A day that didn't go as planned- Case 2
Here is the second case presented at DS World. Another case where things didn't go quite as planned but it had some good tricks and tips.
This is a woman who is in her mid thirties, an engineer and has a twin sister. She had trauma to #9 and her smile no longer looks the same as her sister's smile and she wants it fixed. She also hates the grey band on #8. She has had several consults with different providers and would like both of her front teeth fixed. The important characteristics to her was that they were the same size and they looked "natural."
I struggled a little with this case prepping #8 because there was no prior work done and this was purely for esthetics. I brought up different possibilities of what we could do, but in the end the patient really wanted to teeth to match. For esthetic reasons, it is best have similar prep designs. I also chose to use an opaquer to block out the grey band in the tooth.
For this case I decided to use Biogeneric Individual. This is a case I did in one visit so I did not do a wax-up. When I design case like this, I love to use the Grid Mode to line up the midline and angles of the teeth. This can be placed easily by pushing "Control G".
The other tool I like to use to measure the widths of teeth when working on multiple anteriors is the distance tool. This can be found under Analyzing Tools. In this case both widths were 8.6.
When I first planned this case I decided ot use Vita Mark II because it is gorgeous and can mask a lot of color. After it was milled, I tried it in and it was a little bright but I was going try to tone it down with some staining and glazing. Right as I went to hand the veneer to my assistant...
Yep, I dropped it and when I took a breath in and moved slightly it was like it jumped right under the wheel of my chair and I heard that distinct sound of breaking glass. What a day! The other fun fact was I had no other Vita blocks so I needed to remill. I tend to think Vita Mark II is similar to e.max MT blocks so I chose to remill in an e.max B1 MT but unfortunately this was just way too bright. I use MT a lot in anteriors so I am not one to say they are always too bright. I think they are often really beautiful but if you really look at her original smile she has a lot of translucency and grey in her teeth- more like a c value. I should have picked this up but I didn't, so I milled this case for a third time in one day and settled on a B1 HT.
What can really make or break a case when working on front teeth is making sure you have similar facial contours. I check this by looking down the incisal edges and also by taking pictures to make sure my reflections are similar. I also decided to keep the cingulum on #8 for added strength.
This case didn't need a ton of staining- just some white to set the framework and some I2 for translucency. When I am staining anteriors I always follow a pattern and my assistants do the same.
1. I paint on the glaze first all over the tooth. This is thick in consistency but thin in thickness. I do not mix the liquid in this.
2. I do my body stain next and blend it in the gingival third, however in this particular case I did not feel she needed it.
3. I paint translucency at the incisal edge in a zigzag pattern with a light touch about 1mm down or so or following the pattern of neighboring teeth. In this case I painted the I2 about a 1/3 of the way down.
4. I frame the tooth with white or cream. In this case I used white and just at the incisal edge and mesial and distal marginal ridges
It was a long day but she got caught up on her Netflix episodes and was happy to wait for a result she wanted. She understood that I had other cases at the same time and was grateful we were willing to remill to make it right. She was happy when she left.
Way to save the day! I think CEREC teaches us that even when things go sideways it can all turn out great like this case if we just keep plugging along... There is something to be said for an extra operatory! :)
I think you made the right choice prepping both teeth. The preop of #8 looks a little low in value compared to the rest of the teeth and much more texture than any other tooth. Great final result.
I am very glad you are sharing these. I really wanted to be at your lecture but things didn't work out. You don't need to be told what a great result you got, because you already know it.
Nice service for your patient. I understand how difficult it is to sacrifice a perfectly good tooth for esthetics. It sounds like the patient got exactly what she wanted. Great result.
Great result. Nice save. I'm glad she is happy with the results. Amazing given all the challenges, really!
Let's talk about the "practice management" side of things....yup, how much time did it take to do the case? How did you convince her to start the case the same day she consulted with you when she had visited multiple other dentists trying to get a specific result--this is likely the most important lesson to learn from this case--because of CEREC or something you and your team did that gained her trust while in the office? If you could start over with a wax up, would you have done so (I don't think you needed one, because it looks like you nailed the shape and contours, I'm just asking out of curiosity)? Was she a PPO or full-fee FFS patient? What would you do differently with this case if you had the opportunity to start over again, if anything?
The practice management is my other favorite part ;)
Here was my original schedule...
Here was how the day ended up...
