Abstract: This case details a 7-year follow-up of an adult patient who underwent comprehensive restorative treatment for an esthetic disability managed using established risk-based protocols. The treatment prioritized minimal invasiveness and functional stability without the need for orthodontic intervention. The results demonstrate long-term success and managed risks highlighting the predictability of the interdisciplinary, conservative approach that was taken. The patient continues to experience functional stability, pleasing esthetics, and an enhanced quality of life.
The ability to follow a patient over time who has received treatment provides clinicians with valuable information. This article discusses a 7-year follow-up to a previously published case by the authors,1 examining the stability and long-term health benefits of a structured risk-management approach to diagnosis and treatment. The initial treatment aimed to address the patient’s esthetic concerns, which he perceived as a disability,2 and manage his worries that his teeth were wearing down. Because the patient declined orthodontic treatment, functional considerations were addressed restoratively. Tooth preparation and restorative design were meticulously planned to preserve the structural integrity of the teeth and minimize the risk of future complications.
Clinical Case Overview
In 2017, the then-63-year-old patient presented with chipped and worn anterior teeth. As a public speaker, he felt self-conscious about his “gummy” smile and described his teeth as excessively small and dark. He expressed a desire for larger, whiter teeth, wanting a “million-dollar smile” (Figure 1).
Following the risk assessment and treatment planning protocols taught by the Kois Center,3,4 data gathering and diagnosis were completed. A comprehensive plan was developed to address the patient’s primary esthetic concern while minimizing biomechanical risk. By increasing the patient’s occlusal vertical dimension (OVD), friction within the chewing envelope was corrected, which allowed the posterior tooth preparations to remain in enamel and decreased the amount of occlusal reduction.
Medical/Dental History
Pretreatment, the patient’s medical history was unremarkable. He did not smoke, consume alcohol, or take any medications. The clinical findings included significant attrition and mild erosion. Referral to a gastroenterologist and subsequent endoscopy ruled out acid reflux, and dietary review identified no erosive contributors. Because of his age, he was classified as American Society of Anesthesiologists (ASA) II. His dental history included prior orthodontic treatment and maxillary first bicuspid extractions during adolescence.
At the 7-year follow-up, however, his medical status had changed significantly. In 2021, he underwent cardiac ablation to manage arrhythmia. Additional cardioversion treatments were performed in 2022 and 2023 for occasional atrial fibrillation. His condition was currently well managed, with no emergency interventions required, although ongoing medical monitoring was necessary. Due to these cardiovascular considerations and the need for continued management, his classification increased to ASA III. The patient was currently taking Tikosyn and Xarelto. While these medications impact cardiovascular health and elevate anesthetic and surgical risks, there is no known association with periodontal changes.
Diagnosis, Risk Assessment, and Prognosis
Periodontal: Pretreatment: The patient originally presented with no evidence of active periodontal disease. Mild attachment loss was noted, with 1 mm of gingival recession on teeth Nos. 19 through 21 and less than 2 mm of horizontal bone loss. The periodontal diagnosis was American Academy of Periodontology (AAP) stage I, grade A (Figure 2).5 His periodontal risk at the time was low and the prognosis good.
Seven-year follow-up: Over the past several years, the patient’s overall periodontal condition declined slightly, showing less effective homecare and increased biofilm. Generalized probing depths of 2 mm to 4 mm and some localized 5 mm pockets in the molar areas indicated AAP stage II, grade B (Figure 3 and Figure 4).
Risk: Moderate
Prognosis: Fair
Biomechanical: Pretreatment: The patient exhibited no active caries but had several defective restorations, including amalgams on teeth Nos. 2, 15, and 18; a missing onlay on tooth No. 19; and a fractured tooth No. 31 with both lingual cusps broken below the gingival margin. Structural compromises were also noted on teeth Nos. 19, 30, and 31, with No. 31 having a crown margin concern. Teeth Nos. 6 through 11 and 22 through 27 demonstrated severe attrition and erosion, resulting in a poor prognosis. If left untreated, teeth Nos. 19 and 31 would have a guarded to hopeless prognosis (Figure 5 and Figure 6). The patient’s biomechanical risk at the time was moderate and the prognosis poor.
