clinical | EXCELLENCE

The concept of progressive smile design

By Dr Tif Qureshi, BDS

Progressive smile design... helps us to appreciate the beauty that is already there and which simply needs to be encouraged rather than forever covered with porcelain...

osmetic dentistry has been around in various forms for several decades now. The biggest catalyst was arguably Pincus 1937 invention - the porcelain veneer.1 This gave Hollywood actors a short term solution that would hang on just long enough for the director to say cut. At the time, the lack of any real bond strength meant they were only considered a temporary solution. It was in 1982 when research by Simonsen and Calamia2 showed that porcelain could be etched by hydrofluoric acid and bond strengths between the composite and porcelain meant that veneers could be bonded permanently. Over the last 30 years, bonding has improved further and aesthetics and strength of ceramic materials has vastly improved to a point where carefully cemented veneers can add beauty and function to compromised teeth. The Concept of Smile design3 coupled with the enhancements in bonding and ceramics meant that the provision of cosmetic dentistry exploded around the world, especially in the US and parts of Europe. A large number of educational programmes sprung up that taught postgraduates how to prepare and place veneers, as well as market and sell treatment to patients.

From 2000-2007 in the UK, a massive boom in cosmetic dentistry occurred that transformed practices, spawned business managers, created spa-style practices and forever changed the face of private practice dentistry. Dentistry is a business but the selling of smiles has always been one of the most controversial aspects in the history of dentistry. Computer imaging software was available as far back as 1999. It was and still is used in many cosmetic practices to show patients what is possible. Visual communication is well known to be highly effective in convincing any audience.4 Photographs are taken of a current smile and then using imaging software, a hopefully realistic but dramatically improved result is generated and the patient is shown the potential outcome. This can be used to simulate simple whitening, bonding and of course, smile makeovers. Typically, though many patients chose to have multiple veneers placed based on simple short imaging sessions because of all the images shown, the more dramatic makeover often seemed to be the most attractive and noticeable change - i.e. it was the perfect smile. However I have found through treating many patients who start off wanting the perfect smile

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Figure 1. Close view highlighting teeth needing aggressive tooth preparation.

Figure 2. Arch evaluation.

Figure 3. Before alignment.

Figure 4. After 7 weeks, aligner in position.

Figure 5. After ABB (11 weeks).

Figure 6. Before - Patient was considering veneers.

Figure 7. After Inman and whitening Patient no longer wants veneers.

Figure 8. After edge bonding - Patient is satisfied.

that actually the definition of perfect is highly contentious. I would argue that after treating countless patients with the concept of Progressive Smile Design, that most patients actually prefer their own teeth to look more attractive, rather than a set of veneers. What this means is that after aligning, then whitening then possibly bonding, I have found it to be very rare for a patient who initially thought they wanted veneers to go ahead and have them done. The case shown here will highlight this and I would argue that in the future, for reasons based on simplicity, risk, ethics and litigation, that the processes of progressive smile design will become the norm.

The case
This patient presented a copy of an imaging simulation and a treatment plan to have 10 veneers with another dentist. She was aesthetically aware and was planning on having wider buccal corridors, a gum lift and longer teeth. All this would have involved a high degree of preparation on several teeth in particular. She had been warned by the dentist who offered the treatment that root-treatments might be required. This made her present to our practice for possible tooth alignment first, before having veneers. She decided to have her teeth aligned to reduce the risk of this and asked for an Inman Aligner. On examination involving

x-rays, full mouth examination and arch evaluation3 it was clear that the case was suitable. Only 1.4 mm of crowding was present. The patient decided on the Inman Aligner because she wanted to be able to remove it and for her case to be completed quickly. It would also not impinge on her budget for veneers. Impressions were taken and sent to the certified Inman Aligner lab. The Aligner had incorporated bite raisers to help jump the cross bite. 2-weeks later, it was fitted. Careful progressive, anatomically respectful IPR was carried out. Even though we knew 1.4mm of crowding was present, with IA treatment, 1.4 mm of IPR is never carried out in

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Figure 9. Side retracted view - before.

Figure 10. After ABB at 11 weeks.

Figure 11. Before side smile.

Figure 12. After alignment and bleaching.

Figure 13. After Edge bonding.

Figure 14. Before close view. one go. Only 0.13mm per contact was carried out, and only in accessible contacts. With Inman Aligner treatment, IPR should be carried out progressively and in an anatomically respectful way. Anchors were placed to keep the bows in the incisal thirds. The patient was given instructions, then returned in 2 weeks. After this time, the small spaces opened had already closed up and further measured IPR was carried out. The advantage of performing IPR progressively is that if for any reason the patient cannot carry on with treatment, only minimal amounts of tooth will have been re-proximated. Also, the risk of poor flat contacts is also less likely and better anatomy can be maintained on the contact points. After 5 weeks, the patients teeth were starting to align already and the laterals

