A 10-step guide for predictably
outstanding cosmetic dentistry
by Dr. John Nosti
Cosmetic cases elicit a great deal of emotion and energy in a general
dentist’s practice. With a positive experience and outcome, patients will be
forever grateful for the services you have provided; they will be excellent
referral sources to your practice and many will even have an emotional
connection with you. The effect on your team is that often they develop
a higher sense of purpose and self-satisfaction, and team culture improves
greatly in providing this level of dentistry. Overall, the positive energy
given and received from these experiences become long-reaching in many
areas of your practice (especially team culture).
Negative outcomes and experiences from just one case, however, can
have long-term effects on your team culture, your reputation and especially
your willingness to take on these cases in the future. The negative energy
associated with these outcomes tends to spread throughout the office
into many areas (again, one of the most important being team culture).
We all want positive experiences and outcomes when it comes to cosmetic
cases. Personally, I like systems because they’re step-by-step processes to
apply each time to ensure the results are predictable and successful. A
system allows you to communicate with your team so you’re on the same
page about where you’re starting and where you’re going to finish. It’s the
road map that helps you navigate to success and helps your team know
which turns are coming up before they occur.
When a patient first enters the practice, even if they’re ready for a “smile
makeover,” we begin with a complete examination—a full-mouth series
of radiographs, full periodontal examination, examination of muscles
and joints, and aesthetic analysis. If the patient has instability in any of
these areas, a general rule of thumb is to clear these conditions before
performing any aesthetic treatment.
Step 1: Understand the patient’s
goals and desires.
One of the most important aspects of
cosmetic dentistry is performing a new-patient
interview.
It’s vital to listen to your patient during
the interview process and understand fully
what their goals and desires are. Do they
want to have their treatment done because
they’re attending an event, like a wedding?
Is there a deadline to when they want their
treatment completed? Do they want to
complete their dentistry just because “it’s
time”? Do they want their teeth to appear
straighter, whiter or longer? Are they hoping
to correct wear, attrition or erosion, or to
close black triangles or spaces, to replace
old dentistry, etc.? Are they someone who
wants all the details?
No matter the answers, it’s important
for dentist and patient to be on the same
page throughout the process. The best way
to communicate existing conditions and
discuss the goals of treatment is through
photography.
Step 2: Photograph and communicate
goals and expectations.
When performing cosmetic dentistry,
photographs are required for proper documentation.
High-quality DSLR photos are
excellent, but at times even high-quality
cellphone photos can suffice.1 The American
Academy of Cosmetic Dentistry photographic
documentation series2 illustrates an excellent
way to document a case and allows full
communication with not only your patient
but also the lab performing the case (Fig. 1).
This allows you to understand the patient’s
goals, desires and expectations. It is critical
to judge whether the patient’s goals can be
achieved with direct or indirect dentistry
alone, or if a multidisciplinary approach
is required.
A patient presented to my practice
unhappy with her recently performed
cosmetic dentistry, requesting that all of
her ceramics be replaced. Photos were used
to communicate with the patient exactly
what she was unhappy with and what she
wanted to accomplish (Fig. 2). Although
there were issues with the axial inclination
of the lateral incisors, the patient’s main
complaint was her gingival tissue display.
Using the patient’s clinical photographs, it was
communicated that her complaints required
a surgical solution, not just a replacement
of her existing ceramics.
Fig. 1
Fig. 2
Step 3: Create proper diagnostic and treatment records.
It’s important to provide the lab with
high-quality records to start your patient’s
treatment. These records include patient
photographs, maxillary and mandibular
PVS impressions, facebow record and
centric-relation bite record. For the lab to
perform to the best of its abilities, photos are
important to illustrate where the teeth fit in
relation to the patient’s facial features. Tooth
display, midline, occlusal and incisal cant
and tissue display all can be communicated
with photographs where the lab would
otherwise have to guess.
Providing the lab with PVS impressions,
versus using alginate or similar irreversible
hydrocolloid impression material, allows
the lab to pour the models in the most
accurate way possible, as well as allowing
model duplication.
A facebow record should be considered
the standard of care in treatment when
performing cosmetic dentistry. It transfers
the patient’s maxillary model to the lab
articulator; this transfer is in three dimensions
relative to the rotational axis of the
condyle. The end result is the ability to move
the articulated casts in a way that mimics
as closely as possible the movements of the
condyle in the fossa. Along with allowing
the lab movements to match the patient’s
movements, it transfers the smile line,
midline, incisal and occlusal plane to the lab.
A properly performed facebow (EZ Bow
System: Advanced Dental Designs) is the
best way to correct an incisal/occlusal cant,
as well as prevent these from occurring in
final ceramics (Fig. 3). One of the most
common postrestorative cosmetic errors
I see in my office is patients who present with
an incisal/occlusal cant (Figs. 4–6). This is a
preventable error with the use of a facebow.
In each case shown, this catastrophic error is
what drove the patients to seek correction.
