The Journal of the American Dental Association
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J Am Dent Assoc, Vol 135, No 7, 875-881.
© 2004 American Dental Association
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COSMETIC & RESTORATIVE CARE

COVER STORY
JADA Continuing Education

The effect of esthetic consultation methods on acceptance of diastema-closure treatment plan

A pilot study



DOV ALMOG, D.M.D., CARLOS SANCHEZ MARIN, D.D.S., HOWARD M. PROSKIN, Ph.D., MARK J. COHEN, D.D.S., STEPHANOS KYRKANIDES, D.D.S., M.S., Ph.D. and HANS MALMSTROM, D.D.S.


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. The authors conducted a study to determine which of four consultation methods helped patients best understand a proposed treatment plan for maxillary anterior diastema closure.

Methods. The authors presented 24 subjects with four types of consultation in random order: before-and-after photographs of other patients, diagnostic models with wax setups, resin-based composite/esthetic preview/mock-ups and computer-imaging simulations. After viewing each method, the authors asked the subjects about treatment acceptability. At the end of the demonstrations of all four methods, the authors asked the subjects which consultation method helped them best understand the proposed treatment plan.

Results. A total of 87.5 percent of the subjects indicated that they would accept the proposed treatment plan after they were shown the computer-imaging simulation, 50 percent said they would after they were shown the resin-based composite/esthetic preview/mock-up, 41.7 percent said they would after they were shown photographs of other patients, and 25 percent said they would after they were shown diagnostic models with wax setups. When asked which method helped them best understand the proposed treatment, 54.2 percent of the subjects selected computer-imaging simulation, 33.3 percent selected resin-based composite/esthetic preview/mock-ups, and 12.5 percent selected before-and-after photographs of other patients. None of the subjects selected diagnostic models with wax setups. A {chi}2 test for goodness of fit indicated that these differences were statistically significant.

Conclusion. Subjects preferred computer-imaging simulation to the other three consultation methods, and they indicated that computer-imaging simulation provided a better understanding of the proposed treatment plan for diastema closure.

Clinical Implications. The use of computer-imaging simulation enhances the patient’s understanding of a proposed treatment plan concerning maxillary anterior diastema closure.

The main objective of effective dentist-patient communication is to help the patient picture the anticipated result, thereby increasing the probability of the patient’s not only agreeing to the proposed treatment, but of being satisfied with the treatment outcome.1 Modern dentistry and the demand for esthetics require a comprehensive, multidisciplinary approach that includes the psychological and emotional dimensions.2 The results from studies by Carlsson and colleagues3 and Wagner and colleagues4 indicate that the significance of dental appearance and the preference in regard to esthetic dentistry vary considerably among dentists, dental technicians and patients. Kokich and colleagues5 suggested that the general public may not be as able to detect esthetic defects as dentists, and the level of training in dental esthetics may influence the ability of a dental professional to detect esthetic defects.

The main objective of effective dentist-patient communication is to help the patient picture the anticipated result.

Case presentation or consultation describes the stage in the dentist-patient relationship that pertains to discussing the patient’s dental needs or desired treatment, and it involves a great deal of methodical communication.6–8 Use of good patient education adjuncts generally will increase compliance with treatment recommendations.9 When patients have been involved in the decision-making process, the experience has been associated with an improved clinical outcome.10 Most practitioners feel that they must be able to communicate with patients so that the patients not only understand their maxillofacial problems, but also approve of the services being recommended.11 Furthermore, when the dental team takes the time to develop the case presentation process and cultivate relationships with patients, the results can be more perceptible to the patients,12 and treatment plan acceptance rates can be improved.13 The use of visual adjuncts can enhance the patients’ understanding of proposed treatment plans further.14 There are four methods of visually demonstrating possible outcomes:

