The Use of Smile Libraries for Cosmetic Dentistry - PDF

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					DTAP0306_16-18_Berland          29.03.2006          17:47 Uhr          Seite 1




         16 Trends & Application                                                                                                   DENTAL TRIBUNE                       Asia Pacific Edition




         The Use of Smile Libraries
                                                                                                                                                                        ance. By showing the possibili-
                                                                                                                                                                        ties that dentistry can provide
                                                                                                                                                                        for your patients, you may help
                                                                                                                                                                        create the “want”! 4

                                                                                                                                                                        Cosmetic Imaging and

         for Cosmetic Dentistry                                                                                                                                         Laboratory Communication
                                                                                                                                                                            After treatment is accepted,
                                                                                                                                                                        the cosmetic image continues
                                                                                                                                                                        to play an integral role in com-
         Lorin Berland, U.S.A.                                                                                                                                          munication between the doc-
                                                                                                                                                                        tor, the patient, and the labo-
                                                                                                  It’s easier than ever to give    smile libraries and cosmetic         ratory. The goal, after all, is
                                                                                              cosmetic patients what they          imaging are most beneficial.         to recreate that computer en-
                                                                                              want. The hard part is deter-                                             hanced smile as close as possi-
                                                                                              mining what they want. Pa-              Smile libraries, such as the      ble. Communication at every
                                                                                              tients seeking your solutions to     new improved Lorin Library           step helps ensure that we do the
                                                                                              their cosmetic cases have spe-       Smile Style Guide (Fig. 1) are       right thing the first time.5
                                                                                              cific concerns they can’t articu-    useful to illustrate the many
                                                                                              late. There are of course indis-     options available in cosmetic            After taking pre-op im-
                                                                                              putable aspects to a beautiful,      dentistry. Certain smiles may        pressions and pouring up the
                                                                                              healthy smile, straight, white,      be chosen more, but each indi-       stone models, the laboratory re-
                                                                                              stain-free teeth. However, per-      vidual patient will have the         shapes, straightens, and builds
                                                                                              sonal preferences concerning         pleasure of choosing what’s          out the teeth as detailed by the
                                                                                              the combinations of tooth shape,     best for himself. Patients serious   cosmetic images. This image-
                                                                                              length, and the degree of white-     about cosmetic dentistry can         inspired diagnostic wax-up is
                                                                                              ness or translucency can vary        have very distinct preferences       then duplicated in stone for
                                                                                              greatly. The patient, the dentist,   of which shape, length and           fabrication of the provisional
                                                                                              and the ceramist must all know       color is aesthetically pleasing.2    putty matrix. The putty matrix
                                                                                              where they are going before          Properly presented, smile li-        allows fabrication of bis-acrylic
                                                                                              they ever begin cosmetic or          braries can help you guide your      temporaries in the mouth that
                                                                                              appearance related dentistry.        patient through the smile se-        match the shape, length, and
                                                                                              Every form of visual commu-          lection process.                     contours chosen by the dentist
                                                                                              nication from digital
                                                                                              photographs, smile
         Fig. 1: Lorin Library Smile Shape Guide.                                             libraries to cosmetic
                                                                                              imaging is a tremen-
         The materials, equipment,                         change, but how do we inter-       dous help. After all,
         and technology available for                      pret exactly what that desired     cosmetic dentistry is
         cosmetic dentistry today are                      change is? Teeth, like people,     a visual and func-
         incredible. Unfortunately, we                     come in all shapes, sizes, and     tional art.
         can still find ourselves un-                      colors. Every patient is differ-
         prepared to deal with the                         ent, and so is every smile. Rec-   Smile Libraries and
         many variables that drive peo-                    ognizing this is the first chal-   Cosmetic Imaging
         ple to seek smile makeovers.                      lenge of advanced cosmetic             To build a cos-
         Patients know they want a                         dentistry.                         metic practice, we
                                                                                              must be able to com-
                                                                                              municate with our
                                                                                              patients the merits
                                                                                              and value of elec-
                                                                                              tive, cosmetic den-
                                                                                              tal enhancements.
                                                                                              Diagnostic wax-ups
                                                                                              are critical to the
                                                                                              technical aspects of
                                                                                              a case, but they can Fig. 4: Profile view of Smile design #F5.
                                                                                              often be too abstract
                                                                                              for most patients to understand.          The Lorin Library Smile         and the patient. This provides
                                                                                              “Before and after” pictures of        Style Guide and its CD of 72 dig-   another step for the dentist to
                                                                                              your best cosmetic cases will al-     ital images provide the true 18     verify that the patient approves
                                                                                              ways help during case presen-         esthetic options for the doctor     the shape and length of the
                                                                                              tation.1 But in my experience,        and patient when contemplat-        teeth. The transitional period
                                                                                              nothing beats giving your pa-         ing a smile makeover (Fig. 2).      can also be a good time to con-
                                                                                              tients an idea of what you can        In addition, the Lorin Library      firm function of the desired teeth.
         Fig. 2: Digital Smile Design #P2.                                                    actually do for them. For this,       Smile Style Guide illustrates       Pictures and models of the ap-
                                                                                                                                    the four choices of incisal         proved temporaries along with
                                                                                                                                    length in relation to the cuspids   the cosmetic image can be used
                                                                                                                                    (Figs. 3a–d). Profile views of      by the laboratory to fabricate
                                                                                                                                    each smile style gives the pa-      the final porcelain restorations
                                                                                                                                    tients the most complete and        for the patient’s satisfaction.
                                                                                                                                    thorough selection available.
                                                                                                                                    This will help them narrow              The five cases in this article
                                                                                                                                    down their selection (Fig. 4).      exemplify how the challenges
                                                                                                                                                                        of creating individual smiles for
                                                                                                                                      With computerized cos-            people with different gender,
                                                                                                                                   metic imaging, we can take this      age, and personalities are eased
                                                                                                                                   smile selection process one          by using the Lorin Library
                                                                                                                                   step further. Using a digital full   Smile Style Guide and cosmetic
                                                                                                                                   face portrait, we can show the       imaging.
         Fig.3a,Figs.3a–d:Four different incisal lengths in relation to cuspids.   Fig. 3b
                                                                                                                                   patients how they would look
                                                                                                                                   with different treatment op-         Case #1
                                                                                                                                   tions, including the number of          This delightful woman had
                                                                                                                                   teeth, different smile styles,       been in my practice for more
                                                                                                                                   and different lengths.3 These        than ten years. She had always
                                                                                                                                   “before and after” computerized      been dissatisfied with her
                                                                                                                                   simulations can be displayed in      smile. Her primary concern
                                                                                                                                   the treatment room on the com-       was color (Figs. 5 & 6). She
                                                                                                                                   puter monitor, or printed out on     wanted a “perfect, Hollywood
                                                                                                                                   photo quality paper for the pa-      white smile, but not cookie-
                                                                                                                                   tient to take home and discuss       cutter teeth.” Bleaching her
                                                                                                                                   with friends and family. The         teeth using in-office whitening
                                                                                                                                   cosmetic image helps create          and take home splints had not
                                                                                                                                   the excitement and desire that       achieved the solid, opaque look
         Fig. 3c                                                                   Fig. 3d                                         can encourage case accept-           she wanted. She also experi-
DTAP0306_16-18_Berland        29.03.2006       17:48 Uhr      Seite 2




         DENTAL TRIBUNE                             Asia Pacific Edition                                                                                                   Trends & Application 17

                                                                                                                                                 imaging can play in creating                                                                                                                                                                                                                           Case #2
                                                                                                                                                 a particular patient’s specific                                                                                                                                                                                                                           A good illustration of this
                                                                                                                                                 dream smile. With cosmetic                                                                                                                                                                                                                             point lies with another great
                                                                                                                                                 makeovers, it is imperative to                                                                                                                                                                                                                         lady in the practice. This patient
                                                                                                                                                 realize that even on the exact                                                                                                                                                                                                                         chose ten porcelain restora-
                                                                                                                                                 same day, with the same con-                                                                                                                                                                                                                           tions with Smile Design #R2
                                                                                                                                                 sulting dentist, using the same                                                                                                                                                                                                                        (square centrals/square round
                                                                                                                                                 laboratory, two patients with                                                                                                                                                                                                                          laterals/round cuspids) to re-
           Fig. 5: Case #1 pre-op full face.        Fig. 6: Case #1 pre-op close-up.                                                             similar characteristics such as                                                                                                                                                                                                                        place unattractive anterior
                                                                                                                                                 age and gender may choose                                                                                                                                                                                                                              PFM restorations that exhibited
                                                                                                                                                 two smiles completely different                                                                                                                                                                                                                        opaque, mismatched colors and
                                                                                                                                                 in shape, length, and color. And                                                                                                                                                                                                                       black metal margins. Again,
                                                                                                                                                 although the resulting smile                                                                                                                                                                                                                           cosmetic imaging inspired case
                                                                                                                                                 makeovers may be equally at-                                                                                                                                                                                                                           acceptance and facilitated lab-
                                                                                                                                                 tractive, patient satisfaction is                                                                                                                                                                                                                      oratory communication to ar-
                                                                                                                                                 only possible if the right smile                                                                                                                                                                                                                       rive at a successful outcome
           Fig.7:Case#1cosmeticimagewithtwooptions. Fig. 8: Case #1 post-op close-up.            Fig. 9: Case #1 post-op full face.              is chosen for that particular                                                                                                                                                                                                                          (Figs. 10–14).
                                                                                                                                                 patient.6                                                                                                                                                                                                                                                                                                                                                                                                                                   DT page 18

