American Academy of Cosmetic Dentistry Criteria Workshop

Part 3 - Criteria overview part 3

Instructors:

Dr. Bradley Olson, DDS

Dr. Bradley Olson, DDS

Dr. Olson is one of approximately 300 dental professionals internationally to achieve Accreditation status in the American Academy of Cosmetic Dentistry. In addition, Dr. Olson has achieved the AACD’s highest credentialing honor by becoming the 39th member awarded Fellowship in the Academy.

Principles of smile design such as incisal embrasure and principles of proportion will be reviewed.

Incisal embrasures. Incisal embrasures are increasing as you move distal. So we're talking about the edge of the teeth. We're talking about that V that's occurred right at the very edge of the incisal embrasure as it moves from central to lateral to cuspid will continue to open. When we talk about that, its not only going to affect the embrasure itself but its also going to affect the contact area either of your pontic or your two teeth that are contacting with each other. Okay. So progressive increase, contact moves up and affects connector length. So you can be too deep. You can be too shallow and it can be affected by tooth length. One of the things that can happen here is how you develop your incisal embrasures can go a long way to how you can help your case move through. We know that younger patients tend to have much more open embrasures. So when you're facing a situation with somebody with a really long tooth but it otherwise is a really nice case, one of the ways you might be able to help those contact zones is by opening those embrasures up even if it's a little older patient. By getting there and opening those embrasures you cut down that contact. Our general rule of thumb is the 50, 40, 30 rule where we're talking about from the edge of the papilla to the open of the embrasure is approximately 50% of the length of the tooth. So if this tooth is 10mm long that contact area should be roughly 5mm long. It's a general rule. Again this isn't an exact math. As a general guide. As we moved back here, we go to 40 and here we go to 30. Cause we know those embrasures are opening as we move to the distal. So it's a great tool to keep in mind of how you develope your embrasures of your contact points and what you're doing when you're facing longer teeth. Okay. So, beautiful embrasure development all the way through here. No embrasure development, saw it off, saw if off, a little something going on here that doesn't really look very natural. Same thing here, no development at all. This comes right to the edge. Nothing done. Now the case has other problems of course. We're just picking out one of the criteria. But certainly that's no real development there at all. We saw a case this morning or actually we saw that very issue where the incisal embrasure, it was the single central remember it was having a class 4 resin done it on and wasn't harmonious. The incisal embrasure wasn't developed in such a way that provided harmony from side to side. It was nice on no. 8, when it came to no. 9, it was flat like this. So it created a dysfunction in our eye as we were looking at the case. Principles of proportion. This is a big one to take with you. I mean this is, all of you can do smile design certainly know that this is a big deal is getting the proportions of the central incisor is huge. Creating central dominance and creating proportion central incisors is absolutely huge to getting final outcomes that are going to pass accreditation. They're huge to getting great end results in your daily care of all your patients. Okay. So what we're talking about is the 75% or 80% rule. So if we're talking about numbers, if you have a 10mm long central incisor, the width of your central incisor should be approximately 7.5mm to 8mm. Now again exact measurements aren't as crucial as the way it's going to appear. So that weighs out so much more than golden proportion. If we talk about golden proportion, we're talking about the 1.6, 1 and 0.6 in terms of factoring in the smile position with the lateral incisors being that factor of 1, centrals being 1.6 and then the visible part of the cuspid straight on being 0.6. Now never ever in the time of accreditation have I ever seen an examiner get out any kind of measurement or try to figure out the golden proportion. Golden proportion just happens. You can see it in your eye. It's not an exact measurement. It also does not allow for some slight variance, which are more than acceptable in accreditation if there's a little bit of tooth size from side to side discrepancy. The key is to knock the centrals out of the park. That really becomes the key. You have a little bit of variance in your lateral incisors. In fact, I like that. I love when patients let me put a little tweak or a little turn or a little angle on a lateral incisor. I think it gives it a really natural look. So I love to be able to do that. I don't do it all the time. Some people don't like that. I didn't pay you to give me a crooked teeth. Got it. I'll straighten it out. But the idea is it gives that nice natural look sometimes. So that