Behind the Curtain

The patient situation is then followed by a cursory amount of information and images describing and illustrating the steps the dental team took to fix the patient’s problems. A logical and informative list of procedures and photographs document the seemingly simple path the technician and clinician followed to get to the desired outcome.

At the conclusion of the case, the “after” photographs are shown. In sharp contrast to the images representing the patient’s “before” situation, the “after” images illustrate the vast improvements that were made to solve and esthetically restore the patient’s previous dental dilemma. They range from the nicely done to the spectacular. The audience, or reader, is left impressed and often inspired by the case outcome and returns to the laboratory with renewed vigor to work on his or her own cases.

Sometimes though, the opposite happens. Some members of the audience or readership are left discouraged. The achievements shown in the “before-and-after” shots and the steps taken during the restorative process look too easily achieved. There is no evidence of bumps in the road that could have derailed the case. Furthermore, the case might not reflect the everyday challenges experienced by many technicians and the realities they face. In the end, these types of presentations often leave audience members believing that the problems they encounter when working on their own cases are unique and therefore leave them feeling frustrated and isolated.

Learning from one’s mistakes is important. Learning from others’ mistakes can be an advantage. Learning that others make mistakes can be invaluable.

The following is a case that could be used just as a nice “before-and-after” presentation. The patient presents with an esthetic concern; the dental team presents the simple, easy, and less-than-comprehensive process used to complete the treatment plan and fabrication steps; and the visually pleasing “after” images show an equally satisfied patient (Figure 1 through Figure 4). The case was a success and the dentist and patient were very happy. The presenter could speak about the esthetic advantage of using alumina copings, or VITA^®’s VM7 porcelain, or even the benefits of a custom shade. That could be the end of the story.

However, the problems that occurred between when the patient presented at the clinical practice and the final case outcome make this case a good study in everyday laboratory realities. Wrong turns were made, false assumptions followed, and bad decisions acted on. This case was more a study of errors than successes. It is not always easy to expose one’s mistakes, but it can be humbling and occasionally more helpful than showing only the successes. Feeling like “The Great and Powerful Oz” is not uncommon when a case goes well, but sometimes it is necessary to look behind the curtain.

The patient was a 40-something male with old, badly discolored composite restorations on teeth Nos. 9 and 10. He had lived with the unflattering look for many years and desired an esthetic change. After meeting with his dentist, it was decided that the teeth would be prepared for two full, all-ceramic crowns. The dentist and the author collaborated on restorative materials and chose to restore using NobelProcera™ alumina copings (Nobel Biocare, www.nobelbiocare.com) layered with VITA’s VM7 porcelain (Vident, www.vident.com). The patient came to the dental laboratory where a custom shade was taken. During the shade visit, notes and pictures were taken, and the shade of his natural dentition was analyzed both with careful examination and with VITA’s Easyshade^®. The patient expressed his desires and concerns for the case outcome. The author was under the impression that this would be a straightforward case and had very few concerns about a successful outcome and expressed as much to the patient. (It just so happened that the patient was one of the author’s best friends and maybe he had a little more emotional weight on the outcome of this case than most other custom shades.) What could go wrong?

Time elapsed. The attending dentist did a great job creating provisional restorations and the patient was not in a huge hurry to get his crowns seated. Unlike most cases, this case was not time sensitive, and therefore was put off until the author had “more time to focus.” However, time always gets filled with other more immediate or pressing tasks, and, as we all know, there is never a “good time” to start something. In reality, all that really happened was the case was put off until it was less fresh in the author’s mind. In this case, the author’s familiarity with the patient may have actually caused false confidence to creep in, mistaking familiarity of the person with knowledge of his teeth.

In the meantime, two different external influences had the potential to derail the case. The first was that the patient expressed to the author his excitement over how much “whiter his new teeth would be.” The second was the author’s acquisition of new opalescent VM7 porcelains.

So often, after staring too long at patient photographs, one begins to see what is not there. Unrepresented colors or imagined characterizations that are more intense than they really are can all be envisioned. That is exactly what happened in this case.