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             AD
         enced quick rebound after
         whitening procedures because
         of the porosity of her teeth and
         coffee habits. Furthermore, her
         teeth exhibited many fracture
                                                          36 Risk Management Modules
         lines. They also were too trans-
         lucent for her taste. Teeth #5, 6,
                                                          from Dental Protection
         11, and 12 had cervical notch-
         ing; a highly visible dark spot                  Dental Protection is the largest indemnity
         on #5, and #6 was extruded and                   organisation of its kind with 48,000 members
         bulky. Mostly her upper ten                      in over 70 countries worldwide.
         front teeth contained multiple                       We have used our vast wealth of experience
         old interproximal and incisal                    and knowledge to create 36 easy-to-read risk
         composite restorations.                          management modules to help the whole dental
                                                          team reduce risk within their day-to-day practice.
            This patient had worn brux-
         ism splints for the past fifteen                         The risk management modules will be
         years. A study of her occlusion                  available to download internationally in the
         revealed that the buccal flare of                very near future. If you would like further
         her upper canines did not allow                  information on how to purchase the modules
         proper canine contact, let alone                 please send your name and e-mail address to                                              Case assessment
                                                                                                                                                   Patient input
         function. She reported a life-                   lynne.moorcroft@mps.org.uk                                                               Clinical examination and tests




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Case module 13.3




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Case module 13.4
                                                                                                                                                   Diagnosis
                                                                                                                                                   Treatment plan




                                                                                                                                                                                                                                                                                                                                                               Case module 13.2
         time of bruxism. Furthermore,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Radiographs



         the chronic bruxing had re-                      01) Periodontal disease      14) Under-treatment              27) The compromised                                                                                                                                                                                                                                                                                                                                                                                                                           sometimes reveal
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      the unexpected




         sulted in periodontal pockets on                 02) Endodontics              & supervised neglect             tooth
                                                          03) Trauma                   15) Histories                    28) Computerised
         her second molars along with                                                                                                              Every treatment plan, from                         and care that could reasonably be          Radiographs                                                         absence of relevant x-rays -                                        Similarly, periodontal probing depth                           logical thought process through            treatment options have not been                                    (percussion/mobility testing is a

                                                          04) Third molars             16) Composites                   records                    the simplest to the most
                                                                                                                                                   complicated, employs a dual
                                                                                                                                                                                                      expected of someone in that
                                                                                                                                                                                                      position.
                                                                                                                                                                                                                                                 It is prudent, from a risk
                                                                                                                                                                                                                                                 management perspective, to
                                                                                                                                                                                                                                                                                                                     perhaps no preoperative x-ray was
                                                                                                                                                                                                                                                                                                                     available to forewarn of a root
                                                                                                                                                                                                                                                                                                                                                                                         measurements are a valuable
                                                                                                                                                                                                                                                                                                                                                                                         investigation whether in the form
                                                                                                                                                                                                                                                                                                                                                                                                                                                        the stages leading to any particular
                                                                                                                                                                                                                                                                                                                                                                                                                                                        course of treatment. All the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   discussed with or offered to the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   patient (by referral, if necessary).
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      familiar example of this), perhaps
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      because you see them as a


         multiple cervical abfractions.                   05) Crown and bridge         17) Sedation                     29) Alternative
                                                                                                                                                   process of data collection. The
                                                                                                                                                   initial input from the patient is
                                                                                                                                                   enriched with information from
                                                                                                                                                   the clinical examination and any
                                                                                                                                                   relevant investigations, so that
                                                                                                                                                                                                      As a corollary, other questions
                                                                                                                                                                                                      could then arise
                                                                                                                                                                                                      Why was some crucial aspect of
                                                                                                                                                                                                      the patient’s history or risk profile
                                                                                                                                                                                                                                                 take preoperative radiographs for
                                                                                                                                                                                                                                                 extractions, in situations where
                                                                                                                                                                                                                                                 the patient has reported previous
                                                                                                                                                                                                                                                 difficulties with extractions, or
                                                                                                                                                                                                                                                 where there is a risk of damage
                                                                                                                                                                                                                                                                                                                     curvature or sclerosis, or an
                                                                                                                                                                                                                                                                                                                     exceptionally fine canal, or perhaps
                                                                                                                                                                                                                                                                                                                     no working length x-ray was taken
                                                                                                                                                                                                                                                                                                                     to assist in controlling the length
                                                                                                                                                                                                                                                                                                                     of the filling (although in the latter
                                                                                                                                                                                                                                                                                                                                                                                         of a BPE screening, or a more
                                                                                                                                                                                                                                                                                                                                                                                         extensive chart either around
                                                                                                                                                                                                                                                                                                                                                                                         specific teeth, or all standing teeth.

                                                                                                                                                                                                                                                                                                                                                                                         Occlusal investigations can take
                                                                                                                                                                                                                                                                                                                                                                                                                                                        relevant components of the case
                                                                                                                                                                                                                                                                                                                                                                                                                                                        assessment process (consultation,
                                                                                                                                                                                                                                                                                                                                                                                                                                                        medical history, dental history,
                                                                                                                                                                                                                                                                                                                                                                                                                                                        social history, clinical examination,
                                                                                                                                                                                                                                                                                                                                                                                                                                                        investigations, diagnosis and
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Similarly, it is unwise to steer a
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   patient too forcibly towards one
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   particular treatment option without
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   explaining its risks and limitations.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      routine part of a clinical
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      investigation? Many dentists
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      tend to record only ‘positive’ or
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      ‘abnormal’ findings, whereas
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      ‘negative’ and ‘normal’ findings
                                                                                                                                                   a suitably informed diagnosis can                  not recognised?                            to other structures, (for example,                                  situation, electronic apex locators                                 many forms, ranging from the use                               treatment plan) should be in               Summary                                                            can be equally (or sometimes
                                                                                                                                                   then be made before a treatment                    Why were certain investigations            in the tuberosity area, or when                                     are an alternative investigation                                    of articulating paper, wax, indicator                          evidence.                                  A typical scenario is the situation                                more) valuable - such as “no

                                                          06) Orthodontics             18) Overtreatment                orthodontics               plan is formulated for discussion
                                                                                                                                                   with the patient as part of the
                                                                                                                                                   prudent foundation for the consent
                                                                                                                                                   process. All these stages raise
                                                                                                                                                                                                      not carried out?
                                                                                                                                                                                                      Could the harm subsequently
                                                                                                                                                                                                      suffered by the patient have been
                                                                                                                                                                                                      avoided, had the correct questions
                                                                                                                                                                                                                                                 contemplating extractions in
                                                                                                                                                                                                                                                 elderly patients) where the bone
                                                                                                                                                                                                                                                 quality and quantity may be
                                                                                                                                                                                                                                                 compromised and the risk of tooth
                                                                                                                                                                                                                                                                                                                     which can be defended
                                                                                                                                                                                                                                                                                                                     successfully).

