efecto de los métodos de consulta estética en la aceptación del cierre de diastema. plan de...

8/7/2019 Efecto de los mtodos de consulta esttica en la aceptacin del cierre de diastema. Plan de tratamiento

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Background. The authors conducted astudy to determine which of fourconsultation methods helpedpatients best understand a

proposed treatment planfor maxillary anteriordiastema closure.Methods. The authorspresented 24 subjects withfour types of consultation in random order:before-and-after photographs of otherpatients, diagnostic models with wax setups,resin-based composite/esthetic preview/ mock-ups and computer-imaging simula-tions. After viewing each method, theauthors asked the subjects about treatment

acceptability. At the end of the demonstra-tions of all four methods, the authors askedthe subjects which consultation methodhelped them best understand the proposedtreatment plan.Results. A total of 87.5 percent of the sub-

jects indicated that they would accept theproposed treatment plan after they wereshown the computer-imaging simulation, 50percent said they would after they wereshown the resin-based composite/estheticpreview/mock-up, 41.7 percent said they

would after they were shown photographs of other patients, and 25 percent said theywould after they were shown diagnosticmodels with wax setups. When asked whichmethod helped them best understand theproposed treatment, 54.2 percent of the sub-

jects selected computer-imaging simulation,33.3 percent selected resin-based composite/ esthetic preview/mock-ups, and 12.5 percentselected before-and-after photographs of other patients. None of the subjects selecteddiagnostic models with wax setups. A 2 test

for goodness of fit indicated that these differ-ences were statistically significant.Conclusion. Subjects preferredcomputer-imaging simulation to the otherthree consultation methods, and they indi-cated that computer-imaging simulation pro-vided a better understanding of the proposedtreatment plan for diastema closure.Clinical Implications. The use of computer-imaging simulation enhances thepatients understanding of a proposed treat-ment plan concerning maxillary anterior

diastema closure.

COVER STORY

The effect of estheticconsultation methodson acceptance ofdiastema-closure

treatment planA pilot studyDOV 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.; HANS MALMSTROM, D.D.S.

The main objective of effective dentist-patientcommunication is to help the patient picturethe anticipated result, thereby increasing theprobability of the patients not only agreeingto the proposed treatment, but of being satis-

fied with the treatment outcome. 1 Modern dentistry andthe demand for esthetics require a com-prehensive, multidisciplinary approachthat includes the psychological and emo-tional dimensions. 2 The results fromstudies by Carlsson and colleagues 3 andWagner and colleagues 4 indicate thatthe significance of dental appearanceand the preference in regard to estheticdentistry vary considerably among den-tists, dental technicians and patients.Kokich and colleagues 5 suggested thatthe general public may not be as able todetect esthetic defects as dentists, andthe level of training in dental esthetics

may influence the ability of a dental professional todetect esthetic defects.

Case presentation or consultation describes the stagein the dentist-patient relationship that pertains to dis-cussing the patients dental needs or desired treatment,

A B S T R A C T

JADA, Vol. 135, July 2004 875

The mainobjective of

effectivedentist-patient

communicationis to help the

patient picturethe anticipated

result.

JA D

A

C O N

T I N

U I N G E D U

C A

T I

O N

A R T I C L E1

C O S M E T I C & R E S T O R A T I V E C A R E

Copyright 20 04 American Dental Association. All rights reserved.


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and it involves a great deal of methodical commu-nication. 6-8 Use of good patient education adjunctsgenerally will increase compliance with treatmentrecommendations. 9 When patients have beeninvolved in the decision-making process, the expe-rience has been associated with an improved clin-ical outcome. 10 Most practitioners feel that theymust be able to communicate with patients sothat the patients not only understand their max-illofacial problems, but also approve of the serv-ices being recommended. 11 Furthermore, whenthe dental team takes the time to develop thecase presentation process and cultivate relation-ships with patients, the results can be more per-ceptible to the patients, 12 and treatment planacceptance rates can be improved. 13 The use of visual adjuncts can enhance thepatients understanding of proposedtreatment plans further. 14 There arefour methods of visually demon-strating possible outcomes:d Before-and-after photographs of other patients. A 1996 professionalsurvey reported that more than 50percent of professionals consideredbefore-and-after photographs theconsultation method of choice. 15d Diagnostic models with waxsetups. These models are useful inpatient education, evaluation of existing clinical conditions, restoration design,occlusion evaluation and planning for estheticresults in the anterior region. 16 A diagnostic waxsetup can provide the answers to many questionsregarding the planning and completion of treatment. 17-24d Resin-based composite/esthetic preview/ mock-up. The use of resin-based composite for anesthetic preview/mock-up can help the dentistand patient determine the esthetically acceptableshade, material selection and shape of teeth, aswell as resolve any occlusal concerns. 25 However,there is a limited amount of literature supportingits effectiveness. 26d Computer-imaging simulation. Digital imagesenable both clinicians and patients to view thedesired final outcome of the patients teeth andsoft tissues at the preoperative stage.

