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					          FOCUS                                          Esthetic


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                                                         Dentistry

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                                                Taking your practice to the next level




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                                                                        Jack D. Griffin Jr., DMD, MAGD

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    Cosmetic dentistry has changed our profession                       Fig. 1



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    forever. Advancements in education, materials, and tech-
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    niques have expanded our choices in care as well as changed
    patient attitudes toward dental care. Patients now have a
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    great sense of cosmetic awareness and an acute sense of what
    they want. These are unprecedented times in our profession,
    and the pressure is on to provide care that meets the patient’s
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    vision.
       Because of all of this, we must be on top of our game
    when it comes to providing cosmetic services. It is critical
                                                                      Fig. 1: Despite doing all phases of general dentistry, our patients clearly see
    to be organized, confident, and competent in our esthetic
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                                                                         the emphasis we put on beautiful smiles from our wall art, photo gallery,
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    endeavors, whether doing esthetic procedures everyday in             and enthusiastic staff.
    a cosmetic-minded practice, or for those just beginning to
    focus on esthetics. The following is a systematic approach        2. Learn from the masters
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    to consistent success in esthetics, regardless of perceived       We are dentists — we
    skill or experience level.                                        have a license to drill.
                                                                                                             Fig. 2
                                                                      However, before laying a
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    1. Create an esthetic environment                                 bur to a tooth, we need to
    “I came to the right place … this is where I want my cos-         have a clear idea of what
    metic work done!” When patients walk into our office and
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    meet the staff, we want them to be confident in our abil-         Fig 2: Our consult room features
                                                                         dimmed lighting and a
    ity to satisfy their needs and be comfortable in their deci-         PowerPoint presentation set
    sion to improve their smiles in our office. Patients are well
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                                                                         to music that we show to
    informed about cosmetic dentistry with Internet research,            any patient who asks about
    magazine articles, and advertising. They come prepared.              cosmetic procedures. This
                                                                         also allows the patient to
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    They notice and scrutinize our preparation, organization,            see what type of work we do
    and methodical attention to detail. Office clutter, chaos, and       and build confidence in our
    carelessness are turn-offs to the quality-seeking patient.           abilities.
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       We have no Beverly Hills or Manhattan practice, but pa-
    tients can readily see that we feature esthetic dentistry from      Action items to create a cosmetic environment
    our wall gallery, computerized office portfolio, and staff             1. Keep office clean, fresh, and modern
    members who are always eager to show our work (Fig. 1).                2. Have staff knowledgable and excited for
        No




    It cannot be emphasized enough that the staff is as critical              esthetic care
    in cosmetic case acceptance as any other persuasive com-               3. Wall art: portraits of cases the office has
    ponent. When they show patients the finished cases they                   done
    helped to create, the enthusiasm is transferred to the patient         4. Office portfolio: photo album, PowerPoint
    (Fig. 2). We want the staff to say, “Look what we did!” That              show
    in itself is our number-one case closer in this practice.              5. Web site to impress and educate


1   January 2009 | www.dentaleconomics.com                                                       www.dentaleconomics.com | January 2009
                                                        FOCUS ON: Esthetic dentistry

    materials, procedures, and techniques we’ll need to be suc-                    work will become. Seeing your own work on large moni-




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    cessful. This comes from experience, training, or a mentor.                    tors can be quite humbling and provide the stimulus to be-
    There are more courses, continuums, webinars, institutes,                      come better. Great photography is also the backbone for




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    and journals promoting esthetic education than in the his-                     good communication with your lab technicians. We want
    tory of dentistry, so acquiring knowledge is easy.                             them to experience the case with us, and photography can
       Let someone else make the mistakes and have the head-                       bridge that link between the lab bench and the treatment




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    aches of trial and error, then learn from them. It’s seldom                    chair. This is described in the box below.