Sarah made a fantastic point. I had extra rooms to allow for the extra time. My associate was on maternity leave. The other part of this is that when we schedule, we schedule to goal, meaning our daily goal for this was around $8,500. So although the cases went longer than expected, we were still profitable. Yes you can absolutely break it down hourly and argue that it was not profitable by the hour but what is the bigger picture? Would I have scheduled more treatment that day? My answer is no, not if I can avoid it. My daily goals puts me in a happy place where I work hard but try not to kill myself at the same time. We try hard not to schedule a day full of fillings for this reason as well.
I will schedule 2nd opinions or consults but it is rare. Most of these appointment are scheduled directly from hygiene. There is a general buzz in my office about front teeth. My team knows that I am passionate about it. If I am running late for a hygiene check, my hygienists are typically telling the patient waiting that I will be right there, doctor is just helping someone with their smile, or will tell a story about a transformation. This can be as simple as a story about a young girl who had a dark spot on her tooth, or a space that she was embarrassed about and doctor fixed it and the girl was so happy she started crying which got our whole office crying... They are all true stories, we never use names, but the buzz gets created. It's why we do a lot of anterior work. It gets the patient thinking about his/her own front teeth and viola... When the patients who have work done on their front teeth are getting checked out, the person doing this always makes a fuss about it in a positive way too. It reinforces everything.
These cases were all PPO fees. I'm on about 20 different plans, so FFS is only about 20% of my practice.
No on the wax up. I rarely do them personally.
Great questions Ernie and thank you for the wonderful comments.
Thanks for sharing Kristine! Great point on using Hygiene to expose/educate patients to the capabilities of you and the office when they get a little extra time, turning a potential negative thing (the doc running late) into a positive (we care about our patients to take the extra time and give them the best care and results).
great result Kris!!!!!..your schedule gives me palpitations (but Im a couple of decades older as well!!)
no way to bioreference either of those teeth , or was the width discrepancy too much..
GREAT!!! and thanks for sharing..
On 9/26/2017 at 7:41 am, John Burke said... NICE RESULT. VERY AGGRESIVE TREATMENT PLAN, NOT FOR EVERYONE.
So for John and maybe others that say this was "VERY AGGRESSIVE TREATMENT", I'd love to hear some ideas of how you would have addressed "this patient's" chief complaint with an alternative treatment plan. Kris really struggled with this case and being aggressive and prepping #8. We chatted about this at length after this day was complete. Some of you may say you would have talked the patient out of treatment for #8, and that is fine, but I don't want to hear that. I'm more curious about different ways we could address this particular patient's chief complaints.
There is no doubt Kris got a fantastic result. Cosmetic dentistry is a different world and I think we can all agree that the most conservative means to accomplish the best, most esthetic result would be best. However, I would venture to say all of us take away extra tooth everyday in order to get a more esthetic result. Whether that is a long bevel or prepping a tooth for a crown in this case.
Nice case and result! Looking at the Grid Picture, is there a way to fix a certain position, that can be "reactivated" to go back to the preset position? Like a replay button, so you do not have to realign the teeth again on the grid.
I don't think it was aggressive at all, given the challenges of this case. Aggressive to me would have been crowns/veneers on 6, 8 or 10 teeth which many docs propose DAILY to almost anyone that walks through the door with an "esthetic" chief complaint (not me). #8 needed a similar porcelain thickness to #9 (as demonstrated numerous times here on the boards, saving the cingulum to add strength was as conservative as possible to attain the results needed to satisfy the patient.
As for the day, I'm not arguing about the profitability of the case or day with you Kris at all. I'm always shocked that you accept PPO fees for some of the finest anterior work in all of the USA! Your office is the best bargain on the planet! I hope I don't need anterior dental work, but if I do, I'm flying up there and begging you to do it for me at your normal PPO fees!
