A clinical case by our Community member Dr. Lisa Fernandes Gonçalves

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

The impact of the growing habit of self-education in medical care and wellness, and selfperception being greatly driven by social media can be both beneficial and harmful: on the one hand, having well informed patients facilitates their participation and understanding; however, on the other hand, a substantial amount of misinformation is also present online, which may make the consultation more difficult. Of course, the face-to-face consultation is still—and should always remain—central in creating trust and providing objective information about a procedure.
Although nowadays patients know exactly what they want, dentists are encouraged to ensure that people’s expectations of the treatment are both rational and realistic.
Body dysmorphic disorder (BDD) is an often under-recognised yet severe psychiatric illness, which is prevalent in people seeking non-surgical procedures usually with high expectations which may lead to post-operative depression and anxiety. Performing an aesthetic treatment in
such cases may complicate the procedure for the dentist and, more importantly, does not improve the quality of life for the patient. Because of that it’s important to identify patients with
BDD and patients with unrealistically high expectations before interventions.

A correct planning of a case is a key factor in order to obtain an aesthetically pleasing rehabilitation. Tools such as Wax-Up and Mock-up are still a very important instruments in the planning process. It helps us understand and evaluate the position of each tooth according to the smile design, geometric principles and facial lines based on the natural head position. Use of tools such as digital wax up can reduce the margin of error, disharmonies, canting and incorrect tooth proportions. The digital wax up should be incorporated in facial pictures or scanned faces.
Also the interaction between patient, clinician, and dental technician is crucial in the process of planning a case.

Fig.1

40 Years old woman wanted to improve the aesthetics of her anterior upper teeth. She mainly complained about having small teeth, gummy smile, and unappealing tooth proportions. Because of her high aesthetic demand, she refused orthodontic treatment and additive composite restorations.

Fig.2

All photos were shared with the dental lab, and a digital smile design was made to help improve
communication with the patient.

Fig.3

Digital wax-up. The gingival margins and tooth proportions were corrected.

Fig.4

Three different mock-ups were used to achieve patient approval.

Fig.5

Crown lengthening guided by our mock-up.

Fig.6

Follow-up 6 months after surgery.

Fig.7

Tooth preparation guided by the mock-up.

Fig.8

After tooth preparation and polishing (14-24). The old composite restorations were removed in both central incisors due to marginal infiltration.

Fig.9

The key to a conservative veneer treatment is to use a silicone guide, which allows us to control how much tooth structure is removed.

Fig.10

Feldspathic ceramic veneers by Oleg Blashkiv.

Fig.11

Veneer cementation with rubber dam.

Fig.12

Final outcome.

Fig.13

Details of the cemented veneers.

Conclusions

It’s very important that patients understand exactly what the treatment they need is, what will happen during the treatment, how long the recovery time should be, which potential complications might arise from those procedures, and what type of results are to be expected both immediately and in the long term in order to have a successful treatment.
For that it’s important to remember:
1. Listening is the most important skill in patient consultation
2. Dentists need to be aware and recognize patients who have high expectations
3. Setting realistic aesthetic goals is paramount
4. Make time to plan the treatment before any intervention.

Bibliography

1.Magne P, Belser UC. Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Esthet Restor Dent 2004;16:7–16.
2.Blatz MB, Chiche G, Bahat O, Roblee R, Coachman C, Heymann HO. Evolution of Aesthetic Dentistry. J Dent Res 2019;98:1294–1304.
3.Coachman C, Calamita MA, Sesma N. Dynamic documentation of the smile and the 2D/3D digital smile design process. Int J Periodontics Restorative Dent 2017;37:183–193.
4. Blatz MB, Vonderheide M, Conejo J. The effect of resin bonding on long-term success of high-strength ceramics. J Dent Res 2018;97: 132–139.
5. Dayoub ST, Yousef MA. Aesthetic crown lengthening with flapless piezoelectric surgery in comparison with traditional open flap ap- proach. J Clin Diagnostic Res 2019;13:ZC24–ZC28.
6. Storrer CL, Ostemack HP. Treatment of gingival smile. J International academy of periodontology. 2017 19/2:51-56
7. Naragh M, Atari M. Development and validation of the expectations of aesthetic scale. Archives of Plastic Surgery 2016. Vol.43/No4