practice

Mrs Argeila Wilkes – updated treatment plan

20th September 2021

Dear Argelia

It was nice to see you again last week. I am writing as promised to confirm costs and appointments for the next
stages of your treatment.

The forced eruption of the tooth on the upper right has worked very well and the gum is now very stable and mature
thanks to the length of healing time the pandemic has forced upon us. Gum levels look good and there is enough
tooth above the gumline to make the tooth a good foundation for a new restoration. By making the new crown with
its edges (margins) at gum level (rather than below them as has been done in the past), we maximise the chance
that the gum level will stay stable with the new crown and you will avoid the problem of gum shrinkage and a
visible dark edge on the crown for as long as possible.

Goals of treatment
You told me that you wanted to treat you six upper front teeth and:
- Align the teeth and make them all appear straight
- Place veneers (as opposed to crowns) where possible i.e. be as conservative as possible
- Lighten the colour to match better with the implant retained crowns further back in your upper jaw
- You wanted treatment completed by the end of this year before you return to Venezuela

We will achieve this with a combination of crowns and veneers. I agree that we want to be as conservative as
possible so prefer veneers to crowns where possible. Of the six teeth that we will treat, 3 will definitely be veneers,
two will definitely a crown (the tooth we pulled down where there was a crown before and the left canine, where
there is also a crown already). The other tooth (the left lateral incisor, I will make a recommendation once I have
removed all the old filling in that tooth and seen what is underneath.

General information about porcelain veneers and the treatment process

A porcelain veneer is a very thin shell of porcelain made to fit over the front of the tooth. Sometimes they can be
extended into the spaces between the teeth to close spaces. Sometimes we can also correct minor malalignment.

Step 1: detailed planning

Before we change anything, we will go through our normal diagnostic and planning process, so that we can make
sure that your new smile fits as harmoniously into your face as possible. Based on the photographs and scan we
already have, plus your own preferences and video footage to see how much tooth is visible during speech and
smiling, we will make a three dimensional model – called a diagnostic waxup – that will form the basis of any
changes to the shapes of the teeth that we make.
These days these are often made digitally but they are still referred to as a ‘waxup’ even though wax is no longer
used to produce them.

11c Bell Yard Mews, Bermondsey Street, London SE1 3TN

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Step 2: tooth preparation
Any old restorations are removed and the teeth are carefully shaped to receive the new veneers.
The tooth preparations are guided by the diagnostic waxup, so that the amount of tooth removed is a minimal as
possible. Impressions or a scan are taken and provisional veneers (see below) are fitted to the teeth.
This is carried out under local anaesthetic. After the preparation visit, you may experience some mild discomfort,
which is almost always manageable with normal painkillers.

Step 3: provisional veneers

Between visits you will have some temporary veneers made at the chairside which will be a copy of the shapes on
the diagnostic waxup, so that we can evaluate any proposed changes before they are finalised. You will need to eat
carefully during this time – we will certainly be on hand to repair anything that breaks, but you will need to be
cautious. There may be a short period of your speech adapting to the temporary veneers.

I will see you for a review visit after the preparation but before the fitting appointment to make sure that the
proposed new shapes and colour are acceptable. If we need to make any changes to the proposed shapes, this is the
easiest time to make them.

Step 4: fitting
The newly-made veneers are tried in to make sure that they fit and correspond to what was agreed with the
provisionals, including any changes agreed upon at the provisional review visit.
All being well, they can be fitted onto the teeth, but if either of us are not happy with the try-in, we may return some
or all of the veneers to the technician for refinement and they will be fitted on a subsequent visit.
Like with the preparation visit, you may experience some discomfort in the few days afterwards and there may be
another short period of your speech adapting to the new veneers.

Step 5: Review visit & Maintenance

I will see you for a review visit to check that everything is fitting correctly check that residual cement has not ben left
on the teeth and also to ensure that your biting and chewing pattern (occlusion) will work well with the veneers.
After that, you will need to continue your excellent level of cleaning at home with your toothbrush and floss,
supported by regular visits to our hygienist as you have been doing.

