We all strive to ensure our patients are satisfied with the dental treatment that they receive, but how can we be sure that we know what our patients are actually expecting? Do our patients’ expectations align with what our expectations are? Is it possible to even achieve what our patients are expecting from us?

One of the most common complaints the ADASA receives is from those situations where a patient’s expectations have not been met. In many instances these complaints involve treatment undertaken to improve the appearance of a patient’s smile. In this article we will look at how photographs, diagnostic wax-ups and intra-oral mock-ups can be used to help us define our patients’ expectations before embarking on any definitive treatment.

‘I don’t like my smile and I’d like to get it fixed’. When a patients says this it is imperative that we establish what it is that they don’t like about their smile. While a mirror can be useful in discussing a patient’s concerns with their smile, there is nothing quite as good as looking at photographs of a patient’s smile, blown up to the size of a computer screen, while sitting alongside them. Printing out these photographs and drawing on them can also be a very useful tool, and fantastic for our records as well!

Discussing photos together is a great opportunity for us to point out any concerns that we may have that the patient hasn’t necessarily noticed. ‘The height of the gum around your upper left tooth is different to that on the upper right tooth, is that something that concerns you?’ Pointing out any issues like this to our patients before embarking on treatment is much easier than only considering it after treatment has been started, or completed. Assessing photos is also a great way to ensure that we, as the treating clinician, identify all potential issues to future treatment.

A diagnostic wax up can be a huge benefit to both our patients and us when planning aesthetic treatment. Although we as the treating clinician will often have a good idea of what result can be achieved, a diagnostic wax-up will often help identify issues that we may have overlooked ourselves (will lengthening that lateral incisor be an issue when the patient goes into lateral excursion? Will the teeth look too wide if we close that diastema restoratively?). If the patient has any concerns with the diagnostic wax-up, it is a great opportunity to discuss ways in which those concerns can be addressed and what that might involve.

Taking that one step further, an intra-oral mock-up is a great way of showing a patient what they might expect to see in their own mouth if they decided to proceed with treatment. Taking photographs of an intra-oral mockup to then discuss with our patient is a great way of confirming their expectations. The photographs shown in this article are from a case recently carried out on a 34 year old male. They highlight some of the ways a diagnostic wax-up, intra-oral mock-up and photographs were used to help confirm the pre-treatment concerns and define expectations prior to treatment starting.

 

In this case our patient was concerned about their teeth being discoloured and looking short. One of the options discussed, which our patient was keen to investigate further, was building up the teeth with composite resin veneers. 

But what would they look like? How much bigger would we make the teeth? Would bigger teeth suit his face and smile? These are questions that both the patient and I were asking, so the decision was made to take impressions so a diagnostic wax-up could be constructed. An intra-oral mock-up of the diagnostic wax-up was then produced using a putty key and temporary crown material.

While looking at the extra-oral photographs with our patient, we discussed whether the midline of his teeth not being coincident with his facial midline was a concern. In this case it wasn’t, but again, best to find this out now instead of finding out after treatment that the patient thought this would be corrected as part of their treatment! The patient was also able to see how his ‘bigger teeth’ would look in relation to the rest of his face. In this instance the patient thought they looked natural and if anything that they could be a bit longer.

Looking at the intra-oral photographs with the patient, we were able to discuss the discrepancy in gingival heights around the upper lateral incisors. This was a concern to the patient and so it was decided to increase the gingival margin height around tooth 22 to better match the gingival margin around tooth 12. 

The intra-oral mock-up only involved the upper anterior 6 teeth, which was what the patient had originally considered doing after our initial discussions. On reviewing the photos of the intra-oral mock-up, he noticed the first premolars looked dark and not very visible. We therefore discussed placing composite resin veneers on these teeth as well, along with the extra cost that this would incur.

Our patient therefore had a very clear understanding of what they could expect from the visual aspect of their treatment prior to any definitive treatment starting, thanks to the use of photographs, a diagnostic wax-up and an intra-oral mock-up.

Yet there are other aspects that also need to be addressed prior to starting treatment. Does the patient expect their composite resin veneers to last forever? Do they think the composite resin veneers will be as strong as their natural teeth? What happens if one of the composite resin veneers chips? Is our patient aware of what might happen if they don’t wear a protective appliance while sleeping?

It is imperative that all these aspects are discussed prior to treatment commencing so that our patients’ expectations are aligned with ours. It also goes without saying that all of these discussions should be documented in our records, including informed financial consent. Then even if complications do occur, the patient has been well informed of this possibility and the way in which they can be managed. We are all well aware that despite our very best efforts it is unrealistic to expect our restorative treatment to last forever. It is important that our patients understand this too.

Meeting our patients’ expectations is something that we all strive to achieve on every patient, however our patients’ expectations will not always align with our own. Identifying these situations before any definitive treatment is started will go a long way to preventing negative outcomes in not just aesthetic cases, but all of the treatment that we offer.