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Dental Labs Play Key Role in Tooth Restoration Quality

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Dental Labs Play Key Role in Tooth Restoration

Dental Labs Play Key Role in Tooth Restoration Quality

July 12, 2006
By: Jean Johnson for Dental1

The reason consumer health Web sites like the Body1 Network are succeeding is that readers gain access to badly needed information. Those who visit sites like ours can in turn share knowledge with friends and family so increasingly more people make informed decisions and interact with their dental and healthcare providers from educated perspectives.

Take Action
Ask first for the crowns you want

Ask your dentist what your options are for your future crowns.

Predictable results can come from good communication: Share your questions and concerns as they arise; they may actually help you get the work you want at the price you want.

Find a dentist you can communicate with before you get your crown work done. This one step may save you a lot of hassle down the road.

Consider possible aesthetic downfalls alongside function: The position of the tooth in the mouth, porcelain crown margins versus metal margins (or porcelain fused with metal margins) and the cost of the crown.


We here at Dental1.org think that educating patients is an especially important case when it comes to appreciating the role dental labs play in quality tooth restoration. Since the lab work takes place in locations removed from dental offices, patients oftentimes aren’t aware that they have options and that decisions related to labs and what goes on there are not the exclusive realm of the dentist and lab technicians.

To get a behind-the-scenes look at the business, we spoke with Monique Kramer, business manager at the Ken Lande Dental Lab in Portland, Ore. Owner Ken Lande has been in the dental lab business since 1967 and is recognized in the industry for his particular attention to detail and highly-refined results.

The Informed Patient

Monique Kramer begins with praise for not only Web sites like Dental1.org, but also reality TV shows that do makeovers.

“The exposure from reality TV shows as well as Web sites like yours have increased awareness and education to the public,” said Kramer. “Computers are changing the way crowns were traditionally made and have made it easier to produce higher standards, thus making the industry step up and meet them.

“This information has become a fabulous source for the general public. Because of this, the industry has had to step up a notch since the public is more educated and can ask the proper questions of the doctor,” Kramer said. “An educated and informed public holds the doctors to providing a variety of options that maybe would not have been offered before.”

The industry is stepping up at notch because people are getting more informed and asking more questions? We give that an affirmative thumbs up. Just as in all areas of life, quality generally improves when folks aren’t asleep at the wheel. Kramer certainly agrees.

“Instead of just opening their mouth and letting the doctor go to work, people are coming in and saying ‘hey, what are you planning to do and what are my options?’”

Kramer also noted that “patients need to be comfortable expressing their expectations. If patients aren’t comfortable enough to ask questions, it can lead to misinterpretation and subsequent problems.

“If I had to say what is most important it would be the communication of expectations. So if patients don’t know what questions to ask, they should just inquire what their options are. That way you have the opportunity to have input. Predictable results can only happen with communication from the very beginning between the patient and the doctor.”

Crown Margins – Case in Point on Communication between Patient and Dentist

“I’m not very happy about a couple crowns I got a few years back,” Bill Berg of Phoenix, Ariz., said. “The actual teeth look good, but my gums have receded and there’s a thin line of metal showing right at the gum line when I smile.

“As far as I’m concerned it ruins the restoration, but when I mentioned it to my dentist, he said, ‘That’s simply the metal backing on the crown showing.’

“Excuse me? It was like it was no big deal to him. I don’t get it. Am I being unreasonable? It doesn’t seem like I am. But the way the dentist acted I got the impression I was too picky – even though I hate to tell you what I paid for the crowns.”

According to Kramer, patients who are concerned about gum recession need to discuss this early with their dentist. “The metal lines on the gum lines are caused by porcelain fused to metal crowns in the front of the mouth – the aesthetic zone is what we call that area.

“A lot of people are very conscious of the way they look and would opt to have something in all ceramics in that area if at all possible,” she said. “Also we can do a porcelain margin on metal-backed crowns. That way when tissue recedes up and that slight line won’t show.”

Kramer explains that “receding gums are unfortunately often inevitable because of a couple things – either the crown wasn’t the right size or cleanliness is a problem – the patient is not keeping up on the cleanliness.”

While we were on the subject of crown margins, we also consulted Tom Hilton, D.M.D., M.S., alumni centennial professor in operative dentistry in the department of restorative dentistry at Oregon Health and Science University School of Dentistry.

Hilton said that either all porcelain or porcelain fused to metal with porcelain margins are “routinely done on crowns that are placed in the front of the mouth so that the metal won’t show.”

He added, however, that “the reason some crowns continue to have metal margins is because it usually is possible to get a better fit to the tooth with a metal margin versus a porcelain margin. Also it is believed that the metal margin is more stable under function.’”

