Choices, Choices

Just about every day, a dentist asks me to use a material I know won’t work for the cosmetic case in front of me. Maybe the dentist didn’t provide me with all the information I need to use that particular all-ceramic material, or maybe the dentist’s material of choice just isn’t strong enough for the type of restoration he’s creating. Regardless of the problem, I have to explain to the dentist why it won’t work and why another material is better.

If I’m asked to use something and I disagree then I’ll explain why. We usually end up doing it my way. Dentists trust my technical ability. Nobody wants to risk the case not turning out the way it supposed to turn out.

My dentist clients depend on me to choose the best material for their cases. It’s often left to the technician to educate the clinician about those materials, and the number of options just keeps growing, with many of them combining both strength and esthetics to help us create more natural-looking, more functional cosmetic restorations. That’s why it’s so important for technicians- and everyone at the lab- to really know their stuff, to keep up-to-date on what’s available and to attend the latest CE courses. We need to be able to decide when to use what material and then explain your decision to your clients. That’s huge part of creating successful cosmetic restorations.

Becoming an Expert
Laboratory owners realized that as more options have become available in the last five years or so, many doctors have become confused about what should be used when, and it falls to the lab to lead them in the right direction.
All too often, dentists expect technician to use a certain material but don’t give us the information we need to make it work. If we don’t have proper prep design and stumps shade, we either have to go back to dentists and get the information we need or tell them what we can successfully do with what we’ve been given.
When a case is under prepared, I’ll call and ask the doctor if he wants me to adjust the prep or provide another restoration. It may be a slight compromise over what the doctor asked for originally, but it saves time and money. The doctors still can get a high-quality restoration without bringing the patient back in. I understand that by making a call I allow for this restoration to have a much greater chance for success than if I went forward without making that call.

Technicians are getting more involved. The pressure is getting put more on labs to learn the products. It gives us more credibility. We can give option. It’s saying I can’t do an e.max but I can to another all-ceramic that will look beautiful. Here are the options. It boils down to giving doctors more choices and not just telling them yes or no.


What You Should Consider
When we first get a case in, there’s a lot to think about before we decide what type of material to use, including if the restoration is going in the anterior or posterior and how strong it need to be. But regardless of what else is involved, it all comes down to doing what’s bet for the patient.
The first thing I always think about is using the most conservative material that will satisfy esthetics and durability. It doesn’t matter how good it looks if it breaks. I’m going to use the most conservative material I can.
Porcelain is the most conservative material for anterior restoration, and it should be dentist’s first choice for veneers when there is 50 percent of enamel or more remaining on tooth and thickness of 0.8 mm or less. Every case is different and if that’s not what you’re working with, than the second most conservative choice: glass ceramics, which include the leucite-based IPS Empress from Ivoclar Vivadent (ivoclarvivadent.com) and Jensen Dental’s Authentic (jensendental.com). Both are esthetic, conservative choices for veneers and crowns.
Of course, there will be times when dentist working in a higher-stress environment where s/he is more worried about fracture or bruxing. This is when you might want to think about IPS e.max lithium disilicate. This works better than pure porcelain if dentist have to bond to dentin, which is more flexible than enamel and requires something stronger when bonding to it. Empress also is a good choice in this situation, but you do get more strength from e.max and less chance of fracture.
At Impressive Dental Studio, the two most common materials used are Ivoclar’s e.max and Inceram Zirconia YZ 2000, which are all great choices for single-unit posteriors. We typically use e.max for veneers, single anterior and selective posterior restorations and Zirconia for bridges and single posterior restorations. Those are our materials of choice at Impressive Dental Studio. We communicate that to our clients, but we don’t try to sell them on a certain material because we like to use it, we focus on what’s best for the patient.


