April 2012, Volume 8, Issue 4
Published by AEGIS Communications
Enhancing Communication Skills for Optimal Esthetic Transformations
Effectively managing patient perceptions and expectations is key to a positive esthetic outcome.
Constantly bombarded by manufacturers about new product developments, dental professionals are challenged to determine the best products and technologies for their practices and patients. In making their selections, their goal for their elective dentistry patients is simple: enhance esthetics without compromising health. What is not as simple is accurately identifying the nature of patient expectations and effectively conveying the significance and value of the esthetic transformations.
Superior communication skills are key in meeting these objectives. The challenge dental professionals encounter with patients involves expectations and perceptions. Patients may present with photographs of celebrities’ teeth requesting similar smiles and using terms such as “white,” “small,” “straight,” “natural,” and “beautiful.” Such interpretations often pose an issue, as the words —representing subjective and abstract concepts—have different meanings for different people. To arrive at a shared understanding of these terms, three-dimensional and technological tools can prove to be valuable aids to communication between dental professionals and their patients, as well as one another.
Being an effective communicator provides a crucial edge to both dentists and ceramists in today’s quickly developing technological marketplace. As with any other acquired skill, effective communication requires learning, then practice. Unfortunately, like many other professionals who place negative associations on “selling” and do not consider themselves salespeople, dental professionals may be loath to cultivate their selling strategies. Nevertheless, in reality, everyone sells. Dental professionals sell themselves, their skills, services, and products. By shifting their perception from regarding what they do as “sales” to “communication,” dental professionals can position themselves to be more effective communicators; by honing their skills to share and educate (ie, communicate with) patients about results and benefits—not just products and procedures—they essentially are salespeople delivering value and transformations, not simply negotiating a transaction.
As communicators, dental professionals have two promotional aims: locating and reaching patients who already desire the products and/or services they offer, and effectively educating them about the benefits of these products and/or services.
Dental professionals typically deal with two types of patients—those needing dentistry (eg, their teeth are broken or decayed and require treatment) and those who have pleasing, healthy teeth but are seeking enhancements. These two patient types can be further classified into three subgroups: patients who want every dental procedure to appear natural so it is invisible in the mouth; patients who want every procedure to be flawless, even if the results appear artificial; and patients who do not have the funds for the restorative work they desire.
The strategy for approaching each patient group must be different. Effective advertising or promotion essentially is not about products; it is about “selling” the specific benefits that patients will receive from the products or services proposed. The more effective dental professionals are in accomplishing these objectives, the better they will serve and benefit their patients, which translates into greater professional and financial rewards.
Digital photography is one of dentistry’s most effective tools. Not only is it helpful in capturing patients’ preoperative status, step-by-step treatment procedures, and postoperative results, it also is a useful educational and promotional tool for dentists to use with their patients, and a communication tool between dentists and laboratory technicians. Additionally, web cameras, which facilitate patient and dentist communication, and video cameras, with which patients can be interviewed “live” for their esthetic expectations, also are helpful in maximizing communication between all dental team members.
The treatment process discussed in this article was simplified by the fact that the female patient—a high-profile figure in the dental industry—chose her restorative team in advance. In many dental practice business models, the dentists charge patients for their time and effort; laboratory fees are additional. Faced with so many options (eg, laboratory skill levels, artistic abilities, costs), when dentists recommend a laboratory based on patient-specific considerations such as budget or artistic outcome, they typically assume the additional responsibility of communicating value; the chances of miscommunication also are greater.
In this instance, this was not the case because the patient herself made the selection based on her informed understanding of value, skill, and overall expectations. Additionally, the authors were familiar with each other and their work, and looked forward to collaborating with each other and the patient on the treatment plan.
The patient presented seeking improved esthetics for her smile for personal and professional reasons. With the patient’s dynamic personality, as well as her speaking activities, another objective was to make the restorations “pop” (ie, exhibit brightness and high value).
Clinically, the patient presented with extensive previous dentistry performed on an as-needed basis (ie, tooth by tooth). She disliked the different optical characteristics resulting from the various materials used, and their contrasting appearance with one another as well as the natural adjacent teeth. Abundant bilateral disharmonies were accentuated by different clinical crown heights of the posterior teeth on the left and right (Figure 1).
After a comprehensive evaluation and discussion involving all dental team participants—dentist, patient, and ceramist1,2—a full-mouth restorative treatment plan was developed . It included crown lengthening of selected anterior teeth and left posterior teeth to equalize discrepancies; use of closed flaps for teeth Nos. 6 and 9; and open-flap designs for teeth Nos. 11 through 14.
Given its numerous esthetic and clinical properties and applications, a lithium-disilicate material (IPS e.max®, Ivoclar Vivadent® Inc., www.ivoclarvivadent.com) was chosen as the restorative material, along with a multi-chromatic mapping of 1M1 and 1M2.3-6 One constraint was to approximate the shade of natural teeth in the mandibular anterior region (Figure 2).
Luxatemp® (DMG America, www.dmg-dental.com) was used as a provisional material in a direct technique fabricated from the diagnostic wax-up. The dentist photographed the temporaries and the temporary model, electronically sending these—as well as information on the patient’s tooth structure, preparation guide, and color specifications—to the ceramist (Figure 3 and Figure 4). With these communication aids as reference,7 the ceramist opted to use a medium-opacity IPS e.max ingot (MO0); its brightness would support the desired color value and provide the patient-desired ceramic layering options.
The model was poured and a full-contour wax-up created. Cutback was minimal. The restorations were pressed and fitted to the models . Using teeth Nos. 8 and 9 as custom-made shade trial crowns,2,8 the ceramist applied glazed liquid on the surface of the pressed crowns and used orange IPS e.max powder for the first wash bake layer (Figure 5). A multipurpose A shade was applied to slightly tone down the crowns, which were then fired . Awaiting patient verification, tooth No. 8 was slightly more like 1M1, and No. 9 was slightly darker (Figure 6).
