Indirect restorations can be found on the vast majority of schedules for dental practices across the U.S. every day. These restorations have become one of the building blocks of the clinical business of the practice, yet are an ever-changing art and science, thanks to advances in materials and technology.
How can dentists and dental team members stay on top of these changes and give their patients the best possible restorative treatment options and care? We recently carved out some time with James Braun, D.D.S., M.S., who lectures nationally on the subject of restorative dentistry, to explore the topic of indirect restorations and share his best tips and advice for his dental colleagues.
An indirect restoration is defined as a restoration that is made outside of the patient's mouth, and then placed inside the oral cavity as part of the procedure. These indirect restorations can be produced in the practice through the use of computer-aided design/computer-aided manufacturing (CAD/CAM) technology, such as CEREC®, or in a dental laboratory and then given to the dentist for placement.
Among the most common indirect restorations include crowns, fixed bridge work, dental implants, inlays, onlays and veneers.
Studies show that indirect restorations have a low failure rate and are an excellent choice in the treatment of both class I and II lesions.
For crown and bridge restorations, in particular, there are two types available to today's dental patient — an all-ceramic option made of zirconia, as well as a porcelain fused to metal (PFM) option. All-ceramic crowns made of zirconia are comprised of one material, while PFM restorations have metal with a layering ceramic.
Researchers state that the ceramic on PFM crowns has a lower compressive strength to fracture than all-ceramic crowns. For example, depending upon the type of zirconia, the compressive strength varies from 600 to 1200 mega pascals (MPs), whereas the compressive strength of PFM ceramic is about 80 MPs.
This is one of the biggest benefits of zirconia, as well as the esthetics of the restoration. PFM restorations can often leave metal showing on the tooth if the patient has any gum recession.
That may be a concern with PFM restorations, but researchers have indicated that they have good mechanical properties, satisfactory esthetic results and an acceptable biological quality needed for periodontal health.
While acknowledging the need for both PFM and zirconia is important for catering to a wide range of clinical scenarios, Dr. Braun did, however, point to research recently published in Lab Management Today that shows just how dramatic the rise of metal-free restorations have been since 2005. The climbing numbers of metal-free restorations correlate with the advancements made in zirconia and CAD/CAM technology.
In any event, choosing a material is just one piece of the indirect restoration puzzle. To lay the groundwork for the final result, Dr. Braun suggests five key steps for improving your indirect restoration prep that you can start implementing in your practice today:
While much of the focus of the indirect restoration lands on what will be created to help the patient, Dr. Braun strongly advocates focusing on the existing tooth structure as well.
He recommends asking (and answering) four essential questions before the indirect restoration is created and placed.
"Knowing the answers to these questions can establish a foundation for the goal of the indirect restoration," Dr. Braun says.
For Dr. Braun, once the questions above have been answered, the indirect restoration process begins with the initial diagnostic exam and study models prior to commencing the procedure. These models can include impressions made with alginate that are poured up into stone models.
Dr. Braun emphasizes that, if you're working with a laboratory on an indirect restoration, taking a high-quality impression to give to the laboratory is a must.
With that in mind, one of the biggest obstacles laboratories must often overcome with impressions, Dr. Braun says, is a lack of detail when it comes to the marginal area of the tooth preparation, as well as a lack of attention to the soft tissue and gingival tissues.
This critical attention to detail is vital — together with proper training of your team members — to ensure a complete understanding of the procedure and a focus on the final outcome.
In addition, Dr. Braun cautions the dental practice to be on the lookout for any fluid that may interfere with a proper impression.
"Bleeding can take place after you prepare the tooth, depending on the level of the preparation, and there are other issues with the tongue or the cheeks or saliva contaminating the area," he explains. "All of these are important factors to consider and overcome when taking an impression."
While those are essential points to consider with conventional impressions, Dr. Braun also has advice for those who are working with digital impressions and in-house scanning and milling options.
"Make sure you can clearly identify the margins with a digital scan as much as you would with conventional impression material," he says. "It may take two or three scans to make sure you have all of the information on the margins that is needed, but the extra time with the additional scan is well worth it in the end."
When it comes to other common challenges of indirect restorations, Dr. Braun believes many can be avoided by simply ensuring proper communication with the dental team and the laboratory — and by taking the lead on critical decisions from the start.
"The dentist has to remember that it's important to make the decision on what type of restoration he or she wants to have," Dr. Braun says. "It sounds like common sense, but I have heard so many instances where the dentist sent a case to the laboratory — informing the lab that they wanted a crown — but didn't mention what material to use, including whether they wanted a PFM or zirconia. That's a big decision that they were just leaving up to the lab, and the lab shouldn't have to make that decision."
Dr. Braun also believes it is up to the dentist to share every piece of vital information about the shade of the crown.
"You have to make the effort in order to have the proper shade returned to you," he says. "Certainly, what we consider to be the proper shade and what the patient might consider as the answer to that same question may differ, but it's up to the dentist to have the desired shade communicated upfront so that everyone can be happy with the outcome. Don't leave this decision up to the laboratory and then have to follow up on an issue that could have been avoided at the outset."
All of this will take some additional work on the part of the dentist, Dr. Braun admits. However, having the proper education needed to make these decisions and to be able to communicate them to the laboratory — a business that has a vested interest in the prosperity of its clients — is a key part to the overall success of any indirect restoration.
Communication is important on the patient side of the equation, too. Dr. Braun highly recommends having a discussion with the patient about what to expect from the indirect restoration before the procedure begins.
"It's imperative to set expectations for the patient from the very start on every procedure, including any involving an indirect restoration," Dr. Braun says.
In the clinical setting, an area where an assistant can play a vital role is with retraction cord, which can help ensure the impression remains clean. Dr. Braun recommends asking three very important questions when it comes to retraction cord.
As a reminder from Step 1, while these questions may seem routine, making sure everyone is on the same page is crucial to the success and longevity of the restoration.
Depending on your state's laws and how involved the dental assistant is during the conventional or digital impression stage of the procedure, Dr. Braun believes proper training can pay big dividends for the practice.
"Having the assistant feel confident in knowing, beyond a shadow of a doubt, what it takes to create an environment for an accurate impression is important," Dr. Braun says. "Today's practices are seeing assistants with various levels of dental experience, so I would recommend the dentist and assistant working together on some training to make sure everyone is aligned and confident in their knowledge of the indirect restoration process."
While some practices still use conventional impressions and work with an outside laboratory partner, others have transitioned to in-office options that include digital scanning, digital impressions and milling. Whichever path you choose for your practice's indirect restoration journey, Dr. Braun believes acquiring knowledge on every step from start to finish will lead to success for the practice and the patient.
"Every day, we have the opportunity to change lives by using our knowledge, skills and ever-improving technology. We must never forget that," Dr. Braun says. "The future is bright for our patients, thanks in part to the options that are — and will continue to be available — to keep their oral health at the highest level possible."
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