It’s been a long and productive appointment—a grueling, five hour maxillary arch rehabilitation—to create a beautiful smile and superior functional posterior teeth. You’re getting hungry and your eyes are tired. You feel stress in your neck, a burn in your shoulder blades, and an incredible desire to visit the bathroom. The patient is tired, hypoglycemic, would love a trip to the bathroom, and has a numb neck, too. But now is the best time to finalize your bite relationship, review contours, select shades, the size of the central incisors, test for phonetics, and decide on how much translucency will work best—right? Wrong!
Patients need explanation, but not at the cost of their comfort. Dentists today are responsible for form, function, and health, but more importantly, aesthetic outcome. If you’re not in tune with your patient and the laboratory, you may be redoing the case for aesthetic reasons even if the clinical outcome is perfect.
After initial rehabilitation, most dentists will not see the patient again until the placement appointment. At that time the dentist—and the lab technician—are hoping and praying that the case is exactly what the patient desires. A critical step in which confirmation of the provisional teeth has been lost as an instrument of communication for the dental technician.
Return in 48 Hours
After you rehabilitate a large anterior segment or full arch, have the patient return within 48 hours to refine and define several issues. The patient will be rested and can tell you if the occlusion is off, phonetics are altered, or if the contours of the teeth are acceptable. A simple checklist will help you be certain of the outcome and will show patients your attention to detail. When my patients return for their 48-hour refinement appointments, I review my checklist which includes occlusion, phonetics, central incisors (75-80), contours, and shade.
If tooth position is being altered (in most cases), I check for discrepancies in both vertical and anterior posterior positions, looking for the orthopedic position of the jaw joints. Typically, you can alter vertical position 2-3 millimeters without stimulating muscular activity. But if you alter the anterior posterior position just a quarter millimeter, muscular stimulation occurs. Lateral changes introduce torque, which results in pitch, roll, and yaw relations. If one side is not contacting in centric occlusion, the patient will torque up the deficient side to contact the opposing arch within 24 hours, causing muscular dysfunction – SPASM.
Seventy percent of headaches are contracted types associated with malocclusions. Having the patient back within 48 hours can save you from turning a non-symptomatic patient into a symptomatic patient.
Have the patient relax his or her muscles by using a tensing unit for 30 minutes. Tensing the muscles of mastication provides increased blood flow, removes toxins (lactic acid), and releases adhesions in the muscle so that there is an increase in range of motion. After a four-to-six hour session in the chair, the patient may experience post-operative swelling and truisms. The tensing unit is a great therapeutic instrument to relax muscles so that a true trajectory of function and tooth contact can be evaluated for adjustment. Once patients feel that they are simultaneously contacting bi-laterally, it’s time to stop.
Evaluation of the F-point and incisal edge position can fine-tune phonetics to an acceptable position. In an upright position, have the patient count from 40 to 50 rapidly. Look at the maxillary incisal edge and its relationship to the lower lip. Upon saying “F” sounds, if the central incisors embed into the lower lip, the lengths of the incisors are too long. Adjust the incisal edge on 8-9 by a quarter of a millimeter at a time until the patient is just barely touching the lower lip.
Next, have the patient count from 60-70 rapidly. Watch and listen for a proper “S” sound made by the maxillary incisors and the mandibular incisors. Are they clinging into each other or is there excessive space between them? Adjust by reducing the lingual incline of the upper teeth and labial surface of the lower teeth, or add composite to the incisor to establish an acceptable “S” sound.
Central incisor with length percentage (75-80)—Evaluate the patient’s head type. If their type is brachocephalic—80 percent, mesocephalic—78 percent and doliocephalic—75-78 percent, you decide on the width and length of the central incisors and let the lab establish the proper golden proportion.
This is the best way to develop an eye for an overall aesthetic appearance of teeth. The anatomy of teeth can make you a wonderful artist. Learn how to shape and slenderize, especially canines! Attention to detail at this point is time well spent. Check for overhanging and rough acrylic on the provisionals, especially the facial margins of the anterior teeth. There is nothing worse than having your patient return with apically lifted margins exposing root surface. Can you spell “R-E-P-R-E-P?”
Once completed with the contouring phase, polish everywhere again and ask if there are any rough spots. Use a smile catalog to select the appearance that your patient desires. Take an impression of the provisionals to send to the lab with your case.
Next, review the color mapping of the teeth. Fill out the laboratory prescription in front of the patient. Start by evaluating the shade of the provisionals. I usually use A1 shade, but the patient may want to go lighter. Check for the whiteness in the patient’s eye (Sclera). The two distinct features of a face are eyes and smile. Create the contrast needed for these features to stand out together.
Start with the gingival shade selection first, followed by the middle upper body third, then the main dominate shade in the mid to incisal one-half to two-thirds of the tooth. Finish with a milky translucency of 1 to 1.5 mm of the incisal edge. An example of this using a chromascope shade guide would be: 110 gingival / 040 upper third / 030 main body with a lobed milky translucency incisal edge of 1mm. All along, the tooth becomes lighter in shade as it progresses casually to the incisal edge. Decide surface texture and any occlusal stain.
Within reason, the patient should determine how white the teeth should be. But I find that patients rarely complain of going too light, but they do regret not going light enough.
Following this outline will create certainty not only for the dentist and patient, but for the lab technician as well. To be successful in cosmetic dentistry today, the dental professional needs to be committed to meeting the patient’s wants and desires. Otherwise the dentist must be prepared for reprepping the case at their expense for aesthetic reasons.
James C. Downs received his D.M.D. degree from Tufts University School of Dental Medicine. He is an expert in comprehensive restorative treatment by completing numerous full-mouth reconstruction cases. He maintains an aesthetic, family-oriented practice in Denver, Colorado.