Do you ever think that the case that comes back from the laboratory is really a surprise package? Do the enclosed porcelain laminate veneers create the smile for which you had hoped? How can you take the guesswork out of lab communications?
Here are seven keys to make sure you receive the cosmetic results that not only your patients have asked for, but what you have requested from the laboratory, too.
Key Number One: The initial patient interview
The first key to a really successful cosmetic dental makeover is the initial patient interview. What does your patient really want? You may look at his or her smile and immediately have an idea that will improve his or her appearance and make the patient look years younger. What you think at the initial interview is irrelevant; let the patient tell you his or her concerns.
This is the time just to listen. The patient will tell you what he or she does and doesn’t like, and what he or she would like to change. At this initial interview, many patients have told me information that helped me realize I could not achieve the results they wanted. If a patient blames a previous dentist for problems he or she is having, there is a good chance that nothing you do will please this person either. You will become the “bad guy,” too.
Key Number Two: Taking the patient records
Before beginning any cosmetic makeover, it is vitally important to have a complete set of dental records. The need for a full series of radiographs is obvious. This information will help document the condition of the mouth prior to beginning treatment, as well as assist in diagnosing any lesions and/or preexisting conditions that could influence your choice of cosmetic restorations.
Mounted study models of the upper and lower arches are also a necessity to plan for cosmetic restorations. These study models should accurately represent each entire arch, including the retromolar areas.
Key Number Three: Digital photographs
I also recommend taking several digital photographs of a patient’s face and dentition to help communicate the esthetic disharmonies of a patient’s smile.
The photos should include a:
1) Full-face smile
2) Closeup smile
3) Retracted anterior view
4) Retracted left view
5) Retracted right view
6) Maxillary occlusal view
7) Mandibular occlusal view
These digital photographs will be used in a co-diagnosis exercise with your patient. Having a patient look at digital images often helps the person decide what he or she does and does not like about his or her smile. The photos also provide a documentation of the condition of the teeth before you begin treatment.
Having the digital photographs available during the preparations is invaluable, and can often make or break an esthetic case. Since there is much planning and preparation in a complex cosmetic restoration, digital photos act as a road map to keep you focused on the goal. You can draw tissue corrections on the photos to correct the disharmonies of soft tissue.
You can see where you have to correct midlines, add space in a crowded case, or compress space in a case with diastemas. Referring to the digital photos will help to ensure that all aspects of the case are prepared as planned without compromising the final esthetic result.
Key Number Four: The laboratory waxup
By referring to the mounted study casts and the photographs, it is possible to write a lab prescription for a diagnostic waxup that addresses all of the identified disharmonies. The full-face smile photo especially is useful to check for deficient buccal corridors, clinically short teeth, a poor plane of occlusion, gummy smile, and midline shift. The retracted smile photo is helpful to diagnose gingival height problems, tooth size and position problems, and midline shift problems.
Drawing the ideal smile on a retracted smile photograph will help your laboratory create the waxup. The lab can see where you have raised the gingiva and where you have plumped out the buccals of the bicuspids, and how you have adjusted the length and position of the central incisors.
The waxup will provide a patient an opportunity to evaluate the proposed changes and see an actual model of the new size, shape, and position of his or her smile. Be sure to ask the laboratory to provide you with a Sil-Tech® putty stent (Ivoclar Vivadent) of the waxup so you can transfer the relationship of the waxup to the provisionals. The patient will evaluate the provisionals, and then decide if any changes need to be made to the final restorations.
Key Number Five: The prep guide
The dental laboratory can fabricate a useful tool to take the guesswork out of preparing teeth for the smile makeover: a prep guide. The prep guide is fabricated from the waxup, and is a valuable guide for the eventual reduction of the teeth involved in the cosmetic restorations.
The guide is placed on the teeth, and illustrates how much tooth structure needs to be removed to duplicate the smile achieved in the waxup. This guide can prevent the reduction of too much tooth structure, and promotes conservative preparations. Using a prep guide almost guarantees that there will be no surprises when the final restorations are returned from the laboratory.
Key Number Six: The maxillary central incisors
To have a beautiful and natural-looking final result, you need to concentrate on the central incisors. The midline should follow the long axis of the face. Establishing it is important for the final result since it helps the laboratory to develop the rest of the smile.
The use of a stick bite is helpful to communicate this to the laboratory. Always enclose a digital photo of the stick bite in the mouth for the laboratory to evaluate. This again will prevent surprises, and will make your life much easier.
Pay close attention to the proportions of the central incisors. The width of the central incisors should be about 75 to 80 percent of the height. The last key bit of information about the central incisors is their length. In communicating to the laboratory the desired length of the central incisors, the rest of the case will look remarkably natural.
Key Number Seven: Color
Color and shading for cosmetic restorations usually are divided into two areas: the stump shade and the final color desired for the porcelain veneers. The use of digital photographs showing the tooth preparations and the corresponding stump shade should be carefully packed and sent to the dental laboratory with your impressions.
The shade tab number should appear in the photograph to avoid confusion. This photo will help the lab identify the color of the underlying preparations, and allow the technicians to make any adjustments to create the final shade desired. T
he color for the final restorations also should be captured in a digital photograph and sent to the lab. Again, be sure to capture the number on the shade tab, clearly stating the final shade choice.
In following these seven simple steps, you will have fewer surprises and a greater degree of satisfaction with your cosmetic makeover cases. Digital photography helps you communicate your desires both to your patient and to the dental laboratory.
Editor’s Note: The author wishes to thank MicroDental Laboratories for its helpful input with this article.
Dr. Harry A. Long is a graduate of Fairleigh Dickinson University School of Dentistry. He has completed thousands of hours of continuing education in dentistry with a particular focus on patient care and esthetic dentistry. In 2005, Dr. Long’s practice was recognized as a Levin Group Cosmetic Practice of the Year. As a member of the peer review committee for the Passaic County Dental Society, he evaluates dentists’ work and helps to resolve disputes between dentists and patients. Dr. Long can be contacted by telephone at (973) 694-5101, or via e-mail at [email protected].