John Gammichia, DMD
As you may know, I graduated from dental school nine years ago. I survived the first five years with some mild bumps and bruises. I want to write about the second five years. After we pick ourselves up from enduring the first five years, we slowly start to build our confidence. We have seen most clinical issues. We have dealt with a lot of people and their challenging personalities (was that diplomatic, or what?) So, with this new confidence I set out for the next adventure in my life - years five through 10.
In this stage of my career, I want to work on becoming the best dentist I can be. So I have begun a type of quest. In this quest, I am searching for the perfect filling, the perfect crown, and the perfect restorative case. In this quest for perfection I also want to broaden my range of services to include more aesthetics and cosmetics.
So the first thing I did was start reading articles. I read lots and lots of them. I see work that looks so good. I mean, I work hard at doing great work and some of these guys put me to shame. (I think this is important; you have to read magazines and magazine articles that challenge you.) Then I gathered more information from my study club colleagues (you are in study clubs, aren't you?) Then I attended courses at the state dental meeting or even at one of the big meetings such as the ADA, AGD, Chicago, and Hinman. At that point, I started dabbling into cosmetics, doing a couple of cases and having moderate success. Then I took a leap and decided to do a three- to four-day course at an institute.
Keep in mind this doesn't have to be cosmetics. It is the same if you want to do exquisite posterior composites or posterior aesthetics, but in this article my focus is on anterior cosmetics. The institute instructors were internationally known and very good at what they did. They were approachable, down-to-earth, and I liked them a lot. I am sure they had cemented more than 10,000 veneers and it had become easy for them. In their lectures, they showed lots and lots of before-and-after photos. The photos looked great and I wanted this for my patients.
OK, so all I have to do is desire these outcomes and they will happen, right? Wrong! I went back to the office and waited for the patients to come barreling through the door asking for cosmetics. There were none. Maybe I did get some people inquiring about veneers because they saw it on TV. I told them, "I think veneers would look so awesome on you." I told them the fee (very gently), and they ran like hell (like the cartoon with the little puff of smoke). I know some of you would blame me for not closing the deal, but I do everything correctly - I am relaxed in my delivery, and I am confident. I just think some people are not ready to spend more than 15 percent of their annual income on their upper anterior teeth.
I am exaggerating a little, but I know this is happening to a lot of you. I have grown my patient base to where I do have patients who can afford this kind of work. So, with all my passion for making people look and feel great, I started a couple of cases.
My first case was six veneers on the top and five on the bottom. The preps I saw at the institute never looked like the ones I prepped. The problem I was having was that nothing was "ideal." I was working around decay, there were gum issues I wasn't anticipating, and there were occlusal issues that were not ideal. I guess this is where cementing 10,000 veneers beats four. Nothing "Dr. Guru" sees surprises him. Everything I see surprises me.
So, my preps didn't look like the ideal ones I saw in the pictures. This worried me, but I moved on. I got a great impression because I had done that before and knew I could do it.
I moved on to the temporary stage. In the lectures, why do they whiz right by this? It is such an area of contention for me. The gurus say something like, "Wax up the ideal, and take a suck-down of it. Then after your preps, put the suck-down on the teeth with your temporary material in it." Easy, right? Wrong! I tried that on the six upper preps. I lubed up the preps and did everything I was told and the composite material shrunk (like it always does) and stuck on the teeth. I thought, "So what do I do now? I have a huge mound of composite - that looks a little like teeth - stuck on the preps." My choices were to cut it off and start over, or make the thing look like teeth. Nobody ever says, "Hey, you better watch out for this or you better not do that." So now, the hour I had set aside for making the temporaries is not nearly enough. Meanwhile, my assistant is looking at me, and my patient is looking at me (good thing they can't see the sweat running down my backside). Don't forget that, as doctors, we're always supposed to have this aura about us like, "This is supposed to happen."
I survived the temporary stage and, by gosh, they looked good - 10 hours later. I sent the impressions to the lab. Three weeks later, it was time for the cementation appointment.
The cementation appointment was this huge undertaking. I usually give myself about an hour to cement crowns, so one hour seemed reasonable to cement six veneers, right? Wrong. This was the most nerve-wracking hour of my life (and that was to cement one veneer). You place these fragile little "egg shells" on the teeth and look at them. By the time you get a mirror for the patient to see what they look like, they have all moved! So you say something like, "OK, you can look but you can't talk, you can't swallow, and you can't move. You can't even smile because you will mess them up. How do you like them?"
I cemented them in. Things went so smoothly (I'm lying). After the try-in we were all ready. "Let's go," I said. Then I dropped the syringe on the counter and the veneers got all mixed up. When my assistant was giving them to me she gave me a veneer saying it was number 6 but it was number 8, and she gave me number 7 and it was really number 10. Are you feeling my pain? Isn't this fun? Isn't this glorious?
I finally finished. I was more relieved than happy. I looked at my patient and she looked a million times better. The case was a huge success! ... or so I thought. I went back to my office after checking her out and hugging and kissing and all the warm, fuzzy stuff. I plugged in my camera and studied the photos. They didn't look a thing like Dr. Guru's stuff. Number 9 was a little short, and the gum tissues didn't exactly line up. All smile design stuff was ignored (apparently). Frustration.
OK, so I was a little frustrated. I feel like I failed, so why write this article? To tell you there is hope. This is what is supposed to happen. Do you really think the gurus started out being great? No! They tried and failed, tried again, and failed again, and so on. Understanding this, I can't wait to do the next case. I feel the next case I will study more. My assistant won't put the syringe next to the veneers. I will schedule better. I will be more confident. But, I won't forget that failure or things that don't go exactly like the book says are part of the game. That is why they call it "practicing" dentistry. Fail, get knocked down, but please, get up off the floor and try again.Dr. John Gammichia is a 1995 graduate of the University of Florida College of Dentistry. He is in private practice with his father in Orlando, Fla. He also is a part-time faculty member at the University of Florida AEGD program. Dr. Gammichia is a published author and a speaker on the topics relating to young dentists. He welcomes feedback and questions and may be reached at (407) 889-4868 or e-mail [email protected].