Thoughts on the Dentist-Technician Relationship

Having great mentorship is one of the tremendous advantages I have enjoyed in my career.  However, another advantage also gives me a leg up over most of my colleagues in full coverage restorative dentistry—that is the ability to do laboratory work and the ability to relate to dental technicians.  When I was in dental school, we students had to do our own laboratory work. We learned the basics of how dental technicians work and the problems they face.

When I started in practice with my father, I spent a lot more time assisting him at the dental chair and doing laboratory work than I did treating my own patients.  I carved temporaries all day long—both his and mine. I can carve teeth in my sleep because I have done so much of it. I have even made a denture in one visit without models from a block of acrylic!

My father taught me to make dies and pour models during those early days. I would do his laboratory work as well as my own, and he would check everything.  I usually did laboratory work between patients and for an hour at the end of the day.  I really found that hour at the end of the day extremely relaxing.  To this day I still do all of my own preparatory work—I make all my own dies and pour all my own models.

I do this for good reason.  In dental laboratories, the preparatory work is done by the lowest technicians on the totem pole.  All the restorations are subsequently be made on these models.  It is essential that they be correct.

Obviously, I do not consider laboratory work beneath me, because here I am with the fancy degrees doing it. I study my models carefully to ensure that my technicians will be able to accomplish the job properly without having to question where a margin is or if there is enough room to fabricate the restoration.

I create and measure all of my own temporaries because I want to determine the finished case outcome. Temporaries are the blueprint for the finished case, so it is important that they be made to the correct size and shape.  I try to correct all of the abnormalities with the temporaries and make sure patients are comfortable with the temporaries before any permanent dentistry is made. By doing this I ensure that the mouth is set up properly to accomplish the ideal result that I want. I outline the desired plane of occlusion on full mouth articulators; and I often provide the technicians with models or pictures of my temporaries so that they understand exactly the desired outcome.  The outcome should never be a haphazard result determined by the dental laboratory. It is not the laboratory’s job to guess what outcome the dentist would like.

Because I carve my own temporaries I can tell immediately if I have enough room for the desired result. I measure them with an Iwansen gauge to ensure that there is enough room for finished restorations of the same size and shape.  I  also determine how to design the permanent case by carving temporaries.  It is not uncommon to tilt teeth mesially or redesign teeth over pontic areas so that they look normal sized rather than oversized. Once I know this from carving my own temporaries, I can communicate this information to the technicians so that they can properly fabricate the permanent restorations.

Few dentists do this.  Today’s dental students do little or no laboratory work, so they really have no idea what needs and concerns dental technicians face when fabricating the restorations. If you look at most of the dental work in the lab you will  find most restorations  oversized—both bucco-lingually and incisally.  Oversized dentistry burdens the supporting structures (bone and roots) with extra forces. In many patients, this can lead to periodontal problems.

During my long career, I have attended numerous lectures given by all the well-known practitioners.  I can tell that most of them do not carve their own temporaries.  Many of them have in-office technicians who make beautiful temporaries for them, but many of these temporaries also appear oversized.

I am not afraid to carve porcelain, because I am used to carving acrylic and composite.  The principles of carving are the same regardless of the material.  I don’t think there is a case that I receive from a laboratory where I have not carved the porcelain in some way—even if only to add my own esthetic touch. Dentists should never be purveyors of materials from the laboratory by inserting whatever is given to them.  The technician only sees models–not the patient. Cases inserted in the mouth almost always require some alteration or adjustment in order to achieve an ideal result. My observation is that many practitioners are afraid of carving porcelain because the finished cases in the lectures I attend are often oversized, too “boxy” or too long incisally.

I have worked with both commercial laboratories and in-office dental laboratories.  The in-office technicians that I worked with in NY actually came from a commercial laboratory–Mount Vernon Dental Laboratory.  They were so amazing! My father and I worked with Dave Gresta for over 40 years and with Roger Hall for about 30.  Dave did the metal work and he was the best metal worker that I have ever known.  He could make that metal sing!  Roger was the porcelain expert.  They were both fine human beings who I admired and I considered them both as friends and as colleagues.  What a great team we made!  Unfortunately, they both passed away and I miss them dearly.