A survey of patients attitudes toward estheticprocedures revealed problems in communicationbetween patients and dentists. 27 When computerimaging was introduced in the 1980s, it improvedthis communication. In a 2000 prospective clinical

study, computer-imaging simulation scoredhigher patient satisfaction marks than did con-ventional methods. 28

Dentists who use computer-imaging simulationin their practices report a significant number of positive responses to this method from patients. 29

Some authors suggest that in more complex treat-ment plans, the dentist can convey a treatmentconcept to the patient easier and more realisti-cally when using computer-imagingsimulation. 30,31

However, it is recommended by other authorsthat computer-imaging simulation be used in con-

junction with traditional diagnostic procedures,not instead of them. 32,33 A computer-imaging sim-ulation of a perfect smile can deliver a false

promise to the patient, which canlead to patient disappointment andpotentially to both ethical and legalissues. It does not provide the prac-titioner with the definitive mea-surements and conditions based ontooth position and occlusal relation-ship that are required for decisionmaking during tooth preparation.Furthermore, the cost of purchasingand maintaining a computer-imaging system, which oftenincludes a combination of sophisti-cated software programs for prac-

tice management, charting, and intra- andextraoral cameras, can be high. 34,35

Phillips and colleagues 36 and Turpin 37 con-cluded that video image predictions are a valu-able adjunct for conveying treatment options topatients by indirectly strengthening their self-image, motivation and expectations. Computer-imaging simulation makes it easier to communi-cate to patients what can be accomplishedrealistically and, thereby, avoid unpredictableoutcomes and patient dissatisfaction. 38

METHODS

We selected subjects who had untreated maxil-lary central diastemata from a pool of patientswho sought treatment at the University of Rochester Eastman Dental Center, Rochester,N.Y. Although we did not exclude patientsaccording to the severity of their diastemata, allsubjects in the study did have a Class I occlusionwith midline centered and a normal overbite andoverjet. We excluded from the study patients whohad previous prosthetic or esthetic treatment per-

876 JADA, Vol. 135, July 2004


Digital imagesenable both cliniciansand patients to view

the desired finaloutcome of the

patients teeth andsoft tissues at the

preoperative stage.



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formed on their maxillary anterior teeth. Werequired that the patients right and left maxil-lary central incisors be caries-free to avoid biastoward treatment.

To ensure that subjects could fill out the studyquestionnaires, we required that they had com-pleted high school. Each subject completed twovisits.

We focused our investigation on diastema clo-sure, regardless of its severity. Maxillary spacescan be addressed effectively by both orthodonticsand esthetic restorative dental treatment. In gen-eral, maxillary spaces can result from labialincisor tooth movement, which often is seen inadults with the onset of periodontal loss of alve-olar bone. Furthermore, in some cases, smaller-sized incisors can lead to spaces in the maxillaryanterior region and intermaxillary tooth-size dis-crepancy. In 1958, Bolton 39 first identified inter-maxillary tooth size relationship as a key factorin normal occlusion, and he reported that in aClass I occlusion, the six anterior mandibularteeth were 77.2 percent of the mesiodistal size of the corresponding maxillary teeth. Clinically, if maxillary anterior spaces appear to be the resultof smaller-than-optimal-sized incisors, thenrestorative esthetic dentistry would be the treat-ment of choice, whereas in the case of labiallydrifted maxillary teeth, orthodontics wouldappear to be the best option.

At the first visit, we took impressions. We alsotook preoperative facial and close-up digital pho-tographs with a digital camera (DX4900 DentalDigital Camera Kit, Eastman Kodak, Rochester,N.Y.).

