had 2 people waiting, and the receptionist was intent on her screen with pursed lips and a scowl on her face. She didn’t so much as glance up at me, and continued to ignore me for an additional 30 seconds. Had I been there to theoretically spend money, her welcome behaviour alone would have changed my mind and I would have voted with my feet! This is the same gal my colleague counts on to ‘close’ his cases once patients leave his chair. He says his numbers are way off, and simply blames the economy. But, her poor attitude was contagious – so do you think her behaviour may have a part in all this? How can we control our teams’ attitude? Recently, my marketing company trained us in a Dental Sales program. This was a 2 day seminar event combined with post seminar ‘homework’ to ensure that the training was being used. Most professional offices, whether medical, legal, or dental never entertain such an investment of time and resources. Very few people in ‘professional’ positions understand they have a direct sales role in the final acceptance of customer cases. The rationale is basic: every member of your team or staff is a salesperson, and some are simply better than others. If a team member hates the concept of selling, she or he is undermining everything the rest of you are trying to accomplish. They are ‘unselling’ you. This concept of ‘selling’ may seem foreign, but the last time I checked we dental professionals also have payroll, rent, utilities, insurance, lease payments etc. That sounds like identical overheads that other business people enjoy – and they must typically ‘sell’ their wares to someone to survive. Perhaps we better take a page from their book. The consumer today is savvy and fickle. Thanks to the internet, patients do arrive in our chair with an uncommon familiarity with dental options, pricing, and in some cases real misconceptions we must correct. Everyone on your team has a specific duty to provide all the information your prospects require in order to make their best decision. Today’s buyer has a set number of conditions that must be ‘right’ in order to facilitate the decision to buy. There is a logical chronological order with points that must be satisfied in order for the ‘buying mind’ to move forward. Most practices try and close the deal (be it cosmetic, implant, or restorative) before it is actually open. This is not unlike asking the girl to marry you during your first dance! Not only is it doubtful they will accept, but you actually hamper the chances of ever
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accomplishing your goal because you are trying to jump from step 2 to step 5 with little regard for the other psychological conditions that must be satisfied. In our workshop we learned the most appropriate ‘close’ I have ever experienced – one that doesn’t alienate the patient if they do not immediately accept. It is really about education and communication. In dental school I never studied sales techniques, nor has any of my team in their training. Every new technique requires repetition and scripting at least 20 times before it becomes a ‘habit’, so our facilitators rehearsed us in this workshop environment with repeated role playing until it became second nature. Frankly, without the discipline and supervision in this role playing exercise, this program couldn’t work to its full extent. A sidebar – if you happen to have an employee who is in reality ‘not’ a team member – an off-site 2-day workshop will be troubling for them and this will be self evident. None of us can afford to have the wrong people in any position in our practices, so this type of intensive team training may lead to a restructuring of positions within your office. It has been proven that making the wrong decision in hiring a key member of your team will cost you a minimum of six figures annually. Most dentists hire too fast, and fire too slow. Keeping the wrong individual in the incorrect position prevents them from being more satisfied elsewhere, and it is disastrous to your pocketbook. These same team members accumulate ‘lost opportunities’ not only in new patient numbers but also in acceptance of restorative work with existing charts because they just don’t communicate efficiently - and the consumer leaves your office to ‘think about it’. Our practice was able to develop our own scripting with post workshop assistance from Prosales Systems. Each team position has not only a responsibility to provide the patient with the information they want and deserve – but they have an obligation to present a case properly, providing it is in the patient’s best interests. We are not talking about manipulation or a ‘canned’ process, but rather a structured approach to ensure every patient is making their best decision with every piece of information they deserve. If our front end team doesn’t do their job properly, we don’t get to perform any dentistry. If our clinical team doesn’t present cases properly, we don’t earn the opportunity to do advanced clinical work. If we don’t train our team to professionally communicate in what is absolutely a consumer sales environment – we cannot shape the future of our practice. It is time to take a proactive role. You may wish to go to www.prosales.tv and learn more!
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Johnny Fearon
Tooth Whitening:
Concepts and Controversies
Johnny Fearon talks about clinical aspects of dental bleaching by providing an evidence-based review of modern literature Abstract
Causes of Tooth Discolouration
Today’s society dictates that it is the norm for people to have straight, white teeth. The demand therefore for tooth whitening in dental practice has increased exponentially over the last decade. A common approach to achieving this goal is by bleaching. This article discusses clinical aspects of dental bleaching by providing an evidence-based review of current literature. Topics covered include aetiology of tooth discolouration, indications for bleaching, its mode of action, and different types of bleaching regimes, indications and potential side effects.
Tooth discolouration may be described as intrinsic, extrinsic or a combination of both (Hattab et al 1999). It varies in appearance, aetiology, severity, localisation and adherence to tooth structure (Dahl and Pallesen 2003). The causes of intrinsic tooth discolouration can be attributed to changes to the structure of dentine or enamel (Fig. 1), or by incorporation of chromatogenic material into tooth tissue, either during odontogenesis or post eruption. The main cellular changes observed in intrinsically stained teeth often provide a clue to the aetiology of the pathologic process involved. Discolouration can manifest as either a red, brown, grey or yellow appearance. Internal pulp bleeding caused by trauma or pulp extirpation can cause a temporary red colour change to the crown. Then, as blood degenerates and breaks down, products such as haemosiderin, haemin, haematin and haematoidin release iron (Dahl and Pallesen 2003). The iron can be converted into black ferric sulphide with hydrogen sulphide produced by bacteria, which causes a grey staining of the tooth. In addition to blood degradation, degrading proteins of necrotic pulp tissue may also cause discolouration. If pulp tissue is not completely extirpated and remains in the pulp horns, discolouration may result from the break up of the proteins of the necrotic pulp tissue (Guldener and Langeland 1993), causing a grey or brown hue to the crown (Fig. 2). Yellow discolouration is often due to the reactionary laying down of tertiary dentine sclerosing the root canal and pulp chamber. Because enamel is relatively translucent, the additional volume of dentine obliterating the pulp chamber produces a yellow hue to the crown (Fig. 3) (Faunce 1983). Intrinsic discolouration is also caused by exposure to high levels of fluoride, tetracycline
The Introduction The cosmetic impairment of tooth discolouration, especially in the anterior region, can be treated by a number of invasive therapies such as indirect crowns and veneers, microabrasion, or by the placement of direct composite. In certain clinical situations, the procedure of tooth whitening or bleaching can be employed as a less invasive alternative to restoration with either ceramic or composite. Bleaching of teeth can be achieved either by an external – or vital – approach (nightguard vital bleaching) (Heywood 1991), where vital teeth are bleached by direct contact with an agent such as carbamine peroxide, or by an internal – or non-vital – approach, where non-vital teeth are bleached with an agent such as sodium perborate in a walking bleach technique (Attin et al 2003). A third approach, which is a modification of both techniques, can be employed when bleaching vital and non-vital teeth in the same arch. This is called inside/outside bleaching (Settembrini et al 1997). The aim of this review is to discuss the concepts involved in both the vital and non-vital bleaching of teeth, and to provide advice, based on the evidence from current literature, to reduce the risks of complications and to ensure successful bleaching therapy. 8 I Canadian Journal of Cosmetic Dentistry
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Fig. 1: Intrinsic tooth colour change due to tetracycline staining Fig. 2: Brown/grey appearance of a nonvital central incisor
Fig. 3: Yellow intrinsic discolouration of the upper right central incisor due to sclerosis of the pulp chamber Fig. 4: Yellow discolouration of the maxillary anterior dentition due to extrinsic agents such as food colouring and tobacco use
administration during childhood, inherited developmental disorders, jaundice in childhood, porphyria, caries, restorations and trauma to the developing tooth germ. After eruption, ageing, pulp necrosis and iatrogenesis are the main causes of intrinsic discolouration (Olgart and Bergenholtz 2003). Extrinsic staining results mainly from dietary factors and smoking (Fig. 4). Foods containing tannins such as red wine, coffee and tea can give rise to extrinsic stain. Carotenes in oranges and carrots, and tobacco use, whether it is smoking or chewing, also give rise to extrinsic stain (Watts and Addy 2001). Wear of tooth structure, deposition of secondary dentine due to ageing or as a consequence of pulp inflammation, and dentine sclerosis affect the lighttransmitting properties of enamel and dentine, resulting in a gradual discolouration. For example, tetracycline staining is persistent, whereas discolouration of ageing responds quickly in most instances (Heywood 1995).
History The first publications describing techniques and chemicals for bleaching non-vital teeth appeared in the latter half of the 19th Century. The bleaching agent of choice was chloride of lime (Dwinelle 1850). Other agents described for the bleaching of pulpless teeth included aluminium chloride and hydrogen peroxide,
used either alone or in combination with heat. The active ingredient common to all the early medicaments was an oxidising agent, which acted either directly or indirectly with the organic component of the tooth. Concern about the side effects of some of these agents was justified however, because some chemicals used were ver y poisonous, such as cyanide of potassium (Barker 1861). The walking bleach technique that was introduced in 1961 involved placement of a mixture of sodium perborate and water into the pulp chamber, which was sealed into place between dental visits (Spasser 1961). This method was later modified by replacing water with 30-35% hydrogen peroxide to improve the whitening effect (Nutting 1963). Although most of the early publications described non-vital bleaching, a 3% solution of Pyrozone was used safely as a mouthwash as early as 1890, which not only reduced caries, but also whitened teeth (Atkinson 1893). The observation that carbamine peroxide caused lightening of teeth was made in the late 1960s by an orthodontist (Klusmier), who had prescribed an antiseptic containing 10% carbamine peroxide to be used in a tray for the treatment of gingivitis. This technique, which is the method of home bleaching today, was not widely accepted by the dental profession until 20 years later when it was described in a 1989 publication (Haywood and Heymann 1989). Canadian Journal of Cosmetic Dentistry I 9
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Fig. 5: A white silicone barrier material is used to protect the gingival tissues during power bleaching
Fig. 6: Take-home bleaching tray, extended as far as the gingival margin
Fig. 7: Take-home bleaching tray in situ
Mechanism
External (Vital) Bleaching
Hydrogen peroxide is a colourless liquid with a bitter taste and is highly soluble in water to give an acid solution. It has a wide number of industrial applications, for example bleaching or deodorising textiles, wood pulp, fur and hair, and in the treatment of water and sewage. Hydrogen peroxide, a reactive oxygen species, acts as a strong oxidising agent through the formation of free radicals (Tredwin et al 2006), which attack the organic molecules responsible for tooth discolouration. When complex, pigmented organic molecules (chromaphores) are broken down by the action of free radicals, simpler molecules are produced, which reflect less light (Frysh 1995). During tooth bleaching, more highly pigmented carbon ring compounds are converted to carbon chains, which are lighter in colour. The carbon double bond chains (yellow in colour) are converted into hydroxyl groups, which are essentially colourless. The radicals also reduce coloured metallic oxides like Fe2O3 (Fe3+) to colourless FeO (Fe2+). The bleaching process continues until all of the original pigment is rendered colourless (Albers 1991). The chemistry of carbamine peroxide, used for nightguard vital bleaching, is slightly different from hydrogen peroxide as it also contains urea, which permits the peroxide to remain in contact with the tooth for longer. Although the action of carbamine peroxide also causes the breakdown of pigmented carbon compounds as described above, the degradation is slower than with hydrogen peroxide alone.
