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Inside Dental Technology

January 2012, Volume 3, Issue 1
Published by AEGIS Communications


Patient Care First Philosophy

The future will demand dental technologists who can communicate on a higher level with all team members.

By Peter Pizzi, MDT, CDT, FNGS

Traveling around the country to lecture to both clinicians and laboratory owners, the author has been hearing considerable discussion about the current state of our industry and what the future may bring. Can our businesses ever return to previous levels of prosperity or potentially hope for even greater growth? Will the turnaround be based on improvements in the economy or will it come from reinventing our business models? Laboratory owners seem particularly frustrated in trying to answer these questions. Is it that we just need more work to improve our business situation, or maybe the answer lies in investing in more CAD-type technology, or cutting a few more corners on the material overhead? Although the importance of education is given a great deal of lip service when it comes to making a change in our business direction, that is often the last place we seek guidance in order to make an informed business decision. Often, it is much easier to look elsewhere than to look at ourselves.

There is no crystal ball that will help predict the future for our industry. However, it is clear that our future lies in the quality of the work we produce, not on the quantity. New technologies will continue to play a significant role in our fabrication processes, but as with any new tool, the quality of the work produced is completely dependent on the depth of technical knowledge of the operator or user. The future will demand technicians who can communicate on a higher level with their dentist partners for the case-planning process and who have the ability to produce a high level of esthetic work. Our role will no longer be to open the package, “manufacture” the restoration, and send it back. We will need a deeper understanding of the diagnostic principles governing each case from the impact of functional factors and biological considerations to the effects of periodontal problems in order to meet the patient’s esthetic expectations and understand the limitations of the case. This collaborative team approach will evolve into a “Patient Care First” business model that will continue to grow and demand technicians who can facilitate the process. Rather than thinking that a new product, new invention, or new technology will sustain our businesses, this is the business model we should be looking to create in order to position our businesses for the future. It is a business model the author has adopted over the years and shares with attendees in lectures and courses.

By adopting this business model, the author has found that dentists faced with challenging cases often solicit his help in resolving problems. Even patients, after researching restorative options and materials online, call the laboratory looking for advice or guidance on future restorative work. Times are changing and our value will increase with our ability to be more than a mere “manufacturer” of product.

Meeting the Challenge

A local dentist recently called with what he felt was a challenging case. The patient had very high esthetic demands and wanted to know which laboratory the dentist would be working with. Although the author usually does not accept these types of cases, this one seemed fairly simple. It called for replacing two veneers on teeth Nos. 8 and 9 and the dentist seemed to be a concerned clinician in a tough spot. After a basic conversation about the type of preparation design required for veneer cases and emphasizing the importance of photography, the wheels were set in motion. When patients are local, the author typically visits the dental office and photographs the patient to provide a more accurate photographic representation of the case. This also offers the opportunity to meet patients and listen to their needs and expectations. Face-to-face meetings are one of the more important aspects in the communication process and will hold a definite place in dentistry for all team members in the future. If the patient is not local, the challenge is greater but the use of quality digital photography and the future use of video clips showing the patient smiling and speaking will give us instant access to our patients and provide us with the information we need to fabricate naturally functioning restorations. For point of reference, the author is already using video clips of patients provided by client partners to aid in his understanding of the patient situation and comfort level with meeting patient expectations.

In this case, the patient was local. A custom shade appointment was set. The patient presented with two veneers that were fabricated several years ago (Figure 1). Her primary concern was the “color.” She never believed that the shades of the existing veneers had precisely matched (Figure 2). Further discussion with the patient revealed that she also desired the diastema between teeth Nos. 8 and 9 to be closed (Figure 3). The author explained the importance of the width-to-height ratio of natural teeth to the patient using digital photography (Figure 4). This disclosure allowed the option and advantage of closing the diastema during the provisional stage to evaluate its esthetic value.

