In the past few decades, dentistry and dental technology have advanced by leaps and bounds. These advances have been driven by improvements in computer processing power leading to advances in digital technology (e.g. CAD/CAM). The evolution in biomaterials has led to the development of zirconia. However, the communication between dentists and their dental technologists seems to be lagging. We can all do better!
Anyone who has visited a dental laboratory or had a frank discussion with a dental technician would have seen first-hand the good, the bad and the ugly of the dentist–technician relationship. It essentially boils down to trust that each party will listen to the other’s challenges and will work together to achieve a common goal. Working together as a team from the treatment planning stage to nal insertion can eliminate problems by considering both clinical and laboratory issues simultaneously. This will lead to a result that creates predictable success for the dentist and, most importantly, produces a satisfied patient. Essentially, effective communication results in a win–win–win situation: a happy patient, increased productivity for the clinician and significant reduction in remakes and/or modications for the laboratory.
The goal of this article is to discuss the main aspects of the communication process between the dentist and the laboratory. What is the most effective method of communication available to the dentist? How can the laboratory assist the dentist in the treatment planning and treatment execution phases? What are the responsibilities of the clinician to the patient and the laboratory? What are the responsibilities of the laboratory to the prescribing dentist?
Methods of communication
To effectively treat cases involving multiple teeth, altering the vertical dimension of occlusion, and/or highly sensitive aesthetic situations, involving the laboratory earlier on in the treatment planning phase will allow for a greater chance of a successful treatment outcome (Fig. 1). Communication between the dentist and the patient is critical during the treatment planning phase of a large aesthetic case.
The patient’s expectations may not match the dentist’s expectations. Furthermore, the patient may have specific ideas about how his or her smile should look. If the patient’s vision does not match the final result, he or she will most likely be disappointed and then become dissatised. To ensure that this does not happen, it is important to plan effectively. This means taking time with your patient to make sure that his or her vision is understood. It has been said that beauty is in the eye of the beholder. As such, we are beholden to the patient to ensure he or she is satisfied. Asking the patient to bring in historical photographs or photographs of someone whose smile he or she would like to have mimicked can be very insightful. Ask the patient about shade preference during the consultation period and accurately capture it (Fig. 2). The patient’s presenting condition should be captured as well, both for communication with the laboratory and for medico-legal purposes. This includes the necessary radiographs, accurate impressions (either analogue or digitally captured) to produce models, stable interocclusal records at the correct vertical or horizontal position for accurate articulation, facebow records when required and representative digital photographs to convey both dental and facial parameters (Fig. 3). With this information in hand, the savvy clinician should consult with the labora- tory technician to discuss the occlusal scheme, biomaterial selection, and overall size, shape, shade and contours of the teeth to start developing a plan that will achieve the patient’s aesthetic goals while allowing for a predictable outcome in practice (Fig. 4).
Working as a team member, the laboratory can assist in several ways. First, the material selection process is a service that a laboratory can provide. Often, the difference between success and failure with biomaterial technologies is their proper selection for the case circumstances. The dental laboratory is uniquely positioned to experience success or failure with the myriad of dental restorative materials and their use in particular cases. The laboratory technician is able to offer valuable input as to the material properties and their intra-oral applications and limitations, as well as techniques for success. The goal in selecting the most appropriate biomaterial is to optimise the balance between the aesthetic quality of the restoration and its long-term clinical performance and predictability. Simply put, we want the result to be aesthetic enough to satisfy the patient and strong enough to last.
Second, the best way to communicate with the technician is to allow him or her to see what you see. If you have an in-office laboratory, then the laboratory technician should have an opportunity to interview the patient at the consultation appointment. However, in most cases the laboratory is off-site. As a result, good photographic documentation is crucial. In addition, it would be incredibly valuable to record and share a video of the patient speaking and going through multiple continuous chewing motions to observe the patient in function. Allow the patient to describe his or her vision in his or her own words and allow the laboratory technician the opportunity to meet the patient virtually so that the casts being worked on will come to life. Armed with this information, a laboratory-fabricated diagnostic wax-up can be created (Fig. 5). A wax-up is an excellent tool for the treatment planning phase. It can demonstrate for the dentist and the patient what the laboratory can accomplish with specic restorative materials. Many contours can be created in wax, but the specic dimensions required for a given material are an important consideration. Third, the choice of the restorative material combined with the wax-up can guide the dentist in the amount of preparation required to duplicate the result created in wax. Once the dentist, laboratory technician and patient are happy, the diagnostic wax-up can be approved and the reparation or reduction guides can be fabricated, as well as matrices or provisional shells for making temporary restorations.
