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American Academy of Cosmetic Dentistry Accreditation Workshop

Part 6 - Case Type examples

Dr. Bradley Olson, DDS
Dr. Olson will review examples of each case type and share what the examiners are looking for.

When we're looking at the cases, what I want you to look at is I want you to look at case selection. What the case was testing. How the candidate handle it. So just in your mind, we're not going to get into super detail about grading each little thing on here. We'll look at it in general but again case selection, did they choose a good case. What was the case testing meaning where they addressing the issues that needed to be addressed for that particular case type and how was it handled overall Okay so in this particular case, here's a situation where again ceramic veneers is what it says on here but in the write up hopefully somewhere it tells us that material that was used, what type of ceramic was used for that particular case. Great if you have it on the treatment list. We'd actually prefer to see it here. But it has to be at least in the write up. Okay. I'm wondering no go, we've got to, okay, here we are. Mike answered my question. What I was, obviously we have a little more light in here than we normally have as we're looking at the cases. So just bear with us as we go along on this. So here's what we're looking at case type 1. Here's what you started with as a before smile. Here we are with the after smile and here we are again with the smile before and after. And the flame underneath her on the left side is not actually in her mouth. So what we're looking at is does this fit case type 1. Is it a legitimate case type 1 You know we're looking at teeth that actually needed to be treated. Do we like the overall look of the smile at the end So these two states as an examiner, I'm looking at this and I'm looking this. Do you get a good feeling for her end results when you look at those two shots Yes. No. Yes. I see heads nodding. Okay. I do too. So probably on my score card, I would have gone down and check that little plus 1 box simply because I like what I see in these first two shots. It also didn't hurt that they upgraded their photography from there before to their after as well. Again, its great to have all great photography but really having your after photography upgraded is a fantastic thing as well. When we're talking about composition, let's look also at how the color have changed a little bit. Okay. So we're actually looking at this to me is a little more corpsey looking and this is a little bit more healthy natural looking in terms of tissue tone. So when the tissue tone looks natural the teeth tend to give a little bit more of a natural look to them as well. So yes, this photography does not match. But this is accreditation stuff so in an ideal world this should have happened one time. This should have happened in your first time and then you learned and then all your shots are like this. Once you do this, every shot should be like this from that point forward. Okay. So now we're looking at the other shots. We're looking at retracted views. Okay. We're getting the general overall feel of how is the criteria. Okay. Case selection. So what's our general consensus Was the case a good selection here Okay. There's a lot of modeling and spacing. There's lots of stuff going on here but that's what makes it a legitimate case. Okay. But look at this tissue preoperatively. Okay. That's huge. That tissue, when you get to start there, you are just way ahead of the game when you get to start at this point. Cause you're not having to work all the way through. So you got a beautiful tissue to start with. Okay. Let's look further in here. Shapes, contours, dental anatomy, line angles, embrasures, characterizations. Okay. In our one to one. One of the rules of accreditation examination. If it can only be seen on a one to one shot has a fault it's no more than a minor fault. So what happens if we go back here and I don't see any problem here, here, here, here, here, here, here. Alright, I'm jumping too fast. Then I come here and I say I see a margin right here which I don't. But let say I do. I see a margin right here. I mean if we really want to make a big deal about it. I guess we can say we see a little finish line here. But bottom line is that would be no more than a minus 2. And in this particular case it's a minus 0. But my point being is that's the only it seemed one on one photography is not the place where all of the sudden everything crumbles of an otherwise beautiful case. Okay. So we look at it from the occlusal view in terms of our shape and contours. And then the required shots. Okay. 1, 2, 3. Okay. So case type 1, how many people failed that case It just didn't seem get it done for you criteria wise, you would fail that case. Zero. Everybody passes. Okay. In your practice or in your lab right now is this something that you can achieve in your offices right now. How many would say that this is something you feel comfortable in your practice, in your office, in your lab right now. Okay. Hands are 100%. Accreditation is achievable. Okay. It can be done. It's sometimes an ominous thing that sits out there and you're like my god, how am I ever going to meet all those criteria, I'm going to lose my mind. Trying to check off every one of those criteria. It's not quite that way. Okay. It's finding the right case, attention to detail, follow the protocol, doable. Alright, case