DR. DENNIS HARTLIEB
The Complex Esthetic Case Checklist
Systematic Management for Success
Providing excellent cosmetic dentistry has so many inherent challenges that it is impossible to list them all. In the early stages of my career, just learning what makes a smile look esthetic was an incredible learning opportunity. I fell in love with discovering information on the macro esthetic issues such as tooth size and tooth display, gingival heights and shape, lip movement, facial balance and symmetry – so many variables that are critical when designing and creating a natural and esthetic smile. Then zooming in to look at the micro esthetic issues: gingival and incisal embrasures, line angles and light deflection zones, surface morphology and texture…just so many things to manage with our esthetic cases. When we are doing freehand bonding, we have all of those challenges in our own hands – we control it all. Tooth length, tooth form, surface morphology, midline angulation – it’s all ours. On the other hand, when we are doing indirect restorations, we are dependent on our lab partners to manage many of these issues. I believe that one of the key ingredients to having a successful relationship with our lab technicians is to put them in a position to win. What does this mean – putting them in a position to win? Let me explain.
To begin with, if we are expecting great things from your dental lab technician, we need to provide them with great things from our end. Our diagnostic work up needs to be spot on – if the patient has a canted midline or a canted occlusal or smile plane, this is information that needs to be shared with the technician before beginning the treatment. How is the cant going to be resolved? How do the preparations need to be changed so that the technician can hide the cant? Once we have reviewed the case with our technician and have started the treatment, we need to be certain that we accurately transfer the maxillary cast to an articulator so our technician has a horizontal frame of reference when they are creating the restorations. We must give our technicians impressions that are accurate and show the detail of the margins. That means understanding preparation design so that our lab partner has the restorative space to create the ideal restorations. All of this is of course dependent on creating nice tooth preparations and having nice tissue management.
Finally, for our indirect esthetic cases, we need to create provisional restorations that guide the technician on the tooth shape, length and form that the patient desires with their definitive dentistry. It is a terrible idea to rely on the laboratory technician to create the final tooth form without understanding the patient’s goals and desires. By creating esthetic provisional restorations (temporaries), we can engage with our patients about what they like, and more importantly, what they don’t like with their current temporaries. This information then can be shared with our technician so that they can follow the shape and form of our provisional restorations but improve on the esthetic features dictated by the patient. The closer that our provisionals are to the patients demands, the easier it should be for the lab technician…they just need to recreate the same form that we have created. No guess work, and critically, no surprises for the patient at time of delivery (and much less stress for us at the seating appointment). So, if we want to have a great partner in our lab technician, we need to make sure that we are doing our part as well.
Finally, for our indirect esthetic cases, we need to create provisional restorations that guide the technician on the tooth shape, length and form that the patient desires with their definitive dentistry. It is a terrible idea to rely on the laboratory technician to create the final tooth form without understanding the patient’s goals and desires. By creating esthetic provisional restorations (temporaries), we can engage with our patients about what they like, and more importantly, what they don’t like with their current temporaries. This information then can be shared with our technician so that they can follow the shape and form of our provisional restorations but improve on the esthetic features dictated by the patient. The closer that our provisionals are to the patients demands, the easier it should be for the lab technician…they just need to recreate the same form that we have created. No guess work, and critically, no surprises for the patient at time of delivery (and much less stress for us at the seating appointment). So, if we want to have a great partner in our lab technician, we need to make sure that we are doing our part as well.
The following is a checklist that I have created to help you provide ideal communication with your lab technician when treating complex cosmetic cases (I use a checklist similar to this in my own practice).
Pre-operative
1. Preoperative photographs, x-rays, study models, facebow/earbow, CR bite (if necessary)
2. Case mounted on articulator – evaluate to be certain consistent with patient’s appearance
3. Place photographs in dropbox or some other suitable way to allow lab technician to view patient case
4. Phone conversation or person-to-person review of proposed treatment with lab tech
5. Review with patient treatment recommendations/needs
2. Case mounted on articulator – evaluate to be certain consistent with patient’s appearance
3. Place photographs in dropbox or some other suitable way to allow lab technician to view patient case
4. Phone conversation or person-to-person review of proposed treatment with lab tech
5. Review with patient treatment recommendations/needs
Treatment
1. Shade photos of adjacent teeth if matching or lower teeth if full arch
2. Anesthesia
3. If intra-oral scanning, scan both arches and erase teeth to be prepped
4. Prep right or left side of arch only
5. Fabricate provisionals for the prepped ½ of arch – evaluate midline and provisional length relative to unprepared other half of arch (I take photographs with patient sitting upright in assistant’s stool with retractors in). This allows me to be certain that I am not canted in my preps/provisionals and if I’m not looking to add length, I can document that the provisionals are the same length as the unprepped side. If I am planning on adding length, then I can measure the length added on the provisionals. Adjust occlusion if maintaining the VDO (critical)
6. Anesthetize and prep other half of arch
7. Try-in impression tray (if needed)
8. Isolate, place retraction cords or laser tissue trough…prepare for impressions
9. Photo of preps with shade tabs for lab
10. Scan or impression materials reviewed with team members
11. Remove retraction cords, rinse, or cleanse preps with Concepsis or other appropriate solution
12. Impression…evaluate impression, retake if necessary