– Before-and-after photographs of other patients. A 1996 professional survey reported that more than 50 percent of professionals considered before-and-after photographs the consultation method of choice.15
– Diagnostic models with wax setups. These models are useful in patient education, evaluation of existing clinical conditions, restoration design, occlusion evaluation and planning for esthetic results in the anterior region.16 A diagnostic wax setup can provide the answers to many questions regarding the planning and completion of treatment.17–24
– Resin-based composite/esthetic preview/mock-up. The use of resin-based composite for an esthetic preview/mock-up can help the dentist and patient determine the esthetically acceptable shade, material selection and shape of teeth, as well as resolve any occlusal concerns.25 However, there is a limited amount of literature supporting its effectiveness.26
– Computer-imaging simulation. Digital images enable both clinicians and patients to view the desired final outcome of the patients’ teeth and soft tissues at the preoperative stage.
Digital images enable both clinicians and patients to view the desired final outcome of the patients’ teeth and soft tissues at the preoperative stage.

A survey of patients’ attitudes toward esthetic procedures revealed problems in communication between patients and dentists.27 When computer imaging was introduced in the 1980s, it improved this communication. In a 2000 prospective clinical study, computer-imaging simulation scored higher patient satisfaction marks than did conventional methods.28

Dentists who use computer-imaging simulation in their practices report a significant number of positive responses to this method from patients.29 Some authors suggest that in more complex treatment plans, the dentist can convey a treatment concept to the patient easier and more realistically when using computer-imaging simulation.30,31

However, it is recommended by other authors that computer-imaging simulation be used in conjunction with traditional diagnostic procedures, not instead of them.32,33 A computer-imaging simulation of a perfect smile can deliver a false promise to the patient, which can lead to patient disappointment and potentially to both ethical and legal issues. It does not provide the practitioner with the definitive measurements and conditions based on tooth position and occlusal relationship that are required for decision making during tooth preparation. Furthermore, the cost of purchasing and maintaining a computer-imaging system, which often includes a combination of sophisticated software programs for practice management, charting, and intra- and extraoral cameras, can be high.34,35

Phillips and colleagues36 and Turpin37 concluded that video image predictions are a valuable adjunct for conveying treatment options to patients by indirectly strengthening their self-image, motivation and expectations. Computer-imaging simulation makes it easier to communicate to patients what can be accomplished realistically and, thereby, avoid unpredictable outcomes and patient dissatisfaction.38


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We selected subjects who had untreated maxillary central diastemata from a pool of patients who sought treatment at the University of Rochester Eastman Dental Center, Rochester, N.Y. Although we did not exclude patients according to the severity of their diastemata, all subjects in the study did have a Class I occlusion with midline centered and a normal overbite and overjet. We excluded from the study patients who had previous prosthetic or esthetic treatment performed on their maxillary anterior teeth. We required that the patients’ right and left maxillary central incisors be caries-free to avoid bias toward treatment.

To ensure that subjects could fill out the study questionnaires, we required that they had completed high school. Each subject completed two visits.

We focused our investigation on diastema closure, regardless of its severity. Maxillary spaces can be addressed effectively by both orthodontics and esthetic restorative dental treatment. In general, maxillary spaces can result from labial incisor tooth movement, which often is seen in adults with the onset of periodontal loss of alveolar bone. Furthermore, in some cases, smaller-sized incisors can lead to spaces in the maxillary anterior region and intermaxillary tooth-size discrepancy. In 1958, Bolton39 first identified intermaxillary tooth size relationship as a key factor in normal occlusion, and he reported that in a Class I occlusion, the six anterior mandibular teeth were 77.2 percent of the mesiodistal size of the corresponding maxillary teeth. Clinically, if maxillary anterior spaces appear to be the result of smaller-than-optimal-sized incisors, then restorative esthetic dentistry would be the treatment of choice, whereas in the case of labially drifted maxillary teeth, orthodontics would appear to be the best option.

At the first visit, we took impressions. We also took preoperative facial and close-up digital photographs with a digital camera (DX4900 Dental Digital Camera Kit, Eastman Kodak, Rochester, N.Y.).

