Monday, March 3, 2014

Feelings About Labs

As general dentists, we enjoy a certain degree of autonomy with our work. When I perform a procedure, I like to oversee all aspects of it and therefore, take responsibility if anything goes wrong. I enjoy being in control of the situation and not relying on an outside party for help with this work.

For example, let’s say a patient comes in with a large class IV composite restoration that was done years ago. It is ugly and distracting, and they would like to know what can be done about it. My first thought almost always to redo the composite. Seems pretty logical, right? It would seem so, although not all dentists would go for this approach. I guess it just depends on what you are into. Some dentists like to spend hours trying to find accessory canals in second molars. My biggest practice time-drainer (but also my most enjoyable patient procedure) is contouring and polishing anterior composites.

What else can we do here? Another treatment option for this patient would be a crown (or veneer, depending on the amount of tooth structure present) to restore this tooth. Many dentists prefer this option because they just do their prep and leave the rest of the work to an outside party: the lab. In fact, many dentists will use their lab for just about anything. I recently went to a lecture by a well-known prosthodontist. Let’s just say he was anything but conservative in his treatment planning and was proudly showing off how he places the tiniest class I and II inlays I have ever seen. He LOVES using his lab.

When I send a case to the lab, this is where my loss of control comes in. Since starting to practice, I have dealt with a fair number of them. I like to experiment until I find the perfect match. The problem with labs, however, is that I have not yet found my perfect match. One day, I will get a back a perfectly fitting crown; the next one will come back with extremely overbuilt contacts that I have to spend time adjusting. For the most part though, I have begun to have better luck with single-unit posteriors. My anterior cases are a different story. Granted, I do not do as many of these cases, but the amount of revisions and back and forth messengering that goes into one case makes it seem like a number of different patients instead of just one.

Who is to blame when you get a case back, and it is not what you expected? Keep in mind that you have a disappointed patient in your chair, eager to toss those temporary veneers in the garbage in favor of new shiny permanent ones. It is easy to blame the lab, but you also have to look at yourself and what you could have done. Where your impressions and instructions perfect? Did you miss something? One of the best dentists I know that I really admire said not to cement something in unless it is perfect. I know perfection is not a reality, but I mostly try to follow this guideline instead of desperately trying to adjust a case to make it fit when it seems off at first glance (or try-in).

When you and your lab finally come together and create that perfect smile for your patient, your feelings of hate and frustration instantly vanish, replaced by those of love and admiration. Your patient is happy, and you are ecstatic not to have to make another provisional as well as take yet another impression. However, the memories remain. When that next patient comes in asking about veneers, you start second guessing if you should use that lab again or try another one that will deliver that perfect set of veneers for you on the first try with no adjustments. The color will be amazing, the margins will be indistinguishable. I am starting to realize that this dream of mine is some sort of juvenile myth that I will be chasing for a number of years until I realize that it likely does not exist.

I was watching one of Dr. Frank Spear’s lectures online, and he was discussing permanently cementing a case. He showed photos of his temporaries, and compared them to the final crowns that he received from his lab. Guess what. They were not identical. He mentioned that he always makes adjustments to his final veneers or crowns because, as a lab tech, it is impossible to perfectly duplicate the final shape and contours of your temporaries. You will always have to adjust the occlusion slightly. That is when the light bulb finally went off. If Frank Spear cannot get his lab, which I am sure is amazing, to prevent him from touching those final crowns with a bur, then I really need to calm down.

On the flip side, I am starting to understand all these composite gurus that do so much of it and do it well. They have total control, and although it may seem like a ridiculous undertaking to do an 8-unit case of direct resin when your lab can do the job for you, I am starting to wonder if they are on to something here. Yes, you are dealing with color, contouring and shaping. You will spend hours setting up the case with a wax-up, then polishing and making any occlusal adjustments, but you expect this. When I am spending those same hours adjusting porcelain, I just keep questioning why I decided to go down this road in the first place. I may not have found the perfect lab yet, but I have found the perfect composite, which works better and better every day, the more I use it. Have any of you guys found the perfect lab yet? Do you use several different ones depending on the case or are you loyal to just one?

Have a great week!

Lilya Horowitz, DDS


Jeff C said...

Have you thought about a Cerec?? You may not use it for all your anterior cases, but it will give you total control, perfect contacts and margins, and you can make occlusion adjustments BEFORE polishing and/or glazing!

Lilya Horowitz DDS said...

Hey Jeff,

I have thought about Cerec. I have not had any experience working with it and my office is fairly low volume so I do not think we would be able to justify the costs of having one. In addition, from what I have seen their marginal fit and overall appearance does not seem that great, when I see them in patients mouths and they were done at other offices. I realize this probably depends on how you use them, just with anything and I am sure there is a learning curve but from what I have seen it does not seem like a good alternative for me personally at this time. Thanks for the suggestion!

Chris Perry, MS, DMD, MAGD said...

Lilya: Jeff just stole my thunder, but as I read your post I was thinking you were describing the exact reasons to get a CEREC. As with anything, technique is the key. As with any computer...garbage in, garbage out. however, you will be amazed at the results and how magnifying your work on a 24 inch screen makes you so much better. The fits can be amazing and the fun of staining and glazing your cases is very rewarding for you (and your team if you get them involved). One thing that is great is the consistency from in color from one restoration to the next as you use the exact same material. We just did a hands on program here in San Antonio with the local AGD young dentists group. It was a blast. Come on down and we can play with it. Yes, it is huge investment, but you will recoup it in the overhead saved without a second appointment, materials, provisionalization...and most importantly, with the Omnicam, the patient education you are able to deliver because of the enlarged 3-D color representation of their dentition. Many is the time that I was milling a unit, showed the patient adjacent teeth and ended up restoring multiple teeth at the same time. It's the best intra-oral camera on the planet. Great post. Chris

lilya Horowitz DDS said...

Thanks Chris!
I do see the appeal of the CEREC. I actually use an Itero scanner in my office for most of my posterior restorations and I do like having the camera and seeing the details of the prep a lot closer. Do you ever use it on anterior cases as well?

Bob Oro, DMD, MAGD said...


As my wife does all the cementations I will tell you what I have observed from her treatment over 35 years.

First we do very few veneers now a days as our patient are all over 50 and need more than veneers to support them.
Secondly when my wife went for porcelain veneers back in the 1980s it was really challenging to get the right esthetic look from any lab.

Since 2000 most of her treatment is about changing the facial esthetics of the patient as she creates the new VDO and smile.
Any restorations from the lab will usually need adjustments in the mouth to account for asymmetries of the face, lips, nose etc. This is very hard for the lab to see from models and photos.
They get close but her customization is really amazing and appreciated by the patient.

Many labs will give you great work the first couple of times but if quality fades with time it is time to look for another lab.

Enjoy the Journey,
Bob Oro (for my wife/partner) Debbie


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