13. Bite registration. Because we adjusted the provisionals for the first side prepped, we can place those provisionals when taking the bite registration for the other side, then use the bite registration of the second side to go back and take the bite registration of the side that we placed the provisionals
14. Trim bite registrations, verify fit and accuracy
15. Fabricate and adjust provisionals for 2nd half of arch
16. Full face photo with retractors in place for evaluating horizon/prep plane
17. Cement provisionals, final adjustments
2. Anesthesia
3. If intra-oral scanning, scan both arches and erase teeth to be prepped
4. Prep right or left side of arch only
5. Fabricate provisionals for the prepped ½ of arch – evaluate midline and provisional length relative to unprepared other half of arch (I take photographs with patient sitting upright in assistant’s stool with retractors in). This allows me to be certain that I am not canted in my preps/provisionals and if I’m not looking to add length, I can document that the provisionals are the same length as the unprepped side. If I am planning on adding length, then I can measure the length added on the provisionals. Adjust occlusion if maintaining the VDO (critical)
6. Anesthetize and prep other half of arch
7. Try-in impression tray (if needed)
8. Isolate, place retraction cords or laser tissue trough…prepare for impressions
9. Photo of preps with shade tabs for lab
10. Scan or impression materials reviewed with team members
11. Remove retraction cords, rinse, or cleanse preps with Concepsis or other appropriate solution
12. Impression…evaluate impression, retake if necessary
13. Bite registration. Because we adjusted the provisionals for the first side prepped, we can place those provisionals when taking the bite registration for the other side, then use the bite registration of the second side to go back and take the bite registration of the side that we placed the provisionals
14. Trim bite registrations, verify fit and accuracy
15. Fabricate and adjust provisionals for 2nd half of arch
16. Full face photo with retractors in place for evaluating horizon/prep plane
17. Cement provisionals, final adjustments
Related Course: Digital Dental Photography
Postop appointment (about 3 -5 days later)
1. Review with patient likes and dislikes with provisionals
2. Adjust provisionals to patient’s satisfaction
3. Photographs of provisionals (this is critical)
4. Study cast of provisionals (critical)
5. Facebow / earbow of provisionals
2. Adjust provisionals to patient’s satisfaction
3. Photographs of provisionals (this is critical)
4. Study cast of provisionals (critical)
5. Facebow / earbow of provisionals
Materials to send to lab
1. Impressions (digital or analog)
2. Facebow or earbow of provisionals
3. Model of provisionals (after adjusting and approved by patient)
4. Bite registrations
5. Shade photos of preps
6. Photos of patient with provisionals
7. Lab slip specifying material choice, shade of desired restorations and notations regarding changes from the provisionals for definitive restorations based on conversation with the patient
Go to our discussion page and leave a comment. I’d love to hear any feedback on this post!
Yours for better dental health,
2. Facebow or earbow of provisionals
3. Model of provisionals (after adjusting and approved by patient)
4. Bite registrations
5. Shade photos of preps
6. Photos of patient with provisionals
7. Lab slip specifying material choice, shade of desired restorations and notations regarding changes from the provisionals for definitive restorations based on conversation with the patient
Go to our discussion page and leave a comment. I’d love to hear any feedback on this post!
Yours for better dental health,
Dennis Hartlieb, DDS, AAACD
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Meet Dr. Dennis Hartlieb
Dr. Dennis Hartlieb owns his own practice in Chicago,IL and has been teaching dentistry for over 30 years. Dr. Hartlieb is the CEO and the main instructor at Dental Online Training. He is an active member in the American Academy of Cosmetic Dentistry where he’s both an Accredited Member and Examiner for Accreditation.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Meet Dr. Angela Luek
Dr. Angela M. Lueck is a Wisconsin native and was the youngest female in her class from Marquette University in 1998. Since completing her residency she has consistently taken more than 100 hours a year of continuing education to keep current on the latest trends, techniques, and materials available in dentistry.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
Meet Clare O'Neill
Clare O’Neill is the Director of Operations at Dental Online Training and has a professional background in digital marketing. Clare has certifications in content marketing and digital advertising. Clare has expertise in social media marketing, email marketing, content marketing, website management, and project management. Clare has been using Canva for over 5 years and is a self-proclaimed Canva Queen.
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
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Dr. McKee is a member of the Spear Resident Faculty. He has maintained a private practice since 1984 in Downers Grove, Illinois where he treats a wide variety of cases with a focus on predictable restorative dentistry. He is a member of the American Academy of Restorative Dentistry and former president of the American Equilibration Society.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
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Kirk Behrendt is a renowned consultant and speaker in the dental industry, known for his expertise in helping dentists create better practices and better lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
Meet Dr. Melissa Seibert
Melissa Seibert is a comprehensive dentist proudly serving in the Air Force. She holds a dual faculty appointment at Uniformed Services University and Creighton Dental School. She serves on the editorial board for Inside Dentistry.
Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
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Olivia Wisden is the founder & CEO of TwoLips Creative. What started as an events discovery app pivoted into a creative agency that specializes in working with startups, small businesses, and organizations who are looking for bold, impactful designs and strategies.
She has worked with dozens of brands over the years ranging from the City of Madison to product launches and beyond.
She has worked with dozens of brands over the years ranging from the City of Madison to product launches and beyond.
Meet Dr. Sofya Kats
Dr. Sofya Kats is local to Milwaukee, WI. She grew up in Bayside and attended Nicolet HS, UW-Milwaukee and Marquette University School of Dentistry. Dr. Kats is a member of the Greater Milwaukee Dental Association, Wisconsin Dental Association, American Dental Association, and The Forum Study Club (oldest Dental Study Club in the United States).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).