High Aesthetic Anteriors Made Easier

Probably the most difficult restoration in dentistry is the single anterior restoration. This is compounded when dealing with a ‘particular’ patient – one that wants excellence.

Personally I don’t fault people for wanting something that ‘melts’ into their mouth and disappears. However, what I do believe is that these patients should expect to pay more for this level of service. It is nearly impossible for a dentist to deliver this high level of aesthetics under the PPO fee schedule.

Please don’t misunderstand me. I am not suggesting that you shouldn’t participate with PPO insurance. I am not suggesting that if you do that you can’t deliver highly aesthetic dental care. I am merely suggesting that you should ask for and receive higher fees for this type of work.

In our office an we charge and ‘aesthetic upgrade’ for our cosmetic anterior work. It varies based on the patient desires and difficulty of the case, but generally it is an additional .5x of the standard crown fee.

This is explained to the patient in advance and the patient is also CLEARLY informed that this fee is above and beyond the dental insurance benefits. We have yet to have any ‘contract’ issues approaching these cases this way.

If the patient wants an anterior tooth for just the PPO fee we are happy to do so. We just clearly explain that it will not be done by our master ceramist. Insurance pays for quality dental care, but they don’t allow for high end cosmetics.

Just wanted to spend a few minutes going over this as I know many have questions about this.

Robert came to our office as a new patient. During his initial interview, our treatment coordinator discovered that he was unhappy with a crown he had done on his front tooth a few years back. The crown was initially placed due to a fracture from an accident.

PreOperatie smile with 'unhappy' crown

PreOperatie smile with ‘unhappy’ crown

Closeup view of 'unhappy' crown

Closeup view of ‘unhappy’ crown

As I was talking with him about this tooth I asked him to explain to me – with the aid of photographs on our big screen – exactly what he didn’t like about the tooth. I also asked him to explain in detail what it would take for him to be happy.

I asked these questions to understand his expectations and determine if this was a case I could improve upon. He really had only two major concerns – the color was too white and the crown felt thick. He even went as far as saying that I don’t expect perfection, just want it to be better than this.

I agreed that it could be better and felt that we could certainly make it better. So we agreed to accept the case and our fee for this case was 1.75x of our normal crown fee. I knew in advance that this would take some extra time to achieve the result.

I advised the patient that these types of cases average about 2 adjustments back-forth with the laboratory to get it to where I am happy. He then shared with me that he needed 7 shade adjustments to get where he was currently at.

To best communicate with the laboratory I have found that making the provisional with CEREC has been tremendously helpful. Why you may ask?

First, it allows me to pick a base shade for the lab to work from and allows the laboratory to see how this looks in the mouth. From this we can change materials based on opacity needs (like in cases of dark preps or metal posts). Secondly, it gives me the opportunity to get shape and surface texture communicated to the laboratory. Additionally, it gives me the ability to quickly ‘remill’ the restoration in another shade or make digital changes based on patient feedback.

It is my opinion, that while acrylic provisionals can be beautiful and can do much of this same communication – it simply can’t convey the same as porcelain.

In some cases, I can even mill a second crown to send to the lab to do the custom layering and beautification directly to.

Here is the preparation completed. In this case we literally removed the existing crown and only used a fine diamond to fine tune the margins and smooth everything.

Preparation complete

Preparation complete

The prep was scanned into CEREC and biogeneric copy was used to copy his existing crown. Then the various tools were used to thin the facial surface and verify that we could still maintain material thickness integrity. The biogeneric reference mode could also be utilized to ‘mirror’ the adjacent tooth #9.

Preparation digitally scanned into CEREC using OmniCam

Preparation digitally scanned into CEREC using OmniCam

Biogeneric Copy mode was utilized to copy the existing crown

Biogeneric Copy mode was utilized to copy the existing crown

Design after minor tweaking

Design after minor tweaking

For this case I selected an EmpressMulti B1 block for my provisional. I chose this block because it contains a very natural built in gradient and incisal translucency.

Multi Shaded EmpressCAD was utilized for provisional

Multi Shaded EmpressCAD was utilized for provisional

After milling and minor post mill adjustments the provisional was hand polished only. No custom staining or glazing was performed.

Smile showing CEREC temp

Smile showing CEREC temp

CloseUp view of CEREC temp

CloseUp view of CEREC temp

The photos were sent to the lab along with a second milled restoration for reference purposes. After discussion with the laboratory we determined that we would utilize eMax for our final restoration with custom layering.

Picture of eMax crown returned from laboratory

Picture of eMax crown returned from laboratory

 

The restoration was tried in using trial gels, approved by the patient, and seated in the mouth.

CloseUp view of final eMax crown inserted

CloseUp view of final eMax crown inserted

Smile view of final eMax crown inserted

Smile view of final eMax crown inserted

Here is a photo of the case progression – before, cerec temp, final restoration.

Case Progression - Before - CEREC Temp - Final

Case Progression – Before – CEREC Temp – Final

I quickly admit the case isn’t perfect. There are tweaks that can be done to make it better. But this case took only two trips back-forth with the lab to achieve this result. I firmly believe this is much in part to our use of porcelain as our provisional material and photo documentation for communication.

About the Author Tarun Agarwal

Dr. Tarun Agarwal represents the next generation of leadership for the dental profession. As a respected speaker, author and opinion leader, he is changing the way general dentists and their teams practice.

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  • Andres powditch says:

    there is something I missed…..wich material is the temp and cemented with what ??? it seems to be a multi block…but how did you cement it till you had the final….theoriclly you cant cement ceramic with temp due to the risk of fracture…pls explain me this….thank you and great results.

    • Andres… the temp in this case was milled with EmpressCAD Multi and temp cemented with just flowable composite. I have found that flowable composite on these ceramic ‘temps’ does a great job of holding them in place – especially if you have traditional preparation height resistence/retention form.

  • Jason Tubo says:

    Awesome case T-Bone. I want to employ a similar fee set for high-end cases with my practice… but keep running into the “is it legal?” question by my office manager and insurance coordinator. So we’ve been “eating the cost” on some high-end cases… and it’s just not sustainable. If we’re in-network with an insurance company, and want to still submit to them to pay for the crown, or whatever is being done… do you tell them that you are charging 1.75 times the fee? What fee are you reporting to the insurance company when you do this? I would pay big $$$ to go to a course centered on this topic alone. “How to still do awesome dentistry an leave all options on the table without insurance contracts limiting yours and your patients’ options.” How do you do it in your practice?

    • Jason… i will make a note to create a video or post on this very topic. At the Sirona 3D Drive event this past weekend I had lots of questions on this topic.

      To me it’s pretty cut and dry…..

      Insurance pays for ‘basic’ care – which we are happy to provide a very high level. Basic meaning that it fits and functions very well. Basic means the restoration matches reasonably well, but doesn’t have the touch of a master ceramist. You simply can’t do this for those fees.

      The patient can choose to have very cosmetic care, but has to pay for it. in these cases we simply add an ‘aesthetic fee’ line item to the overall treatment plan of $x.

      We don’t force the patient to choose the ‘aesthetic’ fee. It’s a choice, but if they don’t choose it they don’t get master ceramist work.

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