Seven-year follow-up: The patient required no additional restorative treatment over the past 7 years. He remained free from active caries and exhibited no new erosive lesions, indicating improved biomechanical stability (Figure 7 through Figure 10).
Risk: Moderate
Prognosis: Fair
Functional: Pretreatment: At the initial presentation, the patient exhibited worn and chipped anterior teeth and reported needing to “squeeze” and push his jaw back to achieve posterior tooth contact. He noted that his mandibular anterior teeth were in contact with the palatal surfaces of the maxillary anteriors. He also habitually placed his tongue between his teeth. Moderate attrition (1 mm to 2 mm) was observed on the maxillary and mandibular posterior teeth, and severe attrition (>2 mm) was evident on the anterior teeth. The most significant wear occurred on the palatal surfaces of the maxillary anterior teeth and the labial surfaces of the mandibular anterior teeth, consistent with an adaptive-mediated constricted chewing pattern (CCP). These wear patterns along with the positive responses in the patient’s dental history confirmed the diagnosis of CCP (Figure 11). His functional risk at the time was moderate and the prognosis poor.
Seven-year follow up: There was now no evidence of attrition or chipping of restorations. On the patient’s updated dental history, the only positive response under “Bite and Jaw Joint” was related to wearing a nightguard for preventive reasons. Inspection of the appliance revealed no grooves or anterior wear marks, indicating no aberrant jaw movements during sleep, which helped confirm continued occlusal stability (Figure 12 and Figure 13).
Risk: Low
Prognosis: Good
Dentofacial: Pretreatment: Originally, the patient exhibited excessive gingival display, undersized teeth, a slight diastema between the central incisors, and a deficient buccal corridor, as can be seen in Figure 1. Being a public speaker, he considered these esthetic characteristics a significant disability and expressed a strong desire for larger, whiter teeth and a less “gummy” smile. The patient’s dentofacial risk at the time was high and the prognosis hopeless.
Seven-year follow up: The patient had initially viewed his smile as a major personal and professional limitation. Following treatment, however, he repeatedly expressed how transformative the outcome was in his life. He reported increased confidence and success in social and professional settings, stating people trusted him more and that his improved smile helped him prosper in his business (Figure 14 and Figure 15).
Risk: Moderate
Prognosis: Fair
Treatment
The original treatment (2017) for the patient’s maxillary anterior teeth involved approximately 1 mm clinical crown lengthening to correct the excessive gingival display and improve tooth proportions, followed by indirect restorative procedures to manage worn and chipped anterior teeth. Maxillary posterior teeth were included in the treatment to increase the OVD,6 correct the negative occlusal plane, and enhance smile fullness by addressing horizontal discrepancies.
The anterior teeth were minimally prepared for zirconia-layered, cohesively retained restorations designed to optimize esthetics while preserving tooth structure. The posterior teeth were restored with minimal reduction using adhesively retained restorations, known as additive veneer onlays, as described in the original article (Figure 16).1
The patient’s mandibular teeth were restored using direct composite resin to repair erosive lesions and rebuild worn incisal edges. His severely damaged molars received full-coverage, cohesively retained crowns to re-establish proper function and stability. At the delivery appointment, a Kois deprogrammer (Kois Center, koiscenter.com) was used for the purpose of refining the equilibration and achieving a bilateral, simultaneous posterior occlusal contact.7
Discussion
This case was managed using systematic protocols of data collection, diagnostic assessment, risk evaluation, and treatment planning.3,4 The patient sought treatment to address significant quality-of-life concerns, perceiving his smile as a dental disability.2 His primary goal was to achieve a “million-dollar smile” while avoiding orthodontic therapy.
The treatment plan effectively addressed both esthetic and functional concerns without raising the risk of further dental complications. Functional risk was managed by increasing the OVD and establishing bilateral, simultaneous posterior occlusion. Esthetic enhancement was achieved through minimally invasive, adhesively retained restorations that preserved tooth structure, thereby avoiding an increase in biomechanical risk.
Roughly 7 years after treatment, updated medical and dental histories, along with a thorough clinical examination, confirmed the treatment’s long-term success. The patient reported no symptoms associated with a constricted envelope of function, responding “no” to all bite- and joint-related questionnaire items. There were no failures in the restorations, whether adhesively or cohesively retained, and the patient remained satisfied with the esthetic results. He noted that the treatment positively influenced his self-image and professional confidence as a public speaker (Figure 17 through Figure 19).
