Choices, choices

Photo: RubberBall Productions/Getty Images

Just about every day, a dentist asks Steve Killian, CDT, to use a material he knows won’t work for the cosmetic case in front of him. Maybe the dentist didn’t provide him with all the information he needs 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, he has 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. They (dentists) trust my technical ability,” said Killian, who owns Killian Dental Ceramics. “Nobody wants to risk it not turning out. They want to make sure I’m successful for them.”

Your dentist clients depend on you 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 you create more natural-looking, more functional cosmetic restorations. That’s why it’s so important for you-and everyone at your lab-to really know your stuff, to keep up-to-date on what’s available and to attend the latest CE courses. You need to be able to decide when to use what material and then explain your decision to your clients. That’s a huge part of creating successful cosmetic restorations.

You can be the expert

As more options have become available in the last five years or so, many doctors have become confused about what should be used when, said Daxton Grubb, President of R-dent Dental Laboratory, and it falls to the lab to lead them in the right direction.

All too often, they expect you to use a certain material but don’t give you the information you need to make it work, Grubb said. If they don’t give you the proper prep design and stump shade, you either have to go back to them to get the information you need or tell them what you can successfully do with what you’ve been given.

When a case is underprepared, Killian said he’ll call and ask the doctor if he wants him 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 doctor still can get a high-quality restoration without bringing the patient back in. Not only that, there will be a much greater chance for success than if you went forward without making that call.

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

What you should consider

When you first get a case in, there’s a lot to think about before you decide what type of material to use, including if the restoration is going in the anterior or posterior and how strong it needs to be. But regardless of what else is involved, it all comes down to doing what’s best for the patient.

“The first thing we all need to think about is using the most conservative material that will satisfy esthetics and durability,” said Dr. Ed McLaren, Director of the UCLA Center for Esthetic Dentistry. “It doesn’t matter how good it looks if it breaks, but it also doesn’t serve the patient if you could have used a conservative veneer and the dentist did crowns everywhere. I’m going to use the most conservative material I can.”

Porcelain is the most conservative material for anterior restorations, Dr. McLaren said, and is his first choice for veneers when there is 50 percent of enamel or more remaining on the tooth and a thickness of 0.8 mm or less. If that’s not what you’re working with, Dr. McLaren recommends the second most conservative choice: glass ceramics, which include the leucite-based IPS Empress from Ivoclar Vivadent and Jensen Dental’s Authentic. Both are esthetic, conservative choices for veneers and crowns.

Of course, there will be times when you’re working in a higher-stress environment where you’re more worried about fracture or bruxing. This is when you might want to think about IPS e.max lithium disilicate, Dr. McLaren said. This works better than pure porcelain if you 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 Grubb’s lab, the three most common materials used are Ivoclar’s e.max, Lava Zirconia from 3M ESPE and his own R-brux in-house brand, which are all great choices for single-unit posteriors. He typically uses e.max for veneers and Lava Zirconia for bridges. Those are his materials of choice, but it’s important to remember that every lab is different and has different strengths. Communicate that to your clients, and don’t try to sell them on a certain material because you like to use it; focus on what’s best for the patient.

Educating the dentist

Dentists don’t have a lot of spare time, and some of them may not be willing to return your calls or e-mails to discuss a case. But you can’t miss out on the opportunity to educate those who do. If they wanted you to use Lava or e.max but didn’t provide you with enough information, let them know what you need next time.

Labs should have a technical team that focuses on quality control, Grubb said. Have people on staff who are capable of talking to doctors about preps and making suggestions for improvements. But you have to be consistent. If you call about a case today but miss one tomorrow, it sends a mixed message to the dentist.

Grubb also sends prep models to doctors to give them something they can actually see. His lab even sends doctors the burs he’d like them to prep with, introducing them to a product they may otherwise never have used. This helps get you and your doctors on the same page, and it is a way to build that all-important technician/doctor relationship.

“Labs are inventorying certain things from the clinical side, which is something they didn’t do before. Ten years ago it was paper,” Grubb said. “When you send the same sheet of paper versus putting that instrument or that model in their hand, generally speaking people pick up faster that way. It’s more personal,too. You touch the customer then.”

Why the dentist should be involved 

Even though labs tend to know more about the materials they’re using, the doctor still should be involved in the decision, said Gary Hult, Professional Relations Manager at 3M ESPE. 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,” Hult said. “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 dentist knows the patient the best, 3M ESPE Marketing Manager Angie Hadrits said. They’re going to know individual patient circumstances and any special health concerns. They can provide you 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 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,” Dr. McLaren said. “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, too, Dr. McLaren said. 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 work in partnership with your dentist to determine the best restoration for the patient, said Dr. George Tysowsky, VP of Technology at Ivoclar Vivadent. If you make 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,” Dr. Tysowsky said. “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 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, Killian said. 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, Grubb said. If you go forward without exactly what you need from the prep, including stump shade, your chances of being successful go way down-and that’s even before the restoration leaves the lab.

“It may make it past production, but in one of the next few steps it’s going to fail,” Grubb said. “So if it does make it out the door, if you 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 see 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 your time to become that trusted expert your 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 we should be doing,” Dr. McLaren said. “We evaluate the clinical situation and choose the best material or technique or combination of the two that allows us to treat patients consistent with our philosophy of treatment. People want bright, beautiful teeth. I get that. But how do we get there the least destructive way for the best esthetics and biologic health? There’s usually a clear winner in every situation.”