Communication: The Ultimate in Synergy

Pinhas Adar, MDT, CDT

For the past 29 years, I have worked as a dental ceramist in different parts of the world, making teeth to enhance nature’s inadequacies and people’s lifestyles, or to replace what’s been lost from disease or accidents. In the realm of teeth, I suppose you could say that I have probably seen it all—from the desperate results of inferior work, to incredible dental miracles in which a beautiful, healthy smile now exists where disease and destruction once threatened.

Consumers are learning more and more about the role they play in their own health, both medically and dentally. Today, the desires and interests of patients are driving the decisions of doctors and dentists alike.

Within this environment comes the need for information concerning options, products and the possible implications of your dental care decisions. There are many differences in quality that exist in the marketplace today. The informed consumer wants to know how to get what they want—the first time. Our obligation to the patient is to ensure that the journey to their final destination is one of good thoughts and enjoyment, doing everything possible to communicate freely with the patient and allowing the patient to express him- or herself.

That brings up the subject of communication. People use different keywords in an attempt to communicate. But just what do “white”, “natural”, “straight”, “big”, or “small” mean to the patient you are talking with at that particular time? Do these words have the same meaning from patient to patient, dentist to dentist, and dental ceramist to dental ceramist? Communication is a complex issue. Yet, as in the rest of life, it is an essential part of a satisfactory outcome. To this end, there are specific tools that can be used to ensure a consistent message travels between everyone involved so that the desired outcome can be achieved, with no surprises for anyone. The first step, no matter what type of enhancement is required, is diagnosis and treatment planning.

Diagnosis and Treatment Planning

In esthetic dentistry, successfully creating an illusion of reality is no longer an impossible task, especially when fabricating one central unit (Figure 1). We already have a blueprint to copy. With proper ceramic selection and skills of the ceramist, we can create an illusion of reality (Figures 2 and 3).

When dealing with smile designs, we must understand the patient’s preconceived ideas. Quite often, their expectations may be beyond reality, because the subjectivity of esthetics is like a camera. Whatever you focus on is what you see. Different people focus on different things. In one instance (Figure 4), the restorative dentist sent the same case with the same instructions to 2 different laboratories. You can see the extremely different looks that were returned in the diagnostic wax-up stage (Figures 5 and 6). Each laboratory interpreted the same request with a different vision. The questions that the restorative dentist should ask are: “Which outcome will the patient like?” and “What kind of tooth preparation will this require?” Each of these outcomes requires different tooth preparations for space management.

From the wax-up, a silicone matrix can be made and then filled with acrylic and placed over the patient’s existing teeth. The outcome can then be shared with the patient without tooth preparation (Figure 7). Once this is approved, the restorative dentist can design the outcome-generated tooth preparation.

I think one of my favorite sayings is: “Beauty is in the eye of the beholder, but so is ugliness.” What you or your ceramist might consider beautiful, your patient might consider ugly. That is why it is so important to involve the patient in the process. They should always be given options and alternatives so that they can make educated decisions. Make them aware of the possibilities.

Entire smile designs are very different from just doing a couple of posterior crowns. Without adequate communication, this could be a difficult procedure, with an unpleasant surprise at the end. If the patient decides that the restorations are too artificial, too white, or too natural, the dentist has few alternatives to choose from: either redo the case, convince the patient to like their new smile, or give the patient their money back.

The Trial Smile

Another excellent method of communication for smile designs is the removable “Trial Smile”. With the “Trial Smile”, the patient can see and feel the teeth, as well as the color, in their mouth, unlike with computer imaging, which is a standard in many practices. The “Trial Smile” serves as a blueprint to allow the patient to experience all of these things. However, it is important that the ceramist who will fabricate the final ceramics also do a diagnostic wax-up for the “Trial Smile” and/or fabricate the “Trial Smile” itself. Many details need to be incorporated into these restorations.

