Written by Damon C. Adams, DDS Wednesday, 30 June 2004 19:00
New laboratory-fabricated restorative materials are being introduced to doctors and dental laboratories at a record pace. Keeping up with the new advances is a daunting task for all concerned. Most doctors are very knowledgeable with the direct materials they use on a daily basis. However, how many doctors can name the porcelain that their technician uses over PFM crowns? How many can describe what type of porcelain it is or why their laboratory (unilaterally?) chose that particular porcelain for its doctors?
The need to know when and how to use both well-established and new materials holds significant consequences for aesthetics, function, and longevity. It is vital to know in which clinical situations these materials will perform as expected, or perhaps when they may not. The mutual stress and loss of profits caused from preparing and sending cases to dental technicians before thoroughly understanding restorative materials and their respective preparations is still a problem observed in most of the nationís dental laboratories.
One way for doctors to help overcome the information overload is to develop closer working relationships with their dental laboratory technicians. Dental technicians can be valuable, contributing team members when it comes to the evaluation of-and clinical indications for-dental materials created in their laboratory. They can give crucial insight into preparation requirements and aesthetic considerations related to the materials they are fabricating. In addition, the majority of dental technicians are willing and eager to assist their doctors. Doctors simply need to ask for assistance and then be open and ready to listen.
A doctor/technician communication technique that has proven to be extremely useful in elevating the quality of laboratory-fabricated restorations, reducing mutual stress, and increasing mutual profits by reducing costly remakes is the Treatment Planning Consultation (TPC). In order for a TPC to be effective, all team players must have a clear definition of the process. They should also understand when and why it is being implemented. The TPC can be defined and described as follows: a sharing between the doctor and laboratory technician(s) of all relevant case information that is vital to the functional and aesthetic success of a case.
This teamwork approach to treatment planning is always done before the final patient consultation and before any restorative preparations are done. It may involve single-unit or multiple-unit cases, especially when new materials are being used or when complex aesthetic and/or functional challenges are present. This co-discovery process may often involve the referral of the patient to the dental specialist and subsequent discussion of the findings between all parties, including the dental technician. This is also to be done before the specialist(s) begins any procedure that may affect the restorative outcome. Preoperative fee quotes from the laboratory and/or specialist(s) can be included to assist in planning financial arrangements for complex or interdisciplinary cases.
Implementation of the TPC requires an allocation of time during the business day. It should be scheduled and treated with the same degree of importance as any other patient procedure, since the up-front planning will pay significant dividends in time and money saved. The TPC usually involves one or more phone conversations with the dental technician(s) and possibly with the specialist(s). It may occasionally require a doctor and/or patient visit to the laboratory when geographically feasible.
Once the TPC is routinely integrated into the doctor/technician relationship, one can expect a major shift in the level of care from ìprep-and-prayî to more predictable aesthetic and functional results. There will also be positive effects on the relationships involved. The degree of mutual respect between the doctor and technician will be raised to previously unexpected levels. Mutual stress will decrease significantly. The patient and doctorís staff will often perceive the higher level of communication and cooperation. They will not only benefit from more rewarding technical outcomes, but will observe a deeper sense of patient-centered integrity in the total team approach to care. By employing the skills and knowledge of the entire dental team, the TPC can be a powerful tool for increasing both mutual satisfaction and profits for the doctor and laboratory. As the late Walter Hailey once said, ìGet a group of successes in-sync and thinking together, and you will all be geniuses...so powerful and smart that you will amaze yourselves!î
PUTTING THE TPC TO WORK FOR OUR PATIENTS!
The following clinical case was done utilizing the TPC concept of doctor/technician communication. (Note: TPCs will vary depending on the case being considered.)
Findings at the Initial Appointment
This 17-year-old patient visited her restorative dentist accompanied by her mother. She presented with 2 congenitally missing maxillary lateral incisors (Figures 1 and 2). She had recently completed full-banded orthodontic treatment, resulting in a class I occlusion with an otherwise excellent anterior aesthetic appearance that was pleasing to both her and her parent. Her expressed desire to "fill in the spaces" with something "permanent" (non-removable) and "natural-looking" was noted. Oral hygiene assessment verified a need for continued attention to home plaque control. No evidence of bruxism or other occlusal pathology was observed.
|Figure 1. Pre-op photo showing congenitally missing maxillary lateral incisors.||Figure 2. Pre-op photo (retracted).|
Doctor's First Call for Laboratory Assistance During the Patientís Initial Visit
The doctor called his laboratory to ask about possible restorative choices. He described the overall wishes of his patient. The dental technician asked him if implants had been considered. Implants were discussed as a potential long-term solution, and a consultation appointment with the specialist was offered. The parent was not in favor of this surgical procedure and was unwilling to seek an appointment with the specialist. (This was noted in the patient records.) This decision left only fixed crown and bridge options.