type 2 and we're doing no. 8 and no.9. Again upgraded the photography a little bit there and general impression. It's so hard to tell with the washout like this. So what happens is you were talking about do befores really matter Well if you want the plus 1 they do. Okay because when I'm doing, when I'm looking here to here and I'm undecided whether I'm going to do plus 1 I'm looking at this and deciding do I like what I see here or don't like and how is the transformation made it over to this one right here. Okay. So when I'm looking at that transformation and this is a washout I feel like I don't have something to judge very well, you know. Sometimes I'll pick something out here and I'll say man that's really bugging me. But we look at it, we got five examiners and we go back through it a second time and we look at the whole, it's the whole body of the 12 pictures. So what turns out it was to be something really kind of turns out to be nothing. So in the end of the day, how many people are passing this case Okay. That's everybody. Can you deliver this in your practices or in your labs Do you have the ability to do two central incisors that are handled this way, given this as your starting point Okay that's pretty much everybody shot and nodding their head yes. So you guys already got two cases done. You haven't actually done them yet but you know what I mean. You got them done in your mind. You've got them done that I have the ability. I have the capability to do the kind of dentistry that you're showing there on that screen. It's not perfect. These aren't models. These are regular folks. These are very talented dentist doing beautiful dentistry. So the question is when the examiners are going through this, and they're looking at it, do they have a discussion and does it go from an examiner to examiner. And the answer is and that's a great question, the answer is from the moment the lights are turned down and the slides hit the screen, no one is allowed to speak. It is absolutely silent until all five score sheets have been given to the groom chair of how it was graded. So the discussion can happen in the beginning where you can look at the book and you say did you anybody see the type of material there. Yes, they used, they used Empress. Oh, okay. Yeah and we start the case, I'm sorry can you just real quick what teeth numbers were treated. Number 3 through 14. Thank you. Then it's silent. That's the last discussion that takes place. The only other words that are spoken is could you go back to the one on one shot please and whoever is operating the remote will go back. Could you go back to the full smile again for me, please Thank you. Room is silent. All five are graded. They're passed. There is no discussion. The discussion occurs afterwards in terms of consensus for a failed case. Okay. And there's our radiograph. Take the radiograph seriously. A wide open margin here and here is going to be a problem. Okay. It's going to be an issue. Take it seriously. These are beautiful. Case type 3. Let's look at two different ways you're going to attack case type 3. One way is to go ahead and do an implant. Okay. So they're going to go ahead and they're going to treat no. 9. So here she is before and here she is after and here she is in a smile. Liking it, loving it, hating it. Okay. Alright, no one is in love with it yet, so we're going to take the plus1 off the board. Okay, let's move on. Let's back up for a second. What's case type 3 treating again Your ability to handle to the soft tissue in edentulous site. Okay. How is the soft tissue handled in the edentulous site is the center focus of this case type. The other parameters come into play, don't get me wrong. It's not like you ignore everything else. But that's the center focus. Okay. Let's go onward. Now how you're liking it I see some headshaking. You're not liking this. Tell me why Gingival tissue does not look healthy. It looks kind of it's rolled right here and it's a little bit red compared to where were when we started it off. And it's not equal to the, two different issues there. So let's back up for just a second. Let's back this thing up. So number one is that the tissue looks a little bit red or a little puffier there it does to start with. Major, minor or not existing. Minor. Okay. Maybe. I would say it would go anywhere from nothing to a minor would be the normal, what I would expect a group of examiners to do. Now let's talk about gingival heights. Minor, major. Major. You better believe on every, I can guarantee you on every examiners score card, that is going to be a major that those tissues were not line up. I happened to be on this oral examination and I happened to remember the response and the response was I didn't have time to trim it and get it into place because it was an osseous issue, it wasn't soft tissue. It was going to require more than that and I submitted it understanding that these gingival heights didn't match up. Okay. And well we haven't passed it yet. Hold on Charles. We're still looking here. We got to get some more shots. Got a value issue and body here and we got a change in diastema but tell me about, stop and look carefully and tell me about whether you like proportions better in the before or the after of tooth to tooth not looking at the diastema. You've improved the proportionality of your two teeth even though you didn't get the gingival nailed you improved this tooth. To me it looks like a big honking central next to this one. Of course the fact