works out fine. But in terms of proportion, golden proportion measurement put aside, central incisal proportion huge factor. Okay. So when we start with some gingival asymmetry and precision, one of the ways you get proportionality is putting the tissue in the correct spot. You move the tissue in the correct spot then you get proportion as you move across the teeth. When you start off with a situation of teeth already being very wide and having the issues of the position of these teeth when you come to do your final restorations this is a problem you face. It's going to be hard the way this case is starting in this position to get an end result over here. I'm not saying you can't use this for accreditation, multidisciplinary case as far as I'm concerned. There's work that needs to be done here before you go to here as opposed to just saying I'm going to prep, seat and photograph. So the question is are we allowed to use a periodontist to do our multidisciplinary treatment in terms of moving hard tissue, moving soft tissue. Answer is absolutely yes. Okay. There's nothing in accreditation that says you have to do every facet. So that would mean that for your implant case, you would have to extract the tooth. You would have to do the bone grafting. You would have to do the connective tissue grafting. You would have to place the implant and you would have to restore it. That's not the criteria for accreditation. You are the restoring dentist. That is your responsibility. But the other steps along the way certainly can be done but we all know to get that great end result who has to be the quarterback. That's you. Diagnostically you back up. What you're going to give them is you're not going to tell them, you don't tell the orthodontist put these teeth in a better position for me please. No. What you do is you tell them exactly where you want these teeth. You want to fix that rotation. You want to fix that rotation. You want to fix these gingival heights. You want to close these spaces a little bit. You want to get this in here then you're going to come back and take care of this chip and whatever is on these teeth resin and this chip and discoloration, all the rest of that. And you're going to do your restorations but you will set the table to get those ideal restorations. So just keep in mind accreditation, fine. You just got to go through the steps that are required to get you to that stage. It's not simply take the case, prep, seat, photograph. Some cases work like that and those are the one to look for obviously. But if you have a great candidate for accreditation, just make sure your diagnostically working through the steps that are going to get you to that end result. Okay. Same idea. Even though you're only treating the central incisors, it looks innocent enough until you put them in their final position and then you have length to width ratio issues. So you have to look at this ahead of time and diagnostically just put it on a cast and figure out what do I have to do. We were talking about before about well would plasty help. Might. I'm not saying this so I would hear. I don't think that's a great, this isn't a good situation for that. But we're talking about, we're talking about enameloplasty. Is that okay to do. Absolutely, it's okay to do. Use it any step along the way. Use it any place that you need to to create proportionality. If you need to treat more than one tooth, if you're doing two central incisors and in case type 2, remember that the case dictates that you only treat one or two within direct restorations but it does not limit you in the number of direct restorations. So you simply can add direct restorations into other parts of the smile design in order to create proper proportionality. Okay. Proportion. Questions Question was I have a patient where if we take a situation like this, where we're going to have possibly a proportional issue but they have a low lip line and it's a gingival architecture issue that's going to create my length to width ratio violation, how do I deal with that. And you deal with it simply by delivering an outstanding beautiful result that makes your patient very happy. You simply don't use it for accreditation. That's all. Remember accreditation is a test and you're testing the specific criteria so you pick a case that fits into that criteria. And either the case doesn't fit or the patient doesn't fit or the multidisciplinary treatment doesn't fit, simply do your beautiful end results that you're going to do and make them very happy and move forward. And you know one of the things we do in advance accreditation workshop has been interesting. I have had candidates before where I've done the workshop; they want to argue their case. It's not a court of law. You don't get to argue your case. What we see on the screen is what it is. And I tell them do you want to get accredited or does this case have to get accredited. You've done what you can do with this case. You've done a beautiful job. Move on. Step away. Move on. You critiqued it. You analyze it. You're done with it. It's a great result. You're happy. Patient is