A centric-relation bite record (Fig. 7)
allows the lab to mount the case in the
centric-relation position and to evaluate the
difference between centric occlusion and
maximum intercuspation. By starting from
a centric occlusal position, it is possible—
through a combination of equilibration,
removal of closure interferences and additive
waxup to the maxillary anteriors—to satisfy
cosmetic principles and achieve anterior
guidance of the final case. This is one of the
first steps to functionally design cosmetic
cases and reduce parafunctional forces on
the final ceramics.3–5
Fig. 3
Fig. 7
Step 4: Design the smile (waxup).
An imperative step to cosmetic case success is the diagnostic waxup. Along with
the diagnostic waxup, reduction guides
and putty matrix are fabricated to assist
with the case (Fig. 8). This is important
for several reasons:
- It allows the dentist to place a
mockup and to reduce the patient’s
teeth only where necessary to
achieve the final result. (This will be
discussed in Step 5.)
- It also allows the treating doctor
to place provisionals that match
the diagnostic plan. This part of
the process allows you to test both
the functionality and cosmetics of
the plan. If the diagnostic waxup
is not performed, and a functional
and cosmetic “test drive” of the
proposed design is not performed in
provisionals, then the “test drive” of
the desired plan happens only when
the final ceramics are inserted.
It cannot be stressed enough that you
should not skip this step! Nearly all issues
can be overcome by performing a diagnostic
waxup. If records were performed
improperly and an occlusal cant exists in
the diagnostic waxup, a new facebow record
can be performed, or the cant corrected in
the provisionals. The cosmetics are also
adjusted until the patient approves the plan.
Fig. 8
Step 5: Place a mockup and prepare through it.
With a combination of additive waxup
and the lab reducing the preoperative model
only as necessary to add wax, the doctor
performs the same initial enamelplasty to
place the mockup (Fig. 9). With the mockup
in place, the practitioner reduces and prepares
directly into the mockup (Figs. 10 and 11).
This prevents over- or underreducing the
preparations and allows for the proper
amount of reduction to achieve the desired
end result.
By conserving as much enamel as possible,
bond strengths are increased in final
ceramics and long-term success of the case
can be increased.6–8 This technique also
allows for a uniform thickness of the ceramic,
which helps prevent shade variants.9 Once
the preparations are completed, a photograph
is taken with a preparation shade guide to
provide the lab (Fig. 12). This is a necessary
step so the lab can understand what effect
the color of the preparation may have on the
definitive ceramic. This will affect the lab’s
decision on ingot selection for the ceramic.
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Step 6: Create provisionals.
Several continuing education training
programs and doctors state that provisionals
are an unnecessary process in cosmetic cases,
especially with minimal or no preparation
cases. I believe that by not placing provisionals,
the practitioner is missing an integral
part of the restorative/cosmetic case.
As stated earlier, provisionals allow
the practitioner to test drive the occlusion
and functionality of the case as well as the
aesthetics. Patients can go home and see
their new “trial smile” and offer criticism
or suggestions as to what they like or don’t.
With the trial smile in place, any functional
or cosmetic changes can be made before
fabrication of the definitive ceramics. This
prevents any surprises or disappointments
on ceramic delivery day. The provisionals
should be a reasonable representation of what
the final ceramics will look like.
[Editor’s note: For a step-by-step technique
in fabrication of provisionals in all ceramic
cases, visit the
“Shrink Wrap Temporary Technique” in the
cosmetic forum of Dentaltown here.]
Step 7: Create follow-up
corrections and patient-approved
provisionals.
The patient returns to the office one week
after placement of provisionals to discuss
any functional or cosmetic concerns. The
patient’s smile can be evaluated at this visit,
free of the anesthetic influence that typically
is present at the preparation appointment.
During this visit, any corrections or
adjustments that are needed are performed
and a PVS impression is made of the
patient-approved provisionals (Fig. 13) and
sent to the lab to match for the definitive
ceramics. If functional concerns arise,
adjustments are made and the patient is
scheduled for another follow-up visit one
week later to ensure no further corrections
are necessary. This process is continued until
functional concerns have been addressed and
the patient is stable in the provisionals. In
my office, I do not proceed with fabrication
of the definitive ceramics until the patient
has approved their provisionals.
The EZ Bow facebow is performed on
the patient’s approved provisionals, because
this will be the first model mounted in
the lab. The opposing mandibular model
is mounted to the maxillary provisional
model, and finally the preparation model
is mounted to the opposing mandibular
model. After this process, all models are
interchangeable with one another.
Fig. 13
Step 8: Get the ceramics
to match (lab
communication).
Once the patient has approved the
aesthetics of the provisionals, it’s time to
have the definitive restorations fabricated.
Photography of the patient before
treatment (Figs. 1 and 14), the patient’s
preparations (Fig. 12), and the patient in
the approved provisionals (Fig. 13) are
sent to the lab for communication of the
definitive ceramics. The practitioner and
the lab can discuss which material should
be chosen to achieve the desired results both
cosmetically and functionally, dependent on
the preparation design, preparation color and
desired final shade of the ceramics. If any
cosmetic or functional changes are made from
the diagnostic waxup, the practitioner should
provide an impression of the provisionals,
which will allow the lab to duplicate the
shape and dimension of the provisionals
to the final ceramics with the ceramist’s
added artistry.