A highly aesthetic outcome satisfactory to the patient is dependent on communicating colour (chroma, hue and value), translucency and surface texture. The underlying challenge for the clinician is to determine all these parameters accurately and then to successfully communicate the details and expectations for the patient case. The challenge for the laboratory team is to understand exactly what the dentist is asking for and to successfully implement the information received into the restorative product. In order to facilitate communication, the dentist will provide the laboratory technician with a written prescription describing what is expected. Of course, the detailed prescription needs to be accompanied by impressions, diagnostic casts, a bite registration, facebow records and clinical photographs.
What is expected of the dentist?
1. The dentist must provide a well-written prescription providing the patient’s name, age, sex and mastication habits and the type of restoration needed (fixed or removable).
2. The clinician should provide accurate nal and opposing arch impressions, either analogue or digital (Fig. 6), that duplicate the intra-oral tooth preparations (Fig. 7). Analogue impressions should be free of bubbles, have visible margins and be taken on a stable impression tray. All outgoing materials should be disinfected according to current infection control standards, placed in an appropriate container, packed properly to prevent damage and transported.
3. Accurate bite registrations are essential, using a more rigid material to aid with proper articulation.
4. Digital photographs are important and necessary to create a precise dental prosthesis. A proper shade guide that is identical to the one being used by the dental laboratory is needed. Chairside custom shade taking, including the stump shade for the anterior region, or sending the patient to the dental laboratory is recommended for anterior restorations.
5. In restoring implants, it is important to mention the type of implant being used, how long the patient will be wearing temporary prostheses and whether the nal prosthesis will be screw- or cement-retained.
6. A radiograph showing the placement of the implant is extremely important for the dental technologist. A stone model does not provide adequate information regarding bone level. A radiograph of the patient allows for the proper selection of the correct stock abutment or to customise one to achieve a successful final restoration.
What is expected of the laboratory technician?
1. The laboratory technician should custom manufacture dental prostheses or appliances which follow the written instructions provided by the dentist and should fit properly on the casts and mounting.
2. The laboratory should return the case to the dentist to verify the mounting if there is any question regarding the accuracy of the bite registration provided by the dentist.
3. The laboratory or technician should match the shade which was described in the original written instructions.
4. After acceptance of the written instructions, the laboratory or technician should custom manufacture and return the prostheses or appliances in a timely manner.
5. The laboratory should follow current infection control standards with respect to personal protective equipment and disinfection of prostheses or appliances and materials. All materials should be checked for breakage and immediately reported if found.
6. The laboratory or technician should inform the dentist of the materials used to prepare the case and suggest methods to properly handle and adjust these materials.
7. All incoming and outgoing items from and to the dentist’s office (impressions, occlusal registrations, prostheses, etc.) should be cleaned and disinfected according to current infection control standards, placed in an appropriate container, packed to prevent damage and transported.
The dentist has overall responsibility for the treatment rendered. The laboratory will produce the prosthetic restorations for try-in (Fig. 8), but whether to nalise the case (Fig. 9) is the clinician’s decision. Delegating many procedures to auxiliary team members is possible if all the necessary information is provided to enable them to deliver a high-quality service. When working with a laboratory, however, errors such as insufcient tooth reduction, ambiguous margins, unstable interocclusal records and articulations, and poor communication of the desired shades for aesthetic restorations to the technician will lead to unhappy patients, unproductive practices and a laboratory technician who feels defeated. Good communication coupled with good clinical and technical skills is the winning formula for success (Fig. 10). We can all strive to do better.
Dr Joseph Fava & Karim Sahil, Canada