Shade photographs were taken with standard Vita (Vident, www.vident.com) shade-tab references to the mandibular teeth and the adjacent laterals (Figure 4, Figure 5 and Figure 6). Additional shade photographs where taken using the manufacturer’s ceramic shade tabs (Jensen Dental, www.jensendental.com) in the author’s shade choice for this case (Figure 7 and Figure 8). In addition, photographs were taken of the anterior six teeth with a black background, which gave the author fine details of tooth characterization including mamelon structure, color, and texture (Figure 9 through Figure 11). Lastly, a mirror photograph of the lingual aspects of the maxillary teeth was taken to evaluate the lingual condition of the teeth. This information is crucial in all cases but plays a major role in veneer cases because wear or chemically abraded lingual enamel can result in a higher flexural rate of the teeth. This factor could effect the duration of the new veneer restorations (Figure 12). In this patient, wear was present on the lingual surfaces; however, it was not critical to the case because the patient had worn bonded veneers for several years without any debonding. The wear was noted and the patient informed.

Noting the condition of the teeth in a shade appointment helps the dental team in the diagnostic aspect of the case and is, in essence, an insurance plan for the restorative work. To simply manufacture veneers without examining the scope of the entire case can lead to more chairside adjustments or even worse, a possible remake. The author’s average patient shade appointment is 20 minutes, and there is always a fee charged.

Note: In certain states, it is not legal for technicians to see and photograph a patient without the presence of the dentist.

Preparation Appointment

A diagnostic wax-up and preparation indexes were returned to the clinician with instructions to take photographs of the stump shade and the final provisionals for an esthetic evaluation (Figure 13 and Figure 14). Within an hour after the appointment, the patient came to the author’s laboratory in tears with provisionals in hand. She explained how unhappy she was with the esthetics of the restorations and would not let the dentist photograph them. Unsure how to handle the situation, but knowing “patient care” always comes first, the author quickly poured an impression and used the wax-up to fabricate new provisionals for the patient. Further evaluation of the photographs also led the author to believe that more tooth reduction in the incisal area to remove some previous composites was necessary (Figure 15).

The patient returned to the clinician with the new provisionals and a new preparation index to help guide the final preparations. After completion of the final preparations, the clinician took a new impression and stump photographs, which were e-mailed to the laboratory (Figure 16 and Figure 17). The advantage of seeing the patient again without the provisionals placed intraorally gave the author the opportunity to photograph the stump shades. The photographs taken by the clinician and those taken by the author, when compared side-by-side, demonstrate the importance of the dentist client/technician comfort level in working together. The coloration in the clinician’s photographs did not capture the high chroma of the preparation on tooth No. 9 (Figure 18 and Figure 19). For ceramists, this type of information plays a critical role in the restorative process and cannot be omitted. Although educating ourselves is tough, it b comes a pleasure to share this type of information with our dentist partners. Doing so helps them develop a better understanding of each case and results in much more camaraderie among team members (Figure 20 and Figure 21).

The teeth were re-prepared, photographed, and re-impressioned. Laboratory fabrication of the cast began and the author chose to use a removable-die tissue cast because it helped to dictate the gingival architecture, and define the emergence profile (Figure 22). The refractory dies were duplicated from the original working casts and used to fabricate two laminate veneers (Figure 23 and Figure 24). The final restorations were divested, polished, and etched for the final insertion appointment (Figure 25 and Figure 26). The insertion appointment went smoothly and the patient returned to the laboratory for final photos (Figure 27, Figure 28, Figure 29, Figure 30 and Figure 31).

As dental technicians, our role in the past has been behind the scenes with limited input on the front end of cases and little exposure to the patient. The future dental technologist will be required to participate in all facets of the restorative process, and elevate our image from that of a mass production manufacturing center.

About the Author

Peter Pizzi, MDT, CDT, FNGS
Owner and Manager
Pizzi Dental Studio Inc.
Staten Island, New York


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Image Gallery

Figure 1  Severe early childhood caries.

Figure 1

Figure 1  The patient’s primary concern during the shade interview was the color of her existing veneers on teeth Nos. 8 and 9, which she felt did not match surrounding natural dentition.