                                                                                                                                                                                                                                                                                                                     Cases where it is alleged that the
                                                                                                                                                                                                                                                                                                                                                                                         spray or other occlusal ‘marking’
                                                                                                                                                                                                                                                                                                                                                                                         devices, through articulated study
                                                                                                                                                                                                                                                                                                                                                                                         models, to a more detailed
                                                                                                                                                                                                                                                                                                                                                                                         facebow registration, pantograph
                                                                                                                                                                                                                                                                                                                                                                                                                                                        Reviewing the diagnosis
                                                                                                                                                                                                                                                                                                                                                                                                                                                        Correct diagnosis is the outcome
                                                                                                                                                                                                                                                                                                                                                                                                                                                        of successful and appropriate
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   where a tooth becomes pulpitic
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   very soon after a crown, bridge or
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   veneer is placed and then needs
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   to be root filled. In such a situation
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      tenderness in sulcus”, or “normal
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      response to ethyl chloride”.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Is it clear from the records how
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      and why the diagnosis and

            After reviewing the Lorin                     07) Full dentures            19) Treating children            30) Amalgam-free
                                                                                                                                                   questions that have to be correctly
                                                                                                                                                   answered to ensure a correct
                                                                                                                                                   assessment.
                                                                                                                                                   Sometimes the ‘stations’ on this
                                                                                                                                                                                                      been asked?
                                                                                                                                                                                                      Had the correct investigation(s)
                                                                                                                                                                                                      been undertaken and acted upon.
                                                                                                                                                                                                      Key questions
                                                                                                                                                                                                                                                 or jaw fracture may be high. Third
                                                                                                                                                                                                                                                 molars are another obvious area
                                                                                                                                                                                                                                                 where knowledge of the root
                                                                                                                                                                                                                                                 configuration, the overlying bone,
                                                                                                                                                                                                                                                 and the relationship of the tooth
                                                                                                                                                                                                                                                                                                                     ‘wrong tooth’ has been extracted
                                                                                                                                                                                                                                                                                                                     or filled, or its pulp tissue has been
                                                                                                                                                                                                                                                                                                                     unnecessarily extirpated, often
                                                                                                                                                                                                                                                                                                                     hinge upon the evidence of proper
                                                                                                                                                                                                                                                                                                                     investigations. In situations where
                                                                                                                                                                                                                                                                                                                                                                                         tracing or devices which measure
                                                                                                                                                                                                                                                                                                                                                                                         and record muscle activity. The
                                                                                                                                                                                                                                                                                                                                                                                         use of a stethoscope also has its
                                                                                                                                                                                                                                                                                                                                                                                         place in TMJ auscultation. The
                                                                                                                                                                                                                                                                                                                                                                                         skill lies in knowing which
                                                                                                                                                                                                                                                                                                                                                                                                                                                        investigation including history
                                                                                                                                                                                                                                                                                                                                                                                                                                                        taking, visual and radiographic
                                                                                                                                                                                                                                                                                                                                                                                                                                                        examination and any other clinical
                                                                                                                                                                                                                                                                                                                                                                                                                                                        and pathological examination
                                                                                                                                                                                                                                                                                                                                                                                                                                                        relevant to the patient’s condition.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   it is invariably difficult to persuade
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   the patient that he/she should pay
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   for a root filling, or for a new
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   replacement restoration (if
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   necessary). The clinician may
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      treatment plan reflected the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      patient’s history, the findings from
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      the clinical examination and any
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      discussions with the patient ?
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Was more than one treatment


         Library, this patient narrowed
                                                                                                                                                   journey are passed through at a                    Patient input can be elicited by           to adjacent teeth, the inferior                                     the diagnosis is initially equivocal or                             investigations are appropriate, for                            Sometimes only a provisional               well be asked whether:                                             option recorded?

                                                          08) Adhesive dentistry       20) Clinical records             practice                   brisk pace. When the diagnosis
                                                                                                                                                   is self-evident, and the patient’s
                                                                                                                                                   wishes are clear, there is
                                                                                                                                                   usually no great problem if the
                                                                                                                                                                                                      What’s the problem?
                                                                                                                                                                                                      How can I help you?

                                                                                                                                                                                                      Investigations
                                                                                                                                                                                                                                                 dental nerve bundle, and the
                                                                                                                                                                                                                                                 lower border of the mandible,
                                                                                                                                                                                                                                                 is essential. If radiographs are not
                                                                                                                                                                                                                                                 taken, and a serious problem
                                                                                                                                                                                                                                                                                                                     inconclusive, cases may hinge on
                                                                                                                                                                                                                                                                                                                     whether the investigations carried
                                                                                                                                                                                                                                                                                                                     out were sufficient to support a
                                                                                                                                                                                                                                                                                                                     given diagnosis and treatment. On
                                                                                                                                                                                                                                                                                                                                                                                         which patients, and under what
                                                                                                                                                                                                                                                                                                                                                                                         circumstances. The danger lies in
                                                                                                                                                                                                                                                                                                                                                                                         erring on the side of too few, or
                                                                                                                                                                                                                                                                                                                                                                                         too superficial, investigations.
                                                                                                                                                                                                                                                                                                                                                                                                                                                        diagnosis can be reached which
                                                                                                                                                                                                                                                                                                                                                                                                                                                        leads to further investigation. Each
                                                                                                                                                                                                                                                                                                                                                                                                                                                        subsequent step/investigation/
                                                                                                                                                                                                                                                                                                                                                                                                                                                        diagnosis leads to a definitive
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   A preoperative radiograph to check
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   for any periapical involvement had
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   been taken before placing the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      The more experienced a clinician
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      becomes, the greater the danger
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      that their histories, discussions and


                                                          09) Complaint handling       21) The emergency                31) Minor oral surgery
                                                                                                                                                   investigations are not exhaustive.                 Investigations and tests can take          occurs, the dentist will be under                                   the other hand, there is little point                                                                                              diagnosis which in turn will lead to       restoration.                                                       investigations will be viewed by

         down her smile selection                                                                                                                  For example, it is clearly not
                                                                                                                                                   appropriate to take radiographs of
                                                                                                                                                   every tooth when dealing with a
                                                                                                                                                   chipped filling, or a biopsy of every
                                                                                                                                                                                                      many forms, and the questions of
                                                                                                                                                                                                      Which?, When? and For whom?
                                                                                                                                                                                                      are highly relevant.
                                                                                                                                                                                                                                                 pressure to demonstrate that the
                                                                                                                                                                                                                                                 absence of the radiograph(s) could
                                                                                                                                                                                                                                                 not have contributed to the
                                                                                                                                                                                                                                                 problem in any way.
                                                                                                                                                                                                                                                                                                                     in carrying out full and proper
                                                                                                                                                                                                                                                                                                                     investigations, and then failing
                                                                                                                                                                                                                                                                                                                     to act upon the results.
                                                                                                                                                                                                                                                                                                                                                                                         Recording investigations
                                                                                                                                                                                                                                                                                                                                                                                         The key to the investigation
                                                                                                                                                                                                                                                                                                                                                                                         process is to record what
                                                                                                                                                                                                                                                                                                                                                                                         investigations are being carried
                                                                                                                                                                                                                                                                                                                                                                                                                                                        a definite treatment plan. There are
                                                                                                                                                                                                                                                                                                                                                                                                                                                        occasions when treatment itself
                                                                                                                                                                                                                                                                                                                                                                                                                                                        forms part of the investigation. The
                                                                                                                                                                                                                                                                                                                                                                                                                                                        outcome of such treatment is then
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Vitality test(s) to confirm pulpal
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   health had been performed
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   before proceeding.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      them in this light, with diagnoses
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      made and treatment plans decided
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      upon apparently by ‘instinct’. There
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      is even greater room for criticism



         choice to Smile Design #R4                       10) Implants                 patient                          32) Preventive             mouth ulcer, or a sample for
                                                                                                                                                   bacteriological investigation for
                                                                                                                                                   every infected root canal.

                                                                                                                                                   Unfortunately, dento-legal cases
                                                                                                                                                                                                      Diagnostic phase
                                                                                                                                                                                                      What? (e.g. what is causing the
                                                                                                                                                                                                      patient’s pain?)
                                                                                                                                                                                                      Why? (e.g. why does this filling
                                                                                                                                                                                                      keep fracturing?)
                                                                                                                                                                                                                                                 Radiographs are similarly an
                                                                                                                                                                                                                                                 important investigation in cases
                                                                                                                                                                                                                                                 where orthodontic extractions are
                                                                                                                                                                                                                                                 contemplated (to confirm any
                                                                                                                                                                                                                                                                                                                     Other investigations
                                                                                                                                                                                                                                                                                                                     Many clinical situations pose a
                                                                                                                                                                                                                                                                                                                     series of questions, the answers
                                                                                                                                                                                                                                                                                                                     to which are sought by means of
                                                                                                                                                                                                                                                                                                                     a range of possible investigations
                                                                                                                                                                                                                                                                                                                                                                                         out, and the findings so that, if
                                                                                                                                                                                                                                                                                                                                                                                         necessary, one can demonstrate
                                                                                                                                                                                                                                                                                                                                                                                         at a later date, a logical and
                                                                                                                                                                                                                                                                                                                                                                                         carefully-followed process leading
                                                                                                                                                                                                                                                                                                                                                                                         to a diagnosis and treatment plan.
                                                                                                                                                                                                                                                                                                                                                                                                                                                        fed into the diagnostic process.