Educating the Dentist
I have been working with dentists for over 32 years and I know that they don’t have a lot of spare time, and some of them may not be willing to return calls or emails to discuss a case. But I don’t miss out on the opportunity to educate those who do. If they wanted me to use Lava or e.max but didn’t provide enough information, I let them know what I need next time.
We, at Impressive Dental Studio, take quality control very seriously. Case is being monitored from the very beginning it enters the lab and until it is in the box and ready to go to the doctor’s office. We do it consistently to let dentists know that we are watching out for them and their patients.


Why the Dentist Should Be Involved
Even though lab techs tend to know more about the materials we’re using, the doctor still should be involved in the decision. The dentist and lab technician should come to a collaborative decision about what restoration is best for the patient.

Unfortunately, dentists too often delegate that to the lab and just tell them what shade they want. They don’t get into a discussion about the benefits and limitations of different restorations in terms of what they’re trying to clinically accomplish. Labs and dentists should understand enough based on the patient’s situation and overall clinical needs to determine what would be the optimal choice for the patient.

The dentists know patients the best and they’re going to know individual patient circumstances and any special health concerns. They can provide dental technician with relevant information as well as photos to help the lab create a restoration that the lab, the dentist and the patients are happy with- and an open dialogue is the key to making that happen.

Ultimately, a great ceramist can make an average dentist look great. A bad ceramist can make a great dentist look bad. The ceramist is an important part of the team. There needs to be a close dialogue between the two. It’s not 100 percent the dentist prescribing to the technician. And as patients become more and more informed about their options, they may have an opinion about what’s going in their mouth, as well. For instance, many patients don’t want metal restorations, and zirconia is a strong, esthetic option that can meet that need.


What Can Go Wrong
“Choosing the wrong material can lead to a variety of problems and is just another reason it’s so important to have a partnership between dentist and technician to determine the best restoration for the patient, said Dr. George Tysowsky, VP of Technology at Ivoclar Vivadent. If dentist makes the wrong decision, it’s the patient who suffers.

When choosing a material there is always a fine balance of strength and esthetics that one must consider. If we choose materials that have the highest strength often times they don’t provide the optimum esthetics, and the final outcome can be opaque and not esthetically pleasing to the patient. On the other hand, if we choose a low-strength translucent material, it may not have the final strength requirements to support the function that is required in the appropriate clinical situation. We want a material with a naturally esthetically pleasing result but yet the material which ultimately survives and provides the appropriate function for the appropriate area.

Making the right material choice is especially important when it comes to all-ceramics; the wrong choice can mean complete disaster. There is such a variation on strength and translucencies that using the wrong material can lead to fracture or esthetic failure.

With many all-ceramic materials, the manufacturers make it clear what you’ll need to be successful. If we go forward without exactly what we need from the prep, including stump shade, our chances of being successful go way down- and that’s even before the restoration leaves the lab. Such restoration may even make it past production, but in one of the next few steps it’s going to fail. So if crown does make it out the door, if we sacrificed on requirements with that material there’s a great chance it will fail during seating or after seating.


Your Options Are Growing
Materials development for esthetic restorations is an exciting area, Dr. Tysowsky said, with many new technologies on the horizon. And with all the materials that are coming out, it’s more important than ever to keep up to speed on what’s available and to know what works best in different situations, to make sure you and your clients are providing the best possible restorations with the best esthetic and functional results.

There are now materials like IPS e.max that offer strength and esthetics, something that hasn’t always been available, but is a trend that experts expect to continue.

As the options continue to grow, dentists will depend on their labs more and more to steer them in the right direction- especially when it comes to using something new. This is our time to become that trusted expert our dentist/clients turn to, the one who keeps them from a mistake that will cost them time and money and leave them with an unhappy patient.

Dentists may take a material and try to fit the clinical situation to the material, adapt the patient to the material. That’s not what they should be doing. Dentists should evaluate the clinical situation and choose the best material or technique or combination of the two that allows them to treat patients consistent with their philosophy of treatment. People want bright, beautiful teeth. I get that. But how do we get there with the least destructive way for the best esthetics and biological health? There’s usually a clear winner in every situation.