Compounding the false reality was the arrival of the opal translucent powders. Although it would have been hard to admit, or even recognize it at the time, there was a strong desire to use them. The longer the author stared at the patient images, the more convinced he was that this would be a perfect case to use one of the deeper blue opal translucent powders on the incisal edge. The author thought: “How lucky was that—even though the photos were showing the tooth shade to be in the 3M to 2M range—hadn’t the patient been bleaching? Maybe more 1M1 should be used? After all, didn’t the patient expressly state that he wanted them “white”? The photos must be misleading. Best to go lighter and use that cool new blue porcelain. This is going to look great! My friend will be so happy!”

The author ignored the notes taken during the shade-taking appointment, used the new powders to place imagined colors on the crowns, and gave undo consideration to the patient’s biases. The result? The crowns were too light, exhibited badly out of place incisal blue, and frankly, did not match at all (Figure 5 and Figure 6).

The patient came back to the laboratory and a second shade was taken using the ill-matched crown in the images to show contrast (Figure 7). Fortunately, the patient understood that not all custom shade matches were “nailed” on the first go around. He was willing to wait and go through whatever was necessary to “get it right.”

Prior to building the case the second time, a discussion was held with the dentist. He expressed his opinion about the look of the central incisor crown and said he thought it needed more orange, especially through the middle. Thus the orange seed was planted.

With the newly acquired knowledge that the first crown was built too light in color, the original shade notes were both consulted and followed. However, this did not happen right away. Again the case was put off until it could be fit in at “just the right time.” Well, like with many cases, the right time ended up being right before the seating appointment.

Again, photos were analyzed, porcelains selected, and the crown was built. But during the process, the dentist’s remarks about “needing more orange” nagged at the author. Maybe the pictures are misleading? There was certainly orange in the incisal area, but just maybe there was more there than the author could see in the images. So again seeing things that were not there and allowing outside influences into the process, plus the pressure of self-induced time constraints, the new crowns were made (Figure 8 and Figure 9).

There is nothing quite like getting phone calls from both the dentist and the patient expressing poorly concealed incredulity over your most recent “masterpiece.” The dentist thought, “Maybe there was a little too much orange.” The patient expressed his concerns a little differently with, “Hey, blankety-blank, are you messing with me? I don’t want a racing stripe!”

Embarrassed and ego bruised, the author started the case again. The major problem with the two previous attempts had been that the case was being built as imagined, not as truly seen.

In the world of drawing, many artists run into the problem of drawing what they think they see and not what they truly see. For example, when staring at a live model and being asked to draw an eye, most people will draw what looks like a football with circles in it. Maybe it will have straight lines emanating from it like sunbursts to convey lashes. This is not what an eye looks like. This is not what they see. This is a representation of an eye, a symbol.

It is no different in ceramics. It is important to remember to trust one’s own eyes. Create what is truly seen. Create effects, colors, and contours that are actually there. Do not create ones that one might think should be there.

A metaphoric deep breath was taken, and then the case was looked at anew. It was a fairly straight-forward case. Although there was some orange in the incisal edge area, it was minimal. The original shade evaluation of a combination of 3L1.5 and 2M1 was deemed accurate and was adhered to. The case was given the attention it deserved and the proper amount of time allowed. External influences and imaginary characterizations were eliminated or ignored. New crowns were made and delivered.

The crowns did the job of mimicking the shade and shapes of the contralateral teeth. Not too bright. No racing stripes (Figure 10 and Figure 11). The dentist and patient both called again. This time, they were very pleased. The patient continues to be one of the author’s best friends and the dentist remains one of his most valued clients. The case was a success, but it was more difficult than it had to be. Maybe it would better be called a “successful learning experience.”

Having a case not go well stings. That is the reality. It affects one’s ego and can shake the confidence of both the beginner and the most seasoned ceramist. A case that goes awry can sometimes teach better lessons than cases that are quick successes. The important thing is to learn from mistakes. Many of the “before-and-after” photos seen up on the big screen didn’t have a flawless evolution. Many were the result of several failed attempts or painful learning curves.

Seeing great work in journals, books, and meetings can indeed be inspirational. Everyone appreciates before-and-after photos and even photos of the process. This industry is blessed with so many talented technicians sharing amazing cases. Sometimes though, it is helpful to also share the bumps in the road, showing that every successful case does not always have a direct path. When the curtain is parted, there often is a visible journey of unseen mistakes, self-doubt, and external negative influences that have to be overcome before that last slide on the screen or image on the page (Figure 12).

Kyle Swan, CDT
Vice President, Functional Esthetics
Lewisville, TX