The bleaching of vital teeth can occur inside the surgery (power bleaching) or outside the surgery (nightguard vital bleaching). Power bleaching accomplishes complete lightening during treatment in the surgery, whereas nightguard vital bleaching involves the application of a peroxide gel to the tooth surface via some means of carrier, usually a custom fitting bleaching tray.
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Power Bleaching Power bleaching of vital teeth generally uses a high concentration of peroxide solution (35-50% hydrogen peroxide) placed directly on the teeth, often supplemented by a heat or light source to activate or enhance peroxide release (Feinman et al 1987). Because the hydrogen peroxide concentration is so high, soft tissues must be very well protected to prevent injury (Fig. 5). Definite indications for its use include treatment of generalised gross staining such as tetracycline staining and perhaps dentine sclerosis, which take a long time using the nightguard vital bleaching technique, and for patients who may have difficulty in compliance with the nightguard vital bleaching technique. Power Bleaching has Several Potential Disadvantages: 1. Neither the patient nor the dentist can exactly control the amount of lightening (compared to the nightguard vital bleaching technique). The technique runs the risk of both over- and under-bleaching.
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Fig. 8: The distance between the CEJ and the incisal edge is measured with a periodontal probe on the facial
Fig. 9: Having recorded the measurement between the CEJ and the incisal edge, the periodontal probe now assists in accurate removal of GP
2. The fee is usually higher as a greater amount of chair time is required. 3. There is a possibility of soft tissue damage due to the caustic nature of the high concentrations of peroxide. 4. There is a greater risk of post-operative sensitivity (Goldstein 1988). A higher incidence of tooth sensitivity (67-78%) was reported after power bleaching (Heywood and Berry 2001, Cohen and Chase 1979) compared with the nightguard vital bleaching method, using 10% carbamine peroxide (15-65%) (Nathanson and Parra 1987, Heywood 1996, Leonard 1998, Schulte et al 1994).
et al (1999) examined the efficacy of 10% carbamine peroxide nightly for two weeks. They reported that the lightness of the crown of the tooth increased by, on average, eight shade units on the Vita¨ shade guide, calibrated according to a lightness value.
Nightguard Vital Bleaching Nightguard vital bleaching, or ‘take home’ bleaching, is the more commonly used bleaching technique because it is easy to perform and is generally less expensive for the patient. It involves the use of a 10-20% solution of carbamine peroxide in a gel form (approximately equal to 3.4-7% hydrogen peroxide) delivered to the tooth surface by a custom-made, vacuum formed, plastic bleaching tray (Figs. 6 and 7). Manufacturers have offered carbamine peroxide in a variety of different concentrations, ranging from 10% to over 20%, but the best combination of safety, limited side effects and speed of action is obtained with a 10% solution of carbamine peroxide approved by the ADA (American Dental Association). Products carrying the ADA accepted label have passed a rigorous set of safety and efficacy standards (Tam 1999). A survey by Christensen (1989) indicated that 90% of dentists surveyed used a 10% concentration of carbamine peroxide for take home bleaching (Christensen 1991). Although the evidence base in the dental literature on the efficacy of nightguard vital bleaching is mostly limited to case reports, it is generally advocated that most teeth are susceptible to bleaching (Tam 1999). The process requires longer contact time compared to power bleaching, but it is safe and the results are generally excellent (Fig. 2). The first subjective change in tooth colour is generally observed after two to four sessions of bleaching. In a clinical study of nightguard vital bleaching with 10% carbamine peroxide, 92% of subjects experienced some lightening of teeth after a six-week period (Haywood et al 1994). Another clinical trial by Swift 12 I Canadian Journal of Cosmetic Dentistry
Internal (Non-vital) Bleaching The whitening of endodontically treated teeth can be carried out by an internal whitening treatment known as non-vital bleaching or the ‘walking bleach technique’. This therapy involves placement of a bleaching agent into the empty pulp chamber of a non-vital, discoloured tooth, and is a more conservative option compared to restoration with veneers or crowns. The two most common bleaching agents used for this technique are hydrogen peroxide and sodium perborate, and various sources have been applied to speed up the reaction and improve the bleaching effect. The decomposition of hydrogen peroxide into active oxygen is accelerated by application of heat or light (Howell 1980). The thermocatalytic breakdown of hydrogen peroxide was proposed for many years as the best technique for the whitening of non-vital, discoloured teeth because of the high reactivity of hydrogen peroxide upon application of heat (Hardman et al 1985). In this procedure, heat from a special lamp or hot instrument was applied to a well of 3035% hydrogen peroxide in an empty pulp chamber. Temporary restorations impregnated with 30-35% hydrogen peroxide were often used between visits. Although there is little doubt regarding the clinical efficacy of non-vital bleaching using 30-35% hydrogen peroxide (Chen et al 1993) (either thermoactivated or not), serious concerns regarding the safety of this technique, in particular the risk of producing external cervical root resorption, which is discussed later, have rendered this technique unadvisable, and the application of sodium perborate instead of hydrogen peroxide is now recommended. Sodium perborate is a hydrogen peroxide releasing agent, and since 1907 it has been employed as an oxidiser and bleaching agent, especially in washing powders and other detergents. It comes in powder form and can be mixed into a paste or putty with either pure water or hydrogen peroxide. Several studies have reported bleaching
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Fig. 12: The pre-operative appearance of the maxillary right lateral and central incisors Fig. 10: Good quality root canal treatments, showing thorough obturation and access cavities prepared for internal bleaching
Fig. 11: Sodium perborate (Amosan ÂŽ, Oral-B) mixed with distilled water to a puttylike consistency
Fig. 13: The whitening effect of sodium perborate on the maxillary right lateral and central incisors after two applications
effectiveness by comparing mixtures of sodium perborate with distilled water or hydrogen peroxide in different concentrations. Rotstein et al (1991, 1993) and Weiger et al (1994) did not report any significant difference in effectiveness between sodium perborate mixed with 3-30% hydrogen peroxide, and distilled water, except for the time taken to achieve a clinically acceptable result. However, mixing sodium perborate with hydrogen peroxide was shown to accelerate the rate of colour change. In the case of severe discolouration, it is safe to mix sodium perborate with a 3% solution of hydrogen peroxide; however it is not appropriate to use 30% hydrogen peroxide because of the possible risk of inducing cervical root resorption (Friedman et al 1988). This is discussed in more detail below.
Clinical Stages for Internal Bleaching 1. Radiographic Examination: A recent pre-operative radiograph is necessary prior to treatment to assess the quality of the root canal treatment. The root canal should be thoroughly condensed along its whole length to prevent the apico-coronal migration of microorganisms or bleaching agents, which may have a detrimental effect on the surrounding tissues. Should the quality of the root canal treatment be suboptimal, the tooth should undergo corrective endodontic therapy prior to the commencement of bleaching (Fig. 8). 14 I Canadian Journal of Cosmetic Dentistry
2. Preparation of the Access Cavity: The pulp space should be completely debrided of any necrotic material, pulp tissues, or restorative or root canal materials. The smear layer on the dentinal surface of the pulp chamber is removed by applying 37% phosphoric acid gel and irrigated with 2.5-5% sodium hypochlorite. 3. Cervical Seal: Gutta-percha (GP) is removed with a round ended, long shank bur to a level of 1-2mm below the CEJ (cementoenamel junction). It is helpful to measure this distance pre-operatively by recording the distance from the incisal tip to the CEJ on the facial aspect with a graduated probe (Figs. 9 and 10). The coronal access is then sealed with a glass ionomer cement (GIC) or accelerated zinc oxide (ZOE) plug to prevent the diffusion of bleaching agents from the pulp chamber throughout the root filling, as root fillings do not provide an effective barrier on their own (Fig. 11) (Attin et al 2003). Rotstein et al (1992) demonstrated that a 2mm layer of GIC or composite is essential. Alternatively, Bergenholtz et al (1982) showed histologically that ZOE cement also provides a hermetic seal. 4. Application of Bleaching Agent: A small drop of distilled water is mixed with sodium perborate powder (Amosan¨ Oral-B) until a putty consistency is achieved (Fig. 12). The sodium perborate putty is applied to the empty pulp chamber with an amalgam plugger or
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similar instrument, covered with cotton pellet and sealed with an adhesive provisional restoration. It is often difficult to place the provisional restoration directly over the cotton pellet without displacing it. To immobilise the pellet, it is helpful to first wet the pellet with a bonding agent and then light cure the bond once the pellet is in place. A provisional restoration must then be placed, as a sound seal is required around the access cavity to prevent leakage of the bleaching agent into the oral cavity. A light cured GIC or an accelerated ZOE material can be employed for this purpose. This procedure is repeated every three to four days until successful bleaching becomes apparent. This normally occurs after one to four visits (Fig. 13). 5. Permanent Restoration: Once the desired colour change has been achieved, a sound restoration with sealed dentinal tubules is a prerequisite to a successful bleaching therapy (Abou Raas 1998). The access cavity should be restored with a composite, which is adhesively attached to both enamel and dentine. It is recommended to choose a composite with a high value (light colour) to help compensate if the bleaching therapy alone does not provide the full extent of desired lightness. The timing of placement of the final restoration is also important, as it has been shown that the bond strengths of composite to bleached enamel and dentine is temporarily reduced. It is recommended to wait for at least seven days post bleaching prior to bonding composite as a definitive restoration (Nathanson and Parra 1987).
Inside/Outside Bleaching Another bleaching technique has been described for clinical situations where an endodontically treated tooth is present within the arch and the arch as a whole is to be bleached. This technique, called ‘inside/outside bleaching’ allows the endodontically treated tooth to be bleached both from within the sealed pulp chamber (inside) and from the facial enamel (outside) simultaneously. The technique for
inside/outside bleaching involves the fabrication of a vacuum-processed plastic mouthguard, trimmed to the facial and lingual margins as previously described for nightguard vital bleaching. Coronal access to the endodontically treated tooth (or teeth) is achieved and the coronal GP is sealed with a light cured GIC or accelerated ZOE, as previously described for non-vital bleaching. The patient is instructed how to inject 10% carbamine peroxide gel into the coronal orifice and into the nightguard. The bleach tray is worn for a minimum of two hours, up to a maximum of an overnight period, as described above. The patient is then instructed to insert a cotton wool plug into the coronal access to prevent the ingress of food particles. Once the non-vital tooth has been bleached to an acceptable match with the adjacent teeth, coronal access can be definitively restored with a high-value shade composite resin, and further nightguard vital bleaching can be continued if desired (Settembrini et al 1997).
