Monday, December 1, 2008

Perspectives From A NM Tech To Create Predictable Results

By Bill Marais
Disa Dental Studio, Santa Monica, California

"Dental magicians, not technicians!" This aging cliche places in a nutshell the mammoth expectations often placed on technicians today. More often than not, technicians are asked to perform miracles in the lab environment - cases arrive "sans" (Latin meaning "without") vital information and the necessary tools essential for the successful delivery of that case. When dentists play their part right and provide us with these imperative tools and information, we can channel all our energy and artistic capabilities into creating beautiful restorations. The alternative being expending all our time and efforts in "just getting something to work" so that we can deliver the case the following week. Dr James Carlson once stated during a lecture before a group of dentists:" It is like throwing poop against the wall and all you hope is that it will just stick !!!!!!!" The only thing that suffers here is the outcome of the case!

I strongly believe that these following pointers will help us achieve more predictable and aesthetically pleasing restorations:

1. Never send multiple bites with the intentions of having the lab choose the "correct" bite.There is no means for a technician to make an accurate decision as to which bite is the correct one . This would honestly be a shot in the dark! There is only ONE bite we can work off and that is the one bite the dentist will choose and send to the lab. (I have had cases where I have received three or more bites - all apparently on trajectory - and then it is requested that I choose the bite that would work best! There is no possible means for me to depict a correct bite equivalent to that of the EMG reading!)

2. Don't ask the lab to open or close a bite on an articulator.
There is only one articulator where one can accurately open and close the bite and that is the "Patient".

3. Nothing beats working on/with the present condition.
Working with old impressions, wax-ups, models etc. will bring too many variables into the equation. This is simply asking for trouble!! Do not step over dollars to get to pennies. Make the effort and take the time to take new impressions, new bites, new photographs, etc. every time a new step is taken. I have a saying: "Fresh is Best!"

4. Include the hamular notches from day one of treatment.
These serve as an invaluable diagnostic tool and can save much time during the treatment of patient. For example, if HIP matches Symmetry bite, you do not have to include the Symmetry bite again. As long as photographs are provided, the HIP mounting can be used during the entire treatment!

5. All possible tools, including measurements, data and photographs should be sent to the lab at the very START of a case.
Before I begin work on a case, I insist on pre-ops, photographs, poly-vinyl impressions, hamular notches, symmetry bites and patient expectations. A technician can help tremendously in spotting any problems that just might arise during the treatment. Our hands are bound when doctors do not submit that clear vision leaving us blinded to any red flags that may occur.
Should the lab request more information, be open to providing them with what is needed during manufacturing. Bring the patient back to the chair and provide the necessary information/impressions, etc. to the lab. So many times I have had to listen to: "It is too much trouble for the patient and will cost (the doctor) too much money to bring him/her in again, so just go ahead as is!" In so doing, the doctor compromises the outcome of the case - just to save some money. It does not make any sense. This attitude is just tying our hands behind our backs and then the labs get blamed for all the remakes!
Our lab has made it policy that if a doctor refuses to provide the necessary information, we will not guarantee the outcome of the case AND we will charge for any remakes. It is sad that we have to take such a firm stand but I encourage all labs to adopt this policy - it will only get us (and more importantly, the patients) to a better place.

6. When shipping cases, always provide Poly-vinyls.
I guarantee that models will be damaged or lost. Poly-vinyls just always give us the option to start over which alginates do not.

7. Why rush cases?
So much time is spent stabilizing the patient to the correct bite and then we are expected to transfer all this information into the final restorations in less than two weeks. Why compromise all that hard work, time and effort? I equate the rush case to playing a perfect round of golf and going ten over on the last hole! If the lab requests more time, honor this. There is no reason to rush these cases for a wedding or a holiday in Europe - you are just asking for trouble!

8. Permit labs to use the tools they are most at ease using.
As an example, I have had doctors insist that I use a Specific Articulator. I cannot work on some articulators - they are just not ergonomic for my needs and it will affect the outcome of the case. NM dentistry is a "Feel" ,""A Comfort Level" and "A Trust" in the tools that we use to achieve predictable results! A type of articulator will not make a difference in the outcome of the NM case. Instead, the skills of the NM technician, the provided tools and information will predict the outcome of the case.

9. The doctor and the technician should never presume bites, measurements, etc. are correct.
You can never check too many times so let's all check each other's work. We all make mistakes as there are so many variables that can enter our NM world.

10. Have an open mind.
We don't know what we don't know. Neuromuscular dentistry is a journey, not a destination. We will all make errors. If we refrain from pointing fingers, take the time to learn from these mistakes and we selflessly share our knowledge, it will make us all stronger!

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