For those who like even greater detail, Hilton gave us more. “In other words, as pressure is applied to the back side of the crown, this can increase pressure to the margin on the front side of the crown. Porcelain is brittle and has the potential to fracture under this function; metal won’t fracture and can protect the porcelain from being subjected to this pressure.

Hilton also notes that aesthetic considerations other than gum recession go into decisions on crown margins. “The final reason is that the metal margin can help stabilize the porcelain during firing and prevent the porcelain from distorting as it is heated up – which is in turn why the metal margins can be more accurate and better adapted to the tooth.

“One other thing that can cause a dark line around a crown when the gum recedes beside the metal margin is the fact that the root of the tooth is darker than the crown. So even if the crown doesn’t have a metal margin, it can still appear to have a dark area adjacent to it because of the darker root.”

The larger point here, of course, is that given how much complexity and variability there is with just crown margin decisions related to lab work, patients who get involved early and take an active role in how their case is managed, will often have better outcomes and get greater satisfaction.

It Takes Two to Tango

Hilton also gives a big nod to dental labs and underscores their significant role in the end results. Indeed, in Hilton’s private practice, he will sometimes offer his patients a choice on the lab that will do their work if aesthetics is critical and the patient is particularly concerned about the outcome.

“Part of the reason top-quality dentistry is expensive is that top-quality labs are expensive,” said Hilton. “Dentists that use good quality labs get good quality crowns, but the price is reflected in patient’s bills. Some dentists will leave that up to a patient. They’ll say, ‘we can get a good looking crown from this lab, or if you want a highly-aesthetic crown that is as lifelike as possible, we need to use this other lab.’ If it’s a tooth away from the very front of the mouth, for example a premolar, patients might be more concerned about function and less about esthetics. But if it’s a top front tooth they’ll usually say, ‘I want the best.’”

That said, Hilton offers the caveat that “I warn patients that my goal is to make teeth look as lifelike as possible from normal conversation distance of about three to four feet. If, however, a patient takes a mirror, pulls up their lip and looks from six inches away, they are likely going to be able to see differences between real teeth and restored teeth. Labs do a wonderful job, but nothing artificial can truly replace the natural dentition.”

Natural dentition aside – since by the time patients get to restorative dentists like Hilton and labs like Ken Lande’s, that option has gone by the way side – Kramer points out that no matter how excellent the dental lab, outcomes are dependent on getting good impressions from the dentists.

“When people say the lab controls the outcome of the case, it is true to one aspect since we do make the crowns,” said Kramer. “However, we can only provide as good as we get. We are limited by the prep the doctor gives us. That’s why when we look at the process, it’s really important from the lab’s standpoint to have good rapport with the doctor.

“I say that because a lot of people will look at a crown and ask who did it for you. But my point is, is it beautiful because of the lab or the doctor’s prep?” Kramer said. “I believe that we need to stress equal importance on both sides.

“Our goal is to make sure that when you smile people don’t know what’s real and what’s fake – and that to me is a function of the extra time doctors spend planning a case and communicating with the lab.”

Kramer adds that she has great respect for what dentists do within the small quarters they must work. “When I need more room in the lab, it’s no problem. But dentists taking impressions run into the gag reflex. Particularly on kids and elderly folks this can be a problem since having something foreign in the back of the mouth all of a sudden can cause the patient to gag and jerk which in turn can distort the impression.”

“Sometimes dentists will take multiple impressions if they think the gagging influenced the impression, but it is very easy for us to tell right away once we’ve poured our molds.”

Again, Kramer underscores the critical nature of the impression work the dental lab receives from the clinician. “I can make the exact same crown for three dentists, but one will look prettier because of what the dentist gave me to work with.

“A lot of doctors don’t want to talk to labs because they are busy and don’t want to be bothered. But it’s so important to be able to communicate the expectations back and forth,” Kramer explained.

She also notes that generally dentists who do take the time to talk with the lab save on time in the long run since they will get crowns that fit so well they only take 15 to 20 minutes to put in. (To that Kramer adds a caveat that sometimes it can take longer to place crowns if there have been changes in the patient’s mouth between when the impressions were taken and when the work is cemented into place.)

Communicators Start Your Engines

We hope this read has convinced you that smart dental consumers are proactive and ask questions. Also, we hope readers realize that rather than taking offense, most good dentists welcome patient participation.

A consideration to remember is that we are just exploring the cusp of the age in which patients are more informed consumers.

So our advice is to proceed pleasantly, but ask away. Find a practitioner who you resonate with and then take the initiative to become part of your own dental healthcare team. You might even consider a trip over the lab. Between that and understanding what your dentist is doing, it’s inevitable that you will come away with a heightened appreciation for your dentistry – for the very fine custom, porcelain teeth you are paying serious money for.

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