Smile Makeover: A Practical Guide

A comprehensive guide to successful smile makeovers through meticulous planning, effective communication, and engaging patients throughout the design process.

Getting a smile makeover, for most patients, is quite a significant life event. It is likely that many patients will have perhaps contemplated and pondered over the issue for quite some time before proceeding with treatment. This may be due to financial reasons, a dental phobia or potentially a worry that the results won’t meet their expectations. 

Professor Lakshman Samaranayake, our Advisory Board Chair, discussed issues related to aesthetic dentistry and smile design with an expert in the area, Dr Conor Flanagan.

LS: Hi Dr Flanagan, thank you for sharing your expertise with the DRA Journal readership.  First, tell me in general how we can ensure our patients are happy with the ultimate outcome of their smile makeover?

CF: I am really delighted to share my wisdom with your readership. 

The secret to successful smile design can be summed up in two words, in general: planning & communication.

Many patients are more anxious about the outcome rather than the actual procedure itself; it’s the fear of the unknown. If we address this fear, we can start to overcome it and get patients confident about the outcome.[1]

I find involving patients in the planning process from the very beginning helps build trust and relieve anxiety for both the patient and dentist.

Sitting down with your patient and compiling a list of main concerns, listing them in order of importance, is a good starting point. If we understand the patient’s concerns, we can use that as a basic framework for how we are going to correct the smile and tailor it to the patient’s specific needs.

Having a protocol with checkpoints for the patient’s approval at various design & treatment stages will ensure that your proposed design satisfies your patient’s concerns and aligns with their vision for their new smile.

Let’s for example use a patient of mine, Sarah, to demonstrate a case where we engaged her in the planning process early on and included check points for her approval to help navigate us to a successful outcome.

Sarah wanted to improve the mismatched color & the shapes of her smile but was quite apprehensive about proceeding with treatment as she was nervous about the outcome. She had notably dark canines and an upper right lateral incisor which had stained composite restorations. All teeth were vital and responded normally to all investigations. Tooth whitening had previously been attempted, however the patient was unsatisfied with the result as the color, although brighter, was still inconsistent.

Sarah started her journey with a consultation appointment where we discussed her options, and after consideration she chose 10 upper Porcelain Veneers, however this would also translate to most cosmetic treatment options. 

My planning started with a digital smile design using the DSD app and then after Sarah’s approval, I sent this to the lab to help fabricate a wax up. A mockup visit was made to allow her to get a gauge of how her temporaries would look & feel before confirming the plan and moving to the preparation appointment, where we placed the provisional restorations. After a week we reviewed the design of the temporaries and made minor adjustments along with confirming a shade before finalizing the design for the definitive restorations. 

LS: So, what was the outcome? Was Sarah happy with your treatment? Were there any residual issues?

CF: A recent review at the 4-year mark showed that Sarah was still very happy with her outcome, and she did not have any complaints.

LS: Now could you please outline the process in detail and provide any clinical tips for our readership.

CF: Given below is a short description of what I have gathered over the years to try and make this process seamless for patients, dentists and ceramists.

First, good clinical photography is paramount for planning any case. Ideally at the initial consultation it is best to capture the smile in a variety of positions to allow sufficient assessment of how the teeth and smile relate to the rest of the face. [2]

Lips in repose, a natural smile and an exaggerated smile taken from front on, 45 degree and profile angles help assess the reference points of gum and incisor display along with muscle activity around the teeth.

Here we can get a feel for proportions of the teeth and if we need to lengthen the teeth incisally or gingivally.

The next set of photos are full face with lip retraction showing teeth together and out of occlusion. This set allows assessment of gum line, incisal edge and midline canting along with incisor relationship and occlusion.

Occlusal photos serve to allow analysis of alignment and narrowing of the arches.

Once the photography is completed, sitting down with the patient and discussing their concerns is of immense value. Clinical photography is one of the best tools in our armamentarium for communicating with our patients, a picture paints a thousand words.

The next is the discovery session: Analyzing clinical photographs alongside the patient gives them immense insight into their current situation and how proposed treatment options could improve things.

Furthermore, it is also an opportunity to assess the patient’s expectations of what type of result they want to achieve, as usually patients will have a vision in their mind of how their new smile is going to look.

