October 2009, Volume 5, Issue 9
Published by AEGIS Communications
Communication is Critical
The laboratory-dentist relationship is essential to contemporary dentistry. Here are the five most important steps in a “communication-action-communication process” to optimize team-generated function and esthetic results.
Contemporary fee-for-service dentistry is truly in an exciting era of highly valued functional esthetics excellence and continues to evolve as a prime focus by the entire dental team. The combination of advanced materials technology coupled with increased patient recognition and demand for a brighter, more natural smile has led to an ever-increasing need for a significantly refined level of understanding along with the associated skills necessary to meet this growing trend of “smiles-by-design.”
Equally important is the willingness and ability, from both a clinical and technical perspective, to continuously improve the processes of communication that are so crucial to the overall success of these sometimes clinically unpredictable and unreliable cases. If knowledge is power, then information is the fuel that drives it. The more complex and comprehensive the case, the more complex and comprehensive the information is required to meet the case goals. This single element of the laboratory-dentist relationship can be a building block for professional and personal growth, if not the very essence of contemporary dentistry.
This article will highlight the five most important communication steps necessary to help achieve an ideal harmony in “team-generated function and esthetics.” Each step of this “communication-action-communication process” must present easily recognizable and verifiable information that relates to and dictates the necessary action for the subsequent clinical and technical restorative applications and vice versa, regardless of case complexity. After all, good information must certainly get better—and more meaningful—as the case progresses.
“See” the Patient, “Know” the Patient
Because the laboratory technician rarely has the opportunity to actually see the patient face-to-face, he or she must rely on other means of “getting to know” the patient. The initial understanding of exactly what the patient expects is certainly the first key to case success, but how this information is collected and used by the clinician and, further, how it is incorporated into the design phase of the communication process is absolutely crucial to eliminating variables in function, tooth shape, tooth position, and tissue relationship and, thus, ultimately meeting these expectations.
During the initial consultation with the patient, the clinician should predetermine what the patient wants in his or her new smile along with what needs to be accomplished clinically. All information should then be recorded on a detailed diagnostic prescription, which offers a simple, consistent means of organizing all preliminary information.
Also, during this appointment, accurate, full-arch addition-reaction impressions should be acquired along with the required corresponding bites. Additionally, high-quality digital photographs should be taken using current American Academy of Cosmetic Dentistry guidelines to further aid in a more complete visualization and understanding of the preliminary case complexities and functional esthetic issues (Figure 1 and Figure 2).
Once the preliminary diagnostic information is received in the laboratory, all models are poured and/or duplicated and mounted on a semi-adjustable articulator according to the required bite information. Note that the laboratory should always work on duplicate models when receiving pre-poured models from the clinician, thus preserving the originals as a preoperative case record available for future reference if needed.
Next, a thorough review of the mounted models, images, and diagnostic prescription is made by the diagnostic technician and a telephone conference/consultation is facilitated with the clinician to discuss preliminary case objectives. This call, typically less than 10 minutes in duration, is invaluable to further define and refine the functional esthetic objectives and, perhaps most importantly, to help identify and isolate any/all of the potential barriers to esthetic success.
These three barriers, which include improper tooth position, function or malfunction and improper tooth preparation, either singly or in any combination, stand to profoundly impact or entirely negate the potential for case success. Further, their advance recognition will aid in proper planning, sequencing, and coordination of additional preliminary clinical requirements, such as orthodontic, periodontic, or endodontic treatment, before the preparation appointment.
When a complete, mutual case understanding is achieved, all corresponding new planning information, as well as any noted change from the initial diagnostic prescription, is recorded onto a diagnostic case plan form. The information on this form represents the most up-to-date, accurate case requirements and will be used as an important reference by the diagnostic technician that will be responsible for reviewing the case while in the laboratory. Additionally, it will also help to ensure that the diagnostic plan is both understood and implemented accordingly by each team member involved in the upcoming laboratory phase of the diagnostic wax-up process (Figure 3).
The Precision Communication Wax-up
The next, and arguably most necessary, step in the communication-action-communication process is the diagnostic wax-up. The old cliché, “any job worth doing is worth doing well” certainly applies here. The fundamental purpose—in fact the most recognized benefit—of this laboratory-generated procedure is to accurately and realistically represent the final restorations both functionally and esthetically.
Although an additional benefit of this process includes the creation of a visual effect of the final case, which can in many instances aid in case acceptance by the patient, its primary goal is to quite elegantly and accurately provide the diagnostic team with a fundamentally detailed preview of the final case. More importantly, if accomplished properly, it serves as the ultimate three-dimensional design element that will most accurately communicate and dictate final preparation design, margin placement, anterior/ posterior function, tooth position/shape/form and tissue harmony.
Indeed, approximately 80% of the entire case is completed at this stage—before tooth preparation (Figure 4, Figure 5, Figure 6). Furthermore, it will provide the foundation for highly accurate provisionals, with which every previous element of planning and design can be verified and fine-tuned intraorally (Figure 7 and Figure 8).
Verification and Approval
Information and next-level communications from all of the previous case planning and design efforts will be further used and verified at the preparation appointment. Through careful review of the diagnostic wax-up, the clinician will have a clearly defined, visual guide for ideal tooth preparation.
Dictated and directed in large part by the requirements of the selected restorative materials, which may have already been pre-determined, preparation-by-design should be quite easily accomplished using the next, corresponding level of communication tools that were generated by the diagnostic wax-up, such as a silicon index and/or a clear acrylic matrix.
The highly accurate provisionals that will be generated provide further verification that both the functional and esthetic goals have been met and that the teeth are adequately prepared to protect both the restorations and remaining/surrounding/opposing dentition. Any necessary adjustments related to occlusion, incisal edge position, and gingival/incisal embrasures can be easily accomplished in the mouth, either through additive or subtractive means, and stand to provide the important, functional esthetic information necessary for laboratory fabrication of the final restorations. Plus, this is the first time the patient gets to experience their new smile.
Once verification and patient approval is complete, an impression should be acquired of the approved provisionals as well as new images of the provisionals in place. Both the images and the approved provisional model will provide the further-refined, detailed visual information necessary for the ultimate accuracy of the final restorations, indicating precisely the tooth-tooth, tooth-tissue, tooth-lip, and tooth-cheek relationships as well as the midline position and facial, vertical, axial, and horizontal planes of reference.
The Grand Finale
In this particular case, IPS Empress® Esthetic (Ivoclar Vivadent, www.ivoclarvivadent.com) was selected as the material of choice for the anterior restorations and premolars, and IPS eMax® Press (Ivoclar Vivadent) would later be used for the molars. Once all model preparation and articulation is complete, a silicon index is made from the approved provisional, and detailed, full-contour wax-ups are made from this index. Accurate information continues to move forward. Once pressed, the ceramic cut-back is made for esthetic layering. Next, all shape/shade/color elements are incorporated through further use of the index. Finally, the necessary functional elements are verified and the final surface detail is completed (Figure 10 and Figure 11).
The communication-action-communication process is a complete, evidence-based, proven system that requires a higher level of understanding and organization to implement. Each team member must be totally committed to excellence in application throughout the entire process. The benefits this process offers to both the dentist and technician, such as significantly reduced chair time, high patient satisfaction, increased productivity, and functional esthetic accuracy are well worth the time and effort.