Controversies Tooth Sensitivity Unfortunately the aetiology of bleaching-related tooth sensitivity is neither well understood nor easily measured; however the hydrodynamic theory is a mechanism frequently cited to explain it (Brannstrom 1986). According to this model, peroxide solutions introduced into the oral environment contact available dentinal surfaces and cause retraction of odontoblastic processes, resulting in rapid fluid movement inside the dentinal tubules. This ultimately manifests in stimulation of mechanoreceptors at the pulp periphery, with the resultant feeling of pain when such teeth are exposed to cold or pressure, or even when they are at rest. Tooth sensitivity, if present, normally persists for up to four days after the cessation of bleaching (Frysh et al 1993, Jacobsen and Bruce 2001, Blong et al 1985). Patient selection must be carefully considered prior to prescribing bleaching, as some patients are more susceptible to tooth sensitivity than others. In particular, it
Fig. 14: Generalised gingival recession. This patient presented with severe pain after four days of external bleaching with 10% carbamine peroxide
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is wise not to recommend bleaching for patients with generalised gingival recession (Fig. 14). Age may also have an effect on tooth sensitivity as the dentinal tubules in younger dentine are wider and enamel is more porous. Also the presence of old, leaking restorations provides a more rapid portal of entry into the pulp for irritating chemicals. Several agent-related factors can also affect tooth sensitivity. Increasing the concentration of peroxide provides a more rapid bleaching effect; however it also increases the risk of tooth sensitivity. When prescribing a bleaching regime, it is important to differentiate between the concentrations of hydrogen peroxide and carbamine peroxide. A 10% solution of carbamine peroxide is approximately 3% hydrogen peroxide and 7% urea. Concentrations higher than 10% carbamine peroxide may cause increased tooth sensitivity (Giniger et al 2005). Increasing the temperature can also enhance the effect of bleaching while also having an adverse effect on sensitivity. A 10% increase in temperature doubles the rate of chemical reaction; however temperatures elevated to a clinically uncomfortable level may result in latent tooth sensitivity or even irreversible pulpal inflammation. In addition to concentration and temperature, the degree of bleaching is also related to the amount of time that the bleaching agent is in contact with the tooth surface. The longer the time, the greater the lightening effect and the greater the likelihood of sensitivity (Baratieri et al 1995). Tooth sensitivity can, however, be reduced by reducing the amount of time spent bleaching per day, bleaching on alternative days or by the substitution of a desensitising agent, such as KNO3 gel, into the bleach tray between periods of bleaching. Another approach to reducing sensitivity during bleaching is by the addition of desensitising agents such as potassium nitrate (KNO3) or fluoride, in the form of SnF2, to carbamine peroxide to produce ‘sensitive-formula’ gels. Fluoride acts as a tubule blocker to limit the fluid flow to the pulp. KNO3 penetrates the tooth to the pulp and has a numbing or calming effect on nerve transmission. Unfortunately, neither agent has proven to be particularly effective. KNO3 has a limited capacity to achieve antihypersensitivity unless used for
18 I Canadian Journal of Cosmetic Dentistry
long periods, and fluoride formulations are also slow acting and can cause significant tooth discolouration. In a recent double blind clinical trial by Giniger et al (2005) the effect of addition of amorphous calcium phosphate (ACP) to a 16% carbamine peroxide gel on the degree of hypersensitivity was studied. The results reported significantly reduced hypersensitivity compared to carbamine peroxide bleaching alone after 19 days, both in terms of intensity and duration. There was no associated reduction in the degree of tooth lightening with the ACP solution. This is the first study to show that ACP added to carbamine peroxide may reduce hypersensitivity and, although the results appear promising, further research is required before making a clinical recommendation for the use of ACP-containing products.
External Cervical Root Resorption Cervical root resorption is a painless, inflammatorymediated external resorption of the root, which can be seen after trauma and following internal bleaching. It is usually detected only through routine radiographs; however papillary swelling or tenderness to percussion can sometimes be observed. While the causes of resorption are not fully known, a review of the literature indicates a number of possible causes (Lado et al 1983). Patients tend to be younger than 25 years and most report a history of trauma. From a clinical viewpoint, what does appear to be an important factor is the regime of internal bleaching employed. It has been proven that formulations using either 30% hydrogen peroxide alone, or in combination with sodium perborate, are more toxic for periodontal ligament cells than sodium perborate mixed with water (Harrington and Natkin 1979). Heating the peroxide with a hot instrument also appears to promote resorption. Application of heat leads to a widening of the dentinal tubules and facilitates diffusion of molecules in the dentine (Pasley et al 1983). Moreover, application of heat results in generation of hydroxyl radicals from hydrogen peroxide, which are extremely reactive and have been shown to degenerate components of connective tissue (Dahlstrom et al 1997). Unsurprisingly, therefore, several
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Overview of cervical root resorption observed in clinical studies
Reference
Sample Treatment Number
Heat
Cervical Trauma Resorption Seal
Abou-Raas (1998)4
112
Wbt: sodium perborate +30% H2O2
No
-
-
0
Anitua et al (1990)70
258
Wbt: sodium perborate +30% H2O2
No
-
-
0
Friedman et al (1988)30
58
a) Thermocatalytic - 30% H2O2
No
No
1
b) Wbt: 30% H2O2
No
No
1
c) Thermocatalytic + 30% H2O2
No
No
2
Heithersay et al (1994) 71
204
Wbt: sodium perborate +30% H2O2Thermocatalytic
Yes
Yes
Yes
4
Holmstrup et al (1988)72
69
Wbt: sodium perborate + H2O
No
Yes
Yes
0
Table 1: Overview of cervical root resorption observed in clinical studies
authors have demonstrated that a high concentration of hydrogen peroxide, in combination with heating, seems to promote cervical root resorption (Baratieri et al 1995). Table 1 provides an overview of clinical studies in which the occurrence of cervical root resorption was observed in association with the technique used. When interpreting the data in Table 1 it is important to note that a large number of cases had suffered known trauma. Perhaps the observation of greatest clinical significance is that there have been no reported cases of cervical root resor ption following internal bleaching using a combination of sodium perborate and water, or sodium perborate and a low concentration, i.e. 3% solution, of hydrogen peroxide. The author was unable to find published data on t he incidence of cer vical root resorption using a 10% carbamine peroxide solution in the inside/outside technique.
Stability Advice regarding the long-term stability of bleaching is perhaps the most uncertain aspect of the therapy, as many factors must be considered when attempting to predict the outcome, including the aetiology and original degree of discolouration, dietary and smoking factors, patient age, etc. Data on the duration of both external and internal bleaching are mostly related to case reports, and only a few clinical trials are available for review. Tam et al (1999) reviewed 23 patients 1.5 and three years post external bleaching, and reported that 62% reported slight or no reversal in tooth colour. Another study by Ritter et al (2002) reported that 43% of patients perceived their tooth colour as stable 10 years after a six-week course of external bleaching. Swift et al (1998) reported that two years after external bleaching, regression of two shade tabs on the Vita® shade guide occurred; however the regression occurred during the first six months after bleaching. Amato et al (Amato et al 2006) evaluated the 20 I Canadian Journal of Cosmetic Dentistry
chromatic stability of internal bleaching from a population of 50 patients after 16 years. They reported colour stability in 62.9% of cases.
Effects on Enamel Questions have been raised about the effect of bleaching on the structure of the tooth itself. Surface alterations in enamel topography have been reported in several studies. Shannon et al (1993) evaluated the surface topography of enamel tabs exposed to 15% carbamine peroxide for 15 hours a day, using scanning electron microscopy, and detected significant alterations compared to a control group. This is due to a detectable loss of calcium from the surface enamel along with a loss in surface hardness dept h of approximately 25μm. Bitter (1998) demonstrated that teeth bleached in vivo with 35% carbamine peroxide (35 min/day for 14 days) lost their aprismatic layer and the damage was not repaired after 90 days. However, the concentration of peroxide and amount of exposure may influence the amount of alteration to the enamel. Using infrared spectroscopy, Oltu and Gürgan (2000) compared t he mineral composition of enamel exposed to 35% carbamine peroxide, to 10% and 16% carbamine peroxide, and detected change at 35% but no detectable change at 10% and 16%. A clinical implication of these findings may be that teeth are more susceptible to extrinsic discolouration after bleaching due to increased surface roughness.
Effects on Restorations Bleaching has little or no effect on most of the common restorative materials (Dishmann et al 1994). Bleaching may increase the solubility of glass ionomer and other cements (McGukin et al 1991) and reduce the bond strength between enamel and resin composites, at least for a short time. Because bleaching releases oxygen into t he toot h, t he oxygen released inhibits t he
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polymerisation of the resin (Titley et al 1989). A delay of a week or more following the bleaching process is advised, prior to the placement of a new composite, to allow for this effect to be dissipated (Haywood 1992). Bleaching may cause a slight increase in surface roughness of some types of resin composite, and the hardness may be very slightly increased, but neither is clinically significant (Christensen 1989, Friend et al 1991). Bleaching has no effect on porcelain and, although it does encourage the release of mercury from some types of amalgam, the clinical relevance of this is not known (Hummert et al 1993).
Toxicity It has been reported that the safety of bleaching using carbamine peroxide should not be an issue since both hydrogen peroxide and urea are found in every human cell; however, it must be remembered that the dose makes the poison. Controversy still does exist regarding the safety issues of peroxide-containing products. Heymann (2005) has stated that: ‘Literally hundreds of millions of teeth in the US have been bleached over the past 15-20 years without one credible account of any significant untoward effect appearing in the literature. Dozens upon dozens of clinical trials over this same time period have also affirmed the safety of vital tooth whitening when used in a shor t-ter m treatment duration according to manufacturers’ instructions. However, Heymann accepts concerns regarding the safety of tooth-whitening products, if not used correctly, by stating that: ‘Valid concerns still exist regarding individuals who may ignore manufacturer or dentist instructions and overuse whiteners for months or years. Long-term adverse effects on soft or hard tissues cannot be totally ruled out when these products are badly abused or overused’. (Heymann 2005). Concerns have been expressed over the potential adverse effects of the use of hydrogen peroxide as a bleaching agent. Effects such as localised tissue irritation and external cervical root resorption have already been discussed. However, clinical studies addressing ot her adverse effects, in par ticular carcinogenesis, are lacking (Haywood 2006). Reactive oxygen radicals are a potential source of cell damage, causing DNA strand breaks, genotoxicity and cytotoxicity. Although these radicals tend neither to cross biological membranes nor travel large distances within a cell, numerous animal studies have demonstrated precancerous cellular changes, and indeed carcinoma, when hydrogen peroxide has been in direct contact with tissues, indicating that hydrogen peroxide might possibly act as a promoter (da Costa Filho et al 2002). It is therefore prudent to recommend that until clinical research to address the question of possible mutagenicity is concluded, bleaching t herapies utilising high concentrations of hydrogen peroxide should not be used without gingival protection, and that hydrogen peroxidecontaining products should not be used in patients with damaged oral mucosa (Kinomoto et al 2001). 22 I Canadian Journal of Cosmetic Dentistry
Conclusion • Whitening of teeth can be achieved either by an external – or vital – approach, where vital teeth are bleached by direct contact with an agent such as carbamine peroxide, or by an internal – or non-vital – approach, where non-vital teeth are bleached with an agent such as sodium perborate, in a walking bleach technique; • most teeth are susceptible to bleaching; • during tooth bleaching, reactive oxygen produced by the breakdown of peroxide causes more highly pigmented carbon ring compounds to be converted to carbon chains, which are lighter in colour; • increasing the concentration of peroxide provides a more rapid bleaching effect; however it also increases the risk of tooth sensitivity; • tooth sensitivity, if present, normally persists for up to four days after the cessation of bleaching and can be reduced by reducing the amount of time spent bleaching per day, bleaching on alternative days or by the substitution of a desensitising agent, such as KNO3 gel, into the bleach tray between periods of bleaching; • there is a greater risk of post-operative sensitivity following power bleaching than with take-home bleaching; • there have been no reported cases of cervical root resorption following internal bleaching using a combination of sodium perborate and water, or sodium perborate and a low concentration of hydrogen peroxide; • the stability of bleaching is multi-factorial and variable. Only a few clinical trials are available for review; • enamel may become more susceptible to extrinsic discolouration after bleaching due to increased surface roughness; • bleaching has little or no effect on most of the common restorative materials; and • controversy still exists regarding the safety issues of peroxide-containing products. For a full list of references contact: versha.miyanger@fmc.co.uk
About the Author Johnny qualified in 1993. He completed his Masters in Restorative Dentistry from The Leeds Dental Institute in 2000. He then completed a three-year, full time residency programme in Prosthodontics from Trinity College Dublin in 2004. He gained his MFDS from the Royal College of Surgeons of Edinburgh in 2000. He currently runs his own referral Prosthodontic Practice near Dublin and is part-time faculty at the Dublin Dental School and Hospital. He both lectures and runs courses on Restorative and Implant Dentistry, nationally and internationally.