It is important for the treating dentist to elicit as much information about this as possible to grasp a firm understanding of what they are envisioning. From here we can decide on whether or not it is achievable and if so, which treatment modalities we should implement.

Once it has been established what they want to achieve, the next step is discussing how they can achieve the desired result. When discussing options, I find it is best to keep treatment descriptions very simple to begin with to help make it easier for patients to understand. [3] When the patient has an idea of what each option can achieve, then we can focus on more detail. I give some examples below:

Orthodontics: Straightens teeth & improves bite, however, won’t correct size, shape or color of teeth and generally has a timeframe of months or years.

Composite Edge Bonding (Partial coverage): Shape correction for the lower half of the tooth, color usually blended to existing color of tooth. Results can be achieved within 1-2 appointments.

Porcelain Veneers (Full coverage): Corrects sizes, shape and color of the teeth but can’t change the position of the teeth. The treatment time frame is a few weeks. Veneers are lab made.

Composite Veneers (Full coverage): Same concept as porcelain veneers, however the material is less durable. Results are achieved in 1-2 visits.

Whitening: Color changes only, results are instant.

Patients normally base their treatment decision around three factors: cost, timeframe and expectation of result. As a dentist, we should encourage sensible decision making by our patients to ensure the best outcome is achieved within a timeframe that is suitable to them and is within their budget.

Having this discussion early on in the treatment process should prevent any miscommunication or misunderstanding. Also allowing time for the patient to digest this information usually results in patients returning who are onboard with the treatment plan and have made peace with any limitations before starting the process.

LS: Does digital technology help you in your smile design programs?

CF: Having visual props such as an Invisalign ClinCheck or example before & after photos of similar cases you have previously completed will help patients understand their potential outcome better. 

I find using photo editing software to illustrate the proposed changes to the patient’s smile is one of the best communication tools at our disposal, there are even dedicated apps for this such as DSD or Smile Designer to name a few.  These tools are highly advantageous, as changes to the smile can be made and reversed instantly, allowing patients to preview proposed changes to the smile without touching a dental instrument. 

Dentists can demonstrate how the smile will look when we add length to the incisal edges, adjust the gum levels, close spaces or even just select a whiter color of tooth. They can instantly get a visualization on the plan/outcome, giving us the chance to verify a template for designing a wax up for veneers or even doing a direct mockup for composite bonding.

Once a visual blueprint has been confirmed, you can send the patient a copy to review at home, adding an additional layer of consent to the process. I often send this photo along with my digital wax up prescription to the lab, so they have a visual reference to work off for the ExoCad design. 

LS: I believe that the next step of communication with the laboratory is critical too. So how do you communicate with your ceramists?

CF: Having close communication with the lab is just as important as your communication with the patient. Having a system in place to allow quality control checks for the various lab stages, for example approving a digital design before final processing, will ensure that your instructions are being followed correctly, preventing any deviation from your plan. 

I usually have design approvals for the digital wax up, prefabrication of the veneers and then a final check before glazing. Ideally the lab work is physically assessed in person a few days before the cementation appointment. Following this protocol minimizes the potential for error allowing the cementation appointment to run as smoothly as possible. 

As with many dental practices, the lab is offsite and therefore without them physically seeing the patient our best way of communicating with them is to send detailed clinical photographs of each step.[4] Using shade guides with your photos helps the lab color calibrate everything from the pre op tooth shade, preparation stump shades and the temporary veneer shade. The more information they have when making the restorations, the less likely there will be errors at the try in stage. Full face photos with retraction for the preparation and temporary veneer stages help for verification of correction for smile curve and gum line balance. 

LS: So, what are the other ancillary issues associated with smile design procedures?

CF: To ensure patients are fully informed regarding the treatment, it is recommended to send the relevant written consent forms once a plan has been established. This allows any questions or concerns to be raised and discussed well in advance of the procedure.  It is advisable to discuss any potential or specific risks in person prior to affirming the patient has a comprehension of any limitations to treatment or complications prior to commencing with the preparation. 

