Monday, April 2, 2012

Shades and Cosmetics

Spring is here. Everything in north central Florida is neon green. The weather is nice enough to break a sweat in shorts and a tank top, so we must jump in the pool to cool off. Hope that does not make any of our northern readers to upset.

Let's talk about shades and cosmetics. I have a case on a very sweet girl I am trying to get nailed down on No. 7. Let me go over the history of this tooth and how we got to where we are today.

This tale starts about three years ago when “Susie Q” walks in the door with No. 7 fractured just above the attached gingiva. The tooth had previous endo with a build up and no post from an unknown provider. The tooth/crown and buildup had fractured. We go over the options and decide a post and crown would be needed, though somewhat guarded due to the limited ferrule effect.

Everything goes well, at least for about three years. Then she comes back one day with the root fractured No. 7. Now, after a lengthy discussion, we decide an implant was best since three-fourths have had very little restorative work. My office refers her to an implant place and everything goes well. After initial healing, we place a temporary to help soft tissue development. After a few months everything is going well and we start the restoration process. The patient has thick biotype tissue and everything is healing well. We end up using a Atlantis custom abutment with a layered zirconia crown.

Now the fun begins. No, it is not the dreaded black triangles of death! But, the shade and cosmetics of the crown is driving the patient and me crazy. After about six shade checks, multiple photos, the lab sending a ceramist over for a shade match, and the patient traveling about 75 miles to the lab for an in lab shade match—we get it.

Before she goes to the lab, I tell her to look at everything, the shade, phonetics ... I mean everything! I tell her not to leave the lab until she is totally happy with the crown. She returns from the lab and everyone agrees the color is great, finally. It is cemented and everyone thinks it looks great.

Well, that does not last long. A few phone calls later, the patient decides she needs me to look at it. She now thinks that it is on crooked and the contour is not right. She has gotten herself worked up in such a emotional mess over the weekend about it. “Susie Q” says her family thinks it looks great and they all like it. However, she is just not sure if she likes it! There is a little too much roundness to the facial and the incisal edge is a tad to flared.

I tell her that there is only so much I can do to change it, and that all the shading is on the surface so the color could be effected if I adjust it. Reluctantly, I break the glaze and adjust the crown. I make a few changes to the labial and line angles and she thinks it looks better. I am not sure how she will feel in a few days, but at least now she seems happy.

I get a case like this every few years, and it is always a single anterior on a female. I always tell them before we start that one of the more difficult things for a dentist to do is match a single anterior front tooth! I warn them it could possibly take several shade checks and visits to get it right. I want to warn them and set their expectations before beginning so it does not look like I am a bumbling idiot every time we have to send it back. This crown takes the cake. It has been the most difficult one in a while.

I know there are all kinds of gadgets out there for shade matching. We look at them in natural light with neutral backgrounds, all that text book stuff. Sometimes the human/emotional factor will override everything. I want to make my patients happy; however, chasing perfection with a patient can make you go crazy at times—especially when it seems perfection is a moving target.

Have a good week!



Anonymous said...

Perfection is in the eye of the beholder.

Anonymous said...

OK, I give up. What's going on in the photo at the top of your blog?

Anonymous said...

As a dentist, I can see so many shades of white that I absolutely hate single anterior crowns. I can accept nature's imperfections but have never met a constructed crown I was 100% happy with, even those done by the best- not a happy place to be.

gatordmd said...

The photo at the top is a picture I took when I was doing Class V fillings on #10 and #11. I use a product from Triodent (which now will be Ultradent) called the 360 matrix.
It is clear mold that you push against the tooth and then cure through the matrix.
The pink things are what you hold the matrix against the tooth with.
I really really like them.


Anonymous said...

You have a few options when doing single centrals: 1) refer them out 2) charge patients by the hour to do them so you don't go broke trying to provide a really good result 3) quit doing them.

After 19 years of practice, I know when I'm beat. And certainly no amount of mental prepping of a patient beforehand will work as you found out.

So now before I take on a single central case I look good and hard at the colour AND the patient. If either one is a little squirrelly, I refer it out. End of headache. I can lose money sitting at home doing nothing instead of than raging forevermore over trying to get porcelain to match enamel. G

Oh and btw, the ONLY way to do class 5's is with those press on matrices!


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