July 1, 2007
by Mark Rotsaert
PATIENT –> DENTIST –> SPECIALISTS –> TECHNICIAN –> DENTIST –> PATIENT
In a world abounding with makeovers, patients are seeing restorative dentistry options on TV and in lifestyle magazines. This has dramatically increased expectations. Everyone wants a Hollywood smile but at the same time they want it to look “natural.”
The dentist evaluates a treatment plan on the basis of clinical information but also must take into account the end-result that the patient is seeking. The ability to communicate the possibilities and limitations of treatment between patient and dentist is a core clinical skill. The dentist must be a good communicator during the interview and throughout subsequent treatments. Realistic and thorough communication builds trust which helps the patient accept the proposed optimal treatment plan. The better the communication, the more successful the outcome will be.1
THE TREATMENT PLAN
Function is without a doubt more important than optimal aesthetics. Observations of biologic and functional principles with the correct choice of materials and techniques are especially important in extensive prosthetic rehabilitations.2
An ideal treatment plan can often be created only by a team effort involving the concerted action of various specialists. Orthodontist, endodontist, periodontist, oral and maxillofacial surgeon and the dental technician are all spokes in the wheel.
By creating an initial treatment plan the patient will comprehend the limitations and expectations of the outcome and understand the whole process of achieving an aesthetic result. Sometimes the patient’s expectations may even be impossible to achieve. Never ignore the patient’s expectations; otherwise the case is destined to fail. Instead, educate the patient to a full comprehension of the treatment plan, treatment sequencing and ultimate restoration possibilities. Patients may not fully appreciate the number and practicality of steps actually required to fulfill their desires. Life isn’t “Instant-Everything” — some things are definitely worth waiting for!2
A course of treatment must be chosen which allows the formulation of a good medium- and long-term prognosis, not just in terms of aesthetics, but also with respect to the biologic and functional aspects. A restoration should not only be integrated in the oral cavity but also in relation to the patient’s face. Document everything including periodontal evaluation, endodontic and restorative situation, occlusal, articulator-mounted stone casts and new radiographs as well as current photos of the patient. All this information is indispensable for the formulation of the aesthetic analysis.2
Following the restoration, the patient must adhere to oral hygiene protocols at home, together with periodic hygiene checkups to guarantee adequate maintenance and long-term success of the case.2
An excellent procedural example of an esthetic checklist is provided in the publication “Esthetic Rehabilitation in Fixed Prosthodontics, Esthetic Analysis, A Systematic Approach to Prosthetic treatment” by Mauro Fradeani, (Volume 1, Quintessence Books) (Figs. 1-5).
PLANNING & DESIGNING: DENTIST AND TECHNICIAN
The Working Team
Certainly, the dentist determines the restoration for each patient and makes the final decision.3 The treatment plan dictates the most appropriate materials and techniques for any case.
It is the technician’s responsibility to be educated in the latest materials and techniques, with the understanding of proper function of occlusion and the longevity properties of the materials to be used.4 The dentist should take advantage of the dental laboratory’s knowledge regarding the diverse restorative options offered by modern dental products i.e. all-ceramic crown and bridge, feldspathic veneers, implants, dentures and cast partial designs. The technician should also explain to the dentist the necessary working times the laboratory requires for each step of the procedure. This helps when scheduling appointments for the patient.
All these things must be communicated back to the dentist then to the patient.
Establishing a team relationship with the laboratory helps build confidence for all cases and ensures consistent and successful results, particularly in complex cases.
A diagnostic wax-up not only helps the dentist and technician see the treatment plan, but also allows the patient to visualize what can be done to address their concerns (Fig. 6). It is important to balance the aesthetic needs of the patient within the functional parameters of their dentition. The diagnostic wax-up brings the treatment plan from the intangible to a full-scale visual model and communicates guidelines to be used throughout the entire fabrication of the restoration.5
When prescribing a wax-up to the laboratory there are many considerations to be evaluated in detail: Goals of the Final Case; Overall Smile Design; Restoration type(s); Detailed Tooth position; Gingival Tissue Levels and Occlusal Function. An excellent example of a prescription for a Diagnostic Wax-Up has been prepared by Dr. Stephen Phelan for his seminar “Advanced Techniques in Aesthetic Dentistry and Occlusion” (Fig. 7). (www.phelandental seminars.com).
Provisionals – The Test Drive
Fabricating provisionals, based on a treatment wax-up, is a crucial step where the patient “test drives” the treatment plan (Fig. 8). This is an opportunity to make any modifications for the final restoration. Once the patient is satisfied with the provisional(s), new models are made and these new models are then used for fabrication of the final restoration. The mounted model of a provisional restoration gives the technician a guide throughout fabrication. This model serves other useful purposes as well because it is the source of the customized anterior guide table and anterior index. Including the provisional tryout phase will dramatically improve the long-term success of cases where significant changes are planned.