                                                                                                                                                                                                                                                                                                                                                                                                                                                        Dental care is not static, it affects
                                                                                                                                                                                                                                                                                                                                                                                                                                                        and is affected by the changing
                                                                                                                                                                                                                                                                                                                                                                                                                                                        continuum in the patient’s general
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Any percussion testing of the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   tooth had been carried out .

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   A sufficient period for
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      when the records create the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      impression that the clinician was
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      determined to carry out the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      chosen treatment (whether or not
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      it was justified in the light of the



         (square round centrals/square                    11) Margins of error         22) Cross infection              dentistry                  are invariably viewed with the
                                                                                                                                                   benefit of hindsight, through that
                                                                                                                                                   most wonderful of instruments -
                                                                                                                                                   the retrospectoscope. The most
                                                                                                                                                                                                      Treatment planning phase
                                                                                                                                                                                                      How? Is a question that is added
                                                                                                                                                                                                      at this stage along with
                                                                                                                                                                                                                                                 congenitally absent teeth or other
                                                                                                                                                                                                                                                 pathology), as well as serving as
                                                                                                                                                                                                                                                 an aid to orthodontic diagnosis,
                                                                                                                                                                                                                                                 treatment planning and case
                                                                                                                                                                                                                                                                                                                     such as vitality testing (to hot, cold
                                                                                                                                                                                                                                                                                                                     or electrical stimulus), measuring
                                                                                                                                                                                                                                                                                                                     tooth mobility, tenderness to
                                                                                                                                                                                                                                                                                                                     percussion and transillumination.
                                                                                                                                                                                                                                                                                                                                                                                         It is much easier to defend a
                                                                                                                                                                                                                                                                                                                                                                                         practitioner’s actions if supported
                                                                                                                                                                                                                                                                                                                                                                                         by and consistent with a
                                                                                                                                                                                                                                                                                                                                                                                         meticulously-recorded series of
                                                                                                                                                                                                                                                                                                                                                                                                                                                        health and therefore consideration
                                                                                                                                                                                                                                                                                                                                                                                                                                                        must always be given to the
                                                                                                                                                                                                                                                                                                                                                                                                                                                        possibility of having to change the
                                                                                                                                                                                                                                                                                                                                                                                                                                                        diagnosis and treatment plan as
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   review/evaluation had been
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   allowed if, for example, an
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   extensive pinned core had been
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   placed to support the crown.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      specific clinical circumstances of
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      the individual patient concerned)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      and that no other treatment option
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      was really considered at all It is
                                                                                                                                                   tenacious cases that arise tend                    considerations of What? and                management. Similarly, in                                                                                                               relevant investigations, (even if                              the patient’s condition alters.                                                                               helpful, therefore, to carry out a

                                                          (fixed prosthodontics)       control                          33) Accidental injury      to be those where there is
                                                                                                                                                   some doubt over the logic or
                                                                                                                                                                                                      When?                                      association with the diagnosis and
                                                                                                                                                                                                                                                 treatment of periodontal disease,
                                                                                                                                                                                                                                                                                                                     In the case of some infections,
                                                                                                                                                                                                                                                                                                                     taking the patient’s temperature
                                                                                                                                                                                                                                                                                                                                                                                         subsequently proved to be
                                                                                                                                                                                                                                                                                                                                                                                         misleading or incorrect), than the                             Consent
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Simple audit
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   It is a useful exercise to take any
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      periodic audit of one’s clinical
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      records as described above, not

         round laterals/round cuspids)                                                                                                             appropriateness of the original
                                                                                                                                                   diagnosis and treatment plan, or
                                                                                                                                                                                                      The prudent clinician will also
                                                                                                                                                                                                      be asking
                                                                                                                                                                                                                                                 and endodontic problems, the
                                                                                                                                                                                                                                                 absence of radiographs leaves a
                                                                                                                                                                                                                                                                                                                     can indicate the presence or
                                                                                                                                                                                                                                                                                                                     absence of systemic involvement,
                                                                                                                                                                                                                                                                                                                                                                                         commonly-encountered responses
                                                                                                                                                                                                                                                                                                                                                                                         such as
                                                                                                                                                                                                                                                                                                                                                                                                                                                        When one or more treatment
                                                                                                                                                                                                                                                                                                                                                                                                                                                        options have been identified, or
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   ten record cards for patients who
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   have had a significant amount of
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      only as a valuable self-assessment
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      process, but also as a useful


                                                          12) Complex cases            23) Radiographs                  35) Elective treatment
                                                                                                                                                   perhaps when a diagnosis may                       Why not?                                   dentist highly vulnerable to the                                    and other specific measurements                                                                                                    a provisional treatment plan has           treatment, or an unusual                                           platform for constructive peer
                                                                                                                                                   have been ‘missed’. There are                      When not?                                  allegation that he/she had failed to                                of the site, size and appearance                                    “I would probably have checked                                 been reached, it is necessary to           treatment episode, and to ‘audit’                                  review discussions.
                                                                                                                                                   the occasions when third parties                   How not?                                   carry out a relevant and material                                   of oral lesions (ulcers, swellings,                                 the tooth vitality and looked for any                          involve the patient fully in a             these cards just as a third party


         and Smile Design #R5 (square
                                                                                                                                                   - often, experts in the field                      Who? Etc.                                  investigation. If a delayed                                         white patches, and other                                            tenderness to percussion; I                                    consent process which explains             might do, were a problem to                                        This module should ideally be read
                                                                                                                                                   instructed by the patient’s solicitors             In most clinical situations –              diagnosis and treatment results                                     dysplasia) - perhaps with the help                                  wouldn’t always write it down”.                                the nature, and likely outcome of          arise today.                                                       in conjunction with Module 15 –

                                                          (treatment planning)         24) Oral cancer                  35) Drugs and              - will look very closely at each
                                                                                                                                                   stage of the events leading up to
                                                                                                                                                   an incident, and ask whether or
                                                                                                                                                   not all the necessary and
                                                                                                                                                                                                      including diagnosis and treatment
                                                                                                                                                                                                      planning – the clinician is faced
                                                                                                                                                                                                      with choices. As in any decision-
                                                                                                                                                                                                      making process, the quality of the
                                                                                                                                                                                                                                                 from this lack of radiographs and
                                                                                                                                                                                                                                                 has led to any further problems
                                                                                                                                                                                                                                                 for the patient, the dento-legal
                                                                                                                                                                                                                                                 problems for the dentist are
                                                                                                                                                                                                                                                                                                                     of an intra-oral photograph - can
                                                                                                                                                                                                                                                                                                                     make it much easier to monitor
                                                                                                                                                                                                                                                                                                                     the development of resolution
                                                                                                                                                                                                                                                                                                                     of oral pathology. The increasing
                                                                                                                                                                                                                                                                                                                                                                                         or perhaps
                                                                                                                                                                                                                                                                                                                                                                                         “I presume the periodontal
                                                                                                                                                                                                                                                                                                                                                                                                                                                        each of the possible alternatives,
                                                                                                                                                                                                                                                                                                                                                                                                                                                        compares their relative advantages
                                                                                                                                                                                                                                                                                                                                                                                                                                                        and disadvantages, benefits, risks
                                                                                                                                                                                                                                                                                                                                                                                                                                                        and limitations (and costs, where
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Are there any questions left
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   unanswered by your records?
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Can you demonstrate the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Histories




         round centrals/round laterals/                   13) Case assessment          25) Cosmetic dentistry           prescribing
                                                                                                                                                   appropriate histories were taken,                  decision tends to improve in direct        compounded.                                                         frequency of cases involving                                        condition must have looked better                              applicable). The consent process           investigations you carried out?




