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American Academy of Cosmetic Dentistry Accreditation Workshop

Part 3 - Case submission

Dr. Bradley Olson, DDS
Dr. Bradley Olsen discusses the AACD Accreditation case submission procedure and tips to make sure that the case meets the expectation for successful submission. He will also list the 5 AACD Accreditation case types and begin to detail case type 1,

What are the three most important things in real estate So if you take nothing else out of here today take tip no. 3 please. Accreditation is about case selection. It's also about case selection and oh yeah if I didn't mention it, it's about case selection. What am I talking about When we look at the cases, I'll get into this in a little bit more detail. Well actually when we look at the cases that I'm going to show you that have already gone to accreditation, we're going to talk about were they good case selections. Because remember what you're doing. This is a test. And what you're doing in accreditation is you're presenting the parameters of smile design or the parameter of shade matching or the parameters of contouring or the parameters of resin layering or resin matching on a screen. That's what you're showing. Taking an extremely complex case and trying to bring that all the way home to demonstrate all those principles many times just does not work. Does that make it bad dentistry No. Does that mean it was a bad result for your patient Absolutely not. If I've got a really low lip line and I've got gingival margin heights that are all over the map, my biggest smile that you'll ever get from me is right here. No matter what I do. No matter how much times you ask me to smile. Do we really need to go through stages of periodontal surgery or orthodontic supereruption or whatever different stages we're going to through to achieve a beautiful result for that patient The answer is probably not. But when you take the retracted views, you're going to see the disparities. You have to be able to tell the difference of that case type and simply say okay for this case, this is a beautiful end result for this patient. I did the ideal treatment for them. They got a great fantastic result. It's just not an accreditation case because with this case I was not able to demonstrate all the parameters of the criteria. And that's really what case selection comes down to. Or your ability to be able to look at a case and say this has to be multidisciplinary. It's going to be a great case. I know its going to be a great case. It's a perfect patient. It's a perfect scenario. Everything is ideal. I just know that I'm going to have to do some orthodontics and I'm going to do some perio work and then this case is going to be lined up and it's going to be ideal. Fantastic. Because you understand the parameters. You're going to work your way through it. So that's okay because you've chosen that case ahead of time and see what goes into it. But when you realized that edentulous space is going to take two or three grafts and even then you know its going to be a potentially compromised result. Why are you going to try to kill yourself over that case for accreditation You have to just move on. A great example I gave. We do oral exams and there was a candidate who we were talking about his case type 5 with him. And what he presented to us was that he had his wife as his patient for his first try in a case type 5 and that failed. So he went back and put in a lot of hours redoing this very difficult case on his wife, still and that failed. He said our marriage was right about at this point, you know, because he's frustrated. She's frustrated for having to get in this chair over and over again. Going through all this, while he was trying to work through the third time with her, another patient came in. He saw, his eye now is a little more geared to what he was looking for. First try, passed the accreditation test because he chose a much more straightforward case. Plus he'd had plenty of practice with resin at that point in time which didn't hurt either. But he chose a much more straightforward case. He made his life a lot easier and his still married. Okay. So what are you going to do when you submit these cases So here are the rules and regulations. You're going to get a report form. It's going to happen when you passed a written exam, you're going to get these forms and there will be one form for each case type and these form that you used when you submit. You're going to include the fee when you submit and you're going to use the AACD's photography release form. Now you may have a photo release form in your office that you use on a regular basis. That's not going to get it done. Okay. You have to use specifically the release form from the ACCD, that is available to you as well. So you just have to do that. Ceramist you have a little bit more of a challenge there obviously because you're going to have to get your docs to help you out with this. You have to get your docs with a lot of steps along the way. We'll talk a little bit about that. But you're going to need them to make sure they're getting these forms signed. So you have the release of the case you're submitting. Okay. Documentation. There's going to be a 12 views. We'll talk about those views but they're all digital shots. They're all shot in raw and there's no editing in any way shape or form. Okay that means you can't take the red out of your full face shot. That means if there's a little dust spot that shows up right in the darn central incisor, right in front, you can't go into Photoshop and edit out that little dark spot that's on the tooth. Any of those edits that are picked up when we go through, that's part of job as examiners is to go through and check the metadata involved with each one of these shots. And if it's been altered in any way, the case is kicked out. It's just not acceptable. And what a shame. I mean that's a real shame to have gone through all that written report, submit the fee and go through everything else