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American Academy of Cosmetic Dentistry Accreditation Workshop
Part 4 - Review of each case type
Case type one discussion continued and case type two, one or two indirect restorations, case type three, tooth replacement, case type four, anterior direct resin and case type five, six or more direct resin veneers will be reviewed.
So the idea is that you can only use for each of your five case types one person, one case fits that case type, it's not used in other directions. Okay. So you've got the patient where you bring them in and what they have is they have a little chip on the front tooth and go you ahead and you bond that chip and you get case type 2 all squared away. And then what they do is that that chips off of there so then you go and you put resin across and you do the five or six teeth in resin across there. You finished that on there. Then you strip all the resin off then you go and you put porcelain veneers all the way across for that resin. It's still all the same patient. Okay and then because its your worthless brother-in-law has has been mooching off of you for endless numbers of years, you punch him and you take out his central incisors and you now do a single central incisor as an implant. You put a crown on that. So basically you've just run the whole accreditation gamut on one patient. That's not exactly what we're looking for in terms of definitive treatment. Okay. So the idea of accreditation is also that you're doing definitive treatment for that patient. Alright. So then the next question is it's anonymous. You can submit the cases over its five year time period. How do we know How do we know, Charles Oral exam. When you show up for the oral exam and we put all five cases up to review them to discuss with you and we see the same patient's face more than once you just failed your oral exam. You just failed your accreditation clinical exam as well but that has to be redone obviously. To answer your question that's a long bended answer but the idea is yes for each case type is it an individual patient. Okay. Sorry, case type 2. Questions Okay. Case type 3. Going to replace a tooth and going to do it one of two ways. You're either going to do a bridge or you're going to do an implant. If you're using a bridge, you're replacing either a cuspid or an incisor with your bridge. You're certainly welcome to replace more than one tooth. It doesn't have to be a single tooth. But obviously as you start to try to replace multiple teeth you create great complexities for your end result. The exception of that rule might being congenially missing lateral incisors. Something like that is a pretty straightforward type of case. But somebody is missing two central incisors, probably not going to be an accreditation case. Implant. Remember we talked about that you have to have an x-ray and your photo. Your x-ray and your photo have to be either of the failing tooth or the edentulous space prior to placemen to the implant. Why is that important Example. So a patient comes to my office and they have a failing central incisor and I worked with my periodontist. We take out the central incisor. We graft. I create a temporary that holds that tissue in the correct place. Patient heals for a time. I bring them back in. I put a temporary fixture in there with the temporary crown. I contour and shape that to get it to ideal contour, that tissue shaped beautifully. And they move to, where's home They moved to LA. From LA, case type 3 patient walks in, fantastic. Let's just take the temporary off. Let's put a crown right on there. Walla, all done. But didn't really do case type 3. Didn't really do any of the tissue manipulation, I did all that. What you did is match the front tooth which makes it a good case type 2 but it doesn't make it a case type 3 because what we're testing here is your ability to handle this soft tissue in the edentulous site. Okay. That's the main focus of what this case type is testing. Now smile design factors may or may not play a role because if you're doing a single lateral incisor, implant with a single lateral incisor crown that's going to be judged more like case type 2. If you're doing two three unit bridges, that's going to be judged more like case type 1 cause you're treating six teeth. So you have a smile design coming in play. So you follow me on that Case type 4, case type four moves out of the laboratory phase so you guys are out of the loop on these, we're into the dentist only part of this and for class four resin, it's a class two fracture or greater meaning you fractured at least to the level of dentin and at least 10% of the tooth, OK, so if you are going to replace a missing section of tooth, it needs to be at least 10%, don't make the examiners guess, don't try to submit a little tiny chip and then we got to get out and figure out, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, is it 10%, I don't know, that's probably, if you're having to guess, it's that close, that's not a good case type, it has to be a legitimate place, a legitimate fracture enough of the tooth, that you're replacing enough of the tooth for us to be able to judge your ability to handle the resin and blend it in there. You have another option. Your other option is to close a diastama. The diastama has to be at