At the second visit, we arbitrarily divided the subjects among three practicing dentists (D.A., C.S.M., and H.M.) who presented all four consultation methods to the subjects to demonstrate closure of their diastemata. While interexaminer calibration discussions took place before the consultations, there may have been some level of interexaminer variability. However, rather than introducing potential bias by having only one examiner, we divided esthetic consultations arbitrarily among the three dentists. Additionally, to minimize the bias created by the overlapping effect of giving one subject all four methods in one visit, each examiner gave all four presentations to each subject in a randomized order:

– Before-and-after photographs of other patients. The examiners showed subjects photographs of another patient treated for closure of the maxillary central diastema at the second visit; all subjects viewed the same photographs. This was the only method that did not provide visual information based on the current subject’s face and dentition.
– Diagnostic models with wax setups. Using the impressions taken at the first visit, the examiner replicated the maxillary model and used sculpting wax on the model to close the diastema (Figure 1Go).
– Resin-based composite/esthetic preview/mock-up. During the second visit, the examiner applied a hybrid resin-based composite to the mesial tooth surfaces of the right and left maxillary central incisors, simulating closure of the diastema, without applying any dental adhesive. The examiner removed the material at the end of the consultation.
– Computer-imaging simulation. The examiner downloaded facial and close-up digital images of each subject to a computer and achieved simulation of diastema closure using specialized dental imaging software (PracticeWorks/DICOM Cosmetic Imaging Software, Version 1.73, Eastman Kodak). The examiner produced before-and-after 8- x 11-inch print outputs using a desktop printer (Kodak Personal Picture Maker 200, Lexmark, Eastman Kodak) and glossy photographic paper (Kodak Desktop Medical Imaging Paper, Eastman Kodak). As part of the consultation, the examiner printed personalized before-and-after facial and close-up photographs and supplied them to the subjects (Figure 2Go).



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  		Figure 1. During the first visit, we obtained impressions from each subject. The examiners then made a personalized before-and-after set of diagnostic wax setup models, such as these, and closed the diastema with sculpting wax. The examiners used the models during the esthetic consultation.

 



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  		Figure 2. Facial and close-up digital images of each subject were downloaded to a computer, and specialized computer software was used to simulate diastema closure. The examiners used personalized 8- x 11-inch before-and-after facial (A and B) and close-up (C and D) photographs, such as these, during the computer-imaging simulation esthetic consultation.

 
After the examiners presented each method, they gave the subjects an initial questionnaire that included one question and three possible answers; it was formulated to determine the subjects’ perceptions regarding treatment plan acceptance. Subjects sat in a private room while filling out the questionnaire so they could be candid. Examiners provided them with a hand mirror so they could visualize the proposed treatment plan.

After all four consultation methods and the questionnaire had been completed, we asked each subject to complete a conclusion questionnaire that compared the four consultation methods so we could determine the method he or she preferred most strongly.

We performed pairwise comparisons of consultation methods with respect to the acceptance of and objection to treatment questions from the initial questionnaire, using McNemar tests. We used analysis of variance to compare the subjects’ preferences with respect to age, and we compared the distribution of subjects’ preferred modalities against a uniform distribution using a {chi}2 test for goodness of fit. We used a level of significance of {alpha} = .05 in all statistical tests.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Twenty-four of 27 subjects selected completed the study; 19 were women (79.2 percent), and five were men (20.8 percent). The mean age of the subjects was 34.9 years (standard deviation: ± 9.5 years, range: 18–60 years). The age distribution of the subjects is presented in Table 1Go. There were 11 African-American subjects (45.8 percent), 11 white subjects (45.8 percent) and two Hispanic subjects (8.3 percent).


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  		TABLE 1 AGE DISTRIBUTION OF SUBJECTS.

 
Consultation method preference varied by age. The three subjects who preferred before-and-after photographs of other patients had a mean age of 25.0 years, the eight subjects who preferred resin-based composite/esthetic preview/mock-up had a mean age of 34.5 years, and the 13 subjects who preferred computer-imaging simulation had a mean age of 37.2 years. The mean age of subjects who preferred the before-and-after photographs of other patients differed significantly from that of subjects who preferred computer-imaging simulation.
Acceptability of computer-imaging simulation was significantly higher than that of the other three methods.

Table 2Go illustrates the consultation method that the subjects said gave them the best understanding of the proposed treatment plan. A {chi}2 test for goodness of fit indicated statistically significant differences in consultation method preference.