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    about anything new at this point, rather it’s about taking
    what works for others and melding it into a system that suc-                    Use of photos during a cosmetic case:
    ceeds in your hands. Acceptable esthetics in today’s world is                     1. Analysis of case — full series taken for pre-




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    far from slapping some porcelain on teeth. Combining pe-                             op record; studied away from operatory
    rio, occlusion, materials, photography, tooth preparation,                           distractions to form operative plan, then
    and lab excellence with patient management is the key to                             reviewed with ceramist




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    acceptable treatment and happy patients. Seeing what does                         2. Pre-op lab communication — pre-op images




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    and doesn’t work for other skilled practitioners can build                            allow ceramist to help plan the difficult




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    confidence and form the mental framework for our case                                 case, review preparation needs, and help
    success.                                                                              with material selection




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    3. “Say cheese”… do excellent photography
                                                                                      3. Patient consult — pre-op shown to patient
                                                                                          to reinforce recommended treatment; large
                                                                                          monitor will make patient more aware of
    Marketing is the process of getting patients to want the

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                                                                                          cosmetic needs
    dentistry that we like to do. Quality images are instant
                                                                                      4. Treatment images — allow ceramist to
    credibility. It’s not about making the whole world a bleach                          “experience” case; photos of mock up,
    shade or insisting that everyone needs veneers; it’s about
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                                                                                         temps, bite alignment guide, prep shade
    stirring patient desires, stimulating them to take action,                        5. Postcementation images — check for
    and showing them we can achieve the results they want.                                cement removal and places that need to
    This is a key in increasing the number of cosmetic cases.                             be recontoured evaluate work for needed
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       There are many photographic “series” formats to choose                             enhancements
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    from. The key is to be consistent with the images and                             6. Postop images — Two to three weeks after
    choose a series that fits your needs. We never get a second                           final cement removal and adjustments,
    chance to take pre-op images, so be consistent with your                              repeat pre-op series, analysis of techniques
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    photography so that it becomes as important in treatment                              and materials, marketing
    as radiographs or an exam.
       The office portfolio is the best way to showcase staff tal-                 4. Visualize — know where you are going before
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    ents and transfer that excitement to the patient. These im-                    you start
    ages should be consistent throughout all aspects of patient                    If you don’t have a clear vision of a great finished case in your
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    education and marketing: wall art, album portfolio, consult-                   mind, don’t prep. Our greatest source of information and
    room PowerPoint slides, operatory monitors, Web site gal-                      confidence during a case often comes with the ceramist. Not
    lery, and external advertising. The portrait is the “emotional”                only do they do these cases daily, experienced ceramists can
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    stimulus that actually sells cosmetic dentistry (Fig. 3).                      help with needed preparation amounts, temporary matrix
       Photography is often regarded as merely a marketing                         fabrication, and material selection. Use their advice, prepa-
    tool, but the better your photography skills, the better your                  ration guides, and experience to help you efficiently prep the
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                                                                                   case, which will reduce problems at insertion (Fig. 4).
     Fig. 3                                                                           Before the prep appointment, take time to look at the
                                                                                   pre-op digital images on a large monitor away from the
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                                                                                   normal distractions of the dental office. Print photos to dis-
                                                                                   play in the operatory during preparation, and use them like
                                                                                   a builder would use blueprints during construction. These
                                                                                   photos can be marked with desired soft- and hard-tissue
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                                                                                                                      Fig. 4: Feedback from a skilled
                                                                                                                        ceramist is key in esthetic den-
                                                                                                                        tistry. Wax ups, reduction guides,
                                                                                                                        preparation indices, and other
    Fig. 3: The great emotional selling image is the portrait. Play with various                                        feedback before preparation is
       poses and use them in office wall art, Web site gallery, and other means     Fig. 4                              key to stress-free success.
       of marketing.



2   January 2009 | www.dentaleconomics.com
                                                       FOCUS ON: Esthetic dentistry




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     Fig. 5                                                                        It can be a daunting task to create beauty in patients’
                                                                                minds once advertising, the Internet, their friends, and




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                                                                                their own visualizations have skewed what they see. It mat-
                                                                                ters not that the margins are perfect, the anatomy is perfect,
                                                                                and the result is world class — if the patient isn’t happy.