least 1mm in space. Same idea, they can't be these little tiny space that comes apart, at least 1mm and when you close that diastama, you must place resin on both of the teeth to close the space. So even if you have an undersized tooth and you say well no I was just building that out to make it even with the other central incisor, that's fine, it's just not accreditation. We understand why you did what you did, again the story doesn't matter, we understand that's what you did, it just doesn't meet the criteria for accreditation. OK Case type 5. Now you're doing all the things you did in case type 1. Everything comes into play except the difference is that you are going to build the resin directly, the ceramist is out of the picture on this. So obviously, how you shape these teeth are a huge part of your end result and of what you're being tested on in accreditation. Because so many of the things as dentist that we take for granted our done by our ceramist on a regular basis for us. They do these things day in and day out. They blend these shades. They blend these colors. They build this anatomy and contour. And we just almost take it for granted that's its going to be there. I know I do. I just normally take it for granted that these line angles are done correctly that they jave beautiful facial embrasures, they have beautiful incisors. There are so many of these things are there. Well the things that I deal with my ceramist more than anything else, almost always are shades. Shade is always the challenge. You know of getting that blend or getting it right or maybe contour on occasion. But if you diagnostically work it up again of time in terms of your wax up and your temporaries even that tends to become minor. So those are the things we're facing. Now with case type 5, as dentists we have to be able to demonstrate that we understand and we can handle these principles. Okay. So you're going to take case type 5 and you're going to build six or more direct resin veneers. Now again what is the buzz word in our profession. What is the buzz word in this academy What is on the signs as you walk through of everything related to this regional meeting and that is responsible aesthetics. Okay. The idea of composite resin is it is a beautiful tool to be used ultra conservatively and that's what examiners are looking for. Now it's difficult for us to tell you where you should and should not prepare a tooth. That becomes a little tricky but I will tell you this, that examiners do not want to see anymore aggressive preparations of teeth on this case type and we know it because you have to demonstrate technique on this one. You have to remember this is your technique case as dentist. You're showing your first step is the preparation that you show. That shot alone can end that case for you. You can fail with that shot alone if you're cutting way significant amounts of tooth structure. Okay. So you need to really choose this case carefully to where you're doing minimal preparation or actually better yet no preparation in building a resin. You still have emergence profiles and you still have contours that you have to deal with so that's why we're saying, you know, it's unfair for me to tell you that no preparation is the keyword here. But minimal conservative tooth preparation is absolutely what examiners are looking for. And we've seen way too much over time, way too much over preparation. As dentist dive in to this case and the first thing they have to do is they figure if I've got to layer this resin, if I've got to make this resin look go, I've got to really cut these teeth back. So what's a great way to figure out how you should take that case on Work it up diagnostically. Don't sit down with your patient and don't make your first move the bur and the resin. You're first move is alginate. That's your first move with this case or whatever PBS or whatever impression material that you take. But that is your first move with case type 5. Once you have that model, you now can work up contours of where you're headed. Now can you have your ceramist or whoever does your diagnostic wax up do this for you That's not illegal. However, I would highly highly recommend, I don't do my own diagnostic wax up anymore. I don't do it number one for time and the bigger reason that I don't do it because I'm not as good at it. That's just the bottomline. But for this particular case type, strongly urge you to work that case up either in wax or maybe even in resin. Use resin directly on the model and make yourself a silicone stent and find out once you get those contours nailed down there, use your silicon stent prior to preparation over the top of these teeth to find out where do I need to trim. You could literally do a six tooth case by trimming a corner of a lateral and corner of the central. That can be the extent of your preparation. And now you can build layers of resin. And when we talk about layering resin and building it on top, if a tooth as natural beauty and a natural color to it, why do you have to cut that away and why do you have to put a colored shaded resin over the top. The answer is you don't. If the word is veneer that still means covering the surface of the tooth, that simply means take a translucent resin and cover the surface of the tooth so the natural beauty of the tooth shines through. Well