Considerations When Working on Teeth 6 through 11.
Ray LeGendre, part of Arrowhead’s technical support team, recently talked with Aesthetic Dentistry about cases involving the Social Six—why they merit extra consideration and some things doctors should keep in mind when working on these prominent teeth. Here’s what Ray said:
AD: What are the Social Six and what do you recommend dentists consider before attempting these types of cases?
RL: The Social Six are teeth 6 through 11 on the upper arch. These are the most prominent and most visible teeth when a person smiles and as such, these are typically the go-to units for quick cosmetic cases. These cases are challenging because you are only addressing a small fraction of the total teeth in the mouth. If the proper conditions don’t exist, you will likely have increased chances of fracturing and other problems.
If other issues are apparent with a patient’s teeth like excessive wearing, evidence of bruxism, uneven or missing teeth in the lower arch, or TMD considerations, I typically recommend a more comprehensive approach, including full arch or full mouth reconstruction. If a dentist simply focuses on teeth 6 through 11 may result in restorations that break or degrade.
AD: When you are presented with a Social Six case, what do you focus on with the doctor from a technical support perspective?
RL: The first thing I do is ask the dentist about the patient’s expectations. What does the patient hope to achieve? Some patients are more concerned with aesthetics over function, and vice versa. As a lab, we always strive to take both into consideration—we want to create something that is beautiful, functional, and long-lasting.
If a patient has ideal occlusion and no other problems that are apparent, then the case planning can proceed in a standard fashion. If problems exist, I typically help the dentist develop a more comprehensive approach that not only seeks to deliver the aesthetic objective, but also resolves other issues.
If a more comprehensive option is not possible, then the focus becomes the opposing dentition on the lower arch. If there are potential risks due to malocclusion, we discuss what options may be available. Sometimes, after we bring up a potential issue, the doctor will say, “Let me present this to the patient and then the patient can decide what he [or she] wants to do.” For example, I’ve seen cases where a patient wants increased length on the Social Six, and the doctor can do a certain amount of work, but without addressing the lowers, there is only so much the doctor can do. Failing to address the lower teeth will often lead to persistent problems with fracturing, and over time, the aesthetic result obtained may undergo noticeable degradation.
AD: Do you always look at the lowers when presented with a Social Six case?
RL: Yes. When we see a prescription for 6 through 11 and the lowers aren’t mentioned, we ask if there are any plans for the lowers. Often, it’s the first time the dentist may have thought of addressing the lowers. Sometimes, though, it’s because a patient has limited finances. If that’s the case, I advise the doctor with a comprehensive plan and present both the positive and negative aspects of the case so that he or she can properly manage the patient’s expectations.
Once the realities of the case are understood, the direction of treatment comes down to what options the patient and doctor are open to. If a doctor is only used to doing smaller cases, he or she may ask, “What have you seen work?” This is one of the many areas where Arrowhead’s experience as a lab helps dentists to see issues more clearly and thereby provide patients with better results.
AD: What are some common issues in cases where a patient opts for treatment on just the Social Six?
RL: Many times, patients want work done on these teeth because the teeth are broken down—wear is excessive and sometimes it’s visible. Maybe it’s been years since a patient has taken care of their teeth or there may be other medical factors that come into play. We try to be realistic with what’s possible in terms of the materials that are available. If a doctor says, “We just want six veneers,” we articulate the models and study the mouth as a whole. If we see wear issues we might say, “The forces or the occlusion don’t necessarily agree.” The likely outcome of such cases if nothing else is done is that the veneers will chip or fracture and full crowns would be a better option.
At that point, I start discussing not only function but also the materials and how the dentist is going to execute the case. A lot of doctors want minimal reduction to the tooth structure, which is important and I applaud that. But we also need to consider longevity and how long the restoration will last for the patient.
AD: If a patient has irregular or uneven lowers and they still opt for treatment on only 6 through 11, what are some problems that could arise?
RL: Chipping, fracturing, and bite issues—mostly because the new restorations do not agree with the lower incisal position. In such cases, we recommend that crowns be placed on the opposing teeth as well. In situations where full crowns are not financially possible for the patient, we try to stabilize the lowers with Snowcaps (see “Expedition Snowcaps,” Aesthetic Dentistry, Fall 2015). This option requires some maintenance by the doctor to help maintain the composites at the level of occlusion that we’ve set the Snowcaps to, but that’s part of the case planning. If the doctor and patient are open to it, then it typically makes for a much more successful case in the end.
AD: What should dentists focus on when examining a patient so they can present a comprehensive plan from the beginning—one including the requisite upper and lower considerations?