 In addition, the patient him- or herself should make the final decision regarding the design of their “Trial Smile” because, as stated earlier, esthetics is a subjective issue and a matter of preference, emotional feelings and personal opinion. If the dentist influences the patient’s decision, the patient may return unhappy and say that his or her choice was based upon what the dentist had suggested. There is no right or wrong in esthetics, just variations in opinion.

In the case of a young patient who was unhappy with her smile after orthodontic treatment, she disliked the size, proportion, and spacing of her teeth (Figure 8). An impression was taken without tooth preparation, and a diagnostic wax-up was made (Figure 9). A “Trial Smile” was then fabricated with cold-curing acrylic (Figures 10 and 11). The patient was able to place the removable restoration in her mouth (Figure 12) and visualize the outcome of the new smile prior to tooth preparation (Figure 13).

Communication Must-Haves

There are 8 critical communication tools that should be used and shared between the dentist and the laboratory technician to maximize success.

1. Preoperative study models of upper and lower arches
2. Preoperative clinical digital images (e.g., smile and retracted view with a shade tab of the natural color shown with it)
3. Digital image of the unprepared teeth with the existing color shade tab next to it
4. Digital image of desired shade tab next to the prepared teeth
5. Digital image of provisional restoration, if used (e.g., smile and retracted view)
6. Digital image of patient’s face
7. Two or more accurate impressions
8. List of the desired expectations of the patient and the dentist

All clinical procedures require communication between the key players for that particular case. Synergy among the perio­dontist, general dentist, prosthodontist, orthodontist, and the ceramist should be a priority for treatment. This will integrate communication and, ultimately, lead to success.

The Power of Provisionals

Once the patient decides to proceed with treatment after the “Trial Smile”, then the ultimate diagnostic tool is the provisional restoration, and it is extremely important in some cases. The ceramist can create the same type of effects in acrylic materials that they have envisioned for the final ceramic restoration and previously in the “Trial Smile”. The patient can again feel and now also function with the provisional in place—just as they would with the final restorations—and evaluate the esthetic and overall changes to be made. At this provisional stage, they can determine their likes and dislikes and make changes at this time, instead of when the final restorations are complete, when changes are sometimes difficult to make.

For example, realizing the exact special effects and characterizations and where they are in the natural teeth prior to internally placing them in ceramic is paramount to esthetic success and patient satisfaction. If these internal effects are placed and the patient is unhappy with the results, even if they look very natural to the dental team, removing them becomes a very frustrating endeavor with an unknown outcome.

Conclusion

In summary, let me say what many people have heard me say before: “No man is an island.” We all need each other to accomplish the ultimate in dentistry. No aspect of dentistry can survive this “esthetic rush” if we think we can do it on our own. We must learn to communicate better and, most of all, to respect the professional expertise of our colleagues.

Acknowledgement

The dentistry featured in Figures 1 through 3 was performed by Dr. Cathy Schwartz. The dentistry featured in Figures 4 through 7 was performed by Dr. Anita Tate.

Figure 1 View of maxillary central incisors, 1 of which has been obviously restored.		Figure 2 A single maxillary restoration.
Figure 3 View of the "invisible" restoration adjacent to the natural tooth.		Figure 4 Preoperative view of a patient requesting esthetic restoration of her maxillary teeth.
Figure 5 Example of 1 wax-up returned to the dentist for the patient's consideration.		Figure 6 View of an alternate wax-up sent for consideration for the same case.
Figure 7 The proposed outcome of the first wax-up was shared with the patient prior to tooth preparation.		Figure 8 Preoperative view of a patient displeased with her smile.
Figure 9 View of the diagnostic wax-up.		Figure 10 Occlusal view of the "Trial Smile" on the model.
Figure 11 Alternate view of the "Trial Smile".		Figure 12 The patient was able to place the removable "Trial Smile" herself.
Figure 13 View of the "Trial Smile" in place prior to tooth preparation and provisionalization.
About the Author
Pinhas Adar, MDT, CDT Oral Design Center, Atlanta a division of Adar International, Inc. Atlanta, GA www.adarinternational.com