Going through a prosthodontic residency program at the University of Pittsburgh, I was pretty lucky that I was exposed to a wide variety of prosthodontists, scientists and surgeons trained with different background and philosophies. Also, fortunately, my program director, Dr. John (Yahia) Ismail had given me the freedom and provided the support to allow me to pursue my clinical, research and laboratory interests to the level I see fit for myself.
Looking back, now that I am primarily in private practice, a part time clinical instructor at the University, I asked myself what are the skills I acquired during my graduate training that shaped me to be the prosthodontist I am today. There are many but the one skill that I thought is important during my training and is still important to my day to day practice would be the ability of doing your own diagnostic wax up and tooth set up.
In the past during my graduate training, while it was not mandatory that I do my laboratory work, I did a lot of my tooth set up and diagnostic wax up. Currently, I outsourced most of this type of work to a dental laboratory that understands my needs quite well. But the process of learning to do your own tooth set up or a diagnostic wax up is a very valuable skill. To me, it gives me the opportunity to learn about your patients’ dentition, to see and understand closely how my patients had developed their wear facets, how they function in static and excursive movements or how the initial treatment plan I had developed would work or not work. To me, it is a way of training my eyes to see the contour of their teeth, their line angles, their incisal plane and all the relevant occlusal and aesthetic elements that are important in both treatment planning as well as executing your prosthetic treatment plan.
But to be always doing your own diagnostic wax up or tooth arrangement can be quite tedious and takes up valuable time that can be used for clinical work. Some may even argue that these steps should be done by a technician and not by a dentist. But to me, I believe the training that comes out of this process helped me become a better clinician, helped me make better provisional restorations to communicate with the technicians, helped me foresee problems and challenges faced by the technicians and helped me make better predictable treatment plans. And the biggest advantage now for me is be able to correct the work from the lab and to be able communicate the deficiencies with the technicians. Despite the best efforts and best intentions of the technicians, I believe that they often do not have the luxury of seeing their own work in the patients’ mouth. No matter how accurate you develop your provisional restoration and how accurately you record the patients’ jaw relation, there are information that will be lost along the way and looking at the prosthetic work with the patients’ face attached is the only reliable method of evaluating the work. This often will rely on the clinicians’ ability to see the problem and communicate effectively with the technician.
And often times, this can be the source of communication breakdown between the clinician and the lab. If you cannot develop the ideal provisional restorations and relying frequently your lab to deliver the perfect restorations without providing a copy of provisional restorations that worked well for your patient, then there is a lot of hopeful thinking that your prosthetics will arrive from the lab with perfect esthetics and occlusion. And when you don’t receive what you had wish for, are you the one who can precisely identify the deficiency of the prosthetics to the lab so they can make the correction? Or are you the one who just send it back to the lab and hope that the lab will just make it work? Diagnostic wax up and teeth arrangement is a skill that takes time to develop. It is a skill that allows you to develop or change contours freehand using wax or denture teeth. This skill often becomes handy when you are evaluating the contour of either the provisional or permanent restorations. It is a skill that when you haven’t trained your eyes and hands to this step, that communication can break down between the dentist and the technician. It is a critical step to help elevate your prosthetic dentistry to the next level.
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