and then you decide to go in and edit some photos and we don't know what you're editing. I mean that's not what we're going to check. You're editing could have been completely innocent but we don't know that it was innocent. We don't know if you were going in and filling in a black hole in Photoshop. Okay. So the idea is there's no editing so you're going to learn with your camera to really get it dialed in. Anybody takes Steve's course yesterday. Steve Snow spend some time with him. Isn't he awesome I mean he knows, he knows his way around the camera and photography that's for sure. So again what you're going to do is you're going to gear yourself with your equipment to make sure you're getting those consistently great results with the shot and it comes out just the way it is and you're not editing it. Okay. So just the 24 slides that we go in. When we say slides we mean digital shot. And there's 12 pre-op and 12 post-op. You also have 2 cover slides. And we'll talk about what goes on those slides. It's actually in there. I'm not sure if I have it here on the presentation. On your left side slides, it's going to say case type 4 and its going to have the description of what that is and it's going to have your candidate number. And I'll show you that when we show the cases that we're submitted. That template is online. So you don't have to create these templates. There's a template for it. You just bring it right off online, bring that on, then you have a second one that goes through your treatment list. On the right side slide we're going to go through, this is how we put it up, this is how you put it in your disc is you'll have that second slide that we'll go through and list the treatment that you did on the over of that and then you have your 12 views. But here's the deal. The deal is this is what you're presenting to us for examination. So every angle that's off, every amount of saliva that's covering over the tooth. For every exposure that set wrong, that takes you one step further away from that case having a chance to pass. So we say well wow I failed because of photography. You don't actually fail accreditation from photography. It's very very rare that the failure comes back that says it was photography. But it may come back to you and say we could not judge this case because the photos made the case unable for us to review adequately. Now again what a shame. Specially with a digital camera. Shoot it till you get it right. Shoot it. Shoot it. Shoot it. Shoo it. Shoot it. Until you get those views to where they look great consistently every time. So those are the shots you're going to submit, that's part 1. Part 2 of it is this is also you demonstrating part of what you show. So asked a laboratory ceramist. I have a case that I want to send to you and that comes in with no bite registration. It comes in with no photos. It says on there A1 for shade and has a preparation that caught maybe half of the margin. The opposing impression is chipped and it has stone over the top of it. That's one impression that you get from what I just submitted to you. Now I send you a case that's ideally mounted with beautiful clear to read margins, and duplicate impression. It has a clean, crisp bite registration. It's got numerous digital views taken at different angles with different shade tabs in place. And I've written on there the way I want the shades transformation laid out. Now what's your impression of the work that you've just got from me Same thing when you present for accreditation. Same idea. What you're presenting on your written report. What you're presenting on the screen is somewhat indicative of what you're presenting as your overall work. Keep that in mind as you think about what you submit and send in for evaluation. Okay. You can't get the before shots back. Okay. So make sure whatever you're doing, you're backing those things up and even if you want to play extra safe and you're putting them on a jump drive and saving them somewhere else. Do that as well. You can always call the patient back and bring them back for the after shots again. But the before shots, it's your last chance. Once you've touched the tooth, that's the end of your before shots. So make sure you've got them archived and saved appropriately. Start shooting everything. Ceramists start hooking up with your dentist and asking them to please take the 12 AACD reviews in raw. Oh that's a pain in the neck. Please do me a favor in cases some other cosmetic case we're going to take together, please take the 12 shots in raw. I would really appreciate it if you would do that because we don't necessarily know where our accreditation cases also going to come from. Personal example. Patient comes in. She's got a diastema between no. 8 and no.9. She has one of those old little one piece, two tooth lingual retainer that has been bounded in by her orthodontist, you know, decades ago. The teeth, the one inside had popped lose. So the teeth had migrated and shifted a little bit. It was still stuck in there. It was gunked up and a stain all around it. I said to her, I said Marcia do you want to just get this thing off. It's not even holding to your tooth anymore. Why don't we just get this off She says oh thank you. I hate that thing. It's a nuisance. We popped it off of there. I said to her now, now you know if the space bothers you, I have to tell you, it's very straightforward in closing that space back up. She goes really. I said as a matter of fact, I can do it today. I have the time available if you like me to do it today when we finish your hygiene visit, you can come and I can bond that and close that space for you today cause I have time to do that. She goes that would be wonderful. I would love to do that. We hustle her over. We got in the chair. We're trying on the shades. I tap the shades on there of what I've chosen. I mean dead on the money. It just disappears into the tooth. We all know how that works you know. Sometimes when you're working with resin or you're working with porcelain sometimes