Put Your Heads Together

"We all need to sit together—whether virtually or in person—to discuss the case and determine the goals and objectives," says that prosthodontist, Nicolas Elian, DDS. "We need to discuss what is needed from the orthodontist in terms of tooth alignment and tooth position, what is needed from the laboratory for the final restorations, and everything in between. Only then will I actually do any physical work on the case."

Dental technicians who find themselves in that situation are fortunate; by most accounts, it is very uncommon. Direct interaction between the laboratory and multiple specialists on a case is an ideal, not the norm. When possible, however, the laboratory serving as a vital cog in a complex case executed by various team members is more important than ever.

"It can make your dental laboratory life dramatically different," says Dene LeBeau, Owner of LeBeau Dental Laboratory in Renton, Washington.

Creating synergies with these different team members is critical, as significant value can be found by incorporating the concepts of all disciplines. A number of strategies can be utilized in the pursuit of this high level of collaboration, and the utmost preparation is necessary in order for it to be optimally successful.

"Once you are beyond the realm of conformative dentistry, the minute you need to address questions of high esthetic demands, function, and tooth position, you almost immediately need to have an entire team lined up to look at any case," Elian says, "and the dentist needs to involve the laboratory in the discussion as soon as possible."

Perhaps the rarest of laboratory-specialist interactions involves the orthodontist. Even if a technician is involved in discussing orthodontic treatment to set up a restorative case, that technician is seldom the one fabricating the aligners, so those discussions often occur via the restorative dentist.

"I encourage orthodontics in treatment plans frequently," says Bobby Williams, CDT, Owner of Synergy Ceramics in Plano, Texas. "As impatient as patients can be, I try to avoid ‘instant orthodontics.' We sit down and explain the benefits of proper orthodontic treatment, whether it involves intrusion, tooth alignment, etc. When patients accept that proposal, I work through the general practitioner to ensure that the orthodontics accomplish what we need."

The entire team should be involved in those early stages of treatment in order to ensure that the goals are clear to everyone.

Vincent Celenza, DDS, a prosthodontist in New York, New York, says members of the team who are brought in late are put in a "defensive position." He cites a recent case when a patient who was already undergoing orthodontic treatment was referred to him for the first time. Celenza needed to call the orthodontist just to learn what exactly they were trying to accomplish, and he ended up disagreeing with the direction of the treatment.

"When multiple members of the dental team are on the same page and consider themselves equal in terms of the services they provide and their level of expertise, there really should not be just one ‘quarterback' of the case," Celenza says. "There should be a united front."

LeBeau says directing questions to the general dentist about the orthodontic stages of cases is a good starting point.

"I say, ‘What do you need me to do with this? That No. 6 cuspid is so far out there. Are you going to utilize orthodontic treatment?'" LeBeau says. "The dentist might then say, ‘I am thinking about that,' so I tell them more about what I need to know. I just constantly talk about it. What often happens then is that the orthodontist starts talking to me directly. We all benefit because the case has a more successful outcome."

The perpetually growing popularity of dental implants has made collaboration with periodontists and oral surgeons more advantageous than ever. CBCT scanning capabilities allow the team to collaboratively plan the implant placement in a way that sets up restorative treatment as well as possible.

When the restorative team is disjointed and communicating through only one member, however, it becomes more difficult to work efficiently and effectively as a team.

"If an oral surgeon or a periodontist extracts the teeth, grafts the sites, and places the implants, and the other team members are not brought in until later, it becomes challenging," Celenza says. "When a patient comes to me for the first time and they have already had their implants placed, I immediately have a bad feeling, because instead of contributing to make the overall treatment as successful as possible, the technician and I now need to just do the best we can with what we are given."

Not surprisingly, the laboratory can provide valuable input on implant placement with the restorative phase in mind, making it easier to achieve a successful outcome.

"Good surgeons understand that the laboratory should be the expert on occlusion, restoration placement, and esthetics," says Steve Killian, CDT, Owner of Killian Dental Ceramics in Irvine, California. "They really depend on us for that diagnostic workup and the proper placement of the teeth. Good communication between us is the key."