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Case module 13.5
                                                                                                                                                   or whether all proper investigations               proportion to the quality and                                                                                  missed diagnosis or oral                                            that day, or I would have done                                 is only as good, however, as the           Do they now appear to have been
                                                                                                                                                   relevant to the clinical situation                 accuracy of the available                  In endodontic cases, relatively                                     carcinoma, stresses how                                             some further treatment and made                                quality of the information and             sufficient or might it have been
                                                                                                                                                   were carried out, and if so,                       information.                               common problems such as                                             important this can be.                                              a note in the patient’s records”.                              treatment choices that the clinician       helpful to carry out and record
                                                                                                                                                   whether the dentist in question                                                               fractured instruments and under-                                                                                                                                                                       invites the patient to consider.           additional investigations?


         round cuspids). Being a de-                                                   26) Partial dentures             36)Patients at risk
                                                                                                                                                   had acted upon and interpreted
                                                                                                                                                   the results with the proper skill
                                                                                                                                                                                                                                                 and over-root fillings, have all been
                                                                                                                                                                                                                                                 attributed on occasions to the
                                                                                                                                                                                                                                                                                                                                                                                         The clinical records should make
                                                                                                                                                                                                                                                                                                                                                                                         it possible to follow the clinician’s
                                                                                                                                                                                                                                                                                                                                                                                                                                                        Consent may not be valid at all if
                                                                                                                                                                                                                                                                                                                                                                                                                                                        one or more important and relevant
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Are you omitting to record
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   investigations you do carry out




         signer by occupation, it was
         particularly important for her
         to have different options she
         could visualize. Together we
         decided that we could create
         her dream smile by restoring
         her ten upper teeth, and creat-
         ing some natural asymmetry by
         combining the two smile de-
         signs, with Smile Design #R5 on
         one side and #R4 on the other.
         Her input in designing her
         smile was crucial for case ac-
         ceptance. After seeing the final
         picture with her cosmetically
         enhanced smile (Fig. 7), she im-
         mediately accepted the treat-
         ment plan of ten porcelain
         restorations on teeth #4–13.
                                                                                                      Risk management                                                                                                                                                                                                It is easier to question                                                                                              These x-rays, taken                                                                                                        The failure of this
                                                                                                      module 27                                    The compromised tooth                                                                                                                                             the wisdom of an
                                                                                                                                                                                                                                                                                                                     apparently ambitious
                                                                                                                                                                                                                                                                                                                                                                                                                                           a few years apart,
                                                                                                                                                                                                                                                                                                                                                                                                                                           provide compelling
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      bridge (left) resulted
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      in an even more
                                                                                                                                                   A sizeable proportion of the dento-legal problems                                                                                                                 treatment approach,                                                                                                   evidence that this                                                                                                         heroic attempt
                                                                                                                                                                                                                                                                                                                                                                                                                 Compromised module 27.6




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Compromised module 27.8




                                                                                                                                                                                                                                                                                                                     after one knows that                                                                                                  lateral incisor was not                                                                                                    to restore the
                                                                                                                                                   in restorative dentistry and prosthodontics arise in
             The resulting smile met all
                                                                                                                                                                                                                                                                                                                     it has failed. It is also                                                                                             an ideal choice as an                                                                                                      mandibular arch
                                                                                                                                                                                                                                                                                                                     easier to understand                                                                                                  abutment for a long-                                                                                                       (below)
                                                                                                                                                   connection with the restoration of compromised teeth                                                                                                              the logic of one’s own
                                                                                                                                                                                                                                                                                                                     treatment plans, than
                                                                                                                                                                                                                                                                                                                                                                                                                                           span bridge
                                                                                                                                                                                                                                                                                                                     those of other detists


         of the patient’s expectations in
                                                                                                                                                                            Compromised module 27.2




                                                                                                                                                                                                                Compromised module 27.3




                                                                                                                                                                                                                                                                                                                                                               Compromised module 27.5




                                                                                                                                                                                                                                                                                                                                                                                                                 Compromised module 27.7
                                                                                                                                                                                                                                                                                           Compromised module 27.4




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Compromised module 27.9




         shape, length, and color (Figs. 8
         & 9). Furthermore, cuspid func-                                                              The compromised tooth
         tion was restored with the                                                                                                                Loss of natural tooth tissue can
                                                                                                                                                   arise gradually (e.g. from disease
                                                                                                                                                   processes) or suddenly (e.g. as a
                                                                                                                                                   result of trauma). It can occur for
                                                                                                                                                   physical reasons as in the fracture
                                                                                                                                                                                                      Decisions of this nature are not
                                                                                                                                                                                                      always straightforward - but they
                                                                                                                                                                                                      become all the more important
                                                                                                                                                                                                      when consideration is being given
                                                                                                                                                                                                      to the suitability of the tooth in
                                                                                                                                                                                                                                                 Teeth that are restored following
                                                                                                                                                                                                                                                 trauma are perhaps the
                                                                                                                                                                                                                                                 commonest example of this, and if
                                                                                                                                                                                                                                                 the gradual loss of vitality, perhaps
                                                                                                                                                                                                                                                 accompanied by the development
                                                                                                                                                                                                                                                                                                                     Study models or clinical
                                                                                                                                                                                                                                                                                                                     photographs of the original tooth,
                                                                                                                                                                                                                                                                                                                     if available, can sometimes provide
                                                                                                                                                                                                                                                                                                                     helpful clues as to the angulation of
                                                                                                                                                                                                                                                                                                                     the tooth in a buccal–lingual plane,
                                                                                                                                                                                                                                                                                                                                                                                         In shorter roots, the lack of tissue
                                                                                                                                                                                                                                                                                                                                                                                         for the preparation of an adequate
                                                                                                                                                                                                                                                                                                                                                                                         post length can lead the clinician to
                                                                                                                                                                                                                                                                                                                                                                                         consider options such as increasing
                                                                                                                                                                                                                                                                                                                                                                                         the post width, or creating an
                                                                                                                                                                                                                                                                                                                                                                                                                                                        It is probably well worth reminding
                                                                                                                                                                                                                                                                                                                                                                                                                                                        ourselves that a post is not a
                                                                                                                                                                                                                                                                                                                                                                                                                                                        restoration in itself - its purpose
                                                                                                                                                                                                                                                                                                                                                                                                                                                        is to support another restoration in
                                                                                                                                                                                                                                                                                                                                                                                                                                                        some way, while preserving and
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   History and investigations
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   As always, the patient’s clinical
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   records should be sufficiently
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   comprehensive to come to the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   practitioner’s rescue if such
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Communication
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Clinicians will be aware of the various
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      treatment approaches to this problem,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      ranging from the more conservative
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      etch-retained composite restoration


         porcelain restorations, subse-                                                                                                            of a previously weakened tooth,
                                                                                                                                                   or electively (e.g. preparing a tooth
                                                                                                                                                   to receive a fixed restoration, or
                                                                                                                                                   cutting an access cavity for
                                                                                                                                                   endodontic treatment).
                                                                                                                                                                                                      question to support a crown or
                                                                                                                                                                                                      bridge. When assessing the tooth
                                                                                                                                                                                                      prior to any such restoration,
                                                                                                                                                                                                      therefore, it is important to record
                                                                                                                                                                                                      every piece of evidence that led to
                                                                                                                                                                                                                                                 of an apical cyst or other
                                                                                                                                                                                                                                                 pathological change, results in an
                                                                                                                                                                                                                                                 acute problem for the patient some
                                                                                                                                                                                                                                                 years later, a dentist could be
                                                                                                                                                                                                                                                 vulnerable if the clinical records
                                                                                                                                                                                                                                                                                                                     as can a knowledge of skeletal and
                                                                                                                                                                                                                                                                                                                     dento-facial characteristics. The
                                                                                                                                                                                                                                                                                                                     retroclined upper central incisors
                                                                                                                                                                                                                                                                                                                     and proclined upper lateral incisors
                                                                                                                                                                                                                                                                                                                     of the classic class II div(ii)
                                                                                                                                                                                                                                                                                                                                                                                         eccentric post shape to maximise
                                                                                                                                                                                                                                                                                                                                                                                         retention. Either of these options
                                                                                                                                                                                                                                                                                                                                                                                         can precipitate an early root
                                                                                                                                                                                                                                                                                                                                                                                         fracture.
                                                                                                                                                                                                                                                                                                                                                                                                                                                        protecting the residual root
                                                                                                                                                                                                                                                                                                                                                                                                                                                        structure. Posts fail when they no
                                                                                                                                                                                                                                                                                                                                                                                                                                                        longer satisfy either (or both) of
                                                                                                                                                                                                                                                                                                                                                                                                                                                        these objectives. It is important that
                                                                                                                                                                                                                                                                                                                                                                                                                                                        the patient is made aware of the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   allegations are made. Sadly, all too
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   often, the lack of such records
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   makes any defence of the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   allegations unnecessarily difficult.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   The first step is to record carefully
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      to stabilise the cusp(s), to the more
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      extensive cast restoration. Occasionally,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      of course, the nature and extent of a
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      crack makes it impossible to save the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      tooth, and sometimes the presence of
                                                                                                                                                                                                      that decision. It is not uncommon          reveal no evidence of any                                           malocclusion, with associated                                       Strength                                                       limitations of the restoration.            the history of the symptoms as                                     the crack or fracture is self-evident and

         quently curing her bruxing                                                                                                                Whatever the cause and timing of
                                                                                                                                                   the tooth tissue loss, however,
                                                                                                                                                   there is no doubt that each event
                                                                                                                                                   or intervention in the life of a tooth,
                                                                                                                                                                                                      to find that investigations yielding
                                                                                                                                                                                                      inconclusive results (or negative
                                                                                                                                                                                                      results) are not recorded in detail, or
                                                                                                                                                                                                      at all. In fact, it is just as important
                                                                                                                                                                                                                                                 monitoring of a tooth which was at
                                                                                                                                                                                                                                                 a higher risk of such a complication.

