Joe Blaes, DDS
I am sure many of you have experienced days when things just did not go as planned. I am not sure if it had anything to do with the way the stars were aligned in the sky or some other quirky thing such as the moon or whatever, but it happens. Sometimes it seems like we are powerless to make things better.
In my office, the problems generally begin when I try to correct something that wasn't right in the first place. Let's say I am seating a porcelain fused to a metal crown. I take off the temporary, clean up the tooth prep, and try in the finished crown. It will not go into place.
Now what?
Well, first we must determine if the crown is not seating because of some internal problem or if the contact is too tight. Out comes the Fit Checker. We find a combination of internal problems and contact, so I carefully grind out the crown's internal surface and adjust the porcelain contact. Now, I put the crown in. It seats, but when I floss it, the contact I adjusted is open. By this time, the appointment has gone way past the scheduled time. I am behind, plus I have one or two hygienists bugging me to check their patients because now they are behind.
What do you do in these situations? I often think the solution might be to pack it in and just go home. The stress level in the office usually escalates to a dangerous level, and everyone in the office — including the patients — knows something is wrong. In most cases, we usually work our ways out of problems and get back on schedule.
I teach a two-day course on "Everything You Always Wanted to Know About Veneers." It gives doctors hands-on experience in case selection, setting up systems, prepping veneers, taking impressions, placing provisionals, and cementing cases. During the two days, I spend a lot of one-on-one time with doctors looking at cases they are prepping and I make improvement suggestions. Attendees may bring in cases they consider treating. I sit down with them and discuss treatment.
A few months ago, I received from one of my students an e-mail describing the first case he treated after taking my course. My comments are in bold.
The student writes, "This is my first veneer case since taking the course. I spoke with a local prosthodontist who raved about this great dental lab. I figured I would try them. I prepped the teeth the best I could, took two impressions, a facebow, and diagnostic photos. I personally drove the case to the lab. We discussed labs, and I told him about some excellent labs I had used, and he said he knows about these labs."
? I'm not sure why he changed labs.
"I said to myself, 'Wow, this guy must be great because he's surrounded by some of the best labs in the country and knows all about them and has been recommended by a great prosthodontist.' I couldn't sleep because I was so excited.
"He told me it would take five days in the lab because he likes to get them in the mouth quickly. Wow, that's great! A week and a half went by. No veneers. I called him and asked when to schedule the patient. He said he would start working on them the next day and would send them out the next week. I got the veneers two and a half weeks later. Not one of the veneers had a good margin. The dies were not trimmed at the gingival and the porcelain was stopped on the tissue that wasn't trimmed from the die. The veneers had little spikes in the glaze and porcelain overhangs on the lingual. And here's the corker — one veneer actually had a hole in it where he etched. I have six veneers that I cannot seat and a bill for $1,350. I was looking around to see if I was on Candid Camera. I was depressed for days. I sent the case back and asked what happened."
? At this point, I would have found another lab.
"I didn't get an answer, just a promise to redo the whole case. It came back better this time, but tooth No. 10 was short of the margin by 2 millimeters, and the bill was adjusted to $1,215."
? If the margin is short, how can you seat the case?
"So finally, after five weeks of waiting with bleeding gums, those suckers went in. By the way, my Variolink expired a month ago, so I used Denmat Florestore flowable composite to seat the case. Now, you will probably tell me that those won't work with veneers. So here I sit with a big crab apple stomachache waiting for the patient to call telling me they fell off. Her mom just called to say how excited they are with the new teeth! I'm whispering under my breath that I hope I get through the week."
Questions to ponder
1) What mistakes did he make, and how can you, the reader, gain from this story?
2) Why did he change labs in the first place?
3) Was he having problems with the lab?
4) Why would he ask a prosthodontist for a lab recommendation?
5) What does he know about doing veneers?
If I were that dentist, I would have asked a couple of general practicioners who do veneers in the area who they use to fabricate their cases. Bottom line is that he probably was not taking notes when I told him what lab to use. I have spent years developing a close relationship with David Block at Aesthetic Porcelain Studios. He does great lab work for me, and we discuss cases so that I get the best possible results. I know what he wants in impressions and information such as photos.
If I had a case come back looking like this student described, I would send it back to the lab and tell them to forget it. This was not a simple problem, but major problems with a case. Why would you have confidence that the case would come back any better? I would get the patient back in, take new impressions and send the case to a new lab. I would be honest with the patient. Tell her you want this case to be special for her, and in order to do that, you need a new laboratory. I know this is tough both for dentists and patients, but dentists will learn a lesson that won't be forgotten.
When the case came back from the original lab, it still was not right. The lateral was short of the margin. This was another chance to start over, but he didn't. He compromised his principles and seated the case. Now he hears that the patient is excited about how the case looks. Each time that patient comes back to the office for a recall visit, the first thing he'll see in her mouth will be the short veneer. He'll wonder why he seated it in the first place until he finally redoes the case. I tell you this from experience — I already have been in that position and I felt much better when I redid the case.
Consider your staff in a situation such as this. I value my staff's believing in my abilities as a dentist. If they watch you seat a compromised case, then they will think less of you as a dentist. We need great staffs to support us if we are going to have great dental practices. What happens the next time a patient asks one of your staff members what she thinks about having six veneers done? In my office, they quickly respond to do it, "After all, Dr. Blaes is the best!"
The office in question could spend some non-patient time working on its systems. Someone should have checked the resin cement's expiration date. I have used successfully a number of great veneer cements on the market, such as Variolink II from Ivoclar, RelyX veneer cement from 3M, Nexus II from Kerr, and Calibra from Caulk. The flowable composite would not have been my first choice, but it should work.
I think it is important to train for new types of cases such as the first time you seat six veneers. Get your clinical staff together and talk about what you will do. After brainstorming, document your decisions so you may review them again before the appointment. Make sure you have all the materials and instruments you need. There are some specialty instruments from HuFriedy that make seating veneers much easier. Train so that everyone knows what his or her role is during the appointment.
The worst thing that can happen during a veneer seating appointment is bleeding or seeping tissues. One of the most sinking feelings is to see your resin cement turn pink as you push a veneer into place. Get it off quickly and stop the bleeding. Then start again. It is best to avoid these types of problems with proper case care before treatment. Never attempt restorative treatment until gingival tissues are healthy. To maintain health during procedures, we put our patients on a regimen with Tooth and Gum Tonic from the Dental Herb Company. They begin two weeks prior to the prep appointment and continue while in provisionals and for two weeks after the seating appointment. I never have problems with bleeding during cementation appointments.
Restorative dentistry can become an exciting part of your practice if you follow principles that allow you to produce consistent products the entire office will be proud of. Your patients will love the changes you create in their mouths.