Visual Aspects of Communication
Visualization of the patients’ desires is the hardest feature to communicate. Smile arrangement and composition; tooth shape and character and the many nuances of shading and incisal effects have to be described to achieve aesthetically pleasing results. Digital photography has certainly helped in this aspect of communication (Figs. 9-12). There are many other visual aids that can help communicate this. In our laboratory we use several reference books when designing aesthetic cases, some of which are:
1. Nature’s Morphology an Atlas of Tooth Shape and Form by Shigeo Kataoka, RDT, Yoshimi Nishimura, RDT and Dr Avishai Sadan, DMD. “Maxillary anterior dentition in middle age, Chapter 3, page 51. 2002, Quintessence Publishing Co, Inc., Illinois, USA (Figs. 13 & 14).
2. ANALYSIS the new way of dental communication by Gerald Ubassy, The Analysis of Details” page 5; 1996 by Editrice M.E.A. srl — 25069 Villa Carcino (BS) Italy (Figs. 15-18).
3. Smile design A guide for Clinician, Ceramist, and Patient by Gerard J. Chiche and Hitoshi Aoshima; Case L.D. page 52 and 53; 2004 Quintessence Publishing Co, Inc., Hanover Park, Illinois, USA (Figs. 19-20).
Dr Anthony Mancuso of Millennium Esthetics has also developed a practical communication guide (Fig. 21).
Consideration for colour matching
Understanding the variances in colour and the nuances of Hue, Chroma, Value, and Translucency have been described in several books and articles. One of my favourite’s is: “The Science of Communicating the Art of Esthetic Dentistry: Part III: Precise Shade Communication” by Krikor Derbabian, DDS, Riccardo Marzola, DDS, Terry E. Donovan, DDS and Alessandro Arcidiacono, CDT., Journal of Esthetic and Restorative Dentistry, Volume 13, Number 3, 2001, pages 154-162.
Teeth to be matched should be cleaned to remove plaque, food and extrinsic
stains. If bleaching is contemplated, it should be performed at least two weeks prior to final colour matching to minimize the effects of bleaching regression. If veneers are part of the restoration, a photograph of the preparation is very helpful because underlying tooth structure will affect the final shade.
Patients are asked to remove lipstick since background differences affect how a colour appears. Neutral surroundings both in the lab and the dental operatory are crucial. Strong colours will certainly influence the shade determination process and should be avoided. A light source with a colour-rendering index greater than 90 and a colour temperature of 5000 degrees Kelvin should be used both in the operatory and in the laboratory.6
COLOUR SELECTION AND COMMUNICATION
Digital photography for shade matching
Nothing provides valuable information better than photography. Natural teeth exhibit several characteristics in addition to colour such as translucency, surface texture and surface luster (gloss). A great way to get Digital Photography into your office is take a course. Mrs. Rita Bauer is the Coordinator of Digital Media Education at the University of Toronto and she gives great courses on digital dental photography that can be easily implemented into any practice.
Using photographs for shade rendering
The following “Guidelines for Shade-taking by a Clinician” has been excerpted from Dental Shade Rendering by James Fondriest, DDS.7
An accurate clinical photograph can document numerous details that would ordinarily be missed by the eye (Figs. 22-25).
– First impressions are the best due to eye fatigue.
– Hold the shade tab incisal edge to the incisal edges of the teeth Use as many tabs as you see colors in the tooth (Fig. 26).
– Keep the tabs at the same distance as the teeth from the camera, if brought closer, they will appear brighter (Fig. 27).
– Perform shade selection before treatment. Teeth should be dry when evaluating value, translucency and surface morphology and can be wetted for hue and chroma evaluation to limit the influence of surface orphology.
The value increases and the chroma and translucency decrease as the teeth dry out during treatment.
– Remove saliva to observe the surface of the tooth. Indicate surface texture and luster as heavy, moderate and/or light. The surface texture of a crown must be designed to simulate reflectance pattern of adjacent teeth.
– Use reference book mentioned above to aid in this communication.
– It is easier to identify the translucent areas of a tooth by placing a black background behind the incisors. A black background will stop any light reflected from inside the mouth from re-entering the enamel that would lessen the visual impact of the bluing in translucent areas.
– Take incisal or occlusal shots.
– If using all-ceramics, photograph the prepared teeth and keep the teeth wet for these pictures (Fig. 28).
– If the crown doesn’t match then re-photo with the mismatched crown in the mouth.