Figure 1

Figure 2  White spots shown in a high-risk patient.

Figure 2

Figure 2  A close-up image of the patient’s existing veneers.

Figure 2

Figure 3  Interproximal lesions and white spots in a high-risk patient.

Figure 3

Figure 3  Retracted view of the patient’s diastema.

Figure 3

Figure 4  To address the patient’s desire to close the diastema between teeth Nos. 8 and 9, the author shared images on his desktop to discuss issues of tooth width-to-height ratio.

Figure 4

Figure 5  During the shade interview the author took basic shade photographs using standard manufacturer’s shade tabs to correctly match the veneers to surrounding natural dentition.

Figure 5

Figure 6  During the shade interview the author took basic shade photographs using standard manufacturer’s shade tabs to correctly match the veneers to surrounding natural dentition.

Figure 6

Figure 7  Additional shade photographs were taken for more accurate color information using shade tabs in the author’s choice of color for this case.

Figure 7

Figure 8  Additional shade photographs were taken for more accurate color information using shade tabs in the author’s choice of color for  this case.

Figure 8

Figure 9  The author also took a series of photographs of the existing restorations and surrounding dentition on a black background to capture details of tooth characterization.

Figure 9

Figure 10  The author also took a series of photographs of the existing restorations and surrounding dentition on a black background to capture details of tooth characterization.

Figure 10

Figure 11  The author also took a series of photographs of the existing restorations and surrounding dentition on a black background to capture details of tooth characterization.

Figure 11

Figure 12  A mirror photograph of the lingual aspects of the maxillary teeth was taken to assess existing condition and color.

Figure 12

Figure 13  A diagnostic wax-up was created to communicate the author’s interpretation of the final result, and a photograph taken by the clinician at try-in.

Figure 13

Figure 14  A diagnostic wax-up was created to communicate the author’s interpretation of the final result, and a photograph taken by the clinician at try-in.

Figure 14

Figure 15  A photograph of the stump shade of tooth No. 9 was taken by the clinician and e-mailed to the author.

Figure 15

Figure 16  The author’s photographs of the preparations in the laboratory captured the high chroma of the preparation on tooth No. 9 and incisal flare on both teeth.

Figure 16

Figure 17  The author’s photographs of the preparations in the laboratory captured the high chroma of the preparation on tooth No. 9 and incisal flare on both teeth.

Figure 17

Figure 18  The author then took photographs of the preparations to compare the stump colors presented by teeth Nos. 8 and 9.

Figure 18

Figure 19  The author then took photographs of the preparations to compare the stump colors presented by teeth Nos. 8 and 9.

Figure 19

Figure 20  It is important to understand the differences from camera to camera. Comparing the author’s photographs of the prepared teeth to those of the clinician allows us to understand where and how miscommunication can happen.

Figure 20

Figure 21  It is important to understand the differences from camera to camera. Comparing the author’s photographs of the prepared teeth to those of the clinician allows us to understand where and how miscommunication can happen.

Figure 21

Figure 22  A tissue cast with removable dies was created for use in the refractory technique.

Figure 22

Figure 23  Two laminate veneers were fabricated. The ceramic build-ups were checked for contour on the refractory die cast, then finalized and rechecked.

Figure 23

Figure 24  Two laminate veneers were fabricated. The ceramic build-ups were checked for contour on the refractory die cast, then finalized and rechecked.

Figure 24

Figure 25  After divesting, the ceramic coloration needed to mask the underlying stump becomes more apparent.

Figure 25

Figure 26  The restorations were fitted back to the working dies (with yellow die spacer). Note how tooth No. 8 allows more of the yellow to come through.

Figure 26

Figure 27  The final restorations with lips in repose.

Figure 27

Figure 28  A retracted view of the final restorations.

Figure 28

Figure 29  A close-up of the retracted view of the final restorations.

Figure 29

Figure 30  Right and left views of the patient with final restorations in place.

Figure 30

Figure 31  Right and left views of the patient with final restorations in place.

Figure 31