Implant work is also often handled by prosthodontists. Elian, for example, concedes that he functions as both the prosthodontist and surgeon on his team. By the nature of their jobs, prosthodontists work primarily on cases that require a high level of knowledge and skill from all team members. While a general dentist may be able to send a crown or veneer case to any laboratory, a prosthodontist often needs a laboratory with a strong grasp of function.

"Prosthodontists will always be a little more demanding, and rightfully so," Williams says. "They expect their technicians to understand occlusal concepts and functional concepts. I take pride in knowing those concepts and being able to not only communicate but also execute them on the cases that we do together. Prosthodontists pay higher laboratory bills, so you need to back up those fees with knowledge. Esthetics are great, but one thing I have learned in my career is that function comes first. The best-looking case on the planet will not work if the function or the occlusion is off."

Celenza stresses, however, that esthetics should not be downplayed. While a technician with a mastery of occlusion offers an advantage, the prosthodontist is an expert on function, and Celenza says he needs technicians to be experts in areas that are beyond his control.

"We are in the era of esthetics, regardless of whether it is a tooth-borne case, an implant case, or a combination of both," Celenza says. "Patients demand high levels of esthetics, and they get involved in their cases. The dentist needs to describe what we want to accomplish and demonstrate it via provisionals and photography of previous cases. What I need from my technician is the ability to actually produce what we promise."

Along those lines, Elian says he relies on his laboratory for materials expertise—not necessarily because he does not have in-depth knowledge himself, but rather because the person ultimately responsible for fabricating the restoration should have a voice in material selection.

"Sometimes, the technician might feel that a certain material will allow them to achieve the goals and objectives of the case better than others," Elian says.

Regardless of whether it is function or esthetics, material selection or prosthodontic planning, in order to deliver the best results, the laboratory typically benefits from being involved from the start of the case.

"The advantage of working with a prosthodontist is the planning that occurs before we do anything," says Lucas Lammott, CDT, Owner of M31 Dental Studio in Gloucester, Massachusetts. "A general dentist who typically does single-tooth dentistry might get a complex case and decide to just take an impression, send it to the laboratory, and say, ‘Figure it out.' Sometimes that can work, but when the technician needs to make executive decisions alone, a snowball effect can happen and the case can get out of control. With a prosthodontist, I will get a series of photographs and usually a call within a few minutes. We sit down and chat about the case. We discuss material selection. If it is a bigger case, often we start small and do one-quarter of an arch at a time so that we can meticulously plan everything and make sure each step is executed perfectly."

Offering a high level of expertise is the first step for a laboratory in earning its spot at the table with other specialists. Technicians who not only fabricate beautiful restorations but also provide useful input on a case can carve out spots as indispensable members of the team.

Killian likens his laboratory's level of service to that of a prosthodontist—to the point that he speculates that some prosthodontists may consider him to be competition.

"Our laboratory offers many of the same things that prosthodontists offer in terms of supporting general practitioners and oral surgeons," Killian says.

There are several ways to reach that level. One that Williams suggests is taking clinical CE courses through the Kois Center, the Pankey Institute, Spear Education, or the Dawson Academy.

"The best thing I ever did for my laboratory was graduating from the Kois Center program," Williams says. "As a technician, you really don't know what you don't know about dentistry and the clinical side until you have sat side-by-side with 45 dentists through nine courses learning how they attack a case. It armed me with the knowledge to now talk on the same level as the clinicians we work with, and sometimes even a little higher."

Indeed, Elian tells patients he can collaborate with any other dentist and almost any laboratory, under one condition: "They need to be able to speak the same dental language I do," he says.

Lammott stresses the importance of language also, but in another way.

"If you want to be respected in our profession, you need to elevate your language," Lammott says. "I do not work with clients; I work with dental partners or team members. I do not stack porcelain; I layer it. Dentists do not pack cord; they place it. When you elevate your language in conversations with dentists, it is noticed."

LeBeau emphasizes what he calls "social IQ" in verbal interactions with dentists. He uses the phrase "please advise" daily to achieve the necessary level of collaboration without sounding arrogant.

"You do not need to take over the case, but you need to tell the rest of the dental team what you need to know," LeBeau says. "If you see something that could hinder the chances of a case succeeding, you can say, ‘I worry that if that is not brought out far enough, the esthetics will be compromised. Please advise.'"

