Striving toward 'zero remakes'
Remakes are a killer in a dental practice, says DE Editor Dr. Joe Blaes. If remakes are a problem for you, maybe you need to prepare teeth differently.
Joseph A. Blaes, DDS
Dentists are in a perpetual love/hate relationship with one of the most important members of their team - the dental laboratory. The easiest person to blame for a failure is "the lab man." How many times have you heard yourself blaming someone else for a problem that probably originated in your office? I know that I did it more times than I would like to admit.
I believe that communication is the key to success in any endeavor, and that includes dentistry. When you develop a team who knows how to communicate with people, your practice will be successful beyond your dreams. When people can't talk to each other, the bottom falls out. Why should it be any different with your dental laboratory?
One goal that our team has is zero remakes. Remakes are a killer in a dental practice. Patients are upset because they have to be reappointed and wait another two weeks for their final restoration. Usually, it means another impression, which means packing cord and getting behind in your schedule. Stress in the office jumps to a much higher level, because I hate to be late for my appointments. Since I am in a hurry, things usually go wrong and take longer than anticipated. We usually push the lab for an earlier seating date and squeeze the patient into an already busy schedule for the next appointment, which means another stressful day to anticipate. Remakes are not a pretty picture!
You may not have thought of it, but most labs have the same priority goal - zero remakes. Most disagreements with labs start over who pays for the remake. I always thought that the lab should; after all, it was the lab tech who screwed up! Isn't that ridiculous? There should be a clear (probably written) understanding of who is responsible for what with remakes. Know before you get into a relationship with a lab, because remakes are going to happen. Realize that it is in the lab's best interest, as well as yours, to do all it can to prevent remakes.
On a weekly basis, we talk to the laboratory team who produces our veneers, inlays, and crowns. We also meet face-to-face monthly - usually for lunch at our place or theirs. This process enables us to talk about the successes and the failures, as well as what we can do to reach our goal of zero remakes. We look at models, photos of finished cases, and how we can do it faster, better, and easier. This is not a gripe session where we pick on the lab guys and gals. This is a time for accepting responsibility for the things that are in your control. If you look a model and you cannot see the margin clearly, it probably started with the preparation.
It's all in the structure
The dental laboratory's number-one complaint is that we do not remove enough tooth structure! When my lab tech first told me this, the hair went up on the back of my neck, and I told him that I was the dentist and I would be the judge of that.
Consider this: If you are preparing a tooth for a porcelain-fused-to-metal crown and you remove 1 mm of tooth structure all around it, then your lab tech has a problem. The casting will take up .5 mm of that space, and the opaque requires another .2 mm of space. So that leaves only .3 mm for the lab tech to create the shade you requested. Many times that is not enough, and the lab tech is very limited simply because you did not remove enough tooth structure.
When the lab tech explained it to me that way, I changed my tooth-preparation design. Maybe you need to look at preparing your teeth differently. Do you still prep them the way you did in dental school? Do you still use a feather margin? Do you still bury your margins beneath the gingiva? There have been many improvements in prep design. Go take a course from Dr. John Kois or Dr. Bill Strupp. You will learn the latest on prep design from some great teachers.
The wrong impression
The problem may be your impression technique. Is it difficult for you to take impressions? Can you clearly see your prep when you inject the impression material into the sulcus? Is the prep dry, or is the sulcus filling with blood as you inject impression material? Do you really believe those manufacturer's claims about hydrophilic impression materials? When you examine the impression, can you clearly see all the margins? On the second or third impression, do you compromise if there is a small bubble on the margin or if a small part of the margin is missing?
Do you really think that the lab man can fake it in that area? When the lab man calls and says that he cannot read the margins on the model, what do you do? Trim the model yourself? Tell the lab man to go ahead anyway? Do you get the patient back and get a new impression? Do you tell the patient that the lab man screwed up?
Impressions, of course, are a major complaint from labs. One reason to change your prep design is to have a margin that is easily read in the mouth, in the impression, and on the model. This makes your impression technique easier.
Is the impression material the problem? Probably not, unless you notice that it mixes inconsistently. Looking for a material that always gives you a consistent mix. Usually the technique is the problem, not the material. It is very easy to catch a bubble in the new wash materials, so you must be very careful to keep the tip of the syringe in the material. The new mixing guns give you tips to put on the end, but the guns are heavy and it is difficult to keep the tip where you want it. If you pull the tip out of the material, you have created a bubble, which more than likely will be on your margin.
Remember that as soon as the impression material begins moving through that mixing tip, it starts to set (no matter what they told you about mixing times). Don't waste time; the tray material should be ready to set as soon as you are finished with the wash material. If you are waiting to seat the tray, then you need to train your clinical assistant to coordinate her loading of the tray with your application of the wash material. A great way to get better at this is to practice together with a typodont or a mannequin until you get it right. We spend more time practicing our putting or golf swing than we do training the clinical team to make our procedures faster, better, easier, and more fun!