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Canadian Journal of Cosmetic Dentistry I 23
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Dr. Ron Goodlin
Developement of a Functional Occlusion for Longevity in the Aesthetic Restorative Case Background
Fig. 1: Occlusal stops, note the dots in back and lines in front indicating t he tripod of occlusal stops on posterior teeth and the anterior guidance signified by the lines on the front teeth. (Courtesy Dr. P. Dawson)
The longevity of any dental work is dependent on the functionality of the occlusion. The goal of the occlusal scheme is to allow the patient masticatory efficiency with harmony in the musculoskeletal system while protecting the cosmetic result which has been created. There remains many controversies amongst the proponents of the different theories of occlusion, and there are often many ways to solve an occlusal issue for a patient. Many patients have a high tolerance and adaptability which will often allow any of the various theories to work, while others with low tolerance and adaptability will provide the greatest challenge.
Goals of Treatment The goal is to provide a cosmetic solution for the patient with a responsible, minimally invasive, predictable treatment plan that will provide many years of comfort, function and aesthetics. This article will describe one method of accomplishing this goal.
Occlusal Scheme The fact is that if we do not create a harmonious functional occlusal relationtionship,the dentistry we provide will fail. All the different theories of occlusion basically agree on some areas of common ground. Longevity is a function of time over force. L=T/F 1 The greater the force and the longer the time, the less the longevity. So the rule is to spread out the load of the occlusal forces and reduce the time that the teeth and joint are being loaded. 1. All teeth should have a tripod of occlusal stops on the posterior teeth in CR (Dots in back, lines in front) (See Fig. 1) 2. The centric relation position should match the dental position of maximum intercuspation. 24 I Canadian Journal of Cosmetic Dentistry
3. Anterior guidance should consist of canine guidance in lateral excursions and central guidance in protrusive, both exhibiting posterior disclusion without interferences. 4. There must be freedom of movement within the envelope of motion. Teeth must remain in the neutral zone 2 (See Fig. 2) 5. There should be an even occlusal load and the musculoskeltal system of the TMJ should be free from stress and pain.
Fig. 2: Envelope of motion (Courtesy Dr. P. Dawson)
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Fig. 4c
Fig. 3: Standard series of extra oral photographs full face, R profile, lips at rest, L-M-R smile views
Fig. 4d
Fig. 4e Fig. 4a Figs. 4a-4o: Standard series of intra oral photographs: L–M–R 1:2 retracted (one set each for partially open and fully closed) L–M–R 1:1 Mx and Mdb Occlusal views.
Fig. 4b
There are seven tests for a successful occlusal scheme: 1. Negative load test: No TMJ pain on loading in the CR position 2. Negative Clenching test: patient should nave no pain in teeth or joint when they clench and squeeze hard. 3. Negative grinding test: Patient should have no posterior interferences in excursive movements, protrusive and lateral. 4. Negative Fremitus test: when patient taps up and down, place your finger on the labial aspect of each anterior tooth and you should not feel any tooth movement. 5. Stability test: Teeth are not mobile, no excess wear over time. 6. Comfort test: patient is comfortable. TMJ, lip position and speech., 7. Does it look good test: Patient is happy with the appearance of the case.
Fig. 4f
Predictability The process must be predictable. How can we develop the functional occlusion and the aesthetics at the same time? A system is used to create the appropriate cosmetic result as well as building in the occlusal scheme which will conform to all of the above principles.
Diagnosis and Treatment Planning Using Photographic Assisted Diagnosis3 and the principles of Smile design4 it is easy to look at a case and determine the areas of deficiency and what will be desired to correct the cosmetic situation. By analyzing the various photographs, such as the lips at rest, smile view, full face and profile views and the retracted views, a list can be created according to the principles of smile design. There are several methods to achieve this, overlaying a sheet of tracing paper or acetate and using a marker to draw the new position of the teeth5 Canadian Journal of Cosmetic Dentistry I 25
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Fig. 4k
Fig. 4g
Fig. 4h Fig. 4l
Fig. 4i
Fig. 4m
Fig. 4j
or using computer imaging techniques to make the desired changes and overlaying the after onto the before using a reduced opacity on the layers. (see Fig. 3)6 Once this wish list has been determined, it is a simple matter of determining the best approach, and oftentimes, multiple approaches, to achieve these changes. There are eight steps that have been recommended by Spear 5 when analyzing and treatment planning any cosmetic restorative case. 1. Determine the maxillary incisal edge position. 2. Determine the maxillary incisal inclination and incisal plane. 3. Determine the appropriate gingival height of contour maxillary. 4. Determine the appropriate arrangement of the maxillary anterior teeth and posterior teeth along the correct occlusal plane. 5. Determine the mandibular incisal edge position 6. Determine the mandibular inclination and anterior guidance. 7. Determine the mandibular gingival heights of contour. 8. Determine the mandibular tooth arrangement. 26 I Canadian Journal of Cosmetic Dentistry
Fig. 4n
Fig. 4o
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Fig. 7: Lips at rest: Tooth show is an important variable to understand if the teeth need to be lengthened or shortened.
Fig. 5: Full Face
Fig. 8: Smile view: Determination of gingival “show� and if the maxillary incisal plane follows the lower lip line, as well as midline deviation and canting.
Fig. 6: Profile view
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28 I Canadian Journal of Cosmetic Dentistry
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Fig. 11: Overclosure and VDO must be determined before treatment is begun. In order to gain tooth height, an increase in a VDO is often required. Fig. 9: Anterior Retracted view: Allows the practitioner to determine if the teeth are in alignment and which teeth should be repositioned. GHOC is also determined as well as papilla height and periodontal condition.
Fig. 12: PAD profile view to determine UFH :LFH and VDO requirements. Fig. 10: Occlusal views: Helps determine arch form problems
It is important to remember the interdisciplinary approach7 during the diagnosis and treatment planning stage, which is often a simple matter of emailing photographs of the case to the lab technician, periodontist, orthodontist and oral surgeon for their input. Having a team in place is a critical factor for success in this age of increased patient demand, knowledge and expectations. The standard series of photographs8,9 is the standard of care which will allow the practitioner to provide superior services and results to the patient. (See Fig. 4) Analysis of these photographs using anthropometric and smile design and principles of Photographic Assisted Diagnosis will lead to a working concept of what corrections need to be made to restore the case. (See Figs. 5-10) Once the wish list has been determined, the practitioner will be able to create a comprehensive treatment plan complete with alternative methods to accomplish the outlined goals. Often this plan will involve several pre-restorative phases such as orthodontics, periodontics and sometimes surgery. Cosmetic treatment such as bleaching and multiple diagnostic wax-ups along the way,will follow before a bur is allowed to touch a tooth. One of our primary objectives, of being minimally invasive, will often dictate that orthodontics be used to move teeth into a more favourable position before the restorative phase. It is important to understand that the final result should be planned for before any work begins. 30 I Canadian Journal of Cosmetic Dentistry
Fig. 13: Tooth show at rest
Vertical Dimension of Occlusion In some situations the patient will exhibit overclosure, short incisors due to wear, or loss of teeth which will require the opening of the vertical dimension of occlusion (VDO) in order to restore the correct incisal edge positon, and the dentition to a functional occlusion. (See Fig. 11) The vertical dimension of occlusion can be determined by using cephalometric and anthropometric facial analysis. If the VDO needs to be opened; this will result in the ability to lengthen the IEP, giving the practitioner longer incisors with which to build the anterior guidance and subsequent occlusal scheme. It has been recommended that provisionals be left on the teeth for six months before proceeding to the final restoration stage as research indicates that there will be a ½ 1mm intrusion of the teeth over the first 6 months when the VDO is opened.5
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The use of cephalometric principles of skeletal upper face height to lower face height can be extrapolated to anthropometric guidelines and the use of photographic assisted diagnosis (PAD) to assess the UFH:LFH. The UFH is measured from nasion to anterior nasal spine in the lateral ceph, and can be interpolated to the photograph using glabella to subnasion. The LFH is measured on the radiograph from ANS to Me. The photographic version is from SN to Me. The ratio of UFH:LFH should be about the same, with the LFH being slightly longer in some instances. When there is a difference of more than 95+/- 10% then the practitioner should examine the discrepancy more closely for determination of skeletal dysplasia which would alter the treatment plan. (See Fig. 12)
Maxillary Incisal Edge Position The key to the entire process is the correct placement of the maxillary anterior teeth. Just as in the denture set up, the first teeth we place in the wax rim are the two central incisors, making sure the midline was centered and straight. We also concentrate on getting the ideal maxillary central incisor position as our first step in the restorative process. There are several so called rules to use in determining the IEP, but the final result must be controlled by the practitioner and the patient together. The following are really guidelines to use to locate the approximate incisal edge position. It is recommended that these guideliness be followed in order.
IEP-1 Tooth Show at Rest The lips at rest photograph is one of the most underutilized, yet one with the utmost diagnostic importance. Have the camera lens set to 1:2 magnification ratio and straight on to the patient on both the horizontal and vertical planes. Ask the patient to lick their lips, swallow, then part their lips and stay there...by parting the lips the tooth show at rest will be revealed. (See Fig. 13) Analysis of this photograph will allow the practitioner to utilize PAD techniques to actually measure tooth show. The following table indicates the age appropriate tooth show at rest. As the patient ages the entire facial musculofacial complex will sag and droop, this causes the upper lip to cover the maxillary teeth and the lower lip will become more flaccid causing greater exposure of the lower incisors as a result (See Fig. 14)
Age
Tooth Show
Young 16-30
3.0
Middle 32-50
2.5
Mature 50-65
1.5
Senior 65+
0.5
Fig. 14: Age appropriate Tooth Show when lips are at rest.
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Fig. 15: Trubyte Tooth Form Indicator (Dentsply Corp.)
The practitioner will now measure the tooth show at rest and determine if the maxillary centrals should be lengthened and if so by how much. It is not uncommon to want to increase the length of the centrals by at least 1mm to provide anti aging.