show more cases when we come up to that on there. But if I'm not making my point strong enough here for the dentist in the room, I want you to really take that home cause that's huge with this case type. Okay. Case type 5. Questions. Okay. So all are maxillary teeth. So all the parameters we just laid out in the case types are all maxillary teeth and if you treat additional teeth they will be judged. That doesn't mean that should deter you. Don't let that be a deterantbecause if you're an excellent cosmetic dentist you can handle that and you can do it to accreditation standard. There's a case that we show in examiner calibration that really is a struggle for all of us when we look at it. And the case involves replacing a lateral incisor. And what the dentist did is they replaceed the lateral incisor either it was an old failing crown or it was broken down tooth. I don't remember exactly what was in place there. I don't remember whether it's a veneer or crown to be honest with you. But the idea is it blended beautifully. It was very nicely done case type 2 lateral incisor. Two teeth away, the first bicuspid was the most horrendous looking 50 year old nasty crown that you've ever seen. It was almost impossible to judge the case because your eye went to that funky crown over and over and over. So my fear is when I see that is the candidate took this too literally. They looked at it and they said you know what, I'm just doing this one lateral cause I'm not touching that other one cause they're going to judge that one. You've got to be kidding me. A bicuspid you can knock this lateral out of the ball part but you can't nail a bicuspid. Of course you can. Take that nasty bicuspid off of there. I don't care if they give the thing away. If it's an ideal accreditation case and you've hit a home run with this lateral incisor that blends perfectly, cut that sucker off. Make a beautiful bicuspid crown on there and now you've got a beautiful smile. You've got a great result and you don't have examiners sitting there scratching their head deciding what they want to do with this case. You've made it easy on them. Check marks for a pass. How do you decide should I submit or should I hold it back That's where mentors become so valuable. Mentors are helpful to giving you some feedback of what you've done with that case and can give you what they think that the examiners might look for. Okay. So now we've gone through all that. Now we get to the heart of your question. Your question is so what if I decide to submit it. You know some candidates just don't feel comfortable working with mentors. So one of the ways they go through accreditation is they submit their cases and they learn from them. And I've had candidates do that working with me. They say you know what I know you laid this out to me. I know you told me this was probably going to happen. But I'm interested in what the examiners see. I put my $200 in. I put my written report in and here's my case. So the bad news is that it fails. The good news of a failed case is the detailed feedback you get for that case. It will get criteria point by criteria point listing usually in the order of most severe and then down and will give you that exact feedback. And what it would probably say at the bottom of that is tooth no. 10 was handled beautifully but no. 12 was such a deterrent to overall smile design, the examiners felt that that was a catastrophic fault and the case failed because of that. Candidate should reconsider treating no. 12 and submitting the case again for accreditation. That's a common comment to see down there. Where you see that a lot is case type 5. When you pick a really good case type 5 and you handle the resin pretty well but there was just enough dings on there that it didn't pass. So lots of times that comment will be at the bottom. Say candidate showed promise in handling resin, please consider addressing the criteria and resubmitting the case for accreditation. So that's, you know, it's not all bad. A failure is not all bad news cause how do we learn quite frankly. We learn from our failures. We really do. So if you choose to submit a case, don't feel guilty, don't feel bad. If that's the way you want to go about it, go for it cause you will absolutely get feedback on there. And then I've even had those candidates come back to me as their mentor and say Brad, you're right. This case really probably wasn't ready for accreditation yet. Here's what they noted on there. What do you think about this And I'll be honest. I'll go through it and I'll say well you know what, I, the first two on there I agree with completely. The third item that they listed that probably wouldn't have been on my list. Again what you're getting back is the consensus. Five examiners, 3-2. Okay. Three pass, two failed, that's called a passed case. You will never know that. You'll only know pass/fail. You won't know the ratio. 3-2, 4-1, 5-0. But the idea is there's a consensus that comes back. That doesn't mean every examiner saw exactly the same things on there. That was just the consensus that came on there. I might be the only examiner that took off 2 points for incisal embrasure development. No other examiner in the room may have done that. That probably won't be listed if that's the case. Cause usually it's a consensus at that point. Okay.