January 2018 – Addressing Aesthetic Concerns Requires Treatment Planning

Addressing Aesthetic Concerns Requires Treatment Planning


A 42 year old male had his dentistry done in Europe. He presented with  symptomatic #12 – full crown splinted to crown on #11.  The crown margins were poor and splinting of the teeth made hygiene difficult. Tooth #12 was not responsive to pulp tests and a radiolucent finding of likely Endodontic origin was noted at the apex of #12. A diagnosis of chronic periapical periodontitis secondary to pulpal necrosis was made.

Prior to initiating treatment Endo thru crown #12, I spoke to the patient about his overall treatment goals. He told me that he was dissatisfied withe the color of the crowns on #11 and 12 and wished to improve the aesthetics of his smile. He wanted the Endo on #12 completed to deal with his current complaint and then new crowns placed on #s 11 and 12. He also was concerned about the brown lines around his composites and wanted those removed along with an overall lightening of tooth shade in the maxillary anterior dentition.

I explained to the patient that while Endodontic treatment could easily be completed on #12 though the existing crown, the improvement of his overall maxillary aesthetics required a more well planned, comprehensive solution that needed to be executed by his Dentist.  A “piecemeal” approach would probably not achieve his desired optimal aesthetic result.
Endodontic treatment was completed without incident and a post space was prepared (and filled with Ca(OH)2 prior to closure and his return to the referring Dentist.

I suggested he speak to his Dentist about the following:
1.) Removal of the crowns (#11 and 12)  and temporization with individual crowns
2.) Bleaching of the Maxillary anterior dentition to a shade that was acceptable to the patient
3.) Removal and re-restoration of any composites with discolored margins – to match the teeth that had ALREADY been bleached to the desired color.
4.) Final crown cementations of new crowns #11 and 12, with porcelain to match the adjacent teeth and create a harmonious smile.

The question remained: Did Referring Dentist  talk to him about bleaching OTHER teeth first BEFORE crown replacement? Whose responsibility is and should this not have been discussed with the patient before the referral was made?