                                                                                                                                                                                                                                                 Posts
                                                                                                                                                                                                                                                                                                                     skeletal/facial characteristics, is a
                                                                                                                                                                                                                                                                                                                     good example. Taking due note of
                                                                                                                                                                                                                                                                                                                     the anatomy of the supporting
                                                                                                                                                                                                                                                                                                                     bone overlying a root is a simple
                                                                                                                                                                                                                                                                                                                                                                                         A range of new materials has been
                                                                                                                                                                                                                                                                                                                                                                                         described in the literature, from
                                                                                                                                                                                                                                                                                                                                                                                         carbon fibre and composite resin to
                                                                                                                                                                                                                                                                                                                                                                                         ceramic and other materials. The
                                                                                                                                                                                                                                                                                                                                                                                                                                                        The cracked tooth
                                                                                                                                                                                                                                                                                                                                                                                                                                                        It is a sign of the times, perhaps,
                                                                                                                                                                                                                                                                                                                                                                                                                                                        that patients assume and expect
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   reported by the patient,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   remembering that negative findings
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   can be as important to record as
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   positive findings. The key is to be
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      the treatment of choice is clearly
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      apparent from the outset.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Whether one adopts a cautious, or
                                                                                                                                                   impacts upon the ultimate prognosis.               to record negative findings as it is       Opinions have fluctuated over the                                   further precaution to minimise the                                  traditional cast metal post and core                           that healthcare professionals will be      able to demonstrate that skill, care                               more radical approach, the patient

         habit and reducing the peri-                                                                                                              Investigations
                                                                                                                                                   In the diagnosis and treatment
                                                                                                                                                   planning process, it is important
                                                                                                                                                   to identify any teeth that are
                                                                                                                                                                                                      to report positive findings. Clinical
                                                                                                                                                                                                      judgement and ‘gut’ feeling based
                                                                                                                                                                                                      upon previous experience may not
                                                                                                                                                                                                      sit at the top end of any hierarchy
                                                                                                                                                                                                      of evidence, but they should
                                                                                                                                                                                                                                                 years as to the status of the root-
                                                                                                                                                                                                                                                 retained post within the
                                                                                                                                                                                                                                                 armamentarium of restorative
                                                                                                                                                                                                                                                 dentistry and prosthodontics. The
                                                                                                                                                                                                                                                 fact that post crowns feature highly
                                                                                                                                                                                                                                                                                                                     risk of perforation. In each case,
                                                                                                                                                                                                                                                                                                                     the prudent clinician will pool
                                                                                                                                                                                                                                                                                                                     information from all the above
                                                                                                                                                                                                                                                                                                                     sources when planning the
                                                                                                                                                                                                                                                                                                                     angulation of any post hole.
                                                                                                                                                                                                                                                                                                                                                                                         is still in widespread use, but when
                                                                                                                                                                                                                                                                                                                                                                                         these posts are too thin there is the
                                                                                                                                                                                                                                                                                                                                                                                         ever-present risk that they will
                                                                                                                                                                                                                                                                                                                                                                                         fracture off in situ, which will then
                                                                                                                                                                                                                                                                                                                                                                                         create a particularly difficult
                                                                                                                                                                                                                                                                                                                                                                                                                                                        able to make unfailingly accurate
                                                                                                                                                                                                                                                                                                                                                                                                                                                        diagnoses, and to provide ‘instant’
                                                                                                                                                                                                                                                                                                                                                                                                                                                        remedies for any symptoms they
                                                                                                                                                                                                                                                                                                                                                                                                                                                        might present with. The ‘cracked
                                                                                                                                                                                                                                                                                                                                                                                                                                                        cusp’ or ‘cracked tooth’ is
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   and a logical approach is brought
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   to bear upon the investigation
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   process, using the full range of
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   alternative ‘tools’ available.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      must be given sufficient information in
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      order to be able to understand what
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      treatment is being recommended and
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      why, and to appreciate the range of
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      available alternatives. These


         odontal pockets. Not only did
                                                                                                                                                   compromised in one way or                          certainly not be discounted entirely.      in failed crown and bridge work,                                                                                                        restorative challenge.                                         notoriously difficult to diagnose and      While measurements and                                             discussions need to be carefully
                                                                                                                                                   another - for example:                                                                        has been well documented in the                                     Length                                                                                                                             treat with certainty, and it is starting   recordings of mobility and vitality                                recorded in the patient’s notes. This
                                                                                                                                                                                                      Periodontal                                scientific literature. From a dento-                                Without doubt, one of the most                                      Design                                                         to feature heavily in dento-legal          are usually an important part of the                               clinical situation is highly vulnerable to
                                                                                                                                                   Loss of periodontal support                        Assessing the quality of the               legal perspective, however, it is                                   common problems seen in post                                        This is an area which continues to                             cases. This is likely to be a growing      total information to be gathered in                                the patient claiming, after the event,
                                                                                                                                                   Endodontic/periapical status                       periodontal support of a tooth is a        more valuable to look in more detail                                crown failures is that of insufficient                              create much controversy. Parallel                              problem as patients retain more of         these situations, percussion testing                               that they would have elected for a
                                                                                                                                                   Loss of natural tooth tissue                       balance between direct observation         at what goes wrong, and at what                                     post length. Some clinicians prefer                                 and tapering posts each have their                             their teeth into later life.               is perhaps the most important.                                     different treatment approach had they

         she have the dream smile she                                                                                                              Structural weakness (hairline
                                                                                                                                                   cracks or suspected cusp fractures,
                                                                                                                                                   posts etc)
                                                                                                                                                   Excessive occlusal forces.
                                                                                                                                                                                                      (e.g. of inflammatory changes),
                                                                                                                                                                                                      objective tests such as probing
                                                                                                                                                                                                      depth measurements, and other
                                                                                                                                                                                                      tests which rely to some extent
                                                                                                                                                                                                                                                 can be done to minimise the
                                                                                                                                                                                                                                                 potential problems.

                                                                                                                                                                                                                                                 Four main areas of risk
                                                                                                                                                                                                                                                                                                                     to err on the side of caution,
                                                                                                                                                                                                                                                                                                                     perhaps reflecting their fear of
                                                                                                                                                                                                                                                                                                                     possible perforation, but this often
                                                                                                                                                                                                                                                                                                                     proves to be a short-sighted
                                                                                                                                                                                                                                                                                                                                                                                         advocates, as do cast and pre-
                                                                                                                                                                                                                                                                                                                                                                                         formed post techniques. Each
                                                                                                                                                                                                                                                                                                                                                                                         technique has well-recognised
                                                                                                                                                                                                                                                                                                                                                                                         advantages and disadvantages and
                                                                                                                                                                                                                                                                                                                                                                                                                                                        When treating this clinical problem,
                                                                                                                                                                                                                                                                                                                                                                                                                                                        there are separate aspects that
                                                                                                                                                                                                                                                                                                                                                                                                                                                        must be addressed with equal
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   A dull percussion sound can be
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   diagnostic but here again a normal
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   response to this test is an equally
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   important finding which should be
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      been made aware of its availability.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Occasionally, the need to refer the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      patient for a second (perhaps
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      specialist), opinion arises, and as
                                                                                                                                                                                                      upon subjective interpretation of          Angulation (leading to perforation)                                 strategy. The leverage and lateral                                  will lend itself to some clinical                              care and circumspection. One               recorded. The presence or absence                                  always this should be offered where