Figure 15. After close view. was starting to jump the cross bite. Further minimal IPR was carried out and an anchor was placed on the upper right lateral to allow the tooth to de-rotate. At week 8, it was clear the teeth were improving dramatically. The patient decided to whiten her teeth at this stage and simple take-home trays were made on models taken at this time. Deep cut dam seals were made around the necks of the teeth and the tray was trimmed about 5 mm above this line. Hydrogen peroxide was used over a period of 2 weeks for 45 minutes a day. Simple clear and accurate instructions were given to ensure a good result was achieved. Most importantly, the patient was asked to swallow saliva- then quickly suck air in over her teeth before placing the trays. This dries the teeth and allows the gel to work more effectively. At week 10, the patient returned and commented that her teeth were looking far better than she thought. The combination of alignment and bleaching had very much improved the patients perception of her own smile. In my experience, I find many patients before treatment see their unattractive smile as a collective of problems of colour, shape, angles, length and outline. After alignment and whitening, normally all the patients notice is the irregular outline of the worn or chipped incisal edge. So her question what can we do about the outline of the teeth? was of no surprise. At this point, flowable composite was placed on the chipped upper left central and lateral as a preview. The patient was delighted with the appearance and scheduled to return a week later for bonding. She stopped whitening.

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clinical | EXCELLENCE
After a week, the patient returned. Bleach shade Empress Direct dentine and enamel was matched and chosen before any dehydration occurred. No local anaesthetic was placed and very minor roughening of the exposed edge was carried out before cleaning and etching. After bonding, the missing tooth was built up incrementally in layers of dentine and enamel. I have found that nano-hybrid materials such as Empress direct and Venus Diamond are excellent materials for edge bonding. They possess opacity in their dentines that seem to mask the join more easily and seem extremely reliable on thin edges. The composite was polished and an impression was taken for a wire retainer. The patient continued using her Inman Aligner. A week later, a retainer wire was fitted to the palatal of the front six teeth. It also highlights the intense value of progressive smile design. A patient may feel completely differently about their teeth once aligned and whitened. This is not a little niche area of cosmetic dentistry - its impact is huge and it actually questions the fundamentals of smile design and provokes a radical re-think of what has gone on before and still goes on in many practices. Progressive smile design has the ability to make some veneer-based smile makeovers (even no-prep veneers) look utterly ridiculous and like complete-over treatment. It also helps us to appreciate the beauty that is already there and which simply needs to be encouraged rather than forever covered with porcelain. It further makes us question how important are the parameters of smile design as they are set. Simply, that the view and perception of the patient is infinitely more important than some rules that we are told are correct. This of course does not mean that smile design parameters or veneers are wrong. Veneers can be life-changing for many patients and there are always situations where they are by far the best solution. However, I believe they should be right at the end of a progressive pathway that allows the patient to jump off at any point. The final part of this is to apply the daughter test5 to yourself as a dentist. How many dentists with teeth in anyway similar to this patient would opt for veneers placed just based on a simulation or wax-up? And how many would prefer to progressively align their teeth simply, then bleach and bond? The answer is not difficult to guess.

Figure 16. Light roughening/etch and bonded surfaces.

Figure 17. Empress Direct Dentine placed.

Discussion
This patient was delighted with her outcome. Most importantly, her own perception completely changed once she saw her own teeth aligning and whitening and suddenly the ideal smile design protocol seemed far less important. This meant she could pursue a far less risky approach by just having some virtually no prep composite placed to enhance and repair the outline. Without this, she would have had 10 teeth - arguably unnecessarily - prepared for veneers. A few of which would have been deep preps into dentine. This only happened because the patient was allowed to see her teeth align. Technically, aesthetic flaws still exist, but these become worthless in comparison to the patients feelings. She commented that she never thought her own teeth could look so good.

Figure 18. Empress Direct Enamel placed.

Disclosure
Dr Qureshi runs Inman Aligner education through Straight-talks Seminars worldwide. For info, see www.straight-talks.com

Figure 19. After initial contour.

Conclusion
This case highlights how flawed the process of traditional smile design using computer imaging is. Patients simply do not get the chance to see their teeth improve and are more likely to accept a visual suggestion for a smile makeover. In my opinion, simulating whitening and bonding, though it can be effective, is not enough. Alignment is actually quite hard to simulate and hence often is not shown. So if a patient cannot visualise what their teeth will look like straight, it is no surprise that they might opt for a more radical solution such as simulated veneers.

References
1. Pincus CL.Building mouth personality A paper presented at: California State Dental Association;1937:San Jose, California. 2. Simonsen R.J. and Calamia John R. Tensile Bond Strengths of Etched Porcelain, Journal of Dental Research, Vol. 62, March 1983, Abstract #1099. 3. Macroesthetic elements of smile design Jeff Morley, DDS and Jimmy Eubank, DDS. J Am Dent Assoc, Vol 132, No 1, 39-4. 4. John Berger, Ways of Seeing (1972). 5. The daughter test in elective esthetic dentistry. J Esthet Restor Dent. 2009;21(3):143-6. Burke FJ, Kelleher MG.

Figure 20. After initial appointment polish.

About the author

Dr Tif Qureshi is President Elect of the British Academy of Cosmetic Dentistry.

164 Australasian Dental Practice

September/October 2011