IEP-2 Trubyte Tooth Form Indicator Many years ago the trubyte tooth form indicator (Dentsply) was invented for use in denture setup to determine the appropriate size of the central incisors to match the patient’s facial features . By placing the template over the nose and lining up the eyes and mouth, the practitioner then uses the red slides to touch the side of the cheek laterally and the inferior limit of the chin. The ratio of the face height and width to the tooth size is read off the template. This most often will end up relating to the height to width ratio of 78%. If the facial measurement from the TTFI does not match the 8X10 or 8.5X11 range one should suspect a problem with UFH:LFH discrepancy. (See Fig. 15)
IEP-3 Height to Width Ratio Seventy eight percent height to width ratio is the generally accepted rule of thumb for the height and width of the central incisor. The table below gives the most common height to width ratios of central incisors. The average height of an adult’s central incisor is 10.5mm, giving the appropriate width of 8.25mm. As there is artistic license in the height to width ratio, remember to use these numbers as a guide as opposed to an absolute.
Fig. 16a Figs. 16a-b: Photo showing correct placement of ruler in labial fold and measurement of the IEP at 22mm.
IEP-4 22 mm rule
Fig. 16b
Measure from the labial fold under the lip to the incisal edge and this is often found to be 22mm. (See Figs. 16a-b) By measuring the difference between the existing IEP and the 22mm mark on the ruler, the practitioner can easily use this as a guide as to how much tooth must be added to the existing IEP to achieve the desired IEP.
IEP-5 Golden Proportion The use of a golden proportion ruler; placed from the subnasion to the gnathion, will provide the centre part of the ruler on the location of the desired IEP. (See Figs. 17a-b)
Establishing IEP and GHOC
Fig. 17a Figs. 17a-b: Golden proportion ruler (Safident) and the positioning to determine IEP.
Fig. 17b
32 I Canadian Journal of Cosmetic Dentistry
By putting the first 5 rules together we now know how much we want to lengthen the existing IEP. We combine that with the appropriate H:W ratio of the teeth for that patient from the Trubyte Tooth Form indicator and the H:W ratio smile design principle. Measure the patient’s existing tooth height and then subtract the number of the existing tooth length from the ideal tooth length and determine the amount of tooth we need to add. For example, if the existing tooth is 8mm in height and 8mm width, we need to lengthen the tooth 2mm to get it to the ideal IEP. The ideal H:W ratio for this patient has been determined to be 10.5mm. By adding 2mm to the 8mm to lengthen the IEP we reach 10.0mm which means
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Phonetic Analysis and the Dentition
Fig. 18: Establishment of the IEP, H:W ratio and GHOC
that to achieve the ideal H:W ratio we will want to extend the tooth 0.5mm apically by ortho intrusion, or crown lengthening. (See Fig. 18) We can now determine how much we will use to bring the IEP to the proper length and the rest will be achieved by adding to the gingival level. This can be achieved with orthodontic intrusion, crown lengthening, or surgical repositioning. Analysis of the upper lip and lip mobility will be discussed later in this article, however, it has been argued that if the upper lip line covers the maxillary teeth in full smile, it is not necessary to add the additional length to the apical portion by gingival alteration. Be careful here as many patients have learned to achieve a guarded smile through muscle memory and once the case is completed they lose self consciousness and the lip miraculously uncovers the upper CEJ to the dismay of both patient and practitioner.
Sound
Sample Sentence
Comments
F and V 16-30
very very fine
IEP on vermillion border of lower lip - if dimpled IEP too long
S-Sh
she sells seashells
If lisping the incisal 1/3 of the centrals are too thick or lowers too long
CH
church cheese
Tongue hits palate behind centrals in normal sound
TH
the thing thinks things
Tongue in cingulum may need to deepen cingulum
Fig. 19: Table showing the phonetic sound and the appropriate tooth position.
Direct Composite Buildup Using a mock-up by building composite along the incisal edge of the existing teeth will help to show the patient and practitioner the approximate length that has been determined to be appropriate using the methods as described above. At this stage, the patient and practitioner can analyze if it appears to be appropriate using a subjective approach. Remember that generally these patients have been living with short teeth for so long that this change may appear overwhelming at first.
Phonetic Analysis Testing the phonetics will help determine if the IEP is too long and if the incisal edge position is proclined, reclined or appropriate. The thickness of the Central Incsior at the incisal 1/3 of the tooth will also be analyzed at this stage. (See Figs. 19 and 20)
Overbite and Overjet Analysis of Overjet and overbite will allow the practitioner to make some minor alterations at this point. In most situations the addition of 1mm to the IEP of the central incisors will vastly improve the aesthetics and function of the case and will not inhibit the overbite and anterior excursions of the patient. In some situations however, lengthening the IEP to
Fig. 20: The correct IEP during the “F” and “V” sounds, being at the junction of the vermillion border of the lower lip. This is easily analyzed using PAD with a lateral smile view during a prolonged “VVVVVV” or “FFFFFFF” sound by the patient.
what appears to be correct could result in a very deep overbite that would limit the freedom of movement during excursions, then the practitioner must make a choice here as to whether the lower anteriors will need to be shortened to accommodate the new longer incisal length, or will the ideal maxillary IEP need to be compromised somewhat to account for the overbite. The practitioner must analyze this carefully as oftentimes shortening the lower anterior teeth could result in the need for endodontic and crown lengthening procedures and even possibly full coverage restorations to account for the longer IEP. Problems with overbite and overjet can often lead to pain in the lateral pterygoid mm, chipping and fractures of anterior restorations and wear. Canadian Journal of Cosmetic Dentistry I 33
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recommended that every practitioner make themselves experts in these principles whether or not they are accredited with the AACD or planning to do so. These fundamental principles are the cornerstones of cosmetic dentistry and must be fully understood before they can be applied with confidence and predictability.
Midline
Fig. 21: Diagnostic wax-up
The midline can be off by as much as 1/3 of the width of the tooth without anyone noticing, however, if the midline is canted by even the smallest amount, it will be noticed immediately.10 In cases of crowding, it is important then to make sure the midline is straight up and down, but if the crowding dictates that too much tooth must be removed to create a centralized midline, it is often quite acceptable to create a midline that is marginally deviated as long as it remains vertical.
Incisal Plane The incisal plane is determined by the length of the anterior incisor teeth stretching back and around the arch form to the first molars. These teeth will show during a smile creating the incisal plane which should follow the contours of the lower lip during a moderate smile.
Buccal Corridor The buccal corridor is the concept of teeth showing during a broad smile. If the front six teeth are restored but the back bicuspids are not, the smile will look awkward. The resulting negative buccal corridor from a distance will appear as if the patient has front teeth but no back teeth! Fig. 22: Modified Golden Proportion Software program (www.mydentalgps.com)
Gingival Height of Contour The gingival height of contour (GHOC) should follow the maxillary lip. A line drawn from the gingival crest of central to the cuspid should pass distally along the crestal heights of the posterior teeth. The lateral incisor should rest on or just below this line.
Diagnostic Wax-up
Fig. 23: Template for the wax up using the modified golden proportion
Shimbashi The shimbashi measurement states that there should be 18-21mm measurement from cementoenamel junction of the maxillary central to the CEJ of the mandibular central when the teeth are in occlusion. This used to be a standard of measurement of the VDO but has been disputed. This measurement can be applied as a loose guideline to determine the IEP by establishing the IEP to IEP contacts in the diagnostic wax up phase.
Principles of Smile Design The application of the theories of smile design will ensure the development of a highly aesthetic result. It is strongly 34 I Canadian Journal of Cosmetic Dentistry
Following some adjustment to make the phonetics correct and allow for the subjective input of the patient and practitioner, an index is made of the direct composite mock-up to give the lab technician guidance for the development of the diagnostic wax-up. Face-bow mounting with CR and MIP bite registration records should now be taken with either alginate of full tray PVS impressions. These are then transferred to the lab bench where the models are mounted on a semi or fully adjustable articulator for developemnt of the diagnostic wax-up and development of the anterior guidance, vertical dimension of occlusion and posterior occlusal scheme. (See Fig. 21)
Golden Proportion For many years dentists and lab technicians have been using the golden proportion (1.67:1.67) as the way to develop the width and height of the lateral and cuspid in the arch-form. This like many of our tools is used as a guide only and artistic license was then applied to make it
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“look right”. Methot in his work has developed a computer program that,10 like the “trubyte tooth form indicator” in its simplicity, will allow the practitioner to take a photograph and drop it into the computer program. The program will ask for only the interpupillary distance, and will then develop the correct golden proportion for that patient along with a wax-up template for the lab to use to create the position and size of the centrals, laterals and canines for that patient. (See Fig. 22) Printing out the template on the computer, or even simply just email the case to the lab technician and that will provide the template for the diagnostic wax-up. (See Fig. 23)
Mandibular Anteriors Special attention must be paid to the position of the mandibular incisal edge position dur ing t he development of the anterior guidance so that there is no crossover contact on the lateral incisors during lateral excursions as this is often the cause of fractured lateral incisor restorations. The mandibular incisal edge position must have proper labio-lingual inclination and contact position on the lingual of the maxillary incisors. This positioning is determined by the TMJ anatomy and is created in the lab diagnostic wax-up utilizing the parameters as dictated by the bite registration and face-bow mounting records.
Anterior Guidance On the articulator the index is used to create the new IEP of the maxillary centrals. The existing tooth width is taken into account and rarely adjusted except in cases of crowding where the teeth will be made narrower in the wax-up to straighten the smile (assuming the patient has already declined an orthodontic option) or the teeth may be widened to close diastemata in order to provide an acceptable aesthetic result. The goal of the anterior guidance is to provide maximum load sharing during protrusive between centrals and lower centrals and laterals. In cases where a younger look is the objective, we often will keep the IEP of lateral incisors slightly shorter than the IEP of the centrals to give a younger look. In a more mature appearance, the IEP of centrals and laterals can be even, and incisal embrasures are used to accentuate a youthful - mature look. The lateral excursions will be determined according to several parameters. When possible a cuspid guided lateral excursion that is mutually protected is the preferred situation. This allows for protection of the posterior occlusion from balancing contacts during lateral excursions and minimizes joint problems later, as long as this can be accommodated by remaining within the neutral zone of the occlusal scheme as per the work of Posselt in the Posselt diagram of the envelope of motion. 2
Posterior Occlusion Once the anterior guidance (protrusive and lateral excursion and CR occlusal stops) have been developed, the posterior occlusal scheme can now be determined. It is generally accepted by all the theories of occlusion that tripod occlusal stops should be achieved on each tooth and that during lateral excursion in a cuspid guided occlusal scheme, there should be no balancing contacts or slides on any of the incline planes of the posterior teeth. In the occasional situation where a patient requires a group function lateral guidance such as in a large implant restoration case or a full denture case, then the posterior teeth will need to have a flatter anatomical form to achieve this relationship and not create balancing interferences.
Treatment Phase In the previous section the rationale behind the development of the occlusion was determined and the treatment phase now begins. In a minimally invasive treatment modality the goal is to maximize tooth structural integrity and preservation of enamel by minimizing the amount of cutting into teeth. The ability to “test drive” the final occlusal scheme is of paramount importance whenever undertaking a full mouth reconstruction or even the most minor of cosmetic alteration.
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Fig. 26: Occlusal view before arch form reduction
Fig. 24: Arch form reduction stent
Fig. 25: Arch form reduction stent with hinge to expose anterior segment
Fig. 27: Arch form after reduction using stent
In many cases it will be possible to directly apply the diagnostic wax-up to the patient’s dentition with a minimal or no prep technique. This method will allow the practitioner to supply the mock-up of the finished product for the patient to try for a few weeks or months and to “work out the kinks” by simply adjusting the provisional material until the patient is happy with the aesthetics and comfortable with the bite.