         always wanted, we successfully                                                                                                            This assessment should be made
                                                                                                                                                   in the light of the history,
                                                                                                                                                   symptoms and signs, and any
                                                                                                                                                   relevant investigations and special
                                                                                                                                                   tests, each of which needs to be
                                                                                                                                                                                                      objective facts (e.g. mobility,
                                                                                                                                                                                                      radiographs). The clinical records
                                                                                                                                                                                                      should contain all of these
                                                                                                                                                                                                      elements, especially when the
                                                                                                                                                                                                      quality of a tooth’s periodontal
                                                                                                                                                                                                                                                 Length (leading to loss of retention,
                                                                                                                                                                                                                                                 or decementation and subsequent
                                                                                                                                                                                                                                                 caries, or - if too long - interference
                                                                                                                                                                                                                                                 with the apical seal)
                                                                                                                                                                                                                                                 Strength (often related to length,
                                                                                                                                                                                                                                                                                                                     pressures that a mobile short post
                                                                                                                                                                                                                                                                                                                     creates, can easily lead to a root
                                                                                                                                                                                                                                                                                                                     fracture, which may have the same
                                                                                                                                                                                                                                                                                                                     terminal consequences for the
                                                                                                                                                                                                                                                                                                                     tooth in question as any perforation
                                                                                                                                                                                                                                                                                                                                                                                         situations, but not to others. Some
                                                                                                                                                                                                                                                                                                                                                                                         believe that threaded posts are the
                                                                                                                                                                                                                                                                                                                                                                                         answer, while others believe that
                                                                                                                                                                                                                                                                                                                                                                                         their use is the most reliable
                                                                                                                                                                                                                                                                                                                                                                                         method of splitting roots yet
                                                                                                                                                                                                                                                                                                                                                                                                                                                        consideration is the tooth itself,
                                                                                                                                                                                                                                                                                                                                                                                                                                                        where the symptoms can be
                                                                                                                                                                                                                                                                                                                                                                                                                                                        thoroughly frustrating and
                                                                                                                                                                                                                                                                                                                                                                                                                                                        misleading when trying to reach
                                                                                                                                                                                                                                                                                                                                                                                                                                                        the ‘cracked cusp’ diagnosis, while
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   of tenderness to percussion when
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   the cusp is struck in various
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   directions is an essential test and
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   needs to be recorded carefully.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Further aids such as the ‘Tooth
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      appropriate, the fact being duly
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      recorded in the patient’s notes.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Summary
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Compromised teeth are slowly
                                                                                                                                                   recorded in the clinical notes,                    support is likely to have a long-term      width, and design as well as to the                                 might have done.                                                    devised. The key is to keep abreast                            excluding the many other possible          Sleuth’ have been commercially                                     becoming an ever-increasing dento-

         eliminated her headaches and                                                                                                              in terms of:

                                                                                                                                                 a The investigation carried out
                                                                                                                                                 b The result
                                                                                                                                                                                                      impact upon the prognosis of
                                                                                                                                                                                                      various treatment planning options
                                                                                                                                                                                                      that are under consideration.
                                                                                                                                                                                                                                                 material used for its construction)
                                                                                                                                                                                                                                                 Design (Parallel or tapering?
                                                                                                                                                                                                                                                 Threaded or smooth? Cast or
                                                                                                                                                                                                                                                 pre-formed?)
                                                                                                                                                                                                                                                                                                                     The decementation of a post
                                                                                                                                                                                                                                                                                                                     crown under a bridge that is held
                                                                                                                                                                                                                                                                                                                     firmly in place by other retainers,
                                                                                                                                                                                                                                                                                                                                                                                         of the literature and the evidence
                                                                                                                                                                                                                                                                                                                                                                                         base, to take advantage of new
                                                                                                                                                                                                                                                                                                                                                                                         techniques and materials, and also
                                                                                                                                                                                                                                                                                                                                                                                         to learn from your own successes
                                                                                                                                                                                                                                                                                                                                                                                                                                                        alternative explanations for the
                                                                                                                                                                                                                                                                                                                                                                                                                                                        symptoms. On the other hand is
                                                                                                                                                                                                                                                                                                                                                                                                                                                        the patient, who needs to be kept
                                                                                                                                                                                                                                                                                                                                                                                                                                                        closely informed and presented
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   developed to assist in the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   diagnostic process.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Radiographs
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      legal threat as clinicians try to save
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      teeth in a wider range of difficult clinical
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      situations. The key to their successful
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      management lies as much in effective
                                                                                                                                                 c The conclusions drawn.                             Follow-up                                                                                                      can lead to massive root caries and                                 and failures. Certainly, there have                            with their treatment options at each       Radiographs are not always                                         communication with the patient, as it

         the need to wear a bulky oc-                                                                                                              Endodontics
                                                                                                                                                   Sometimes conclusions are drawn
                                                                                                                                                   from a variety of different sources,
                                                                                                                                                   some of which are more helpful
                                                                                                                                                                                                      The assumption that a
                                                                                                                                                                                                      compromised tooth ceases to be of
                                                                                                                                                                                                      concern, as soon as it has been
                                                                                                                                                                                                      restored, is an easy trap to fall into.
                                                                                                                                                                                                      Nothing could be further from the
                                                                                                                                                                                                                                                 Angulation
                                                                                                                                                                                                                                                 One of the problems of providing
                                                                                                                                                                                                                                                 post restorations is that the coronal
                                                                                                                                                                                                                                                 tooth tissue is often reduced or
                                                                                                                                                                                                                                                 missing altogether, which deprives
                                                                                                                                                                                                                                                                                                                     a major restorative problem unless
                                                                                                                                                                                                                                                                                                                     it is identified and dealt with at an
                                                                                                                                                                                                                                                                                                                     early stage. Bridges which rely on
                                                                                                                                                                                                                                                                                                                     one or more posts, especially when
                                                                                                                                                                                                                                                                                                                     these are the last retainers at one
                                                                                                                                                                                                                                                                                                                                                                                         been many failures associated with
                                                                                                                                                                                                                                                                                                                                                                                         virtually every post technique, and
                                                                                                                                                                                                                                                                                                                                                                                         there seems to be no magic
                                                                                                                                                                                                                                                                                                                                                                                         formula which will avoid all of the
                                                                                                                                                                                                                                                                                                                                                                                         potential problems, all of the time.
                                                                                                                                                                                                                                                                                                                                                                                                                                                        step along the way, together with a
                                                                                                                                                                                                                                                                                                                                                                                                                                                        realistic explanation of the prognosis.
                                                                                                                                                                                                                                                                                                                                                                                                                                                        Perched at the end of this clinical
                                                                                                                                                                                                                                                                                                                                                                                                                                                        dilemma, in many cases, is an angry
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   very helpful in the diagnosis of a
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   cracked cusp, but they are often
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   a necessary part of excluding other
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   possible explanations of the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   patient’s symptoms. On the other
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      does in finding new technical solutions
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      to longstanding clinical dilemmas.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Tempting as it may be to seek to
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      reassure the patient by playing down


         clusal guard every night!
                                                                                                                                                   than others. An example of this is                 truth, and indeed, it is necessary to      the clinician of valuable anatomical                                end or the other of a bridge, are a                                                                                                patient faced with the prospect of         hand, transillumination can be of                                  the problem (or potential problem), and
                                                                                                                                                   the combination of reported                        monitor the health of any such             guidance. A good pre-operative                                      particular risk.                                                    However, it is helpful to bear in                              losing the tooth in question, or the       particular value, and can readily                                  conveying a confident ‘we have the
                                                                                                                                                   symptoms, clinical examination,                    ‘high risk’ tooth on a regular basis,      x-ray is a useful starting point to                                                                                                     mind that almost by definition,                                cost of having endodontic treatment        detect hairline fractures and                                      technology’ approach, the extensively
                                                                                                                                                   radiographs, percussion and vitality               these reviews being chronicled in          minimise the chance of mesial or                                    Due account needs to be taken of                                    posts are placed in teeth which                                and a crown, and invariably the            cracks that are often invisible                                    restored or otherwise compromised
                                                                                                                                                   tests, that together lead to a                     the clinical records.                      distal perforation, by enabling the                                 root morphology; fine, tapering                                     have already reached, or are fast                              patient’s dissatisfaction includes         to the naked eye.                                                  tooth, or the cracked tooth/cracked
                                                                                                                                                   diagnosis that a tooth requires                                                               clinician to identify the angulation                                roots are easily fractured by long                                  approaching, ‘last chance saloon’.                             allegations that they have ‘paid all                                                                          cusp are clinical traps that can deceive
                                                                                                                                                   endodontic treatment.                                                                         and anatomy of the root which lies                                  posts which leave insufficient                                                                                                     that money for nothing’ or that they                                                                          and embarrass the most capable of
                                                                                                                                                                                                                                                 beneath the gingival level.                                         enclosing root structure and                                                                                                       ‘would not have needed all this                                                                               clinicians. A cautious and careful
                                                                                                                                                                                                                                                 Following the course of a pre-                                      strength to survive on a long-term                                                                                                 treatment if you had done your job                                                                            approach, meticulously recorded in the
                                                                                                                                                                                                                                                 existing RCT is another time-                                       basis.                                                                                                                             properly in the first place’.                                                                                 notes, will minimise the many dento-
                                                                                                                                                                                                                                                 honoured precaution (although this                                                                                                                                                                                                                                                                                   legal risks associated with these clinical