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  		TABLE 2 DISTRIBUTION OF PREFERRED CONSULTATION METHODS.

 
When we asked subjects specifically about treatment plan acceptance, 21 (87.5 percent) said they would go ahead with the recommended treatment plan if it were demonstrated only with computer-imaging simulation, 12 (50 percent) said they would go ahead with the treatment plan if it were demonstrated only with resin-based composite/esthetic preview/mock-up, 10 (41.7 percent) said they would go ahead with the treatment plan if it were demonstrated only with before-and-after photographs of other patients, and six (25 percent) said they would go ahead with the treatment plan if it were demonstrated only with diagnostic models with wax setups.

When we performed pairwise comparisons of consultation methods with respect to treatment plan acceptability, we found that acceptability of computer-imaging simulation was significantly higher than that of the other three methods. We found no pairwise differences for treatment plan unacceptability. Results of the conclusion questionnaire illustrating subjects’ reasons for their choice of preferred consultation method are presented in Table 3Go.


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  		TABLE 3 REASONS EXPRESSED AS FACTORS IN DECIDING PREFERENCE.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
The results of this study support Papasotiriou and colleagues’28 findings that indicated that computer-imaging simulation is more effective in achieving treatment plan acceptance than were the other three methods.

A limitation of our study was that we did not offer before-and-after photographs of other patients as part of the resin-based composite consultation. It should be noted that in some clinical practices, when a resin-based composite/esthetic preview/mock-up is performed, a photograph is taken before and after the application of the resin-based composite material. The patients then are able to bring the photographs home and share them with family and friends, in a manner similar to that of computer-imaging simulation.

It is possible that if before-and-after photographs of other patients were added to the resin-based composite/esthetic preview/mock-up group, the photographs could have explained some or all of the differences attributed to the computer-imaging simulation, and the difference between these two consultation methods could have been reduced significantly.

Furthermore, this study did not include a cost-benefit analysis. Resin-based composite/esthetic preview/mock-up requires professional chair time, which can be costly, depending on the dentist’s skill and efficiency.25 Computer-imaging simulation also can be time-consuming,37 although a trained auxiliary can do the simulation. Factors such as these will enter into the determination and comparison of the actual costs associated with each type of esthetic consultation.

Additionally, the small size of this study did not facilitate the investigation of the role that the patient’s sex or ethnicity might play in the acceptance of esthetic consultation methods. A larger, more comprehensive study would be required for this purpose.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
In this pilot study, subjects expressed a preference for computer-imaging simulation as the consultation method that most improved their understanding of a proposed treatment plan. More than one-half of those who preferred the computer-imaging simulation consultation method indicated that they liked the ability to take the photographs home to share with friends and family.

To better understand the correlation between consultation methodology, case acceptance, treatment outcome and patient satisfaction, it is hoped that researchers will conduct more comprehensive investigations with larger study populations.


   FOOTNOTES
 

Dr. Almog is an associate professor, prosthodontics, University of Rochester Eastman Dental Center, 625 Elmwood Ave., Rochester, N.Y. 14620, e-mail "dov_almog{at}urmc.rochester.edu". Address reprint requests to Dr. Almog.


Dr. Sanchez Marin is a graduate student, General Dentistry, University of Rochester Eastman Dental Center, Rochester, N.Y.


Dr. Proskin is an associate professor, University of Rochester Eastman Dental Center, Rochester, N.Y.


Dr. Cohen is a clinical instructor, General Dentistry, University of Rochester Eastman Dental Center, Rochester, N.Y.


Dr. Kyrkanides is an assistant professor, orthodontics, University of Rochester Eastman Dental Center, Rochester, N.Y.


Dr. Malmstrom is an associate professor, General Dentistry, University of Rochester Eastman Dental Center, Rochester, N.Y.


The authors thank PracticeWorks at Eastman Kodak (Rochester, N.Y.) for providing the PracticeWorks DICOM Cosmetic Imaging Software used in this study, and Eastman Kodak for providing the dental digital photography kit and supplies used in this study.


Copies of the questionnaires used in this study can be obtained from Dr. Almog.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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