What I do want you to consider though is the breakdown of your day. As I read this (and this is a question, so feel free to straighten me out where I'm wrong)...you performed all the pink and teal services (?) for $5205 and 4(?) hygienists produced the remaining $3205, and giving HYG #1 on the left column the benefit of starting at 11 rather than 9, plus lunches, I see 26 hours of hygiene rather than 32 that exist between 9 and 5. Is that correct? If so, the $3205 was produced at a rate of $123.27 an hour (including the DOCTOR'S exams) and 1/3 of that production number (which should exclude exams), is $41.09. If the RDH is getting paid $38 or more hourly base rate (plus the mandatory extras pushes it up to ~$41), they are not producing up to "industry" standards solely because of the PPO fee would be my argument. If you take out the exams, they clearly aren't. I know, they are selling dentistry. They are doing a great job. But you know I'm a numbers guy...and this one is a hard one to deal with getting a reduced PPO fee and paying hygiene what they should be paid to do their jobs. I don't have a good solution to share, I'm just pointing it out. Are you still making a profit from hygiene, yup. As much as the industry says you should? Perhaps not.
Given that breakdown, I'm not sure if you are planning or already using SPS, but I'm willing to bet their services and/or a PPO negotiating consultant could increase your income by $100k a year.
Fantastic result! We enjoyed your presentation - very practical and applicable to many offices. Sorry about the cracked veneer.
I am curious - did you pick this day as your "presentation day" prior to the day or after it happened?
Shelley
Absolutely incredible!! Thank you for sharing your stain and glaze technique. You are amazing!
Ginger
On 9/26/2017 at 4:51 pm, Shelley Lewchuk said...Fantastic result! We enjoyed your presentation - very practical and applicable to many offices. Sorry about the cracked veneer.
I am curious - did you pick this day as your "presentation day" prior to the day or after it happened?
Shelley
Thank you for coming to the lecture! This was one of those crazy things where I survived the day, and I think the next day or so I got asked to speak at DS World and thought it would make for a good topic.
I hear so many doctors when things don't go as planned say "I didn't make any money that day," but did they? That was the point of my lecture.
On 9/26/2017 at 4:24 pm, Ernie Johnson said...I don't think it was aggressive at all, given the challenges of this case. Aggressive to me would have been crowns/veneers on 6, 8 or 10 teeth which many docs propose DAILY to almost anyone that walks through the door with an "esthetic" chief complaint (not me). #8 needed a similar porcelain thickness to #9 (as demonstrated numerous times here on the boards, saving the cingulum to add strength was as conservative as possible to attain the results needed to satisfy the patient.
As for the day, I'm not arguing about the profitability of the case or day with you Kris at all. I'm always shocked that you accept PPO fees for some of the finest anterior work in all of the USA! Your office is the best bargain on the planet! I hope I don't need anterior dental work, but if I do, I'm flying up there and begging you to do it for me at your normal PPO fees!
What I do want you to consider though is the breakdown of your day. As I read this (and this is a question, so feel free to straighten me out where I'm wrong)...you performed all the pink and teal services (?) for $5205 and 4(?) hygienists produced the remaining $3205, and giving HYG #1 on the left column the benefit of starting at 11 rather than 9, plus lunches, I see 26 hours of hygiene rather than 32 that exist between 9 and 5. Is that correct? If so, the $3205 was produced at a rate of $123.27 an hour (including the DOCTOR'S exams) and 1/3 of that production number (which should exclude exams), is $41.09. If the RDH is getting paid $38 or more hourly base rate (plus the mandatory extras pushes it up to ~$41), they are not producing up to "industry" standards solely because of the PPO fee would be my argument. If you take out the exams, they clearly aren't. I know, they are selling dentistry. They are doing a great job. But you know I'm a numbers guy...and this one is a hard one to deal with getting a reduced PPO fee and paying hygiene what they should be paid to do their jobs. I don't have a good solution to share, I'm just pointing it out. Are you still making a profit from hygiene, yup. As much as the industry says you should? Perhaps not.
Given that breakdown, I'm not sure if you are planning or already using SPS, but I'm willing to bet their services and/or a PPO negotiating consultant could increase your income by $100k a year.
Ernie- I always appreciate your feedback and pushing me to learn more. I want to spend time on this answer so I will get back to you. Right now I am off to chase kids around ;) I love this though so thank you!
As a quick note, yes, the PPO for hygiene is not ideal at all. My hygiene dept performs at 27% as an average minus exams. Hygiene can do restorative here in WA state so they help in that area a little and do almost all of my anesthetic for me so the patient is ready when I walk in the room. They are invaluable at educating patients about treatment as well. On this day in particular we either had a new patient or SRP cancel out in the morning so then she either clocked off or worked the recall list. Not a perfect day in that regard either but unfortunately days like that happen from time to time to keep us humble I suppose.
I also totally agree that SPS is a fantastic service!