At the second visit, we arbitrarily divided thesubjects among three practicing dentists (D.A.,C.S.M., and H.M.) who presented all four consul-tation methods to the subjects to demonstrate clo-sure of their diastemata. While interexaminercalibration discussions took place before the con-sultations, there may have been some level of interexaminer variability. However, rather thanintroducing potential bias by having only oneexaminer, we divided esthetic consultations arbi-trarily among the three dentists. Additionally, tominimize the bias created by the overlappingeffect of giving one subject all four methods in onevisit, each examiner gave all four presentations toeach subject in a randomized order:d Before-and-after photographs of other patients.The examiners showed subjects photographs of another patient treated for closure of the maxil-

lary central diastema at the second visit; all subjects viewed the same photographs. This was theonly method that did not provide visual informa-tion based on the current subjects face anddentition.d Diagnostic models with wax setups. Using theimpressions taken at the first visit, the examinerreplicated the maxillary model and used sculptingwax on the model to close the diastema (Figure 1).d Resin-based composite/esthetic preview/ mock-up. During the second visit, the examinerapplied a hybrid resin-based composite to themesial tooth surfaces of the right and left maxil-lary central incisors, simulating closure of thediastema, without applying any dental adhesive.The examiner removed the material at the end of the consultation.d Computer-imaging simulation. The examinerdownloaded facial and close-up digital images of each subject to a computer and achieved simula-tion of diastema closure using specialized dentalimaging software (PracticeWorks/DICOM Cos-metic Imaging Software, Version 1.73, EastmanKodak). The examiner produced before-and-after8- 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,

JADA, Vol. 135, July 2004 877


Figure 1. During the first visit, we obtained impressionsfrom each subject. The examiners then made a personal-ized 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 estheticconsultation.



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Eastman Kodak). As part of the consultation, theexaminer printed personalized before-and-afterfacial and close-up photographs and suppliedthem to the subjects (Figure 2).

After the examiners presented each method,they gave the subjects an initial questionnairethat included one question and three possibleanswers; it was formulated to determine the sub-

jects perceptions regarding treatment planacceptance. Subjects sat in a private room whilefilling out the questionnaire so they could becandid. Examiners provided them with a handmirror so they could visualize the proposed treat-ment plan.

After all four consultation methods and the

questionnaire had been completed, we asked eachsubject to complete a conclusion questionnairethat compared the four consultation methods sowe could determine the method he or she pre-ferred most strongly.

We performed pairwise comparisons of consul-tation methods with respect to the acceptance of and objection to treatment questions from the ini-tial questionnaire, using McNemar tests. We usedanalysis of variance to compare the subjects pref-erences with respect to age, and we compared thedistribution of subjects preferred modalitiesagainst a uniform distribution using a 2 test forgoodness of fit. We used a level of significance of = .05 in all statistical tests.

878 JADA, Vol. 135, July 2004


A B

C D

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



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RESULTS

Twenty-four of 27 subjects selected completed thestudy; 19 were women (79.2 percent), and fivewere men (20.8 percent). The mean age of thesubjects was 34.9 years (standard deviation: 9.5years, range: 18-60 years). The age distribution of the subjects is presented in Table 1. There were11 African-American subjects (45.8 percent), 11white subjects (45.8 percent) andtwo Hispanic subjects (8.3 percent).

Consultation method preferencevaried by age. The three subjectswho preferred before-and-after pho-tographs of other patients had amean age of 25.0 years, the eightsubjects who preferred resin-basedcomposite/esthetic preview/mock-uphad a mean age of 34.5 years, andthe 13 subjects who preferredcomputer-imaging simulation had amean age of 37.2 years. The mean age of subjectswho preferred the before-and-after photographsof other patients differed significantly from thatof subjects who preferred computer-imagingsimulation.

Table 2 illustrates the consultation methodthat the subjects said gave them the best under-standing of the proposed treatment plan. A 2 testfor goodness of fit indicated statistically signifi-cant differences in consultation methodpreference.