Arch Form Reduction The creation of an arch form reduction stent will allow the practitioner to remove only the part of the tooth that is required so that the diagnostic wax-up can be directly transferred to the patient’s dentition for analysis and assessment.12 In cases of crowding or where the teeth do not lie within the arch form of the diagnostic wax-up, (the lab technician has had to prep the models to bring the teeth into t he archform) t hen a polyvinylsiloxane bite registration material such as Sil Tek putty (Ivoclar) can be placed in onto the diagnostic wax-up to create two occlusal bite pads and an attached labial band lying on the buccal aspects of the incisors. (See Fig. 24) A slice is made into the material and transferred along the middle of the incisor across to the opposite side where the cut stops before coming back up over the occlusal so as to create a hinge of sorts. This putty matrix can now be gently pulled back away from the diagnostic 36 I Canadian Journal of Cosmetic Dentistry
model to expose the incisal half of the labial aspect of the teeth from cuspid to cupsid. (See Fig. 25) The putty matrix is now removed from the diagnostic model and is applied to the patient’s teeth. This allows the pracititoner to gently place the labial hinged matrix against the actual teeth. When the natural tooth is out of the arch form that is required by the diagnostic wax-up, this interference is gently removed with a bur until the entire putty matrix will fit passively onto the arch form. (See Fig. 26) This minimally invasive met hod allows t he practitioner to develop the required arch form for the diagnostic wax- up to be utilized. (See Fig. 27)
Provisional After the arch form is reduced, the diagnostic wax-up is transferred to the patient’s teeth using a polyvinylsiloxane impression (Clear bite -Discus) . The impression is taken of the diagnostic wax-up. (See Fig. 28) Once hardened, try in the clear bite to make sure it seats completely onto the patient’s teeth. (If the archform has not been correctly modified, this impression will not seat correctly and the entire provisional guide will be inaccurate requiring a lot of adjustment or complete removal and starting over). If the provisional stent does not seat, go back and make sure the arch form reduction has been completed such that the provisional stent will seat completely and passively.
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Fig. 28: Clear bite impression of diagnostic wax-up
Fig. 30: Anterior view of provisional material
Figs. 29 a-b: Application of provisional material using clear bite
Fig. 29a Fig. 31: Preparation of anterior restorations using provisional material as a prep guide.
Fig. 29b
Then the patient’s teeth are spot etched, washed and dried, bonding agent placed and cured and the provisional material is placed inside the clearbite and transferred to the dentition. Minor adjustments are now made. (See Fig. 29) As this material will often need to last many months make sure you are careful to make sure air bubbles are sealed, IEP is correct and that the occlusion is milled in to provide stability and longevity.
Test Drive The patient will now be dismissed from the office and will take the provisionals which are a direct copy of the diagnostic wax-up, out for a “test drive” (See Fig. 30) The patient is invited back in a couple of days to check on the occlusion, the fit and the margins. One week later the patient is invited back for a fitting. This is a free appointment where the patient will ask for some teeth to be made longer, some shorter, some turned or straightened. Once this has been accomplished the patient is asked to sign a release that they are satisfied with the provisionals. At this time an index is made of the provisionals (Sil Tek Putty - Ivoclar) and the patient is dismissed. If the patient is not yet satisfied with the appearance of
the provisionals they are invited back to the office in one week for a 30 minute adjustment session which has a fee applied (this is made clear before the case is begun during the initial consultation and fee discussion stage). In cosmetics we can sometimes run into a patient who is indecisive and finds it difficult to get to the next step. These patients would often attend the office for multiple appointments having a tooth lengthened one week and shortened the next, never being able to finally say yes let’s compete t he case. In t hese cases, unless t he practitioner is fairly compensated for all the extra time, bad feelings could be generated from the experience. The additional fees will often times help the patient be able to come to a decision much earlier in the process. If there has been a substantial amount of adjustment made to the provisionals, a new provisional clear bite can be taken at this time.
Preparation Once the patient has signed off on the provisionals, the maxillary anterior teeth (cuspid to cuspid) are prepared. The preps are done ideally into the provisionals as these are where the final restorations will be developed to. There will be some areas where the natural tooth will be not even touched by the bur as the thickness of the overlying provisional material is thicker than the required preparation depth, while other areas will have the maximum area of preparation into the tooth material if this is sticking through or just covered by the provisional guide. (See Fig. 31) Canadian Journal of Cosmetic Dentistry I 37
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Fig. 32a Fig. 32a: Facial view (Before)
Fig. 32d Fig. 32b
Fig. 32d: Facial view (After)
Fig. 32b: Smile (Before)
Fig. 32c
Fig. 32e Fig. 32e: Smile (After)
Fig. 32f
Fig. 32c: Before retracted
Fig. 32f: Immediate post insertion
The provisional clear bite impression is now used to reapply the provisional material. At this stage it is often advised not to spot etch the teeth but to use a “shrink fit” technique. The margins are adjusted using a Zakrya (See Fig. 32) instrument to reflect the gingival tissue to allow direct access to the margins, and a needle nosed fine diamond bur or a multifluted carbide bur. Air bubbles are sealed with flowable composite and the provisionals polished.
The case can now be completed in phased treatment as follows:
Try-in and Cementation When the restorations are returned from the lab they are inspected and cross referenced against the shade mapping and lab prescription. The patient is then invited to the office for the try-in and cementation stage. The provisionals are “flicked” off the teeth and the maxillary anterior teeth tried-in. If shade alterations need to be made and cannot be accomplished by the use of value altering try-in cements (variolink veneer Ivoclar) then the restorations are returned to the lab for custom shading. If the appropriate shade can be achieved with the use of the value shades then the maxillary restorations can now be cemented to place. 38 I Canadian Journal of Cosmetic Dentistry
1. Prep max anteriors 2. Cement max anteriors’ 3. Prep mdb ants 4. Cem mdb ants 5. Post UR 6. Post LR 7. Post UL 8. Post LL
Post-op Check The patient is invited to return one week post cementation of each phase, and every 6 weeks thereafter, as sometimes finances or time will dictate that the case be completed over a prolonged period of time. In such cases it may be advisable to use a lab fabricated or an in office oven fired material that may last longer. This author has used Ivoclar System for many of these cases with only minor alterations or adjustments required over prolonged periods of time.
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Once the case is completed, the patient is seen one week post-op, then 3 weeks post-op for final photos and tissue health analysis. Any alterations can be finalized at this point. The patient is then again invited to return 3 months later for a final assessment. At this stage the patient is released to the referring dentist or back into the recall pool. (See Fig. 32)
Conclusion The determination of the incisal edge position of the maxillary incisors is the first and most important factor in any reconstructive case. The principles of smile design are used to determine, midline, tooth size, shape colour and arrangement follows. The incisal plane is t hen determined by t he arrangement of the anterior teeth using the principles of golden proportion, and modified golden proportion. Application of principles such as “age-genderpersonality� factors and the contour of the lower lip line are used to complete the positioning of the maxillary anterior teeth. The maxillary lip line is used to guide the gingival heights of contour. Development of the anterior guidance, the posterior occlusion and occlusal planes (curves of spee and wilson) follows in order, using diagnostic wax-ups before transferring t he information to t he mout h, and minimally invasive arch form reduction and provisional guide techniques. This method of developing the occlusal scheme is recommended for every case whether it be a full mouth
reconstruction or a simple cosmetic change to the anterior teet h, in order to achieve a predictable, minimally invasive and long lasting restorative solution for the patient.
References 1. Goodlin R.M. Functional Stability, the 10 best secrets of Cosmetic Dentistry Cdn J of Cos Dents Vol 4 No.1 April 2008 pg 32 2. Dawson. P, Functional Occlusion from TMJ to Smile Design Mosby 2007 3. Goodlin, R.M.Photographic Assisted Diagnosis Cdn J Cos Dent Vol 1 Issue 1 Feb 2005 4. Blitz, N. Steel, C. Willhite, C. Diagnosis and Treatment Evaluation inCosmetic Dentistry AACD Accreditation criteria guide edn 1. 5. Spear, F. MASTERING THE ART OF ESTHETIC DENTISTRY Toronto Academy of Cosmetic Dentistry September 19 - 20, 2008 6. Goodlin, R.M. Computer imaging for Cosmetic Dentistry DVD learning seminar www.smiledental.ca 7. Spear, F, Kokich V. Mathews, D. Interdixciplinary Management of Anterior Dental Aesthetics J Am Dent Assc. Vol 137 No. 2 160-169 8 Goodlin R.M. The Complete Guide to Dental Photography Michael Publishing ISBN 0-96901957-1-0 1987 9. Goodlin R.M. Digital Dental Photography Cdn J Cos Dent Vol 4 No 1 April 2008 pp 26-27 10 VO Kokich, H ASUMAN KIYAK, PA SHAPIRO Comparing the perception of dentists and lay people to altered dental esthetics - Journal of Esthetic and Restorative Dentistry, 1999 11. Methot, A. Goodlin.R.M. The Modified Golden Proportion Cdn J Cos Dent April 2006, vol 1 no. 1 12 Goodlin R.M. Minimally invasive cosmetic dentistry Cdn J Cos Dent Vol 3 No 2
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Hilary Ford
Speaking the same Language Hilary Ford of Blue Horizons emphasizes the importance of communicating correctly with your patients ave you ever wondered if the messages you try to get across to your patients are falling on deaf ears? Are you perhaps puzzled at why you don’t get more people actually taking up a treatment that they have asked about? Or maybe you’ve moved from one region to another, and are regularly bemused by the locals’ turns of phrase? We may all live on one island, but the English language is complex and constantly evolving, and if you want your practice to be as successful as possible you need to make sure you are using the same language as your patients. You need to ensure that what you are saying is being understood, that you use words which have relevance to your patients, and that you are not unwittingly putting them off having treatment.
H
Cosmetic vs. Aesthetic Take for example the common debate over the words cosmetic and aesthetic when used to describe dental treatments. This is something we struggles with for some years – we just couldn’t find a definitive answer as to which phrase was the best. It is only in more recent times that we have discovered that that is because there is no definitive answer – it depends on where your practice is located, and what type of patients you are treating. In some areas, the phrase aesthetic dentistry really doesn’t mean a lot to patients. They don’t fully understand what the word aesthetic means, and how it applies to dentistry. They certainly don’t make the link between the word and how such treatment could benefit them. 40 I Canadian Journal of Cosmetic Dentistry
Conversely, there are also some areas where patients do not view the word cosmetic as meaning a quick fix, in much the same way that make-up – also, of course, referred to as cosmetics – is a temporary solution. In fact, some of our clients have had patients tell them that they do not want cosmetic dentistry, they want something that lasts!
Speaking the Jargon We’re not always aware when we speak that we are using jargon – ‘in’ words used by those we work or socialize with. It becomes so natural to us that we no longer notice it, unless someone who is not au fait with your phraseology starts looking bewildered or simply asks straight out what on earth you are talking about! As a dentist, you are used to using clinical language, day in, day out. You are happy to use phrases like buccal and mesial, to talk about pocket depths or shades of B3 or A2. But most of your patients won’t have a clue what you are talking about. We’re not suggesting that you change the language you use when, for example, charting a new patient. But you need to make sure that you avoid any clinical expressions when you are talking with patients, especially when explaining treatments. You are far more likely to have a patient agree to treatment if they understand exactly what it involves, and, more importantly, how it will benefit them.
