Can you imagine building an expensive home or a complicated remodeling project without accurate measurements or plans? Unfortunately everyday our dental laboratories are asked to fabricate restorations with inaccurate records. I spoke with lab technician extraordinaire, Walt Richardson CDT from Bay View Dental Laboratory to add a lab’s perspective to my 34 years of dental experience.
Let’s make the assumption that a patient comes to your office with the thought that they may need treatment. Whether it is a new patient or an existing patient, where do you start? We all know the correct answer; the patient is invited for a Complete Exam.
The pre-clinical conversation and exam is the opportunity to make a lasting impression that you are the best dentist for your patient. Listening to your patient’s wants and any barriers to proceeding with treatment is paramount. Both of these pieces of information are crucial for creating a treatment plan that will work for (and be accepted by) your patient.
For you math junkies: Exam Findings + Wants + Barriers = Appropriate Records.
The sequence of Records should be:
- Dawson Academy Photographic Series
- Impressions and Models
- Facebow Record
- Appropriate Radiographs
- Lab Prescriptions
The common areas that we see the need for improvement in records are the following:
- Photos aren’t taken first. You should be taking all of your photos first. They are easier on patients than impressions, the photos can be reviewed for re-takes and it allows your assistant to view the anatomy of the mouth & what must be captured.
- Photos are not on a level plan. The patient should be sitting directly in front of and eye-to-eye with the operator.
- The head is not properly positioned. The majority of mistakes we see with head position is because the head is tilted upward, which makes it impossible to analyze the occlusal plane.
- There is a lack of depth of field caused by shooting at too large a F-stop (aperture).
- You can have over/under expose images.
- Full & Side Face shots are out of focus. This is often caused by not changing your camera to AF and the F-stop is opened to F5.6 for Full face, side view and occlusal plane shots.
- There is no or little difference between close-up smile and E-position photos. You must have your patient exaggerate a smile to show lip mobility.
- They are difficult shots, but full arches need to be complete without showing the opposite arch.
Impressions and Models
- There is a lack of anatomical detail and extension. This is generally caused by lack of impression material or ill-fitting tray. There are circumstances when a custom tray is necessary for a diagnostic casts.
- Matrices don’t fit properly because of distortion in the impressions.
- Models wear quickly & feel soft because plaster is used instead of die stone.
- Mountings are inaccurate because you have not trimmed or groomed your models of blebs and discrepancies. The blebs often become the 1st point of contact.
- The original models aren’t duplicated. This is necessary so there is documentation of the beginning of treatment.
For our instructional video on how to pour proper casts & take flawless impressions, click here.
- Maxillary casts are inaccurately positioned, which represents the relationship between the Maxilla & Condyles. This can be caused by:
- Not accurately using the 3rd point of reference by marking a dot on the patient’s face & placing the reference point locator on the dot.
- Screws on the facebow and transfer jig are not tightened fully.
- Not using a maxillary cast support stand, which causes the bite fork to drop.
- The Maxillary Plane on the articulator does not duplicate that in the mouth. This can be caused by:
- The patient lying back in the chair & not sitting up or standing.
- Not using the level.
Centric Relation Records
- The bite is captured in forward position. This is caused by an improper bi-manual manipulation technique and if the Delar wax is not dead soft. You can read my tips on how to properly perform bi-manual manipulation in this article.
- Improper mountings due to CR bites that have not been trimmed back so there isn’t a stone wax stone relationship. If models are mounted in the office the doctor has not verified that it truly is a CR mounting (notating the first point of contact and verifying it on the model)
- Incomplete lab script. You must include things such as a definite treatment plan and indicate if future treatment may occur. If you have any inaccurate records before this point, your lab prescription will be affected (and inaccurate). For tips on lab communication, click here.
Taking accurate records every time takes practice, but once you have the techniques down and get in the habit, you will see a major difference.anitakhart via Compfight cc