When we asked subjects specifically abouttreatment plan acceptance, 21 (87.5 percent) saidthey would go ahead with the recommendedtreatment plan if it were demonstrated only withcomputer-imaging simulation, 12 (50 percent)said they would go ahead with the treatment planif it were demonstrated only with resin-basedcomposite/esthetic preview/mock-up, 10 (41.7 per-cent) said they would go ahead with the treat-ment plan if it were demonstrated only withbefore-and-after photographs of other patients,and six (25 percent) said they would go aheadwith the treatment plan if it were demonstratedonly with diagnostic models with wax setups.

When we performed pairwise comparisons of consultation methods with respect to treatmentplan acceptability, we found that acceptability of computer-imaging simulation was significantlyhigher than that of the other three methods. Wefound no pairwise differences for treatment planunacceptability. Results of the conclusion ques-tionnaire illustrating subjects reasons for theirchoice of preferred consultation method are pre-sented in Table 3.

DISCUSSION

The results of this study support Papasotiriouand colleagues 28 findings that indicated that com-puter-imaging simulation is more effective inachieving 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 patientsas part of the resin-based com-posite consultation. It should benoted that in some clinical prac-tices, when a resin-based com-posite/esthetic preview/mock-up isperformed, a photograph is takenbefore and after the application of the resin-based composite

material. The patients then are able to bring thephotographs home and share them with familyand friends, in a manner similar to that of com-puter-imaging simulation.

It is possible that if before-and-after photo-

JADA, Vol. 135, July 2004 879


TABLE 1

AGE DISTRIBUTION OF SUBJECTS. AGE (YEARS)

Younger Than 20

20-29

30-39

40-49

50 and Older

1 (4.2)

5 (20.8)

13 (54.2)

4 (16.6)

1 (4.2)

NO. OF SUBJECTS (%)

TABLE 2

DISTRIBUTION OF PREFERREDCONSULTATION METHODS.

NO. OF SUBJECTS (%)

Before-and-After Photographsof Other Patients

Diagnostic Models With Wax Setups

Resin-Based Composite/ Esthetic Preview/Mock-up

Computer-Imaging Simulation

TOTAL

(12.5)

(0.0)

(33.3)

(54.2)

(100.0)

3

0

8

13

24

PREFERRED CONSULTATIONMETHOD

Acceptability of computer-imaging

simulation wassignificantly higher

than that of the otherthree methods.



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cated that they liked theability to take the pho-tographs home to sharewith friends and family.

To better understand thecorrelation between consul-tation methodology, caseacceptance, treatment out-come and patient satisfac-tion, it is hoped thatresearchers will conductmore comprehensive inves-tigations with larger studypopulations. s

Dr. Almog is an associate professor,prosthodontics, University of RochesterEastman Dental Center, 625 Elmwood

Ave., Rochester, N.Y. 14620, [email protected]. Address reprint requests to Dr. Almog.

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

Dr. Proskin is an associate professor, University of RochesterEastman 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, Univer-sity 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 Soft-ware used in this study, and Eastman Kodak for providing the dentaldigital photography kit and supplies used in this study.

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

1. Goldstein RE. Communicating esthetics. N Y State Dent J1985;51:477-9.

2. Sheets CG. Modern dentistry and the esthetically aware patient.JADA 1987;115(special issue):103E-5E.

3. Carlsson GE, Wagner IV, Odman P, et al. An international com-parative multicenter study of assessment of dental appearance usingcomputer-aided image manipulation. Int J Prosthodont 1998;11:246-54.

4. Wagner IV, Carlsson GE, Ekstrand K, Odman P, Schneider N. Acomparative study of assessment of dental appearance by dentists,dental technicians, and laymen using computer-aided image manipula-tion. J Esthet Dent 1996;8(5):199-205.

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6. Bush JB. Communication and patient education. Dent Assist 1968;37(2):19-21.

7. Derbabian K, Marzola R, Arcidiacono A. The science of communi-cating the art of dentistry. J Calif Dent Assoc 1998;26(2):101-6.

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9. Ley P. Communicating with patients. London: Croom Helm; 1988.10. Lefer L, Pleasure M, Rosenthal L. A psychiatric approach to the

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graphs of other patients were added to the resin-based composite/esthetic preview/mock-up group,the photographs could have explained some or allof the differences attributed to the computer-imaging simulation, and the difference betweenthese two consultation methods could have beenreduced significantly.