At this stage, there was a three-dimensional visual of the actual restorations, enabling all parties to preview the final outcome.2,8 Any necessary or desired adjustments could be made prior to completion of the case.
Because the patient and dental ceramist resided in the same city, this allowed the ceramist to view the patient custom trials directly and improve the communication process. The ceramist elicited her reaction to the try-in restorations by asking a series of questions, most notably whether she detected a difference between the restorations and natural teeth. Quite often, most patients do not see a difference, and the restoration process can proceed as planned. If a difference is perceived, the patient should be made to precisely verbalize what he/she sees in order to finalize a preference that is clearly understood by all dental team members.
In this case, the patient indicated minor adjustments (ie, the midline shift, found to be slightly to the patient’s left, needed adjustment; building out the posterior teeth for a fuller smile). Color also was discussed; the patient wanted a “natural” yet “powerful” smile (ie, “youthful” and “bright”).
Therefore, before proceeding further with the 12 IPS e.max restorations, the question for the ceramist became this: Precisely what do these words represent for the patient? By practicing good communication skills that included the three-dimensional visual and active personal interaction between the patient and her dental team, a clear consensus of the desired final outcome was established to ensure optimal value and patient satisfaction.
To achieve the desired final restorations, the ceramist used the brightness of the MO0 ingot (IPS e.max), in a unique way in the cutback stage. The cervical area around the tooth was reduced minimally to overlay the ceramic slightly less on the bulky area, thus allowing the ingot’s brightness to come through. While minimal, this preparation was key, because it used the ingot as a support for the value, which needed to be maintained. Cutting and fettering the incisal edge created natural incisal effects.
Next, the cervical dentin, also showing translucency, was used to further enhance a natural effect. The dentin shade was overlaid in full contour, using the index to determine the final length for the build-up. After the dentin cutback, space was created for the incisal edge using high-value enamel (TI1, IPS e.max), bleach and opal clear (OE1, IPS e.max). To minimize grayness, the OE1 was diluted by mixing it with neutral translucent. This mixture was applied in a segmented lateral build-up (Figure 7). To create the incisal wall canvas, mamelon effects (mamelon light, and salmon mixed half and half) were applied. As an overlay, a thin layer of the OE1/neutral translucent mixture was used. The crowns were baked and re-fitted on the model. The silicone index was tried in to verify that the length matched that of the patient-approved temporaries.
The cutback reduction for the maxillary posterior teeth required a minimal layering technique; made thickest for strength, the pressed material core for the posterior restorations nevertheless achieved the same enhanced esthetics (ie, ceramic finish) as the anterior due to this layering concept. For the mandibular posterior teeth, high transparency (HT) translucent ingot (A1, IPS e.max) and the IPS e.max staining technique were used to obtain the shade characteristic exhibited by the patient’s natural adjacent teeth (Figure 8).
After all of the units were shaped on the model, soft tissue was removed to eliminate interference, interproximal spacing was closed, and contacts were checked and tightened to ensure an esthetically exact restoration that would require minimal chairside time (Figure 9).
The patient presented for restoration try-in; Mach-2® die silicone (Parkell Inc., www.parkell.com) was used to stabilize the crowns and check the contact points and bite for final patient approval for shape, color, and alignment. Upon verification, the dentist placed the permanent restorations.
The patient was pleased with the outcome (Figure 10 and Figure 11). She commented that it was the experience of how she felt during interactions with the ceramist and dentist that provided the value and affirmation for her decision to proceed with treatment.
Communication through temporization is essential to any restoration, regardless of the types of products and/or systems used. Patient understanding cannot be taken for granted; patients might understand one thing when the dental professional meant another. For best results, dental professionals must take great care to always be clear, direct, and work as proactive collaborative team members. Whatever dental professionals tell their patients before treatment is a treatment plan; anything offered posttreatment is an excuse. To eliminate the need for excuses, dental professionals must clarify all messages by making the most of modern technological tools and their clinical/technical expertise while also fostering personal connections through their interpersonal communication skills. For professionals, knowing and performing their jobs well are minimum requirements. What truly matters is how expertly dental professionals can educate—ie, “sell”—patients that they are receiving premium value and service for all their esthetic expectations.
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2. Kahng LS. Patient-dentist-technician communication within the dental team: using a colored treatment plan wax-up. J Esthet Restor Dent. 2006;18(4):185-195.
3. McLaren EA, Phong TC. Ceramics in dentistry: classes of materials. Inside Dent. 2009;5(9):94-103.
4. Ivoclar Vivadent. IPS e.max lithium disilicate: this changes everything. Amherst, NY: Ivoclar Vivadent; 2009:1-6.
5. Culp L, McLaren EA. Lithium disilicate: the restorative material of multiple options. Compend Contin Educ Dent. 2010;31(9):716-725.
6. Ivoclar Vivadent. IPS e.max lithium disilicate: the future of all-ceramic dentistry-material science, practical applications, keys to success. Amherst, NY: Ivoclar Vivadent; 2009: 1-15.
7. Terry DA, Leinfelder KF, Geller W, eds . Aesthetic and Restorative Dentistry: Material Selection and Technique. 1st ed. Stillwater, MN: Everest Publishing Media; 2009:152-153.
8. Adar P. Avoiding patient disappointment with trial veneer utilization. J Esthet Dent. 1997;9(6):277-284.
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About the Authors
Pinhas Adar, CDT, MDT
Oral Design Center
Michael R. Sesemann, DDS, FAACD