Other important things you need to know about porcelain veneers

Longevity and maintenance
Porcelain veneers usually look at their best for 10-15 years, during which time the gum at the edge may shrink away
exposing the join between the tooth and the veneer. Exposure of the join can be unsightly but only if this area is
visible when one speaks or smiles. As far as I can see your upper lip does move up high enough to reveal the
gumline, so this may be an issue in the future.
With today’s porcelains, we will try to keep the porcelain as thin as possible at the edge so that we minimize the
transition from tooth to veneer, i.e. we will try to minimise the possible effects of this problem. However if
everything is still healthy, then there is no need to change anything as long as you are still happy with the
appearance – so it is usually your choice, rather than there being any clinical need for replacement.
To put replacement into context, I have many more patients who have veneers that are now 12-15 years old who
have not replaced them than those who have changed them all.

Root canal treatments

In order for the veneer to fit onto the tooth, we need to shape the tooth so that it can fit snugly against the tooth.
This means that a degree of preparation is inevitable, i.e. it is not a reversible process. We will take every precaution
to minimise the invasiveness of any preparation.

11c Bell Yard Mews, Bermondsey Street, London SE1 3TN

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Partly this will be to do with the preparation technique (there are specific techniques which we will use to only
remove what we need to, but also by adding veneers to the upper first premolars, we greatly reduce the amount
that needs to be removed from the canines).

There is a small chance when we prepare any tooth for a veneer, crown or bridge it is possible that the nerve inside
the tooth will become inflamed and the tooth may require root canal treatment. This risk is in the region of 1-2 for
each tooth veneered. Therefore I think the risk of a root filling being needed for you is small, but you should be
aware that it is a possibility. Should this be necessary, additional fees of between £300-700 per tooth would be
payable.

Breakages and debonds

Veneers can chip or debond if they are treated carelessly. If you do the things that nature designed your teeth to do –
i.e. smile, speak and eat normal foods – then these problems are very rare.
Whether you have veneers on your teeth or not, please do not do things that nature did not design your teeth to do,
such as hold keys or pens between your teeth, open parcels or bottles or bite string or fingernails. Eating very hard
foods such as chewing chicken bones should be avoided.

Veneers can also break if subjected to trauma, which hopefully will not happen. If you plan on taking up any form of
contact / team sports, please advise and we will make an appropriate sports mouthguard. Fees for this would be
£95.00.

The main reason that veneers can chip or debond in the first 6-9 months after fitting is usually to do with your
chewing pattern, i.e. the way that you bite and chew with them. The technical name for this is your occlusal scheme.
Even though you do not appear to grind your teeth at night, we try to intercept any potential problems by checking
your bite thoroughly at the review visit after fitting, and at subsequent examination appointments over the first year
after fitting. The cost of these appointments is included in the treatment plan.

The other thing which can contribute to problems is poor maintenance – i.e. eating excessive amounts of sugary or
acidic food or not keeping things as clean as they should be. Having assessed your mouth at the consultation, I feel
you are at low risk of problems from dental decay or acid erosion. Your gums are in very good condition and you are
maintaining things well.
In other words, if you continue your current good habits, I do not foresee that you will be at any particular risk of
problems arising from poor maintenance.

Warranty for porcelain veneers

Please be aware that when one is providing treatment for a living creature (i.e. you), the nature of the human body
means that nothing can be guaranteed.

Having said that, we are proud of our work and genuinely expect that you will be happy with the end result. For your
peace of mind we offer the following assurance:
- Any veneers which chip or debond within two years of fitting will be repaired, refitted or replaced at our
discretion provided that:
o you have attended for the post-treatment review appointment and routine examinations 4 and 12
months after fitting;
o you have attended a dental hygienist, either at our practice or at your regular dentist’s practice for
the recommended number of routine visits;
- This limited warranty will not apply if the problem arises due to trauma or poor maintenance on your part.

11c Bell Yard Mews, Bermondsey Street, London SE1 3TN

T: 020 7940 0880 F: 0207940 0888
Fees
Total fees for treating the 6 upper front teeth will be £7500.00 – this is the same fee that we gave you for this
treatment when we started in 2019. See highlighted sections of original treatment plan attached.

Fees for the veneer stage of the treatment plan include:

- all the planning and clinical visits for the veneers mentioned above
- all the technician’s fees for the veneers
- minor modification to the gumline on the day of the preparation, if needed
- a post-treatment session with one of our hygienists to ensure that you are familiar with the daily cleaning
routine
- post-treatment review appointments – the first 1-2 weeks after the veneers have been fitted, and the final
one 12 months after the veneers have been fitted. These appointments are to ensure that the veneers settle
into your mouth harmoniously and that any issues with your bite which might lead to breakage or debonding
can hopefully be intercepted.