you just get that shades, you nailed it right out of the gate and it just blends perfectly. You know other times you struggle a little bit. Got to kind of work your way back and forth to get it to blend. Well this was on the money right out of the gate. Getting set up. Getting ready to pumice an extra tooth and get the camera. Shoot the 12 shots. Sit her back down the chair. Put the bonding on there. Shoot it afterwards. Send it off to my mentor. He writes me back. He said perfect case. Great case selection. Beautiful result. Just do the little touch up. He told me touch up one corner. Do a little refinish and the polish. Obviously re-shoot it again cause everything was a little dehydrated and the tissues was a little irritated. Bottomline, bottomline is at the last minute I took those before shots. So you got to start gearing yourself in the directions of accreditation. If you're taking these 12 shots over and over and over again you never know where your case is going to come from. Same thing happen to me really on my case type 3. It was patient, who wound up being diagnosed with a cancer on her lip. We put a temporary in place. I'll share more of that story with when we get to the part talking about case type 3. But the bottomline is she was gone for an extended period of time. I submitted another case type 3 when I did my original presentation of five cases and that was the one that didn't pass. The other four did. So I was going to have to find a new case. She just reappeared back in the office. She had that temporary on for months and months so she was going through this other process. There was my case. Look back just to double check we've taken the 12 shots. They were in there. Look back in the slides. They were in place. I went ahead and finished her, that case pass. So again you just never know. You just never know what's going to happen as time goes by, shoot everything, have it in the raw format and then you're ready to go if the case comes through. Documentation for the dentist on case type 5, show us these different steps along the way. Your going to show the initial preparation of the teeth. That preparation will be no preparation or it will be minimal preparation and we will spend some time talking about case type 5 and preparation. Your going to show your initial layering of the composite. You can do this with one tooth or you can do it with two teeth or you can do it with all of the teeth, it's really up to you. Everybody has a different style. Some people put on initial layers all the way across, some people initial layer one tooth at a time or do them in twos. However you do them is fine. So you can see on here, this candidate on here actually showed a preparation then initial layering of one tooth, OK. And then they showed any use of tints and opaquers which they really didn't have here so that went and placed that layer on and here is all of them in the final contour in place. So all of the teeth being treated if you're doing 6, 8, or 10 teeth show the final contour and then of course your final is in the body of the work, your final polish case but it's showing the final contour in place. Layering and contouring. We talked about raw shots why they are important and for radiographs your going to be taking post-operative radiographs and lab techs you're going to have to have your dentists on top of this. If you have a dentist going through the process it helps so much because they're following the same protocols. If they're not going through the process your going to need to have a checklist for them and many dentists are happy to help out or if you're working with a dentist, let's say you're working with me, I'm all ready accredited, I'm not going to be going through the process but what you're going to do is you want to have a checklist for them and say just so you know this case I'm really counting on for accreditation if you'll please follow the checklist and that's remembering to get a post-operative radiograph of all the required treated teeth. So we'll talk about the requirements again but just quickly as a review if you're doing six, if you're doing case type 1, six or more indirect restorations, well if you do ten teeth, you still only need radiographs that cover the six, three shots will do it. No pano's, PA's only but usually that's going to get it done because you can take those three PA's. You don't have to worry about the teeth behind that. Even though you treated them, they weren't part of the requirement. So it's only what was required that you have to place in that. If you choose to do an implant, you're going to need a pre-operative X-ray of either the failing tooth or the edentualous site. We'll talk about that with case type 3 but just for review when we get to it, we'll already have talked about it at this point. Again with case type 3 pre-operative radiograph either failing tooth or edentulous site. We'll talk about why coming up. You're written report, there is a template right online, pretty straight forward, so you just see the template how it's laid out there and an example of a written report. Concise report. We want just the facts, we don't need all these glowing details of everything under the sun that went into that case, your consultation, you served a wonderful merlot and there was some Frank Sinatra playing in the background, well that's great, I'm so glad for you and I'm glad you have that type of practice but we don't need to know that. Just the facts. Restorative matarials have to be peer reviewed. So if you're deciding that you're going to prepare a lateral incisor for full coverage and then you're going to double cantilever the two central incisors because you think that's a great idea, you're going to need to show us where in the peer reviewed literature that that technique is shown to be a proven successful technique. You also need to follow the manufacturers rules for the technique as well so doing a three unit anterior bridge with Empress, doesn't follow the, Empress 1, does not follow the manufacturer