happy. You're paid. Everything is grand. Lab is paid. Everybody is happy. Move on. And find a case that fits the parameters that will demonstrate all of those in there. So that's where case selection becomes huge in terms of case selection, I don't mean just the case, selecting the case but also selecting how you manage the case to get it to that end result. So that's the real deal here. Speaking that out. It's not diving folks. You know when you dive. Well this dive is going to be 4.5 in difficulty level. So they get extra points for the extra complex dive. Accreditation doesn't work that way. Say look what an incredible result I've got for an incredibly complex case. You're right. That was a beautiful end result. It's just not accreditation. You don't get extra points for the more difficult level of case that you've chosen. Profile anatomy and contour. Obviously they're important with your ceramist because you have to dictate to them what it is that you want them to do. You have to have communication with them in moving that forward becomes really important in case type 5 because you're developing this with your hand as dentist. So again ceramists are pretty comfortable with these types of situations for the most part. But I've seen plenty of ceramist cases that don't come through that had been handled correctly in terms of the contours. So you're looking at the three planes, from the facial plane, one, two, three and we're looking at lobe formation and the mergence profile comes off the tissue and we're looking at line angle, position, and development both. So not only do they need to be developed, but they need to be developed in the correct position. Okay. So when we look at this case, case type 5 and remember what I told you when I showed you that case this morning, the money shot was the occlusal shot. Okay. This is a big view. So when we look at an occlusal shot, we're looking at how this arrow head, how this facial embrasure is developed inside here. We're also looking at the lateral view of how the lobes were formed. Some people have big deep lobes. Some people have minor lobes. That's okay. Artistically, they can differ from patient to patient. But there needs to be the development in there breaking up the light and showing the anatomy, that also helps lead to the development of the positional line angles as it does here. So both the facial embrasure and the lobe formation lead to how you develop those line angle positions. And one of the things I put in here resin, finish, and polish. If you talk to any of the folks who are the top leaders in teaching resin and there are so many of them. I almost hated list names cause I always forget somebody but I think of Corky Wilhite, Newton Fahl, Brain LaSage John Weston, Buddy Mopper, Jim Patton. I mean the list goes on of people who are really really talented with resin and do resin and do beautiful work with it. And one of the things that universally you will hear them tell you over and over and over again is contour. in king. Contour is king. You're going to spend your time on contour. When you talk to them about finishing and polishing boom, boom, boom. They go through and polish a case. It's light, fast touches and its going through each of the different disc or whatever system or cups or whatever system you choose to use. But it's going boom, polish, boom, polish, boom, polish, boom. Bring me the next one. Boom, boom, boom, boom. So the polishing is very rapid and goes just like that. The more time you spend polishing and finishing is the more time you're going to take away all of the lobe formation, line angle and anatomical development you've put into that tooth. So the longer you grind and the longer you finish and the longer you polish the more you're going to lose what you've put in there to start with. So contour is king. Make sure you get that in place and then come back and your polishing should be really quick. If you feel like you're not going to get there with the polish, you need to work more on the contour. Trying to polish a case home is a great way to take it right down and we'll look at some cases that we're going to show on there. Preparations. We're talking about minimal preparation. We're talking about no preparation. We're doing case type 5. Also when you talk about doing our other cases as dentist, where do we cheat you. Where do the ceramist, where do we cheat you guys when you're trying to develop these three planes. Incisal edge. We cheat in the incisal cause we start with our burs up at the gingival and we cut up there and that's when we start to create our shoulder champer whatever our style of preparation is. And then once we do that, we drop down and we flatten it out to follow that contour and we let that and then we cut that incisal edge back to the right edge. No, I'm not saying everybody follows that exact protocol or have your own style but the idea is still is the same. The last place we fail to give them is the last little edge right up there in the front. Sometimes that's the only preparation you need at all. Sometimes you can take a virtually, a no prep, a minimal