Appointment schedule
No Length What will be done Interval after Fee due at
previous that visit
0 - Reception – tell CO to organise waxup with lab - £1500.00
1 3h Preparation, impressions & provisional restorations 2 weeks £3500.00
2 30 min Review provisionals, adjust as needed 1 week -
3 3h Fit restorations 2 weeks £2500.00
4 60 min Review 1-2 weeks -
5 60 min Final review 12 months -

Aftercare & Maintenance

Once treatment has been completed, it is essential that it is maintained well so that it looks as good as possible for as
long as possible. There are three parts to this:
1. Home care: this is the foundation – scrupulous cleaning of your teeth at home is the foundation for
everything. Our hygienist will recommend an appropriate combination of toothbrushing and other cleaning
aids.
2. Hygienist sessions: these are intended to complement home care and help you achieve the best possible
home care regime. We will advise on a frequency that suits your needs based on the overall condition of
your gums, the amount of dental treatment you have had (both with us and in the past) and also reflecting
how you are coping with looking after things at home. Normal practice fees will apply for these
appointments.
3. Dental examinations: an annual dental examination, together with xrays at appropriate intervals, will help
us intercept any decay, gum problems, jaw joint issues and also screen you regularly for mouth cancer.
Normal practice fees will apply for these appointments.

Please also note the following

Changes to the treatment plan

11c Bell Yard Mews, Bermondsey Street, London SE1 3TN

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This is intended to be a definitive treatment plan based on information available at the time of preparation. If more
information comes to light which requires a change to the treatment plan, we will discuss the clinical and financial
implications with you in advance of carrying out substantially different treatment.

Appointment cancellation policy

We require 24 hours notice to change or cancel or change an appointment of up to 90 minutes’ duration (48 hours
notice for appointments over 90 minutes) or we regret that a charge will be made at the rate of £120.00 per hour of
booked time.

Payments
We accept payment by cash, debit card or credit card (Mastercard / Visa / American Express).
We can also accept payment by bank transfer (BACS) if you prefer – please ask for our account details. Please note
that if you are paying by BACS we need you to make the relevant payment the day before the appointment takes
place.
We do not accept payment by cheque or banker’s draft.

Fees mentioned in this document are valid for a period of six months from the date of writing. We do our best to
avoid revisions to our fee scales, but unfortunately due to periodic changes in costs of materials, our technicians’ fees
and other overhead costs in running the practice, it is inevitable that we need to revise prices from time to time.

For treatments over a value of £2000.00, we are able to offer 0 finance over a 12 month period through our finance
partner, Tabeo. Please ask for details if this is of interest.
Please note that Tabeo is not like a credit card - it needs to be set up for you in advance of treatment. If you wish to
use Tabeo for payment, you need to complete the online application no later than 3 weeks before your
first appointment, so that everything is set up before you come. If you wish to use Tabeo but have not set it up
before the first appointment, we will require a credit or debit card payment to cover treatment provided at that
appointment.

Insurance forms / paperwork

If you have dental insurance, we will be pleased to assist you in completing the forms and providing receipts to help
you clam your entitlements under your policy. We will also be happy to look at your policy and advise on your
entitlement. Please note that some insurers require prior approval for certain items of treatment.

Whilst we are usually able to provide these services at no charge, we reserve the right to make a charge for
administrative time if the insurance company requires a significantly higher amount of information than average to
approve or process a claim.

Aftercare & maintenance

The success of any treatment is dependent on maintaining a good level of oral hygiene at home and seeing the
hygienist regularly. We will be happy to advise an appropriate regime for this and we offer a Member’s plan to
patients whose mouths are healthy after a completed course of treatment. The Member’s plan is paid monthly and
provides the needed appointments with the dentist and hygienist for annual maintenance at a reduced rate.

Any questions?
I hope all this is clear but please feel free to ask any questions either by email if you wish, though if you prefer to
come in and discuss things again face to face I will be happy to see you for another consultation either face to face or
over Zoom as you prefer.

11c Bell Yard Mews, Bermondsey Street, London SE1 3TN

T: 020 7940 0880 F: 0207940 0888
11c Bell Yard Mews, Bermondsey Street, London SE1 3TN
T: 020 7940 0880 F: 0207940 0888