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