RL: It’s really looking at the uppers and lowers to make sure there aren’t any patient behaviors or considerations that might lead to issues with the uppers later on. For example, look at the wear pattern and ask the patient how it came about. Why are the teeth functioning that way? Is it TMJ? Is the patient grinding his or her teeth at night? If teeth are wearing down quickly (they were once 9 mm and they are down to 5 mm), always ask why. If we don’t take into account any behaviors or habits that are happening, it can affect the restorations. Crowns aren’t going to wear like teeth—they’re going to chip and break more easily. There’s usually a story with the wear pattern and when a doctor takes that into account and communicates it to the lab and the patient, then everyone is working together for an optimal result.
Creating a habit of always looking at the lowers when doing a restoration of the Social Six is important. If everything lines up perfectly with the new restorations, then great! But if the lowers don’t line up in an ideal fashion, then asking the right questions will save the dentist from having to return to the patient with recommendations for additional care.
AD: It’s important to be upfront with patients about the possible pros and cons of just addressing the Social Six. Is that correct?
RL: Absolutely. Taking a step back and looking at the larger picture usually opens new windows of opportunity. This can help eliminate concerns that otherwise might be missed. While for some cases, working on teeth 6 through 11 is enough, a thorough discussion with your patient will set your case up for success. The patient may even be more open to additional care, which can ultimately lead them to the smile they dream of.
AD: What are the problems you may run into if someone wants a really aesthetic case, but they’re only doing 6 through 11?
RL: There can be a compromise in longevity. The existing and uneven wear pattern endemic to the lower teeth will interact with the new restorations. This interaction will result in restorations that are more prone to fractures and shearing issues, and (over time) will suffer degradation of the overall aesthetics. Helping the patient understand the larger picture by including the lowers will yield a result that will function and look better in the future. This is not only important for the patient, but also for the doctor’s reputation. A patient who is continually going back to the dentist because of chipping or aesthetic issues is going to take up chair time with ongoing repairs or remakes. And patients who return for repairs or remakes may not be as likely to give a doctor and/or the practice a good online review, or refer their friends and families.
AD: How do you advise a dentist on the bite? What can be done to test the bite forces and timing?
RL: The best option for doing these types of diagnostics is to use the excellent technologies available. I highly recommend the T-Scan®, as it allows dentists to get an accurate measurement of not only present forces but also forces over time. This takes a lot of the guesswork out of such cases. It allows dentists to take measurements during the visit that will make it easy to see if simply doing 6 through 11 is a reasonable and effective choice.
AD: As far as doing 6 through 11 and doing 22 to 27 at the same time, is that something that only veteran dentists should try?
RL: No. The technologies, materials, and resources available to dentists make these cases approachable by dentists of all skill levels (for more information, read the article “Goodbye, Gremlins!”). The one piece of advice I would offer in this regard, especially to dentists who are doing this for the first time, is to make sure that you use a lab that has the resources to support you in designing that case.
AD: What are the benefits for the doctor of doing both uppers and lowers at the same time?
RL: The benefits for the doctor are less stress, fewer fractures, and finding that the patient has fewer visits to the office because the doctor will have addressed any and all issues up front. The doctor will get enhanced results and hear more positive things from patients because the work will last longer, and it just goes more smoothly from start to finish.
AD: What are the benefits for the patient of doing both uppers and lowers at the same time?
RL: Sometimes it’s a hidden benefit for patients because it is primarily a functional benefit. Some patients don’t necessarily understand or take into account occlusion or other issues. But the benefits to the patient are huge because the restorations will last longer, and the health risks from improper occlusion and other issues are mitigated. The benefits from the doctor and lab perspectives are huge, too—with fewer cracked or chipped restorations, longer-lasting crowns, and a happier patient overall. Additionally, there are often potential improvements in facial symmetry, and patient confidence increases.
AD: What does the ideal 6 through 11 case look like? Under what conditions would you agree that only teeth 6 through 11 need to be addressed?
RL: Usually it’s a nice ideal bite, nice occlusion (something where the lowers aren’t completely off), ideal arch form and incisal edges across the occlusion are relatively level, and the canine rise doesn’t pose any type of abnormal hits. Those types of cases usually help a typical 6 through 11 case fly right out the door with minimal challenges.
AD: What are the most important things you recommend for doctors regarding treatment of the Social Six?
RL: When dentists encounter a case involving teeth 6 through 11, I recommend that they take a step back and look at the patient and ask, “How did this patient get here? Why do the teeth look this way and what can we do to achieve or exceed the patient’s expectations?” And then tell the patient, “I understand and I know what your expectations are—let’s see what we can do with white wax-up models to strategize a plan that will help you achieve that.” Laying out a plan that not only includes the Social Six but takes all the teeth into consideration will yield a better result and a happier patient. There is peace of mind knowing that you offered the best care possible. Correspondingly, this will earn dentists the reputation of someone who sincerely cares for their patients.