The restorative doctor asked his dental technician what restorative options might be best. PFM bridges? All-ceramic bridges? Standard Maryland bridges? Indirect composite Maryland bridges? He also noted that he felt the mesial contours of both cuspids were somewhat "deficient," and wondered if this problem should be treated with direct composites. The dental technician, instead of hastily suggesting a possible solution over the phone with limited information, asked the doctor to consider taking some time for a more detailed analysis. The TPC definition and concept of communication was briefly introduced to the doctor. He agreed with this team approach and was willing to send models, a bite registration, and photos to the laboratory. He was then informed that a 10- to 15-minute phone call would be needed to discuss the case once the laboratory staff had a chance to review the information being sent. The dental technician sincerely thanked the doctor for involving the laboratory before making the final restorative choice and before starting the preparations. (Remember that the restorative choice dictates preparation design.) In turn, the restorative doctor informed the patient and her parent that he would like to send models and photos to his dental laboratory. He told them that he wanted to discuss the material options with his laboratory team members in more detail before presenting the best treatment options.
TPC Information Arrives for Discussion by the Laboratory Staff
The laboratory staff assembled the mounted models, photos, and notes from the initial conversation with the restorative dentist. All restorative options were discussed along with any potential positive and negative implications. If aesthetics were to be optimized, PFM or all-ceramic bridge preparations would be quite aggressive for this young patient. Standard metal-reinforced Maryland bridges, although done with conservative preparations, would exhibit an aesthetic challenge with metal show-through for the retainer teeth. For this laboratory, past experience with indirect composite, fiber-reinforced Maryland bridges resulted in a remake rate above its accepted standards. One material that has been achieving a higher degree of success for conservative, indirect, composite, single-pontic anterior bridges is Cristobal+ (DENTSPLY Ceramco).1 It is uniquely indicated for use either with metal substructures or without substructure of any kind, including fiber reinforcement.2 The low wear of opposing enamel against Cristobal+ was also a plus for this young patient.3 Since the patient had no current contraindications for the use of this material, the laboratory staff felt that Cristobal+, with the highest flexural strength of any indirect composite (195.6 MPa), used for Maryland bridges with no fiber or metal reinforcement, would be sufficiently strong if used over well-designed preparations.4 Since the indirect composite technician felt he would also be able to achieve the aesthetic goals required, including matching the hypocalcified areas of the adjacent teeth, the decision was made to present Cristobal+ as the laboratoryís recommended material of choice for this patient.
Laboratory Makes TPC Call to the Restorative Doctor
The laboratory called the doctor to discuss its findings and make its treatment recommendations based on the information shared. The pros and cons of the various options available were discussed. The thought process used by the laboratory technicians leading to the decision to recommend Cristobal+ was briefly summarized. Of course, these treatment options were made as suggestions from a laboratory perspective, since the responsibility for final treatment decisions rests with the doctor. The doctor asked again how to handle his concern with the "deficient" contour on the mesial aspect of both cuspids. If direct composite were to be utilized, ideally it would be best to do this before the preparations and impressions were done. Or, if the preparations were planned properly for the indirect composite bridges, the ìdeficientî contours might be remedied within the design of the bridges.
At this point, the doctor was asked if he would like a model with study preparations for "modified" Maryland bridges along with a diagnostic wax-up. These would allow pre-planning of the preparation variations needed to accomplish the structural and aesthetic goals of the case. They are also done to help eliminate the increased stress and money lost from potential re-preps and additional impressions. The restorative doctor agreed that this would be valuable information to assist him with his decisions and preparation of the case.