that it's yellow made that an issue as well. Okay. So even though the diastema grew in size the proportionality at least in terms of here to here looks better to me in general. So that part I think would not be a factor but value would be. Value is going to be an issue. Major, minor, catastrophic. I know you're getting, major. Alright, alright. Now let's stop and think for a second. Look at how, remember this tooth as been taken out of the mouth. It's been extracted and this now is a false tooth entirely with an implant in place. Stop and think how the soft tissue was handled. How the case was handled in general and we've given it two majors and we now flushed this case and told this candidate they failed. Alright is everybody in the room comfortable with this failing. Now you're shaking your heads. No. So now you understand what examiners deal with all the time. It's not just necessarily jut purely by the numbers. So in my score card I would have either had to be married to the two minus 4 but I would have gone back to that smile again and probably would have said, you know, I think it looks pretty good. I'm going to check the plus 1 box and that's going to be pass case. So again we have to weigh this as examiners all the time. Are we ready to say that the ability to handle that soft tissue there was a failure in this case Now the way this candidate makes their life worlds easier is get this tissue heights correct. Now this other issues become a non issue but they were borderline here. With this beautiful work, you're still, you come out borderline. You've got to look at all these parameters carefully. Beautiful handling of the soft tissue in here. Really decent ceramic work. Yes some value issue no question about it. But some really decent ceramic work. Proportionality, all these things diastema, another thing I like to, I used this case, diastemas are okay. If proportionalities are correct. A diastema is not a failure point on this case. I've had people before that say oh well you didn't close the diastema. But that's not the criteria here. Cause it's graded more like case type 2. Remember that your preoperative radiograph has to show the failing tooth or missing tooth. Okay. So there is the failing tooth. We see it both in the photos and in the radiograph failing tooth, an implant in place. Okay. Now another way to tackle this is you're going to do some bridge work and this is going to be two bridges. It's going to be replacing lateral incisors, altered some gingival heights, use some composite on no. 8 and no. 9. Okay. Here we go. Red eye. Oh, well, examiner don't care. Okay. Don't try to worry about it. I mean if you can get it out of there in your photography, fine, but that's not an issue here. So do you like her before better in the smile or do you like her in the after more in the smile. But there is a little more criteria to it obviously than just that. I mean obviously than just a missing teeth. Meaning does the overall harmony of what they've done in the after give you a good feeling and a good effect. So yes you can say that's potentially on some of your cards that maybe a plus 1. Okay. Let's move on. Look at the shapes and contour. What we're looking at is if you're replacing a missing tooth, I don't want to have a photograph that shows me that you're replacing a missing tooth. I want to get the feeling like that's the real tooth that's in place there. And when I look at that shot, I get a pretty good feeling about that. I don't get connectors that look like these long long lines drawn where the teeth are fused together. I don't get that effect on this side either. Okay. So now we look at retracted. Does the tooth looks like, does it look like it comes directly out of the soft tissue Does it look like it's a natural tooth Yes. Maybe. Yes and maybe. Okay. Let's look from the side. Compress a little in the papilla. Yes. Okay. Well now all of the sudden I'm not so, I mean I was not so happy before but now I look at that shot, I'm like that's not too shabby. Okay. Not too shabby. Okay. Let's look up close. That's not bad. That's not bad. Again, no compress in here. Close in pretty nicely here. Took advantage of a young patient with nice big open incisal embrasures so we don't have these big long honking contacts. Oh and did anybody see what kind of bridges were used Zirconia. Okay. Any other guesses. How about good old Maryland Bridges with metal. Aha, what do you know What do you know, the old stuff works. Jack always makes fun about how old I am. I was instructed by Van Thompson and Gus Lividitis were my instructors in dental school as they were developing the Maryland Bridge. I went to the University of Maryland. They're the designers of the Maryland Bridges and they were my instructors as they were designing Maryland Bridges back in the good old days. So again it's not the material that makes the difference. Okay, it's how you handle the soft tissue in edentulous site and how you chose your materials and how you use them. That might not work in all cases but it worked here. Okay. So who can do this Who can do this in their labs or their practices I see most every hand going up. How about the last implant, is that doable That single tooth with that soft tissue coming out that way. This is one of the hardest cases to do and you all are shaking your head yes, you can do this in your labs and you can do this in your practice. It can be done. Find the right cases. Work through the detail. Work through the protocol and it's achievable.