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                                                                                Not meeting patient expectations can make for a miserable




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                                                                                practice life. From the first cosmetic consult through de-
                                                                                livery of the restorations, we are careful in our description
                                                                                and promises. We must exude confidence to patients while




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                                                                                tempering expectations.

                                                                                6. Lab communication is key: photos + models +




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                                                                                feedback = great case




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                                                                                An experienced lab that understands esthetics is critical.




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                                                                                Regardless of how great your case planning is, poor lab
                                                                                work will ruin the case. However, their artistry can never




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    Fig. 5: Reviewing pre-op photos and using them as “blueprints” during the
       preparation appointment can be an invaluable tool.

    preparations and placed in the operatory during treatment
                                                                                be better than the quality of work you send them. The lab
                                                                                should have experience with a variety of esthetic materi-
                                                                                als, and above all, be willing to discuss treatment options




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    (Fig. 5).                                                                   to optimize outcome. If they aren’t willing to share ideas
                                                                                and experience with a cosmetic case, they may not be the
    5. Manage the patient                                                       right lab for the case. By the same token, a dentist with the
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    It’s amazing how we all want to “graduate” from just regu-                  attitude “I have the degree, how dare they suggest chang-
    lar old family/general dentists to “cosmetic” dentists — as                 ing my plan” is self-centered instead of patient-centered.
    if keeping the world in sound, healthy, able-to-chew-with                   The best results are achieved by open communication and
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    teeth isn’t enough. I am one of those family dentist types                  working together.
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    who has recession-proofed my practice by doing all types of                    Obviously, void- and distortion-free impressions, accurate
    dentistry. However, our two to four cosmetic-enhancement                    occlusal records, and excellent tooth preparation are needed,
    cases per week have provided our staff with the wonderful                   but we must be diligent in our case materials and consis-
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    positive feedback this treatment can provide, while at the                  tent in what we send to the lab (Fig. 6). You cannot expect
    same time confirming over and over just how meticulously                    work back from the ceramist that is better than what you
    picky many of these patients can be (see box below).                        gave him or her. Allow an experienced technician to discuss
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    Management of the esthetically conscious patient:
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    1. Never imply “perfection, “permanent, or “exactly.
                                 ”              ”          ”                            restorations, and they are an important “trial” phase
       Instead, communicate that “we are working together                               for the final restorations. Use a shade that is similar to
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       to create a smile ideal customized for your teeth and                            the color chosen, and tooth shapes will be similar to
       face.”                                                                           what you are trying to achieve.
    2. Show the patient before-and-after cases that you and                        6.   After cementation, stress to the patient that work is
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       your staff have done, so there is no misconception                               not finished. Further clean up, bite adjustments, and
       of what can be done in your office. If you have an                               flossing will be done in one week.
       office portfolio in an album or PowerPoint show, let                        7.   Tell the patient that “Someone you are close to will say
                                      for




       your patients point out the tooth characteristics they                           they are ‘too long,’ ‘too white,’ or ‘too straight’ simply
       like most and use that as a “rough template” for their                           because they are used to seeing you with your old
       makeover.                                                                        smile. Changes will take time for everyone to adapt to.
    3. Before treatment, encourage patients to help with                           8.   Inform the patient that we will make no changes to
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       shade selection (from photos of old cases, shade                                 length or appearance for two weeks to allow time to
       guides, etc.) and have them sign in their chart the                              adapt. Then you can adjust the porcelain slightly to
                            No




       shade they selected.                                                             alter length and shape if needed.
    4. For the mock-up (without anesthesia), allow                                 9.   Most important, be positive. You and the staff need
       patients to preview it. Listen to their concerns, make                           to tell the patient how good he or she looks. Remind
       corrections, and take photos and impressions to                                  them of how they looked before treatment by showing
       communicate these likes and dislikes with the lab.                               the pre-op photos and point out the changes that have
    5. Stress that the provisionals are a basic and “rough”                             been made.
       idea of what you are going for in the final




4   January 2008 | www.dentaleconomics.com
                                                       FOCUS ON: Esthetic dentistry

      Fig. 6                                       Fig. 7                                                Fig. 8