Full-facial images offer the technician a better idea of the patient’s personality by providing details that cannot be conveyed using a standard plaster cast, such as skin color, face shape and position of the teeth in relation to the lips. By supplying your lab with precise visual images coupled with written instructions, the lab achieves more accurate results.8
The end result of a restoration depends enormously on the quality of communication between the dentist and technician (Fig. 29). Each has a responsibility to the other to impart information concerning restorative limitations and parameters. The laboratory needs as much information as possible from the dentist in the forms of models and written instruction and photos. The dentist needs feedback from the laboratory as to feasible materials, techniques available and time frames required for each restoration.12
An ideal lab is focused on the needs of their dentists’ practices. They should consistently provide technical competence and ensure the reliability of the products it produces. The dentist needs to be able to trust his or her lab and the lab should be utilized as the resource it is. The ideal lab should emphasize education to both their technicians and the dental team.13
From a laboratory perspective, there are guidelines which should always be followed. Never assume anything! Always document and communicate with the dentist. Work authorizations must be completely legible. Whether communicating on the telephone or face-to-face, when a concept is unclear, ask for an explanation. When providing instruction to the dentist or dental staff, always ask for feedback. Dentist and lab should mutually determine which method of communication is best and then utilize that medium as much as possible. These simple work procedures will avoid many pitfalls.14
Mark Rotsaert is a co-owner with his sister and brothers of Rotsaert Dental Laboratory Services Inc. in Hamilton, Ontario. The lab was started by his father Henri Rotsaert in 1963. Mark can be reached at 1-800-263-2113 or at www.rotsaertdental.com
Note: Every effort has been made to credit the respective authors for any material used. In the interest of grammatical correctness, some wording has been changed, but the original author and article has been referenced.
Photos and dentistry by Dr. Douglas Lobb (Figs. 8, 26-29); Dr. Robert Margeas (Figs. 9-12); Dr. Stephen Phelan (Figs. 22-25).
1.Patient-Dentist-technician Communication within the Dental Team: Using a Colored treatment Plan Wax-up by Luke S. Kahng, CDT, Journal of Esthetic and Restorative Dentistry, Blackwekk Munksgaard, Volume 18, Number 4, 2006
2.Esthetic Rehabilitation in Fixed Prosthodontics, Esthetic Analysis, A Systematic Approach to Prosthetic treatment, by Mauro Fradeani, , Volume 1, Quintessence Books
3.Esthetic Restorations – Improved Dentist-Laboratory Communication, by Paul J. Muia, Quintessence Books
4.Patient-Dentist-technician Communication within the Dental Team: Using a Colored treatment Plan Wax-up by Luke S. Kahng, CDT, Journal of Esthetic and Restorative Dentistry, Blackwekk Munksgaard, Volume 18, Number 4, 2006
5.The Diagnostic wax-up: A 3-D Communication Tool by Paul Rotsaert, RDT. Rotsaert Dental Laboratory Services Inc., 71 Emerald St. South, Hamilton, ON Canada L8N 2V4
6.The Science of Communicating the Art of Esthetic Dentistry: Part III: Precise Shade Communication, by Krikor Derbabian, DDS, Riccardo Marzola, DDS, Terry E. Donovan, DDS and Alessandro Arcidiacono, CDT., Journal of Esthetic and Restorative Dentistry, Volume 13, Number 3, 2001, pages 154-162.
7.Dental Shade Rendering by James Fondriest, DDS
8.Visual Communication in Dentistry by Daniel L. Martinez, DDS
Other articles which were resourced are listed as follows:
a.Dentsply/Labs Discovery Session, Executive Summary, iQuest Inc. Brand New Ideas, Tuesday, January 22, 2002
b.The Evolution of the Dental Treatment Plan in Restorative Dentistry by Elizabeth N. Hofstee, DDS / Robert P. Renner, DDS, QDT Yearbook, 1988
c.Precision Milling and Partial Denture Constructions: A Manual; Modern Design, Efficient Production, 1st Edition, by Henning Wulfes, dental International School BEGO Germany 2004, Chapter I – Planning and designing, pp 31 – 47.
d.Effective Communication for Aesthetic Success – Ten Point checklist for aesthetic success by Matt Roberts. The Canadian Journal of Dental Technology, March/April 2001 pp 16-20.
e.With permission from seminar handouts by Dr. Stephen Phelan on Aesthetic Analysis, www.phelandentalseminars.com
f.Excerpted from seminar handouts by Team Aesthetic Seminars 185 South Capital Avenue, Idaho Falls, ID 83402
g.SmileDesign – A Guide for Clinician, Ceramist and Patient by Gerard J. Chicke &
; Hitoshi Aoshima, Quintessence Books
h.Bonded Porcelain Restorations In The Anterior Dentition, A Biometric Approach by Pascal Magne,PD, DR MED DENT and Urs Belser,PROF, DR MED DENT.