Accentuate the Positives Which brings us nicely onto the marketing technique of
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stating benefits, not features. In terms of treatments, patients are generally more interested in how a treatment will benefit them. Will they look better, will eating be easier, will it stop those chronic headaches? Sometimes they can be so taken with the benefits they will scarcely care what the treatment will involve. On the other hand, if you explain in great depths every stage of treatment, and barely mention the benefits, you are far more likely to end up with another non-conversion.
Eliminate the Negatives According to communications experts, the brain does not register negatives. So if you say to your patients that a treatment is ‘not very expensive’, the word they will focus on will be ‘expensive’. Similarly, a patient who is told they will ‘not fell much pain’, will only register the word ‘pain’. Find positive ways of expressing things. Treatments are ‘affordable’ or ‘great value for money’ rather than ‘not very expensive’. Your dentistry is ‘gentle’ and patients will feel ‘comfortable and relaxed’, rather than being ‘virtually pain-free’. You should take a similar approach when encouraging patients to go ahead with booking further appointments or committing to new treatment plans. For example, if you would like an enquirer to book an initial consultation, don’t ask: ‘Would you like to book an appointment?’ This hands them an easy opportunity to say no, or not yet thank you. Instead, you should say something like: ‘What day would suit you best for an appointment?’. This makes it far more difficult for the enquirer to turn down the offer – instead they are more likely to give you a day of the week, and you can take it from there.
Ask the Right Questions Take the time to really get to know your patients and their needs by making sure that you ask open ended questions as often as possible. The answers should give you far more information than a simple yes or no, and could well highlight an issue that had not previously arisen, and that could lead to additional treatment.
The Written Word Remember to follow through with your written communications as well. Make sure your practice literature is well written, with a strong focus on the benefits of being with your practice and of the treatments you are promoting. Use reader-friendly language, and keep all your messages positive. Written words, unlike most spoken words, are a permanent record of what you say, so it is well worth investing in a professional copy writer to ensure that what you say is perceived to be what you actually mean! Finally, remember that a picture paints a thousand words – use lots of great, aspirational photos (no gory clinical ones!) and get your literature professionally designed to portray the right image.
Oral Surgery for the GP A Practical Approach Dr. Lawrence I. Gaum DDS, FADSA, FICD
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Career & Practice Transitions
Nadean Burkett
Attraction and Retention
uilding a loyal patient base is what most dentists strive to achieve. This is a two-way street. In order to discuss this topic, however, we must first acknowledge that not all patients are retainable in every practice. Some statistical data may help to clarify this point – according to the ADA and CDA, only 50% of the population in North America sees a dentist on a regular basis (at least once per year for recall). This percentage has not changed since 1955, and is not influenced by dental benefits. Therefore, statistically only 50% of the population of any community is retainable. That is not to suggest or imply that every practice has a 50/50 patient component. Every practice, no matter its location, visibility or age will have a certain percentage of retained and transient patients. Let’s define a “transient” patient. This is a patient who has sought treatment in your practice, but is not on at least an annual recare schedule in your practice. Typically, these are emergency patients or “walk-ins”. You may be asking – what’s the difference, so long as I have a “busy” practice? The answer is that it DOES matter, and should matter to you because the difference in these two basic categories of patients, both short and long term, is significant. The comparative value of a retained patient is significantly more that of a transient patient. The revenues generated by transient patients are not only lower, but the net cash flow is also much lower than that produced through services to retained patients. The difference in value to your practice comes from several sources:
B
1. Referrals through word of mouth to family, friends, co-workers and neighbours come from retained patients. This is without question, the best form of advertising any business can get! The investment is in your relationships with your patients and employees and has minimal financial cost. 42 I Canadian Journal of Cosmetic Dentistry
2. Reliability of future revenue through regular recare visits; this ensures that you will have a patient in your hygiene schedule at least every 12 months which enriches your relationship through prevention and education. 3. Case acceptance is much higher by retained patients. 4. Collection of fees for services rendered is simpler and faster when dealing with retained patient. Bad debt (uncollectible accounts) is more common when dealing with a transient patients. 5. In transition, retained patients are more transferable to a new owner, with the endorsement of you and your dental team.
Patients know what they hear, see and experience. The value of your practice to them is based on their experience with you and your team.
There are many ways to “attract” prospective patients to your practice. The focus in today’s dental marketplace tends to focus on the external options – display ads in community newspapers; visibility through physical placement of the clinic or signage, and convenience factors. Ads which offer specials or bonuses to new patients exclusively are known as “an invitation to treat”. It has become fashionable and popular to employ advertising in community newspapers, magazines and on the Internet in order to “attract” patients. This method of “promotion” is very expensive and generally ineffective. If you have a general announcement to the community – such as a relocation of your clinic – which is short term
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(+/- six months) placing a display or print ad can serve your purpose. Websites can be useful in patient education and communication especially for the internet-savvy patient, but I caution my clients not to expect it to be more than an internal communication tool. We have all seen examples of “invitation to treat” ads in our local papers. They offer “free” whitening kits, or discounts on cleaning with a “new patient exam”. In my opinion the “invitation to treat” ads are the most damaging to the dental practice because they are a net loss to the practice – you are working on that patient for nothing. Worst of all they can contribute to loss of patient retention in a practice because they demonstrate utter disregard for a patient’s loyalty. If you are going to make a special offer, make the offer to those patients who have “earned” it – give a whitening kit to a patient as a “thank you” for referring a friend or co-worker to your practice, or an electric toothbrush to a patient who has just completed a major restorative procedure, for example. If the patient has been loyal for several years and is celebrating a milestone in their life, why not recognize that with something special from you? They will appreciate your recognition and your simple gesture tangibly expresses the value you place on your relationship. Visibility and convenience by physical positioning of the clinic or through signage to a broad spectrum of people
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(traffic) presumes that “if you build it, they will come”. Again, seemingly a reasonable premise if all you want is practice traffic, not patient activity/retention. Physical positioning for maximum visibility generally requires a street, mall or other store-front location which is subject to retail tenancy rates which increases your cost of doing business and reduces your cash flow. This also makes you more vulnerable to changes in community demographics. Patients know what they hear, see and experience. The value of your practice to them is based on their experience with you and your team. That starts the first time they hear your name in conversation with a friend and continues with their first call to your office. When they see you and your team for the first appointment, their first impressions will either be affirmed or discounted to some degree.
About the Author With more than 30 years of practice and business management experience, Nadean Burkett is a career and practice transition coach to the dental and other professionals in private practice. Headquartered in Greater Vancouver, British Columbia, Nadean Burkett & Associates Inc provides consultation, counselling and assistance to dentists throughout North America since 2003. Nadean offers online resources through her web sites www.dentalbusiness.ca and www.edu-dent.com. All published articles are the intellectual property of Nadean Burkett & Associates Inc.
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Announcements Ronald M. Goodlin, DDS Elected to the AACD Board of Directors Ronald M. Goodlin, DDS of Aurora, Ontario, has been elected to the American Academy of Cosmetic Dentistry (AACD) Board of Directors. Ronald was elected to the AACD Board of Directors during the 25th Anniversary AACD Scientific Session, held in Honolulu, Hawaii, April 27 - May 1, 2009. “I am honored to serve on the Board of Directors of the AACD. This is the premier organization for advancing excellence in cosmetic dentistry, and I am excited to help lead the profession into the future,” commented Ronald. The AACD Board of Directors is comprised of 16 elected officials from varying cosmetic dental backgrounds. Its chief responsibilities include: supervising the direction of the AACD, determining its policies, and maintaining the AACD standard of excellence throughout all aspects fo the organization. The AACD is the world’s largest non-profit membership organization dedicated to advancing excellence in comprehensive oral care combining art and science to optimally improve dental health, function, and esthetics. Comprised of more than 7,000 cosmetic dental professionals in 70 countries around the globe, the AACD fulfills its mission by offering superior educational opportunities, promoting and supporting a respected Accreditation credential, serving as a user-friendly and inviting forum for the creative exchange of knowledge and ideas, and providing accurate and useful information to the public and the profession. For more information, please visit www.aacd.com, send an email to pr@aacd.com, or call 800.543.9220. Ronald M. Goodlin, DDS practices cosmetic dentistry at 15213 Yonge Street, Ste. 6, Aurora, Ontario, Canada. He may be contaced by telephone at 905.727.6453 or via email at ron@smiledental.ca. His practice can be located online at www.smiledental.ca.
Fourteen AACD Members Achieve Accredited Designation
Fourteen American Academy of Cosmetic Dentistry (AACD) members achieved t he AACD Accredited designation and were recognized at the organization’s 25th Anniversary AACD Scientific Session, held in Honolulu, Hawaii, April 27 - May 1, 2009. These AACD members join 320 dental professionals in the history of the AACD who have earned this prestigious designation. The highly sought Accreditation credential represents the standard of excellence in cosmetic dentistry. These AACD members were awarded this status through the demonstration of advanced skills and knowledge. Newly Accredited AACD Members Include: Kenneth L. Banks; Sandra M. Cook, CDT; Keri L. Do, DDS; Richard P. Durkee, CDT; Marilyn S. Gaylor, DDS; Steven A. Gorman, DDS; Jack D. Griffin, Jr., DMD; Edgar Jimenez; Suzanna N. Lee, DDS; Trinh N. Lee, DDS; Stevan J. Orser, DDS; William K. Parks, CDT; Wayne B. Payne; and Bonnie J. Rot hwell, DMD. For more infor mation regarding the AACD, visit www.aacd.com, send an email to pr@aacd.com, or call 800.543.9220 or 608.222.8583.
Accredited Status in the AACD
Sandra Cook, CDT, Richard Durkee, CDT, Edgar Jimenez, Wayne Payne, and William Parks, CDT, have achieved Accredited status in the American Academy of Cosmetic Dentistry (AACD) – joining 27 AACD Accredited member laboratory technicians in AACD history who have earned this prestigious designation. The highly sought Accreditation credential represents the standard of excellence in cosmetic dentistry. These dental laboratory technicians were recognized during the organization’s 25th Anniversary AACD Scientific Session, held in Honolulu, Hawaii, April 27 – May 1, 2009 and represent t he largest g roup of dental laboratory technicians to receive Accreditation at one time since the inception of the AACD’s Accreditation process. For more information regarding the AACD, visit www.aacd.com, send an email to pr@aacd.com, or call 608.222.8583
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Product Showcase 3M ESPE - Elipar S10 LED Curing Light 3M ESPE introduces the Elipar S10 LED curing light featuring a one-piece stainless steel housing that brings together form and function in a robust new face to the curing light market. The Elipar S10 LED curing light has been designed to inspire confidence with its unmatched features for convenience and versatility of use. The Elipar S10 LED curing light possesses a unique, ergonomic V-shape body that provides a comfortable grip from various angles. The small size offers an excellent weight balance. The shield of the device serves as a flat surface rest for roll-off protection; and the wand is cordless, making handling and performing procedures easier. In addition, it has an innovative magnetic light guide fixture for quick attachment and removal of the light guide, allowing for easy insertion, removal and positioning. For more information call 1-888-363-3685 or visit www.3MESPE.ca.