Stepwise touch points are recommended at this appointment. At the preparation visit, I do a final check on the plan using clinical photography, this time in conjunction with the 3D digital model. The patient is given time to assess the wax up and in cases where it is suitable a direct mockup is placed to enable a preview of the temporaries.[5] 

When performing a gingivectomy to correct an asymmetrical gum line, a good tip is to numb the attached gingiva only locally around the tooth/teeth that require gingivectomy. This preserves the patient’s ability to smile and enables accurate assessment of how the new gum position looks with the patient’s smile before moving on to fully numbing the patient for tooth preparation. It is advisable to show the patient the gum line adjustment for their approval before moving on to the next steps. I prefer to use an Electrosurge due to accuracy and healing response of the tissues. [6]

My aim at the preparation is to adjust the temporary restorations to ensure they are comfortable; the occlusion is balanced and allows for soft tissue healing to take place. 

I will adjust the aesthetics to around 80% to how I feel the final design should look and then refine the design a few days later, once the patient has had time to assess for any adjustments they request. 

LS: Do you have review appointments before design finalization with the ceramists.

CF: Yes, it is highly recommended to review the temporary restorations with your patient prior to finalizing the design in porcelain with the lab technician. 

Touching base with the patient allows us to get direct feedback on their thoughts of the size, shape and color, allowing adjustments to be made if necessary.  This ensures they are satisfied with the aesthetics and occlusion, keeps everyone on the same page with expectations for the final restorations. The closer you can refine your temporaries to the desired framework, the easier it will be for your ceramist to copy and therefore less likely a request for adjustments from the patient whenever they try in the final porcelain restorations. 

Multiple review appointments may be required for some patients who are unable to commit to a definitive design. It is advisable not to proceed to the porcelain stage, until they are happy with the temporary restorations, as adjustments and appointment times will take significantly longer as the ceramist is required to make these adjustments. 

If the previous steps have been planned correctly, this appointment should be relatively straightforward. 

If the preparations are limited to enamel, it is often possible to carefully section the temporary restorations to remove them without giving any local anesthesia. The big advantage here is that the patient’s smile will be preserved for a more accurate assessment of the final restorations. 

Trying in the restorations with a try in cement is the final verification point. Trying in with a clear try in paste first allows for better shade analysis of whether a more opaque or higher value cement may be required to block out the stump shade of the natural tooth. Giving the patient sufficient time by themselves to assess the final restorations under natural daylight is preferred.

I find it is essential that patients are aware that at this point, adjustments can be made to the veneers, however once they are cemented in place, that window of opportunity is lost. 

Once approval has been given and we have selected the desired cement shade, we can go ahead and permanently insert the veneers. I usually book a follow up review around 4 weeks later to assess occlusion and gum healing.

LS: Can you summarize the essentials of the above discussion in a few sentences for our readers.

CF: Of course, there are four major issues that are important although all the details outlined above are important as well. These are first, successful outcomes are the end product of good planning and communication. 

Second, involving and engaging with the patient early on in the planning process can save a lot of time, energy and frustration, then trying to work backwards at a later stage. A visual representation of a proposed outcome is usually easier for patients to comprehend and should ensure there is no miscommunication. 

Third, checkpoints along the way to touch base with your patient and verify they have a comprehension of the prospective outcome. 

Finally, good temporary restorations are the best form of communication. They keep the patient, dentist and ceramist on the same page.

LS: Thank you Dr Flanagan for sharing your wisdom with our readers.

CF: Thank you, Professor Samaranayake, for allowing me to air my views on your platform.

References 

1. Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review 

2. OpreaBogdan Dental photography: Why? What? How? Part 1 Why? The role of dental photography in daily practice.

3. PMohan Kumar Role of jargon in the patient–doctor communication in the dental healthcare sector—A systematic review and meta-analysis

4. A. Casaglia P. De Dominicis, L. Arcuri, M. Gargari, and L. Ottria – Dental photography today. Part 1: basic concepts

5. Paula Pontes Garcia, Rogério Goulart da Costa,Murilo Calgaro, André Vicente Ritter, Gisele Maria Correr, Leonardo Fernandes da Cunha, and Carla Castiglia Gonzaga – Digital smile design and mock-up technique for esthetic treatment planning with porcelain laminate veneers

6. Sheeja Varghese, Gingivectomy by different Techniques – A Comparative Analysis