American Academy of Cosmetic Dentistry Criteria Workshop

Part 5 - Top ten reasons for failure part 1

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.

The AACD accreditation examiner guidelines and the first few reasons why candidates fail a case they submitted.

Let's talk about what examiners do. What we're doing as examiners is we're going through and again just to lay out for you what happens in an exam room is that the case is there, there's no id associated with it other than a number, there are your written reports in the desk but they are all ready pre-loaded by the staff into our computers and put up on the screen. So we simply look upand see we have candidate 1234 and case type 3 so we pop up candidate 1234 case type 3. That goes up, before and after screen, one side says it's a class 4 resin, I mean a case type 4, the right side class 4 resin, mesial incisal lingual of number 9, we read the written reports, the meta data is examined by one of the examiners, we all take turns doing that and we look at that and we go through the meta data that's on there to make sure the images have not been altered in any way shape or form and then the lights are turned down, the discussion ends and the case is examined, it's gone through one time fairly rapidly, pretty brisk pace, it's started back again and goes at a much slower pace. Examiners have theirtime then to write up their thoughts on the case and we have a pass fail check sheet that we check it off and we hand it to the room chair and when all five are collected the vote is announced and then the discussion can happen in the room. The discussion is usually well almost always for a failed case because we have to give you feedback. There has to be a concesus and that's what you get for putting your case in when it fails is you get a return on your investment which means feedback which is a learning tool from that case. So that's the way the process works. There are guidelines that we ask of the examiners and what we ask them to do is we ask them to follow the calibration. So when we get together the day before we start our exam process and we go through about a three hour retraining session where everybody comes together in that period of time and the accreditation chair takes us through case after case after case after case and we talk about them together in the room. We talk about what people are seeing and we talk about where people are going and we vote, would you pass it, would you fail it, what would your vote be, what kind of numbers would you have and what it allows you to do is bring yourself into the zone. You can be on the one end where your passing everything that goes up on the screen, you can be on the other end where your failing everything that goes on the screen and you're probably out of the limit . If you're not with the group, over and over and over again, you're probably seeing things way different than everybody else and you need to come in there. And the chairman of accreditation watches this very carefully and they also monitor our scoring and they go through and examiners who continually score outside the zone of the rest of the examiners are not invited back. It's a harsh reality, it's just the way it works. Cause we have to stay as consistent as we can. Let's be honest, this is not an objective situation, it's subjective and it always will be. It's human beings doing this so we need to be as tightly calibrated as possible. We remind the examiners that we need to pass excellence. If the standard of care, if you're in an exam room and your examiners happen to be Brian LaSage and Michael Sesemann and Betsy Bakeman, are we now going to judge the case at the standard of Betsy Bakeman, Michael Sesemann and Brian LaSage. We hope not because that's going to be a real challenge, that's a steep hill to climb but they will be the first ones to tell you that this is where they were at accreditation time and this is where they are today. It's a continual learning curve, a continual step up. We're looking to pass excellence, we're not looking to pass perfection, we're not looking to pass an ideal, we're not looking to pass what we would have done. You heard me say on that case this morning. That case bugs me. Well tough, get over it. Judge it, judge it for it's merits, judge it for the case that it is. It doesn't matter if it bugs me or not. It's not about me, it's about what's up on the screen and does it follow. So again that ties into know your biases. Some people have a bias about buccal corridors, some people have a bias about line angles, some people have a bias about contours, some people have a bias about shade. Whatever your thing is you have to keep moving away from that zone so that you're not looking at every case, buccal corridor, buccal corridor, buccal corridor, every case has a buccal corridor deficiency, no they don't, every case does not have a buccal corridor deficiency. Some do, some don't. If you are having trouble as an examiner, remember the case that we saw this morning and we saw the situation that they took care of one central incisor but there was a major shift in the gingival architecture in the two centrals and there was a major shade issue as far as I'm concerned that is right on the border that was a -8, the rest of the case was handled beautifully, the gingival shaping and health was beautifully done in the area of the implant you couldn't tell it was an implant, no one could ever know that that was an implant. So we have to look at that and you have to decide right on the border what do we do with that case and what we decide is what I told you this morning that that case was so well handled in other aspects, I maybe gave it a plus one at the bottom of my scorecard to make sure that it was a passed case. Again we don't live purely by the numbers. We live by the overall effect. What was the case testing and how did they deliver what the case was testing So again, tie goes to the runner. When you're evaluating your own cases, what we mean by double dipping and an example of double dipping would be in your scoring is that you look at contact length of these two teeth of number 7 and 8 is too long, it's excessive, so I'm going to give that a -4, the cervical embrasure on this tooth, on these two teeth is constricted, I'm going to give that a -2, there was a lack of development in the incisal embrasure, I'm going to give that a -2. that just made it -8 for