Smile design is a comprehensive treatment that many patients can benefit from.
Although these days, we are looking to carry out the least invasive treatment to provide an excellent result, porcelain veneers can be frowned upon in certain circles.
Confusingly, I refer to most of my full mouth rehabilitation treatments as "veneers", and the reason is that I want to keep things simple for my patients to understand.
For the most part, this works very well.
I tell them, that a crown is a veneer that wraps around a tooth, and what we end up doing will depend on the health of the tooth, and how much is remaining.
It could be a veneer, a crown, or something in between.
In this article, I will give you my 6 key tips to be able to provide a smile design for your patients and get great results.
Now, obviously, this is not going to cover every aspect of how to do this, but it will give you a good insight into how I do it, and how I have done it for every single one of the cases you see on my Instagram page! (well, apart from the implant cases... but even those follow a similar process.)
1. Plan the case on paper.
Take a smiling photo, and draw on it. This is how we used to do it, and it's still my favorite way to do it.
You can use iPads and a stylus, but there is something organic about pen and paper.
However you do this, the principles are the same.
Look at the smile as a whole - forget about individual teeth.
The lower edge of the teeth usually follows the lower lip, the midline is parallel to the middle of the face. These two lines give you the cornerstone of a perfect smile.
From there, draw in your golden proportions, and gum lines and you have a fantastic tool to explain to a patient what a great smile looks like.
This process also helps you to develop your eye. You can send these photos to the lab to have a wax up, be specific, for example, you want the UL1 to be 1mm longer than it currently it.
If you are not specific, then the lab has no idea what will look right for the patient you have in the chair.
Personally, I never get a wax-up, but if you're starting out, getting a wax-up is a great way to go.
2. Put the patient in control.
Doing the dental work is easy, as there can be a set process, but managing the patient can sometimes be messy.
Often we know that treating more teeth will give a better result, but this dramatically increases the cost for the patient.
How do we get around this?
Simple, we explain what a great smile is (see point 1) and then let the patient know about costs (ideally they know about costs before even seeing you!), and if veneers cost £1200 per tooth - then ask them: how many teeth do you think you need?
If there is a minimum number (maybe needed to increase the OVD and provide support), you should explain this now.
Explain the concept of support... Not the number you need. Once your patient understands support, they will realize that they need more units.
The key to patient management is education. If you explain the situation in a way that the patient truly understands what is going on, then they will always agree with your plan.
So if your patient is interested in aesthetics, speak the language of aesthetics, and explain smile design.
If your patient is breaking teeth and wants a solution for this, the treatment may be the same, but you should focus on explaining everything from a structural point of view.
Often for these patients, I will say
"look, we are known for aesthetics, I know that's not the most important thing for you, but by improving the structure, we will make things look a lot better by accident!"
If your patient is happy with the plan (because they chose how much they want to do), then you have your case acceptance, and you have not been pushy, in fact, your patient may push you to start treatment!
3. Create your vision.
Now you need to do your prep and create outstanding temps.
The secret to our smiles is in the temps - we spend a long time trying to get these right.
If you are starting out, take a matrix of your wax-up, fill it with a composite-based temp material and replicate the wax-up in the mouth.
Most of the time, the wax-up will need modification, as what the lab sees is hardly ever perfect in the patient's mouth.
Remember, you want to aim for perfection, and you can only see how good a smile is, once it is in the patient's mouth.
before then, it's just a bunch of teeth on a table.
Spend time looking at the smile line, refining the incisal edges, midlines, golden proprtions and making the smile look perfect. (like what you drew)
This is hard in the early days, and I used to ask a much more experienced dentist to look at my trial smiles, to see what I could improve - this really helped me to develop my eye.
The aesthetics are only one half of this equation.
4. Get the function right.
Function and occlusion are concepts that are really difficult to understand, and put into practice, but when you do get it - it's super simple!
In a nutshell, you want your patient to be able to come together (in centric relation), and all the teeth to touch at once.
This means that there is no slide and in dental terms CO=CR.
There are a bunch of other confusing terms, but I just use Centric Occlusion and Centric Relation.
This position tells us only the contact when someone is biting. We also need to know about the jaw pattern as they chew.
This is the envelope of function or even guidance. Although strictly speaking these things are different, they are similar enough for the purpose of this article.
When your patient chews, the lower jaw needs to have enough freedom to move in its natural motion, without catching the upper incisal edges.
If your patient breaks a temp in the first week or so, it means that you have accidentally created an interference, and you need to look at the function again.
5. Have your patient approve the provisionals.
There is only one person that needs to love the smile you create - and that is your patient!
By getting your patient to choose how much treatment they have, and by letting them have the final say on the aesthetics, you are carrying out patient-centric cosmetic dentistry and dramatically reducing the risk of your patient not being happy with the final result.
Nobody wants that.
So you can change the temps as much as needed so that your patient is ecstatic with the results.
Then once they are, you can scan or take an impression of the temps, choose a colour, and you are ready to send this record to the lab, to get a great set of veneers back.
6. Working with a lab that "gets it"
I have worked with really well-known labs, that just don't get this workflow.
They think they can do a better job of creating a great smile, without copying the temps.
At the end of the day, copying temps is adding extra work, and some labs don't want to do this.
I have had several patients who have told me that they like their end smile, but they preferred the temps!
You have two options, if you have an open-minded lab technician, then you will be able to work with them, and they can make matrices to ensure that the temps are copied properly.
If you have a closed-minded lab, and your temps are not copied - it's time to switch labs.
I always remove half my temps first, then try in the veneers, to see how well my temps have been copied - this is probably the best way to check.
If you can find a lab that can create a great result, and does what you ask, I think it's worth paying a little more per unit.
Once you have great veneers, it's just a case of fitting them for your patient, and congratulations, you have transformed their smile and changed their life for the better.
That's it! Simple right!?
For those who want to take things to the next level, I do offer mentoring and a whole bunch of online courses that will help you get better case acceptances, and understand occlusion, the exact workflows for carrying out these treatments.
You can find out more by clicking the link below.