William G. Dickerson, DDS, FAACD
This article attempts to explain why I think having a quality diagnostic wax-up before proceeding with an esthetic case is one of the most important aspects of the treatment. All too often, a case is deemed a failure for reasons that could have been avoided if a proper diagnostic wax-up had been performed in advance. Think of it as an insurance policy. Would you be willing to spend around $200 to $400 to make sure your preparations are adequate, you dramatically reduce your preparation appointment time, and your case is successful with a satisfied and happy patient?
One of the advantages of having a wax-up of what you want the final results to look like is for a better understanding during your preparation appointment. By comparing the diagnostic models and the diagnostic wax-ups, a dentist can better visualize the requirements of tooth reduction. Obviously, if the wax-up is much more facially placed than the diagnostic model, then little or no tooth reduction is required on the facial surface of that tooth other than the creation of a margin. However, it also may be evident from the wax-up that more tooth reduction will be required on the lingual surface to bring that same tooth out labially.
Doctors may want to prepare models to portray ideal arch form before sending the diagnostic models to the laboratory for wax-up. Otherwise, the lab may not reduce enough tooth structure to achieve the desired results.
A quality lab that is used to doing many esthetic cases should have a proper understanding of what is required to achieve optimal esthetics and the golden proportion of the anterior segment of the case. However, it is imperative that doctors understand that, if they don't reduce adequately, the lab's hands are tied by the design of the preparation. I would encourage all dentists to allow their laboratory to reduce the dies as necessary to create ideal results, as well as have it make a reduction coping for further preparation at the cementation appointment.
Rapid quality temporization
The other reason to have a quality wax-up of the desired final result is for the construction of temporaries. Because of the more accurate representation of the actual mouth, an impression should be taken with a good, high-quality impression material instead of an alginate. By doing this, the fit of the temporaries will be superior, and there will be much less flash than with a temporary stint made from an alginate impression.
This temporary technique amazes the attendees at Las Vegas Institute, and many say the program is worth the investment for this one aspect. In less than five minutes, you can temporize an entire arch with unbelievable esthetics.
This technique involves making a Sil Tec (Ivoclar) - relined with any wash impression material - off of the diagnostic wax-ups. The stint is filled with Integrity (Dentsply) and placed over the prepared teeth for two minutes. Peeling off the stint reveals beautiful temporaries that can be polished to mimic final restorations.
I would encourage the doctors to use a lab for the wax-ups. Let someone who does them for a living do it. We have seen wax-ups by doctors at LVI that don't come close to what the labs are capable of doing. Remember, this is your patient's first impression of your work.
Diagnostic temporary stage
Since everyone has a different opinion of what a smile should look like, it is also imperative that your patient be happy with the temporaries, as they will mimic the final restorations. You can appease your unhappy patients by telling them that they are only temporaries.
How do you know they will be happy with the permanent restorations? You can ensure the case will be successful by having patients pick out their favorite smile from the "Smile Catalog" (LVI) and having the lab create the wax-up appropriately. Many doctors make the mistake of not having the patients choose their favorite smile from the catalog until the preparation appointment. This should be done at the preliminary appointment so your wax-ups will look like what patients want the final result to be.
If patients do not like the temporaries, find out what it is they don't like and make any necessary changes.
Perhaps they want the laterals shorter. Adjust the temporaries and get the patient's input. Perhaps they think the cuspids are too pointed. Round off the cuspids and get the patient's reaction. Perhaps the patient wants the teeth slightly longer. Add some composite to the temps until the patient is happy. When the patient approves of the temporaries, take an impression of the new temporaries, and send it to the lab to have the duplicate with the final restorations. Of course, if the patient is happy with the temporaries from the beginning, send the wax-ups back with the case for the lab to duplicate.
How comforting is it to know that your patient will love the final result after a "trial period" with the temporaries? Would that be worth the cost of the wax-ups? I would think so. Adding this one procedure to your armamentarium will help you become a more successful dentist because of the increase in your preparation skills, efficiency, and your patient's satisfaction.
Good luck and enjoy dentistry.