the same problem, for the same problem, they all tied together, it's a major fault I give it a -4 and I write all that criteria down that's the way I score it so that case still has a chance, it hasn't failed yet. If you just judged it that way. So when you're evaluating your own cases, watch how critical you're getting about all these things that can potentially tie together. A little empathy goes a long way and we're not looking for default smiles. We talked about that this morning. We're not looking for perfect chiklets, we're not looking for 10 chiklet veneers that are these bright white things that jump off the screen at you that have no variation and translucency. A little variation is fine, a natural look is fine. A lot of the natural imperfections that we see in smiles. So what I did is I went to, I took about 5 or 6 of the more seasoned examiners, seasoned means old and I asked them to go through because we really don't have a database to pull this up, we will shortly and this will be even more purer but for now I used the seasoned examiners, I said go through in your mind of cases that you've examined and give me the top ten reasons that cases fail by criteria. So that's what I'm going to share with you right now. This is a consensus of some of the more experienced examiners and again soon there will be a database where we can just pop these right out in the future but I imagine we'll be pretty close to what I'm going to show you here. And reason number 10 is moisture and debris and that's criteria number 34. Simply stated what that means is that when you take your photos do not coat the teeth with anything, it was fashionable at one time, especially for the direct restorations, it was fashionable to paint on some kind of glycerin or something else on there so they looked like they would shine like enamel and they don't, trust me, especially in the photography and especially in the one to one photography. So painting stuff on is the worse thing you can do. So it went out of vogue for a while and then here recently, I shouldn't say last exam session was pretty good but the last exam session before that I was noticing that people looked like they were trying to paint something on to give it a sheen or a finish to it. Not the right idea, it should have a natural enamel luster to it, they should not look desiccated but itshould be clean and dry. Spit all over the place here all in between here, doesn't work spit bubbles especially in between the cervical areas don't work because we don't know, stick your tongue up there put a bunch of spit up there and they won't see the black hole, we've been around the block guys, we've seen it all so that doesn't work, all right, if there's spit bubbles in there it's just like you had a giant black hole. If we can't see it we can't judge it. What a waste of your time, what a waste of your money to submit a case that can't be judged. OK, so all this stuff, painted all over the teeth doesn't work, there's nothing natural about that, that's not a natural enamel luster. Spit bubbles up in between here and all over the teeth don't work. OK, So we start here and then the final photograph has all this on here, so we know, the teeth do actually get dry, you just have to make sure that they are in your after photo and again not desiccated, just dry enough so they can be judged. How you get there is up to you. If it's a little blast of air, if it's have them run their tongue over one time and then smile. You might have to take those retractors out a couple of times and then put them back in. Whatever it takes because we know that some people just pump saliva. You know that's just how it works, it's just got to get off the tooth for your photographs. OK, number nine, pontic design, one of the things that we used to say is failure to use a ovate pontic, well that's not fair because you might have used an ovate pontic and that would make a candidate angry because you say yes I did use an ovate pontic. Well OK you did, you just didn't happen to do it correctly and you didn't happen to do any ridge or soft tissue augmentation so your ovate pontic doesn't work in that site. So what we're talking about here is pontic design. Whatever your design that you chose, you know in terms of ovate, ovate is not necessarily the final say, because the Eubank technique involves slicing off that pontic and seating it up in there so it creates almosta sulcus like effect up in that site. You guys do that at all, used that before. You've found that to be effective, No, Yes, Yes, so it's mixed but again that's why you work as a team, you work with a ceramist, you talk about the case ahead of time. How do want to form this tissue, how shape do we want our pontic, how are we going to get an outstanding end result. So there's nothing natural about the way the tooth comes out of the tissue, there's nothing natural about the way the tooth comes out of the tissue not to mention that the connectors don't look anything natural. OK, pontic design also goes hand in hand with implant site design, OK, they go hand in hand. How you choose to form that tissue in the implant site is up to you. Personally, I like the technique where I feel it's more predictable in my hands is that I make a screw retained acrylic temporary restoration. And once the tissue is healed, I like to keep the support there when possible, my temporary whether it be a flipper or an essex whatever, I like to keep thattissue supported with my temporary but once it's time for me to begin working with the implant and time to load it, I like to put in in the anterior region, I like to put in a screw retained acrylic temporary and then I shape the tissue, I mean I shape the temporary in the cervical area the way that I like to see it finished, now sometimes I end up having to cutting it back, sometimes I have to add to it but to me it's a lot more predictable in two ways. Number 1 is I can photograph it for my lab of the way that the shape came out for my temporary, second thing I can do is when I take that impression is it's in place and the third thing I can do is I take an impression of the shape of the temporary and let them have that so they have that as well so those are the steps that I give them in terms of shaping that in the cervical area so again you're not only doing it in your pontic but you're also doing it in the cervical area of your implant site so you get that ideal architecture.