             The previous case illus-                                                                                                                                                                                                            presumes that the RCT itself is in
                                                                                                                                                                                                                                                 the correct place!).
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      situations which are growing in
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      frequency.




         trates the extreme importance
         a smile library and cosmetic
DTAP0306_16-18_Berland        29.03.2006        17:49 Uhr       Seite 3




         18 Trends & Application                                                                                              DENTAL TRIBUNE                          Asia Pacific Edition

           DT page 17

                                                                                                                              Case #3                                 our patients in the decision mak-
                                                                                                                                  For the next patient, imaging       ing, from number of teeth in-
                                                                                                                              showed how cosmetic dentistry           volved to color, tooth shape,
                                                                                                                              could give this gentleman the           shade, and even length.7 Smile
                                                                                                                              smile makeover he wanted. An            libraries and cosmetic imaging
                                                                                                                              old injury and resultant PFM            can help improve communica-
                                                                                                                              crown on #9 had resulted in ex-         tion between the patient, the den-
                                                                                                                              tremely recessed gingiva reveal-        tist, and the laboratory. These are
                                                                                                                              ing a black marginal line. He had       essential considerations to any
                                                                                                                              a severe periodontal defect be-         cosmetic makeover. DT
           Fig. 10: Case #2 pre-op full face.      Fig. 11: Case #2 pre-op close-up.                                          tween #7 and 8 that still exist-
                                                                                                                              ed after periodontal surgery.           References
                                                                                                                              Twenty porcelain restorations           1. Hornbrook, D, Nash, R, Ro-
                                                                                                                              created a final dazzling smile,            senthal, L, Trinkner, T. Making
                                                                                                                              with an all porcelain crown for            the Case for Proposed Treat-
                                                                                                                              #9 and porcelain veneers for               ments. CERP Sept 2003; 7(9):
                                                                                                                              the remaining teeth (Figs. 15–19).         56–59.
                                                                                                                              Porcelain successfully created          2. Roberts M, Trinker T: Commu-
                                                                                                                              the illusion of filling in the trian-      nication guidelines for achiev-
                                                                                                                              gular space left by the defect. By         ing aesthetic success. Signa-
                                                                                                                              doing both upper and lower                 ture 5(3):18–21, 1998.
           Fig. 12: Case #2 cosmetic image.        Fig. 13: Case #2 post-op close-up.   Fig. 14: Case #2 post-op full face.   teeth, cuspid guidance was built        3. Dunn WJ, Murchison DF,
                                                                                                                              in to prevent future wear.                 Broome JC. Esthetics: Patient’s
                                                                                                                                                                         perceptions of Dental attrac-
                                                                                                                              Case #4                                    tiveness. J Prosthodont 1996;
                                                                                                                                  Cosmetic imaging can even              5(3): 166–171.
                                                                                                                              show young patients how cos-            4. Berland, L: Digital Art helps
                                                                                                                              metic dental work can improve              patients accept treatment.
                                                                                                                              their appearance. Our fourth pa-           Dental Practice Report June
                                                                                                                              tient, a young attractive female,          2000 pp. 22–25.
                                                                                                                              saw that through cosmetic imag-         5. Dickerson W: Cooperative
                                                                                                                              ing she could perfect her look by          treatment planning in creating
                                                                                                                              improving the proportions and              smiles. Signature Magazine.
                                                                                                                              shape of her four upper incisors.          1996; Summer:2–8.
           Fig. 15: Case #3 pre-op full face.   Fig. 16: Case #3 pre-op close-up.                                             Final treatment consisted of gin-       6. Chiche GJ, Pinault A. Esthetics
                                                                                                                              gival contouring, bleaching the            of Anterior Fixed Prosthodon-
                                                                                                                              lowers, and ten upper porcelain            tics. Chicago, Quintessence
                                                                                                                              veneers. This resulted in yet an-          Publishing Co, pp 121–123,
                                                                                                                              other smile that shows how re-             1994.
                                                                                                                              warding and exciting cosmetic           7. Wathen WF. Restorative den-
                                                                                                                              dentistry can be for both you and          tistry in the millenium: ad-
                                                                                                                              your patients (Figs. 20–24).               hesive, esthetic, predictable.
                                                                                                                                                                         Quintssence Int. 1997;28:
                                                                                                                              Case # 5                                   291–292.
                                                                                                                                  This wonderful lady had been
           Fig. 17: Case #3 cosmetic image.     Fig. 18: Case #3 post-op close-up.      Fig. 19: Case #3 post-op full face.   in my practice for several years
                                                                                                                              (Figs. 25 & 26). As she looked                    Contact Info
                                                                                                                              through the Lorin Library during
                                                                                                                              her consultation, she remem-
                                                                                                                              bered that her teeth had once
                                                                                                                              looked long, shapely, and attrac-
                                                                                                                              tive. As a result of serial posterior
                                                                                                                              dentistry throughout her life, her
                                                                                                                              bite had changed, reducing her
                                                                                                                              vertical dimension. After an ac-
                                                                                                                              cident fractured a front tooth,
                                                                                                                              the six maxillary anterior teeth
                                                                                                                              had been restored with a crown
           Fig. 20: Case #4 pre-op full face.      Fig. 21: Case #4 pre-op close-up.                                          and five veneers. Combined with
                                                                                                                              a bruxing habit, these factors re-
                                                                                                                              sulted in a gradual but dramatic
                                                                                                                              shortening of her teeth and facial
                                                                                                                              dimensions.
                                                                                                                                                                       Dr. Lorin F. Berland has built
                                                                                                                                 So through the years she had
                                                                                                                                                                       an international reputation
                                                                                                                              gone from having long, round-
                                                                                                                                                                       for his expertise in cosmetic
                                                                                                                              shaped teeth to very short, flat
                                                                                                                                                                       dentistry. He is one of the most
                                                                                                                              teeth. When rounded teeth are
                                                                                                                                                                       published authorities on cos-
                                                                                                                              worn, they become flat or square.
           Fig. 22: Case #4 cosmetic image.        Fig. 23: Case #4 post-op close-up.   Fig. 24: Case #4 post-op full face.                                            metic dentistry and has ap-
                                                                                                                              This can mean an older, aged
                                                                                                                                                                       peared on the television pro-
                                                                                                                              appearance. A cosmetic image
                                                                                                                                                                       gram “20/20,” Inside Edition,
                                                                                                                              using Smile Design #R6 (round
                                                                                                                                                                       Fox News. In addition, Dr. Ber-
                                                                                                                              centrals/round laterals/round
                                                                                                                                                                       land has been in Time, The Wall
                                                                                                                              cuspids) showed how she could            Street Journal, Reader’s Digest
                                                                                                                              look with longer, rounder teeth          and many more. Dr. Berland
                                                                                                                              (Fig. 27). By doing 28 porcelain         is the creator of the Lorin
                                                                                                                              restorations on both her upper           Library Smile Style Guide,
                                                                                                                              and lower arches, we increased           www.denturewearers.com,
                                                                                                                              vertical dimension. We then were         and is the founder of Arts Dis-
                                                                                                                              able to increase the length of her       trict Dentistry, a multi-doctor
                                                                                                                              teeth with the round shape she           specialty practice that first
           Fig. 25: Case #5 pre-op full face.   Fig. 26: Case #5 pre-op close-up.
                                                                                                                              desired, giving her back the             pioneered the concept of spa
                                                                                                                              youthful, beautiful smile that na-       dentistry. You may contact
                                                                                                                              ture originally intended for her         Dr. Berland at,
                                                                                                                              (Figs. 28 & 29).
                                                                                                                                                                       Dallas Dental Spa
                                                                                                                              Conclusion                               2100 Ross, Suite 960
                                                                                                                                 The technology, materials,            Dallas, Texas 75201
                                                                                                                              and techniques are available to          U.S.A.
                                                                                                                              provide our patients with the            E-mail:
                                                                                                                              highest quality treatment and            drberland@dallasdentalspa.com
                                                                                                                              most esthetic cosmetic make-             Web site:
           Fig. 27: Case #5 cosmetic image.     Fig. 28: Case #5 post-op close-up.      Fig. 29: Case #5 post-op full face.   overs. However, every cosmetic           www.dallasdentalspa.com
                                                                                                                              case is a mandate to first involve