Hurry up and wait!
The next major complaint is rush jobs. I know that we all are faced with situations when we need the case yesterday. I will never forget an over-the-shoulder course that I took with Dr. Omer Reed. He was seating a quadrant of gold inlays (nobody did it better than Omer), but the last inlay would not go into place. So he cemented the other three and took a new impression for a new inlay.
He was saying goodbye to the patient when she asked when the inlay would be ready. A couple of weeks, he answered, and she replied that she was leaving for Europe for three months on Friday (this was on Tuesday afternoon). The clinical assistant was already on the computer in the treatment room, looking at the appointment schedule. Omer told her to get the patient back on Thursday, but the assistant pointed out that the only time available was 5 a.m. The patient said fine, and Omer said that he would be there. Notice that she did not squeeze the patient into a crowded schedule but put her outside the main schedule.
Try to limit your rush jobs to those that really require a rush. When you need something fast, try to let the lab know ahead of time if you can. If you are requesting too many rush cases, you have a scheduling problem. Before long, it will destroy your relationship with the lab. When the relationship fails, most dentists go find a new lab. Too bad!
The biggest communication problem is no information. Go to a lab sometime and look at the prescription forms on the pans. Most will say something like: "#3 - PFM - shade C1," "#s 6,7,8,9,10,11 - veneers - shade A2," or "call me." It is important to give the lab as much information as possible on every case that you do. You should have a checklist for your lab cases that tells everyone what is required before a case can be sent to the lab. The list should include "before" photos and close-up prep photos. The Polaroid Macro 5 is ideal for this information. You can even take photos of shade tabs with this camera to show stump shade and finish shade. Do a shade map. The Las Vegas Institute (LVI) sells an excellent kit to get you started doing shade maps.
You can get into imaging now by buying a digital camera and using it to get your images into your computer. Then use a software system to manipulate the images and show the patient what they can expect.
In the past, these systems have been very expensive and difficult to learn. They also have involved a time-consuming process just to create the new images. Kodak has introduced a new system that allows you to do all of this for around $3,000. DICOM is supplying the software system - an excellent system that is quick and easy to learn. You can show your patients how they will look and send them home with prints of before and after to help reinforce the cosmetic changes you are proposing. You can use this same digital camera to take images of the case, then either print them to send along with the case or e-mail them to the lab.
'Practicing' with temps
Do a wax-up on every cosmetic case. If you are just beginning to get into this type of treatment, do the wax-up yourself. This will give you some practice cutting preps on the model. You will be surprised how much faster and easier this makes the case go when you prep the teeth in the mouth. I use composite instead of wax, because it is easier for me to work with composite. The wax-up is a good way to sell the case to your patient, and it is great for making temporaries for the patient. You can take an impression of the wax-up and use it for making your temps. When you have finished the temps, take an impression so the lab tech will have an idea of how you want to finish the case, including length and design of the teeth.
When Dr. Bill Dickerson was working on my smile at LVI, he showed me his book of tooth shapes and asked me which one I preferred. I was actually able to get very involved in how the finished case was going to look. All of this information makes it easier for the lab tech to produce the end result that you and the patient want. When the temps look like the finished case, patients get a chance to see what they like and dislike. Are the teeth the right shape? Are they too long or too short? Can they talk with them? Call the patient after a couple of days and ask specific questions to determine their likes and dislikes. Communicate that information to the lab tech.
Some dentists will tell you not to make your temporaries look too good. I think that is crazy! Today's patients expect to leave the office looking at least as good as when they came in. If you can make them look better when they leave, they are thrilled! I have fun watching the patients' reaction when I hand them a mirror after finishing their temps. They are always excited to see their new smile so soon.
The thing to remember here is that we want to establish a relationship with the dental laboratory. Don't just quit one lab and jump right to another because your buddy down the street said it was better and cheaper! There is a better way to select a dental lab. Find out everything you can about what your lab expects and let them know everything that you expect. Design an interview process with key questions and goals. Can you meet their expectations, and do you feel they can meet yours? If not, interview another lab until you find one you are comfortable with. Sometimes, this has to be a telephone relationship, which makes the information you send even more critical! Long-distance relationships need even more time to make them work well.
To build that relationship, your entire team must be able to communicate with the lab. The clinical assistant should be taken just as seriously as the dentist. I have run into situations where the lab tech would only talk to me because she was just my "girl." In reality, my clinical assistants know as much about the case as I do and should be treated with the respect that is due them.
Summing up, remember that communication is the key! My goal is no remakes. Take a look at your preparations - could they be better? If so, make it your goal to get the training you need to make them the best. This year, set aside time to train and to practice techniques. You will be surprised how much this can lower the stress levels in the office. This year, create a lab checklist with all the information to be shared with the lab. Then every case will have the information required to make it the best!