Once the laboratory has developed that level of expertise, the challenge becomes convincing dentists of the need for direct collaboration with the entire team. Killian says he has reached a point in his career where he almost exclusively works with dentists who share that attitude, but he adds that laboratories can influence those attitudes.

"There are so many things we can do," Killian says. "First and foremost, use your education and experience to convey a sense of confidence in any situation. Additionally, make sure you always know what is new."

Knowing what you do not know is important as well. Lammott says one way to earn respect is to concede when another laboratory may be better equipped to handle a particular case.

"A few years ago, I had a case that involved a full-arch implant-supported prosthetic, and there were issues with the spread and the angulation," Lammott says. "I told the dentist, ‘I think the best strategy would be for you to approach a high-end removable laboratory that can fabricate more of a hybrid restoration than I can.' Although I gave up the payday on such a big case, I avoided the likely disaster that would have occurred if I had just milled out zirconia as the dentist initially suggested, and I earned his respect in the long run."

Finding those dentists to align with in the first place is a challenge, of course. One resource Killian utilizes is manufacturer representatives—especially for implants—to help promote his services.

"There is this whole group of salespeople out there," he says, "and if you cultivate and maintain those relationships, then they will pass the word along to the best dentists who are looking for laboratories that offer what they need. We make sure our manufacturer representatives know we are on the cutting edge, which puts us in a great position with their clinical clients."

Lammott suggests going after top specialists directly as well. He has met some of his top dentists simply by reaching out to them on Facebook or Instagram. However, he does not just ask them to send cases. He compliments their work. He talks about music, movies, and more. He asks what camera they use and how they handle certain types of cases.

"There are so many young, hungry, talented prosthodontists out there," Lammott says. "Find one and try to connect on a personal level. Do not just bother them about sending a case. Talk with them. It can be intimidating because prosthodontists often present as being very high-end, but if you have confidence in your own value and can genuinely connect with them, you can develop a very productive working relationship."

Attending clinical conferences, whether regional or national, can prove beneficial for developing productive relationships with specialists as well.

"It is really important that dentists know who you are and what you look like," Celenza says. "Attend their conferences. Show not only what you are doing, but also who you are. Ask questions and have one-on-one conversations."

LeBeau suggests getting involved first with local study clubs and then earning invitations to larger meetings.

"Not only do you learn what they are doing," LeBeau says, "but you immerse yourself in being around dentists, and you become accustomed to it. What they are talking about involves technicians. Once you start looking, you will find so many places where technicians belong."

Nurturing those relationships once they are established is important as well. For example, one dentist brought his young daughter on a visit Lammott's laboratory, and Lammott took portrait photographs of her that the dentist still has framed on his wall today.

"Little things like that make a difference," he says, "going above and beyond rather than just calling when there is a problem or at the end of the month to get paid."

Regardless of how hard technicians work to wrestle their way into conversations with specialists, collaboration is a two-way street. Specialists themselves need to be receptive to everything that laboratories have to offer.

Elian says he encourages fellow dentists in his lectures to pursue this level of collaboration because, no matter how skilled they are, another expert perspective can always be helpful.

"With the knowledge that we have as a profession along with the technology and photographic capabilities at our disposal, if we are not all communicating from the start of the case, then we are putting the patient at a disadvantage," Elian says. "One person, usually the restorative dentist, is responsible for collecting data, but that one person should not also be responsible for all communication. Of course, I depend on the laboratory's keen eye for esthetics, color, tooth form, and anatomy, but I also need the technician to look me in the eyes and say, ‘If you put the tooth or the implant here and you give me the soft tissue in that environment, I will get you the outcome you want.' Knowing that, I cannot simply tell them, ‘I put the tooth here and the tissue here, and I expect this.' That would be asking the technician to make the crown, not to make the tooth. I want them to give me teeth. In order for them to give me teeth, I want them to be part of the decision making."

Lammott says many dental teams will never reach that level of collaboration, but he cautions against a defeatist attitude.

"You always will have people who are OK being McDonald's and people who are OK going to McDonald's," Lammott says. "However, if you want more than that, it is out there and it is not as unattainable as some might think."