In light of the patient’s refusal to undergo orthodontic therapy, the choice to proceed solely with restorative treatment was further justified by the stability of the results. Since the treatment’s completion, the patient’s occlusion has remained stable, with no reported discomfort, no signs of tooth mobility or rotation, and no indications of occlusal instability.
While orthodontic treatment is often recommended to enhance tooth alignment, reduce tooth reduction, and decrease restorative needs, in this case it likely would not have provided additional benefits. The patient’s functional and esthetic concerns were effectively addressed through crown lengthening, increasing the OVD, and placing conservative restorations. The absence of orthodontic therapy also significantly reduced treatment costs and duration, which are crucial factors for patient acceptance.8 The total treatment time was approximately 3 to 6 months, compared with an estimated 2 years if orthodontics were included. For this patient, such efficiency represented an important quality-of-life consideration, particularly given his professional commitments and emphasis on appearance and confidence in the workplace.
Despite the overall treatment success, the slight increase in periodontal risk at the 7-year mark, likely biofilm-mediated, warranted attention. This highlights the dynamic nature of patient health even with structured protocols. During follow-up, homecare instructions were reinforced, and a more frequent recare schedule was implemented, underscoring the necessity of continuous maintenance and adaptation of initial risk management strategies.
As Sartorius described, health can be viewed as a state of balance within oneself and one’s environment.9 This patient appears to have achieved such an equilibrium in his dental health. However, systemic factors, such as medication-induced xerostomia and an elevated periodontal risk profile, can disrupt this balance over time, highlighting the need for ongoing evaluation and maintenance.
Conclusion
A treatment plan is essentially a suggested approach to addressing a patient’s dental issues; true success is gauged not by how the restoration looks when finished but by the lack of negative outcomes over time and the noticeable enhancements in the patient’s quality of life. In this instance, the treatment successfully resolved esthetic and functional issues without elevating biomechanical risks. The patient’s dental impairment was managed to a level of health he found acceptable, as shown by the absence of symptoms and his ongoing satisfaction 7 years after the treatment.
ACKNOWLEDGMENT
The authors thank John Kois, DMD, MSD, for providing the structure and fundamental protocols to create the vision necessary for the successful treatment of this case, Swanson Dental Associates for the patient’s professional hygiene maintenance, and Protea Dental Studio for its excellent laboratory support.
ABOUT THE AUTHORS
Kris Swanson, DDS
Clinical Instructor and Course Facilitator, Kois Center, Seattle, Washington; Private Practice, Bellevue, Washington
Leon Hermanides, CDT
Clinical Instructor and Scientific Advisor, Kois Center, Seattle, Washington; Founder, Protea Dental Studio, Redmond, Washington
References
1. Swanson K, Hermanides L. Biomechanics and function: altering paradigms to treat a patient’s esthetic disability conservatively. Compend Contin Educ Dent. 2020;41(5):284-289.
2. Baiju RM, Peter E, Varghese NO, Sivaram R. Oral health and quality of life: current concepts. J Clin Diagn Res. 2017;11(6):ZE21-ZE26.
3. Kois JC. New challenges in treatment planning: incorporating the fundamentals of patient risk assessment – Part 2. J Cosmet Dent. 2011;27(1):110-121.
4. Kois JC. New challenges in treatment planning: shifting the paradigm toward risk assessment and perceived value – Part 1. J Cosmet Dent. 2011;26(4):62-69.
5. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: framework and proposal of a new classification and case definition. J Periodontol. 2018;89 suppl 1:S159-S172.
6. Kois JC, Phillips KM. Occlusal vertical dimension: alteration concerns. Compend Contin Educ Dent. 1997;18(12):1169-1177.
7. Jayne D. A deprogrammer for occlusal analysis and simplified accurate case mounting. J Cosmet Dent. 2006;21(4):96-104.
8. Gold T. I know why your patients are leaving. Do you? Dental Economics. 2019;109(10):34-36.
9. Sartorius N. The meanings of health and its promotion. Croat Med J. 2006;47(4):662-664.
Figures and Images
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