3M ESPE - Expanded Lava Precision Solutions Portfolio 3M ESPE unveiled an expanded Lava™ CAD/CAM System with the release of several new products including hardware, software and materials. Labs will be able to achieve a higher level of automation with the new Lava™ CNC 500 Milling Machine. In keeping with its goal of making it easy and efficient for dental labs to use, 3M ESPE announced an upgrade to Lava Design Software 5.0. A major software upgrade, version 5.0 will offer more dental technician-friendly features to enhance productivity. Supported by the new software and milling machine, the new Lava™ Digital Veneering System is both a material set and a restoration procedure that facilitates better productivity for dental labs. The system allows dental technicians to produce more units per day than with pressed ceramics or traditional hand-layered porcelain techniques. 3M ESPE is also introducing its own wax block and new Lava™ Zirconia blocks. For more information visit www.3MESPE.ca/lava or call 1-888-363-3685.
compliance. The essential elements of this Herbstalternative comprise protrusive bars and inclined planes fixed to cast splints or prefabricated brands on the vestibular surfaces of t he poster ior teet h in t he gingivobuccal fold. Item No. 330-0100. For more information, please call SNF Forestadent at 800.387.5031, 416.510.2220 or visit www.forestadentcanada.com.
Prescribevita.com Vident has launched prescribevita.com, an interactive website that provides a place for doctors and technicians to share before and after case photos, explore the entire line of VITA restorative materials and gain access to specials and discounts. The site includes downloadable prescr iption notes t hat can be personalized with a logo and practice information, a VITA lab finder using Google maps, and will feature an annual award for the best “before and after” case using VITA materials as judged by a panel of experts. Visit www.prescr ibevita.com or call 800-828-3839 for additional information.
Zest Anchors - Locator for All-on-4 Implant Procedure A special Locator Abutment with a titanium collar has been designed for direct placement onto the Nobel Biocare MultiUnit Abutment for the All-on-4 Implant procedure. The use of free-standing Locator Abutments eliminates the high cost of a cast bar, while reducing the vertical height of the restoration. Patient oral hygiene is easier to maintain with individual Locator Abutments rather than the complex structure of a cast bar. The Locator Attachment directs the patient into the proper seating of their overdenture and provides long lasting performance. For more information, call Zest Anchors, Inc. at 800-262-2310.
Functional Mandibular Advancer (FMA) Ivoclar Vivadent - IPS Empress® Direct The Functional Mandibular Advancer (FMA) is a new-type fixed appliance, developed for t he cor rection of Class II discrepancies, which is nondependent on patient 46 I Canadian Journal of Cosmetic Dentistry
Ivoclar Vivadent introduces IPS Empress Direct, a highlyesthetic direct composite system offering the esthetics of a ceramic combined with the convenience of a
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Product Showcase composite. A wide range of shades, various levels of translucency and a simple application protocol provide dentists with impressive options to easily mimic the natural esthetics of teeth in all indications, similar to ceramic. To further facilitate the restorative procedure, the IPS Empress Direct material demonstrates convenient handling characteristics in combination with superior polishing properties and long-term shade stability. Its physical properties are designed to satisfy the highest clinical demands. In addition, IPS Empress Direct offers extended working time providing freedom to design lifelike restorations. For more information, call 1-800-5336825 in the U.S., 1-800-263-8182 in Canada.
Multilink® Automix “Easy” Now Available from Ivoclar Vivadent In response to market demands, Ivoclar Vivadent is pleased to introduce Multilink® Automix “Easy”. This new “Easy Clean-Up” version of the clinically proven self-etching adhesive resin cement offers extended clean-up time for those dentists choosing to pre-polymerize excess material with a dental curing light. Additionally, dentists will still recognize all of the Multilink Automix advantages including: high immediate bond strengths; effective sealing of the dentin; fast and easy application; and the ability to bond restorations made from metal, metal-ceramic, all-ceramic, and composite materials. Due to its patented, hydrolytically stable phosphoric acids (acidic monomers), Multilink Automix “Easy” is capable of meeting the expectations of dentists and their patients regarding high bond strength and efficient, durable adhesion. Within only 10 minutes, Multilink Automix “Easy” establishes a reliable and long-lasting bond to a large variety of restorative materials. For more information, call 1-800-533-6825 in the U.S., 1-800-263-8182 in Canada.
Ivoclar Vivadent Introduces OptraStick ® Ivoclar Vivadent introduces OptraStick®, an easy-to-use, flexible plastic instrument that enables clinicians and dental technicians to easily and quickly pick up, hold, and place/handle indirect restorations. Even if only slight pressure is applied, the OptraStick adhesive tip precisely adheres to a wide range of small objects, such as inlays, onlays, crowns or veneers.
OptraStick features a ball-shaped, flexible adhesive tip that can be easily bent and flexed in all directions to accommodate a var iety of clinical or laborator y situations. The OptraStick adhesive tip is removed or separated from restorations wit h a simple rotar y movement (twist), or a hand instrument can be used to hold the restoration in place. OptraStick is available in refill packages containing 50 instruments. For more information, call 1-800-533-6825 in the U.S., 1-800-263-8182 in Canada.
Dentsply TruRx™ - Digital Denture Solutions A new, integrated approach to tooth mould selection and denture prescription, TruRx Digital Denture Prescription software shows great promise in improving process ease-ofuse and clinical outcomes. TruRx is a chairside, digital prescription tool that facilitates the denture consultation while addressing key therapeutic considerations, helping to make the denture process easy, consistent, and profitable for denturists and dental professionals. Tr uRx guides t he dental professional/denturist and the patient through the key denture considerations with interactive screens. The unique strengt hs of t he Tr uRx Digital Denture Prescription software lie in built-in intelligence to select suitable dental restoration options interactively with a patient and view the results live with them. The win for patients, dentists, and laborator ies is improved information, selection accuracy, efficiencies, esthetic outcomes, and overall satisfaction. For more information, please contact 1-800-263-1437 or email prosthetics.canada@dentsply.com.
Successful Launch of NobelActive™ Implant NobelActive – a new implant design with innovative features – was Nobel Biocare’s most successful product launch ever. More than 130,000 implants have been sold to date. NobelActive is the first product launched according to Nobel Biocare’s new scientific and clinical standards. NobelActive is a hybrid implant: slightly tapered in design, although parallel walled drilling protocols are followed in insertion site preparation. NobelActive is an implant for advanced users, especially designed for extraction sockets and soft bone indications. For additional infor mation please visit www.nobelbiocare.com. Canadian Journal of Cosmetic Dentistry I 47
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Book Shop Drug Information Handbook for Dentistry
Manual of Clinical Periodontics
This handbook for Dentistry, 14th Edition, is specifically compiled and designed for all dental professionals who require quick access to concisely-stated drug information pertaining to commonly prescribed medications. Authors: Richard Wynn, BSPharm, PhD, Timothy Meiller, DDS, PhD, Harold Crossley, DDS, PhD
This manual provides a quick reference for general dentists, dental hygienists, dental students and dental hygiene students. Both basic and clinical science topics are arranged in a tabular form to allow for easy access to each chapter. Authors: Francis G. Serio, DMD, MS, MBA, Charles E. Hawley, DDS, PhD
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PRICE: $53.95CAD/US, plus shipping & handling Oral Surgery for the General Dentist Literally leads the practitioner through numerous surgical procedures in a well organized fashion. Utilizing a step-bystep approach for a variety of surgical techniques accompanied by detailed color photographs. Author: Lawrence I. Gaum, DDS, FADSA, FICD
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Oral Soft Tissue Diseases 3rd Edition, is a visually-cued manual designed as a quick reference to assist in the management of oral soft tissue diseases. Authors: J. Robert Newland, DDS, MS, Timothy Meiller, DDS, PhD, Richard Wynn, BSPharm, PhD, Harold Crossley, DDS, PhD
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Manual of Dental Implants This manual is designed to initiate dental professionals and their staff into the world of implant restorative dentistry and maintenance. It is usable at multiple levels of knowledge and training so the reader can continue to benefit from it as he or she gains implant experience. Authors: David P. Sarment, DDS, MS, Beth Peshman, RDH
PRICE: $53.95CAD/US, plus shipping & handling Your Roadmap to Financial Integrity in the Dental Practice provides a structured format to assist in placing proper internal fiscal controls in the dental office. This reference explains how establishing good internal controls helps minimize potential problems such as theft, fraud, and unintentional errors in recording accounting data. Author: Donald P. Lewis, Jr., DDS
PRICE: $43.95CAD/ US, plus shipping & handling Oral Hard Tissue Diseases
Advanced Protocols for Medical Emergencies
2nd Edition is designed as a quick reference for the visual recognition and diagnosis of common bone lesions. Author: J. Robert Newland, DDS, MS
is a must for all offices that administer nitrous oxide, conscious sedation, and general anesthesia. Authors: Donald P. Lewis, Jr, DDS, Ann Marie McMullin, MD, Timothy Meiller, DDS, PhD, Cynthia Biron, RDH, EMT, MA, Harold L. Crossley, DDS, PhD
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Dental Office Medical Emergencies 2nd Edition, covers the most common dental emergencies and is designed for use by the entire office staff during times of crisis. Authors: Timothy F. Meiller, DDS, PhD, Richard L. Wynn, BSPharm, PhD, Ann Marie McMullin, MD, Cynthia Biron, RDH, EMT, MA, Harold L. Crossley, DDS, PhD
PRICE: $48.95CAD/US, plus shipping & handling Illustrated Handbook of Clinical Dentistry This handbook is a valuable reference manual for dentists and dental students that concisely summarizes the major disciplines of clinical dentistry. It is written as an aid for transition into clinical practice, or as a refresher for a seasoned dental professional. Author: Richard A. Lehman,DMD, MPH
Lexi-Comp ON-DESKTOP for Dentistry is a complete Medication Management System. Elevate the standard of patient care and help protect your practice from liability with this innovative electronic platform. Our complete library of databases is downloaded to your desktop computer, or hosted on your network server, eliminating the need for a constant Internet connection.
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PRICE: $64.95CAD/US, plus shipping & handling Clinician’s Endodontic Handbook 2nd Edition, was developed as a quick reference to address current issues in clinical endodontics. Authors: Thom C. Dumsha, MS, DDS, MS James L. Gutmann. DDS, FACD, FICD
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Mail orders to: Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON Canada L3R 9Z4 Phone Orders: 905. 489.1970 Fax Orders: 905. 489.1971
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50 I Canadian Journal of Cosmetic Dentistry
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Tru Innovation Whether it’s for the Laboratory, the Dental Professional or the Patient, TruRx is the Intelligent Denture System that gives everyone a reason to smile.
Laboratory: • Drives premium denture business • Provides patient’s post-therapy image, face shape, mould forms, arrangement & denture base • Produces a complete and easy-to-read TruRx detailed prescription that can be received via e-mail, fax or print-out
Dental Professional: • Provides an interactive, custom denture consultation • Standardizes and simplifies the denture process • Enables the denture consultation to be delegated to an auxiliary • Shows patients their post-therapy image during their FIRST visit
Patient: • Educates patients for improved understanding and acceptance of the treatment plan • Shows patients a cosmetic approximation of what they will look like with their new denture • Helps to ease fears and promotes more positive appointments
For more information on TruRx - The Intelligent Denture System, please contact your authorized DENTSPLY Distributor at 1.800.263.1437.
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1.800.263.1437 © 2009 DENTSPLY Canada. All rights reserved
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