recommended use of that material. If you choose to do that in your practice and you and your ceramist are comfortable with that and you feel the patients function is so low that it's not going to be an issue, that's OK, that's your business, you just can't submit it for accreditation cause that material according to the manufacturer is not to be used in that fashion. And make sure all of the id's are off. No identifications left on there. We don't want to know who your laboratory was, we don't want to know what dentist you worked with, we don't want to know who your mentor was, we don't want name dropping so when we say identification I don't mean just your identification. We don't want any identification. The identification that you will have of course will be in the reference section of your written report and that will simply be references for your written report where you got that written information. The prints, it goes back to the same principle, these are the four prints that you're going to have in your written report, OK, and they will show up in this order. So what you will have is the full face shot, before and after, turn the page, smile, before and after, turn the page, retracted 1:2 before and after, turn the page, retracted 1:1, those are the shots that will be in the written report. We go back to the same principle we talked about in the written report that goes with your slide presentation or your powerpoint presentation or your disk or whatever we want to call digital shots is that this is the first thing that examiners see. So just to give you real quick what goes on in the exam room. We get ready to examine a case, what we'll do is all the lights are up, we're going to sit at the desk and the room chairman will pass out the written report or somebody in the room will pass out the written reports. One examiner will go up and be examining the meta data that was provided with the photography and they are going to be reviewing that, so they are going to review that part of the examination. Now three other examiners or four other examiners are going to review the written report. So the first thing, the first impression of your work that's provided to examiners is the written report. So again, does it need to be a leather bound volume with the most expensive paper made, no, neat, clean, concise, beautiful prints. OK, we talked about the digital submissions. Raw befores, raw after, two disks. K, you're going to have jpeg conversions on there, a lot of cameras these days do that automatically for you so you can just set it where it says raw and jpeg so you get them both in your shot so if you don't it's a simple conversion. You take your raw and you just go into whatever program that you're using, that your photos are in and you simply go in and change that file format and just click them, boom, save them all right after that so you've got your 12 raw shots you'll click that and you're 12 jpegs will come in right behind it. So we talked about what the five required case types were and now we're going to go through them in a little bit more detail. Because again choosing your cases, case selection being so critical knowing what each case is testing is so important to you choosing your cases and completing them to meet accreditation standards. Okay. So case type 1, six or more indirect restorations. And this is going to be treating upper incisors and upper cuspids. Alright, no lower teeth. So lower teeth are not part of the accreditation process. And when I tell you that, that's the testing end of it. If you have to treat a lower cuspid because of wear and you chose to do resin or you chose to do a veneer on that, that's fine. In fact that's the correct treatment. If you're doing it for a cosmetic blending of another tooth, that's fine as well. So doing these things together to get a beautiful overall end result is fine. It will be judged. Everything you treat is judged at accreditation standard. But failing to treat it will also be judged. Okay. So you have to keep in mind the fact that you know we really have to worry about you restoring this top beautiful teeth with the lower teeth sawed off at a 45 degree angle into the pulp. I'm exaggerating of course but you get the idea is that comprehensive treatment, correct treatment for each individual patient is important. So you're treating upper incisors and upper cuspids and what we're doing is testing your ability to take and blend these materials into the dentition getting a beautiful end results, working in conjunction with the laboratory ceramist. Now when you go through the criteria sheet, we're going to do that this afternoon but there's a criteria sheet that you should have in your pack there but if you don't it's online. And the criteria sheet will list on there every single criteria come into play with this case type except one and that's the one that says pontic design. Okay so pontic design is thrown out for case type 1. But otherwise, every single parameter comes into play with this case type. So all the smile design factors macro smile and micro smile design factors all come into play. How you choose the restorations are really up to you. We're not going to be passing judgment on whether you chose to do a veneer case or veneer and crown case combined, whatever went with it. Word of caution though. One of the things that you saw on the sign for this regional meeting and you're going to see over and over and over again is responsible aesthetics. That is the buzz word in our profession and that is the buzz word in this academy and it is the buzz word for accreditation. So taking a 16-year-old who has some minor wear and chips on some front teeth and doing six full covered zirconia crowns is going to get you a failure notice for good reason. I don't care how beautiful the restoration came out. Okay. So you have to take into account when you're choosing what you're going to do here how you're treating that individual patient. You get to case type 5, becomes even bigger issue and we'll talk about why.