Furthermore, this study did not include a cost-benefit analysis. Resin-based composite/estheticpreview/mock-up requires professional chair time,which can be costly, depending on the dentistsskill and efficiency. 25 Computer-imaging simula-tion also can be time-consuming, 37 although atrained auxiliary can do the simulation. Factorssuch as these will enter into the determinationand comparison of the actual costs associatedwith each type of esthetic consultation.

Additionally, the small size of this study didnot facilitate the investigation of the role that thepatients sex or ethnicity might play in the accep-tance of esthetic consultation methods. A larger,more comprehensive study would be required forthis purpose.

CONCLUSIONS

In this pilot study, subjects expressed a prefer-ence for computer-imaging simulation as the con-sultation method that most improved their under-standing of a proposed treatment plan. More thanone-half of those who preferred the computer-imaging simulation consultation method indi-

880 JADA, Vol. 135, July 2004


TABLE 3

REASONS EXPRESSED AS FACTORS IN DECIDINGPREFERENCE.

NUMBER OF SUBJECTS (%) INDICATING EACH REASON AS A FACTOR IN THE SELECTION OF THE PREFERRED

CONSULTATION METHOD

Before-and-AfterPhotographs of OtherPatients

Diagnostic Models With Wax Setups

Resin-BasedComposite/EstheticPreview/Mock-up

Computer-ImagingSimulation

TOTAL*

3

0

8

13

24

2 (66.7)

0 (0.0)

4 (50.0)

4 (30.1)

10 (41.7)

3 (100.0)

0 (0.0)

7 (87.5)

13 (100.0)

23 (95.8)

0 (0.0)

0 (0.0)

0 (0.0)

8 (61.5)

8 (33.3)

1 (33.3)

0 (0.0)

0 (0.0)

2 (15.4)

3 (12.5)

CONSULTATIONMETHOD

N

DescribesBest

VisualizesBest

Can BeTaken Home

Other

* The percentages are the percentage of total.



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extensive bonding. Gen Dent 1989;37(1):58-9.19. Greeley JH. Planning for fixed prosthesis. J Prosthet Dent

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treatment planning. Tex Dent J 1985;102(2):10-2.23. Magne P, Magne M, Belser U. The diagnostic template: a key ele-

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24. Cardash HS, Gansherowitz J, Serebro L, Marshak B. The role of

study casts in prosthodontic treatment. Quintessence Int 1985;16:263-9.25. Morley J. The role of cosmetic dentistry in restoring a youthful

appearance. JADA 1999;130:1166-72.26. Behle C. Placement of direct composite veneers utilizing a silicone

buildup guide and intraoral mock-up. Pract Periodontics Aesthet Dent2000;12:259-66.

27. Goldstein RE, Lancaster JS. Survey of patient attitudes towardcurrent esthetic procedures. J Prosthet Dent 1984;52:775-80.

28. Papasotiriou OS, Nathanson D, Goldstein RE. Computer imagingversus conventional esthetic consultation: a prospective clinical study.J Esthet Dent 2000;12(2);72-7.

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30. Goldstein CE, Goldstein RE, Garber DA. Computer imaging: anaid to treatment planning. J Calif Dent Assoc 1991;19(3):47-51.

31. Grubb JE, Smith T, Sinclair P. Clinical and scientific applica-tions/advances in video imaging. Angle Orthod 1996;66:407-16.

32. Brooks LE. Smile imaging: the key to more predictable dentalesthetics. J Esthet Dent 1990;2(1):6-9.

33. Nathanson D. Current developments in esthetic dentistry. CurrOpin Dent 1991;1:206-11.

34. Berland LF. The shape of teeth to come. Dent Econ 1998;88(4):44-5.

35. Nathanson D. Dental imaging by computer: a look at the future.JADA 1991;122(3):45-6.

36. Phillips C, Hill BJ, Cannac C. The influence of video imaging onpatients perceptions and expectations. Angle Orthod 1995;65:263-70.

37. Turpin DL. The need for video imaging. Angle Orthod 1995;

65:243.38. Goldstein RE, Miller MC. High technology in esthetic dentistry.Curr Opin Cosmet Dent 1993:5-11.

39. Bolton WA. Disharmony in tooth size and its relation to the anal-ysis and treatment of maocclusion. Angle Orthod 1958;28:113-31.

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