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    Fig. 6: Nothing can replace accurate         Fig. 7: Show everything to help ceramist properly
       physical records — ceramists can only        contour and shade the case. All phases of treat-




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       do work as good as the quality of mate-      ment should be shown with all cases, including
       rials we send them.                          tooth preparation color so proper translucency/
                                                    opacity can be placed into the restorations.       Fig. 8: Pre-op, mock-up, and temporary smile with patient




                                                                                                        dis
                                                                                                          feedback can be invaluable as the ceramist decides
    things with you if preps, impressions, Fig. 9                                                         incisal edge position and final proportions. This is par-
    or materials requested would give a                                                                   ticularly true in canted or midline discrepancy cases.




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    compromised result. Be consistent                                             up a veneer in the suction.




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    from case to case by providing them                                               By sticking to an organized sequence of
    with excellent written descriptions of                                        treatment and keeping meticulous attention to
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    what you and the patient want (Fig.                                           detail, every practitioner can experience great
    7). Let them know what luting materi-                                         rewards in cosmetic dentistry. What a great


                                                                                        tro
    als you plan to use and show them the                                         time to practice dentistry.
    mock-up, temporaries, and preparation
    shades (Fig. 8).                                                              Jack D. Griffin Jr., DMD, FAGD, PC,
                                                                                 lec
       It is so easy to blame the lab for a                                       practices in a very busy high-tech
    failed restoration. We are quick to                                           practice that emphasizes cosmetics
    send them a re-make form and criti-                                           while doing all phases of modern den-
                                                                           re

    cize their work, but when was the last                                        tistry. He has been honored by being
    time we told them “Great case!” and Fig. 9: The ceramist must be givensent to published many times and asked to
                        Pr

                                              positive feedback. Images are
    sent them photos? (See Fig. 9.) Allow     him or her to show good results and speak to many groups on digital pho-
                                                                   no



    them to bask with you in the glory of a   cases that met expectations.        tography, esthetic veneers, CAD/CAM restorations,
    great case — it may help the next time                                        practice management, and practice promotion. You
    you ask for a “rush” on a veneer case or accidentally suck may contact him via e-mail at Esmilecenter@aol.com.
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                                                                                    ▼ Photos or digital images (CD, card, e-mail)
    Cosmetic checklist for every cosmetic case:
                                                                                        • Pre-op
                                                                                        • Prep shades
                                                       ca




    ▼ Written description of case history, treatment, and
                                                                                        • Bite alignment guide
       expectations
                                                                                        • Mock up or accepted temps
        • Approval of plan by patient
                                                                                    ▼ Patient experience and feedback about temporaries
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        • Forms signed
                                                                                        • Esthetic check
        • Color and shape selection by patient; signature in chart
                                                 ub




                                                                                        • Phonetic check
        • Review of treatment with patient
                                                                                        • Function check
    ▼ Prepreparation co-planning with the technician
                                                                                        • Impression and photos taken
        • Wax up
                                                                                    ▼ Seating appointment
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        • Reduction guide
                                                                                        • Removal of temps
        • Stent for temporaries
                                                                                        • Verification of fit
        • Feedback on material considerations and case limitations
                                                                                        • Cleaning and bonding of restorations and teeth
    ▼ Pre-anesthetic mock-up on patient
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                                                                                        • Placement of luting material. seating, curing, clean up
        • Esthetic check
                                                                                        • Occlusal adjustments
        • Phonetic check
                                                                                    ▼ Patient expectations
        • Function check
                                                                                        • Home care
        • Impression and photos taken
                                                                                        • Adjustment period
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    ▼ After preparation — impressions or models to lab
                                                                                        • Followup visits
        • Pre-op
                                                                                        • Bruxism splint (if needed)
        • Preps
                                                                                    ▼ Follow-up care
        • Bite alignment, occlusal guides
                                                                                        • Final images
        • Opposing
                                                                                        • Consent for image use in marketing
        • Mock up or accepted temps
                                                                                        • Recall schedule

6   January 2009 | www.dentaleconomics.com

				
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