Fig. 14
Step 9: Verify everything on delivery day.
The delivery day should be an exciting
day for your patient, your team and you. The
first tip for proper cosmetic case insertion
is to deliver the anesthetic palatally, instead
of traditionally into the muccobuccal fold
for the maxillary arch. This is performed
by placing topical first, then delivering the
anesthetic bilaterally between the first and
second premolar, and halfway between the
hard palate and the gingival margin (Fig. 15).
If you deliver the anesthetic palatally,
the patient will be comfortable during
the try-in and insertion while still having
full movement of their lip to evaluate the
ceramics and aesthetics.
After the anesthetic has taken effect,
the provisionals are removed and each
ceramic is first tried in one at a time to
ensure marginal integrity. After verification
of the margins individually, the ceramics
are tried in simultaneously, starting from
the centrals and moving distally to the
second premolars.
During this step, contacts are verified
and margins are examined again to ensure
proper fit. If an open margin is detected, the
appropriate contact is adjusted until the ceramic
fits as it did when it was individually seated.
Before showing the patient the result,
the ceramics are tried in simultaneously
with try-in paste. This step is necessary to
hydrate the ceramic and to demonstrate its
true color and shade. If the ceramics are
tried in while they are dehydrated, they will
look more opaque and brighter, compared
with the hydrated ceramic (Fig. 16). This
is a critical mistake often made in cosmetic
dentistry and the reason why many practitioners
believe that they see a “color shift”
in ceramics once cemented.
[Editor’s note: For a step-by-step technique
in inserting all ceramic cases, click here to be taken to the “Inserting the
Maxillary 10—‘Tac and Wave Technique’ ”
discussion thread in the Cosmetic forum on
Dentaltown.]
Fig. 15
Fig. 16
Step 10: Enjoy a postoperative
celebration.
The patient is scheduled for their postoperative
insert visit about two weeks after
delivery day. At this visit, any fine-tuning to
the occlusion is performed and postoperative
photos are taken.
This is a prime opportunity for a team
member to request consent from the patient
to use their photography as part of the
office’s before-and-after marketing. If the
patient shares any stories or reports a positive
experience, a team member can also
request a testimonial from the patient to
use in marketing in conjunction with their
photographs. The patient is congratulated
and their smile celebrated (Fig. 17).
Fig.17
Conclusion
Each of the steps outlined is a critical
component for cosmetic case success in your
office—from listening and connecting to your
patient before treatment, to designing trial
runs of the smile, all the way to cementation.
Following this process, you will build more
confidence in your treatment, your patients
will have an outstanding experience resulting
in more referrals, and the office culture
surrounding cosmetic cases will soar.
References
1. Hardan, Louis. Mobile Dental Photography with Auxiliary
Lighting. Quintessence Publishing (2020).
2. Photographic Documentation and Evaluation in Cosmetic
Dentistry: A Guide to Accreditation Photography. American
Academy of Cosmetic Dentistry, Copyright 2009–13.
3. Dawson, Peter E. Functional Occlusion e-Book: From TMJ to
Smile Design. Elsevier Health Sciences (2006).
4. Thornton, Linda J, “Anterior Guidance: Group Function/Canine
Guidance. A Literature Review.” Journal of Prosthetic
Dentistry, Vol. 64, Issue 4, 1990, Pages 479–482.
5. Kerstein, Robert B., and Radke, John. “Masseter and Temporalis
Excursive Hyperactivity Decreased by Measured Anterior
Guidance Development, Cranio, 30:4, 243–254, DOI:
10.1179/crn. 2012.038.
6. Fradeani, Mauro, Redemagni, Marco, and Corrado, Marcantonio.”
Porcelain Laminate Veneers: 6-to 12-Year Clinical
Evaluation—A Retrospective Study.” International Journal of
Periodontics & Restorative Dentistry 25.1 (2005).
7. Horn, Harold R. “Porcelain Laminate Veneers Bond To Etched
Enamel.” Dent. North Am. 27 (1983): 671–684.
8. AlJazairy, Yousra H. “Survival Rates for Porcelain Laminate
Veneers: A Systematic Review.” European Journal of Dentistry
(2020).
9. Pop-Ciutrila, I.S., Ghinea, R, Dudea, D, Ruiz-López, J, Pérez,
M.M., Colosi H. “The Effects of Thickness and Shade on
Translucency Parameters of Contemporary, Esthetic Dental
Ceramics.” J Esthet Restor Dent. 2021 Jul; 33(5): 795–806.
Learn more from Dr. John Nosti
and earn CE credits!
Dr. John Nosti has created more than a dozen video CE courses
for Townies about restorative dentistry, implants, occlusion,
cosmetic dentistry, prosthodontics and more. To check them
out, click here.
Dr. John Nosti practices
in Mays Landing and
Somers Point, New Jersey,
with an emphasis on
functional cosmetics,
full-mouth rehabilitations
and TMJ dysfunction.
Nosti is a member of
Dentaltown’s editorial
advisory board and the
clinical director of the Clinical Mastery Series, geared
toward advancing knowledge in occlusion, aesthetics
and restorative dentistry.