prep case. I don't care if it's in ceramic or if it's in resin to where sometimes it's just beveling off that edge is enough to let the ceramist build some beautiful effects, some halos, and translucency into that edge and then almost contact lens the tooth all the way, the rest of the way cause all you maybe doing is correcting shape. You're not trying to change color a whole lot. You can do the same thing with your resins. When we say a resin veneer, we're not saying that that shaded resin has to run all the way from the incisal edge all the way up to the gingival. You may only use a little bit of the shaded resin, you may finish that up with an enamel shade or a translucent shade, it almost gives a contact lens effects that you can polish and finish with minimal coverage. So again the place you discover this is in your diagnostic work. A photograph and a bur is not enough. Okay. That doesn't get it done. You need to set these cases ahead diagnostically knowing exactly what part of the tooth structure you're going to cut and why you're going to cut it. And then that leads to the rest of this and if that means working in conjunction with your laboratory, by all means. I do it all the time. I've gotten so spoiled now it's almost like its autopilot. You know I mean I take the impressions. I write down what I want to achieve. I get back this gorgeous diagnostic wax up and I get back this matrix so I can make the temporary with. I get this cut back matrix and I sit down before I touch a tooth and the first thing I slide on there is that cut back matrix. I run that right over the top of the teeth. I can't get it on cause it's rubbing on there. Okay. So I set it aside and that's where my first preparation begins. Now I slide it all the way on. All of the sudden I don't have to touch the laterals. I'm bonding to all enamel. What are you kidding me That only last 50 years. Exaggerating of course. Never tell a patient that. But you know we're bonding the sucker straight to enamel. I mean it doesn't get any better than that. Plus I didn't have to cut any tooth structure. There is no sensitivity. There are all the positive things that go along with that. So, again your diagnostic work huge for all of these cases. Okay. So here we go just comes right off here and just comes straight down. One, two, really very laying anatomical development. Look at the lobe formation in the lateral view. Look at the nice lobe formation one, two, three. Almost like an, almost like an exaggerated plane but still beautiful. Occlusal view. Just nothing, direct resins. Minimal I'll give you that, minimal preparation, minimal addition, thumbs up there. But you've got to develop some anatomy. You can't just make it all the way across. Minimal preparation, minimal resin added but looked at the development in here. Look at the lobes here, here. Look at the line angles here, here. Look at the facial embrasure here. Use that occlusal shot, valuable tool. This morning you heard me saying let nature be your guide. And you knew I was going to say it again after I've warned you it was coming. But it's one of my mantras that I said over and over again to accreditation and I have to remind myself all the time of that. Look at these teeth here. For me personally, I love these teeth. You'll say what you love these teeth. No there's facets of it that obviously will be enhanced with cosmetic dentistry. No question in my mind about that. But look in general at the coloration of the translucencies, of the natural characteristics of anatomy and contour of these teeth in general, the line angle position. Just in general look at the teeth and then look at the way they look at the end of treatment. Okay. That's unfortunate to say the least, that's unfortunate. I'd rather have this than that. I'd rather than just go along and live with or at least somebody close my little gap here and fix my edge and take care of that dent. Okay and maybe some bleaching or something else. Now I'm not saying that this isn't a good case to go ahead and do six direct resins. It's a great case for that. It's fantastic. It requires minimal preparation. It requires just following nature. Follow the natural contours and shapes of teeth. Always refer back to it. Use it as your photo to go back to over and over again as you build your case and resin. There's nothing natural about this, in shape, in color, opacity, none of it. Translucencies, halos, line angles, we can go on and on and on. Now it sounds like I'm beating up this poor candidate. And you know the great thing about this is also though its resin, right. I mean just do, you know, just cut it back. Do a cut back, just like a ceramist does a cut back. Do a cut back. You can build this. You can get it there. It could be done. I don't have a, I would feel very uneasy. I'm not sure I even want to see what the preparation looked like. Cause I'm fearful that they may have really cut a major amount of tooth structure when it was completely unnecessary. Maybe I don't know that for sure. But that's the key is minimal preparation and letting nature be your guide as you build the case.