The Laboratory Completes Study Preparations and Diagnostic Wax-Up
The proposed preparations were first cut on the study model. Ideally, the same burs to be used by the doctor should be utilized in the mock-up procedure. (A Brasseler 5856-016 diamond chamfer bur was used for these preparations.) A ìreciprocal armî style preparation was cut into the interproximal and lingual aspects of both central incisors (Figure 3). A modified laminate preparation was then done, which covered approximately two thirds of the facial surface and extended distally to the distal transitional line angle (Figure 4). As in closing diastemas with laminate veneers, the cuspid preparations were carried through the interproximal surfaces to the mesio-lingual line angles. The margins were also placed approximately 1 mm sub-gingival to allow the technician to create natural interproximal emergence and contours. (Note: For anterior Cristobal+ bridges, the manufacturer recommends an interconnector size of 4x4 mm as ideal for strength.)
|Figure 3. TPC study preparation of central incisors.||Figure 4. TPC study preparation of cuspids.|
Final TPC Information Was Returned to the Doctorís Office
The diagnostic wax-up, along with a model of the suggested preparations, was returned to the doctor for examination (Figure 5). The doctor was informed that it is always prudent to give the patient a guarded long-term prognosis before beginning any treatment utilizing a new material and/or procedure. This was important information to be considered by the patientís mother before actual tooth preparation was begun, given her desire for no implants and an aesthetic fixed restoration. This was also to be balanced with the doctorís concern for conservative preparations due to the patientís young age.
|Figure 5. Completed diagnostic wax-up over TPC study preparations.|
Final Patient Consultation and Treatment
The restorative dentist reviewed all of the TPC findings, including a fee quote for the laboratory services, and scheduled a final patient consultation to discuss his treatment recommendations. The patient and her mother agreed to proceed as outlined. The preparations were then done as the laboratory had suggested and the doctor had accepted. A full-arch VPS impression (Aquasil Ultra; DENTSPLY Caulk) and VPS bite registration (Regisil Rigid; DENTSPLY Caulk) were taken. The case was sent to the laboratory with shade information that included preoperative photos that clearly demonstrated the enamel characterization needed for proper aesthetics.
The 2 Cristobal+ anterior bridges were created uneventfully as preplanned in the TPC and returned to the doctor. Instructions for the bonding procedure for indirect composites were included with the case by the laboratory. The restorations were tried in for fit and aesthetics. Once the doctor, patient, and parent were satisfied with the results, the restorations were deep-cleaned with 38% phosphoric acid gel for 20 seconds, rinsed, treated with fresh silane for 60 seconds, and bonded with Calibra dual-cured resin cement (DENTSPLY Caulk). The occlusion was then checked, adjusted, and polished. The patient was given postoperative hygiene instructions including the use of floss threaders.
Postoperative photos were then sent to the dental laboratory (Figures 6 and 7). Sharing post-op photos with the laboratory technician is a wonderful way to improve the quality and content of future TPCs. Postoperative photos can also be used to send praise for a job well done or to give immediate feedback to the laboratory for any technical changes that could have further improved the case. (For example, it was noted that the creation of aesthetic pontic sites, along with a more ideal relative gingival crest height of the lateral incisors as compared to the central incisors and cuspids, would have improved the aesthetic result. However, since the parent wanted a fixed, aesthetic solution without surgery for implants, this additional surgical treatment may not have been accepted.)
|Figures 6 and 7. Cristobal+ nonfiber-reinforced anterior ìmodifiedî Maryland bridges. (Clinical work and clinical photos performed by Dr. Carl Meier; laboratory work created by Douglas H. Baker, CDT; laboratory photos courtesy of DH Baker Dental Laboratory.)|
This article has defined and described a typical working example of the Treatment Planning Consultation as an effective doctor/technician communication tool. The use of the TPC as a co-discovery technique for discussing cases early in the diagnostic and treatment planning phases can lead to improved functional and aesthetic outcomes for our patients. Being willing to engage in a total team approach to cases can also decrease stress and increase profits by reducing needless remakes. In addition, it will build trust and respect between all the team members. It only takes openness to working together and a mutual understanding of the TPC concept, and everyone can benefit.
1. Leinfelder KF. Developments in indirect resin composite materials. Dent Today. 2000;19(3):58-61.
2. Kurdziolek S, Leinfelder KF, Delahaye A. Properties and characteristics of an indirect Bis-GMA/barium-glass polymer ceramic restorative system. Compend Contin Educ Dent. 2000;21:1031-1038.
3. Suzuki S, Nagai E, Taira Y, et al. In vitro wear of indirect composite restoratives. J Prosthet Dent. 2002;88:431-436.
4. Nash RW. Processed composite resinóa versatile restorative material. Compend Contin Educ Dent. 2002;23(2):142-148.
Disclosure: Dr. Adams serves as the doctor/technician liaison for DH Baker Dental Laboratory in Traverse City, Mich.
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