Some Thoughts on Dentist-Laboratory Relations

I’ve always had a special relationship with laboratory technicians because of the way I was brought up in Dentistry.  My story begins way before dental school.  When I was a teenager, I started helping out  with the family  dental business.  I would walk to the office from high school after school let out and I would drive home with Dad at the end of the day For several hours I would pitch in wherever I could help.

In those days there were no computers, no “automatic” processors and no digital X-Rays. X-Rays had to be developed chemically in a dark room and then mounted by hand. Then the X-Rays were air-dried and mounted so that they could be read and ultimately they were placed in the patient’s envelope–file.  I also poured and mounted models in the lab.

In the 70s, my father built a dental laboratory and hired two technicians to do work in-office.  The technicians came from Mount Vernon Dental Laboratory, which is still open for business.  I believe that Sam Sussman is still there working with doctors on removable cases!  For many years after we started our in-office laboratory, we continued to work with Sam Sussman and Joe Leggerio (now deceased) to create our removable partial denture  cases. We were happy to work with them and we had a close relationship.

Mount Vernon Dental Laboratory used to train the very best laboratory technicians.  My father had a great relationship with several owners and he proved that—at least in his day–it was possible to get great work from a commercial laboratory.

I developed a very close relationship with the two technicians who came from that laboratory.  Dave Gresta was the metal technician.  Dave was an old-world craftsman who emigrated to the US from Italy.    Dave had that picayune personality that made him truly great. He would have lots of picayune reservations about the specialized work that was given  to him.  Dentists today—who always seem to be in a hurry—would no doubt have found this trait annoying.  However, we had lots of great dialogue because Dave was so caring and detail-oriented.  The work always ended up PERFECT and  was always completed quickly.  I have yet to meet anyone who could match him in sheer skill and quality.

However, Dave was not only one of the finest technicians I have ever known, he was one of the finest human beings I have ever met.  I considered him a trusted friend.  After I moved out of the office, I continued to work with Dave because he had a dental laboratory in his basement.  I think he was very happy to spend time in his basement because it allowed him to  escape from his crazy family.  I worked with him until I moved to Arizona.  Shortly after I moved to Arizona he passed away.

I also had a great relationship with Roger Hall, the porcelain specialist in the dental office laboratory.  Roger and I would spend a great deal of time talking and listening to the radio….he would be crafting the porcelain and I would be doing all the preparatory work—pouring models, making dies etc. and laboratory maintenance (i.e., changing the plaster trap).  Roger and I went on many enjoyable fishing trips together.

Unfortunately, Roger passed away at a young age from smoking–induced lung cancer.  However, I still work with one of his protégés—JD Giordano of J and C Dental Lab (now in Mt. Kisco, NY).  He is a very fine technician and a fine human being who is willing to work with his clients no matter what their needs are and no matter what they do to  his porcelain.  I know that I can pick up the phone and he is always ready to help me.

I discovered that the caliber of the laboratory personnel that I have met since I moved to Arizona do not come close to the caliber of the individuals that I worked with for the first 41 years of my dental practice career.  I always valued working with technicians one on one in a local setting.  However, it is apparent that it may be impossible to have the same types of relationships with laboratory personnel that I have enjoyed in the past.   There seems to be a lack of caring in many.  They fail to follow directions, even when directions are  clear and include pictures of similar cases.  I’ve waxed up deficiencies on porcelain restorations to demonstrate where I wanted porcelain added.  All to no avail.  The technicians just follow their own rote playbook and do whatever they want without regard to what the dentist wants.  The turn-around time for lab work is far longer now than it ever was when I worked with Dave and Roger.  Not paying attention to directions adds  extra weeks in between appointments, while technicians “fix” what they should have corrected previously.   The increased time can lead to loss of control of the patient resulting in case failure.

Since moving to Arizona I have the dubious distinction of having  been “dismissed” by two dental laboratories!  I always make all my own models, so there was never any dispute about the models.  I always paid my bills immediately so there was never a dispute over money.  Why was I dismissed? Well one letter stated flat out that I could not be “controlled.”  Laboratories never see the patient, so they can never be the controllers.  They are supposed to serve dentists and help them with their needs.

I think the problem is that today’s dentists don’t know anything about laboratory work so they  happily take orders directly from the laboratories.  Since the laboratories are now calling the shots, today’s dentists are essentially purveyor of materials from the dental laboratory.

When I was in dental school, I had to do all of my own laboratory work.  But not so for today’s dental students.  They have no idea what  needs and concerns laboratory technicians have.  And worse—the laboratory technicians have no idea what needs and concerns dentists face.

If you walk through any dental laboratory in America, you can’t help noticing that most of the dentistry on the workbenches  is oversized.  If the dentist can only remove 1.5-2.0 off of a vital tooth, it is imperative that the restorations are not  made thicker.  I try to make the dentistry smaller than the original because I want to put less stress on the supporting structures—bone and roots.  It is easy to make dentistry thick and make it look “esthetic,” but it is difficult to make dentistry thinner.  In addition, most full coverage restorations are also too long—often many millimeters too long.  Again, it is easy to make dentistry  esthetic and not pay attention to incisal length.

Interestingly, the approach of most technicians to making full coverage restorations almost guarantees that the dentistry will be oversized.  Typically a technician will wax a case to full contour first.  Their idea of full contour is usually oversized to begin with.  Then they cutback the  wax to make room for the porcelain.  Technicians are more concerned  about having “unsupported” porcelain than they are about making oversized dentistry.

This approach is not where the industry evolved from.  The first full coverage restorations were gold or gold with processed acrylic facings.  They were made by swaging gold or platinum foil on the die and then applying the wax to the foil to a thickness of .5mm on vital preparations.  When cast, the foil became part of the casting. In the1980s, the foil technique was replaced by aplastic-like  dipping wax.  The temperature of the wax pot was set so that each die that was dipped produced a wax up that was .5mm thick.  The technician simply added wax to form the lingual collar and interproximal struts (and occasional build up of missing axial walls). Ready for investing– Easy and Fast!

Sadly, digital techniques have not adopted the “Easy and Fast” approach.  Technicians still go through the laborious effort of digitally waxing to full (over) contour and cutting back digitally for the porcelain.  The exact same method of creating oversized cast restorations is being applied digitally to create oversized milled restorations!  Does this make sense?

Try telling this to laboratory technicians who already “know everything.”  It has become increasingly difficult to find laboratory technicians who are not upset when the dentist reshapes his porcelain creations. I have to reshape it because is oversized.  Most technicians never see the patient and they have no idea how that restoration is going to look and function in the hostile environment of the mouth.  They don’t understand the ramifications of oversized dentistry on patients who are susceptible to periodontal bone loss.  The dentist will have to deal with those ramifications long after the technician got paid for his or her work.

There is one laboratory here in Arizona that I have great respect for, and that lab specializes in removable partial dentures.  Tom Wiand, the owner of Wiand Dental Laboratory, is very receptive to working one on one with dentists.  He recently built a brand-new state of the art facility with a classroom for continuing education. I really admire what he has built and the caliber of the staff members he hired to serve on his team.  He recently hosted a great grand opening party and it was fantastic!

My experience leads me to believe that it is now important to work with several laboratories and each should be chosen for one area that it excels in.  No lab today seems to have it “all,” as in the “old days.”  Equally important is to choose labs that have the right attitude—that they are there to serve their customers and not themselves.