A case for collaboration

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  Posted by: The Probe      20th November 2020

A patient contacted the practice for an appointment after seeing promotions via online promotions. They were interested in composite bonding due to being unhappy with the shape of the upper right lateral and the appearance of a diastema between the centrals. They had previously completed orthodontic treatment and remained happy with the alignment of the teeth, though their dog had recently damaged their retainer. The patient was also in the process of whitening their teeth at home.

I took a comprehensive medical history, showing that the patient took no medications, had no allergies, was a non-smoker and had never smoked. The patient was therefore found to be fit and well, as well as a regular dental attender at her usual practice. Dental charting was performed, along with BPE scores and an oral health assessment – which demonstrated good hygiene and no existing restorations. All of this information was shared with the dentist [Dr Miten Mistry], who also checked function and clinical suitability for different treatments. Radiographs and photographs were taken to check for any pathology and complete the patient’s records.

The patient then attended a consultation with both the dentist and I. This enabled us to ensure that we offered all the possible treatment options.

Treatment planning

Treatment options were discussed between dentist, dental therapist and patient. These included:

  • Orthodontics – the patient declined this option as they were happy with their current tooth alignment and wished to improve the shape of the teeth rather than the position.
  • Veneers and crowns ­­– the process was explained by the dentist, covering the pros and cons compared with composite bonding. The patient declined this options as well, as they did not like the preparation concept and wished to preserve the natural tooth tissue.
  • Composite bonding – the process was explained by both the dentist and I, including aftercare and outcomes.

As the patient was most interested in the last option, I provided a mock-up/trial smile with composite so that the patient could see the potential outcome. An edge bonding technique for the upper laterals and upper centrals was described. To close the small diastema on the upper centrals, the mesial surfaces would also be restored. The patient was encouraged to take a photo so that they could look again at home and discuss with family/friends to ensure an informed decision-making process.

The patient chose to proceed with composite edge bonding. They were advised to continue with whitening at home and to book an appointment for composite bonding at least 2 weeks after the last whitening treatment so as to not compromise the composite. The patient also agreed to have a new upper Essix retainer – provided by the dentist – following treatment to also help protect the composite bonding.

The treatment plan was created and signatures captured for consent and use of clinical photography. The images also provided another opportunity for the patient to ask any further questions.

Treatment

The patient returned at least 2 weeks after the whitening was finished, presenting with B1 shade dentition. Pre-operative photos were taken, the teeth were isolated and the soft tissues protected with cotton wools. PTFE strips were placed interdentally to ensure tight contacts and prevent resin from bleeding into the contacts.

Each surface of the teeth were then etched for 60 seconds with 37% phosphoric etching gel, before being washed and dried with a high speed suction. A bond was placed and light-cured. Composite in B1 E was then placed. StyleItaliano-designed, LM-Arte instruments from J&S Davis were used to shape and mould the composite for good aesthetics. This was then polished with an ultra-fine, long, tapered diamond bur and smoothed with a full sequence of flexi discs, diamond paste and gloss rubber points.

The patient was shown the result in a mirror to check they were happy, post-operative instructions were given and photographs taken. The dentist also attended the end of the appointment to assess the patient and take impressions for the new upper Essix retainer.

The patient returned to the practice a few weeks later for review. I performed further fine polishing and refinement – this is always completed over two visits to allow the composite to settle and the patient to get used to the new shape of the teeth. New photographs were taken and the dentist attended to fit the retainer.

Conclusion

In this case, the patient was very happy with the outcome as the dental team were able to address all their initial concerns and dislikes. The spaces were closed and the shape of the laterals had been improved significantly.

The dental therapist and dentist working in this way is valuable to everyone involved. Quite often a patient will need orthodontic treatment prior to composite bonding, as is described with the ABC approach (align, bleach and contour). This can be very rewarding for both clinicians and financially beneficial to the practice.

Working in this way also affords the highest standard of care for the patient, as two clinicians have assessed the case and offered all the options available. The dentist is there to provide support when treatment options are beyond the scope of the dental therapist, such as with the aforementioned orthodontic treatment. As the clinicians discuss these cases and work together, it can really enhance skill set of the individuals, as the treatment planning and outcomes are always being discussed and modified with experience.

Case images

 

For more information on the industry-leading products available from J&S Davis, visit www.js-davis.co.uk, call 01438 747 344 or email jsdsales@js-davis.co.uk

 

Author bio:

Nina has worked in the dental industry for 20 years. Nina progressed from working as a dental nurse to a dental therapist in June 2013 at Sheffield University.

Not long into her career, Nina became passionate about taking a whole body approach with her patients and after 3 years of studying whilst working, Nina graduated as a nutritional therapist in February of this year.

Due to this holistic approach, Nina developed a keen interest in minimal intervention and uses this approach to help improve dental aesthetics in her patients.


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