J.1708 8240.2006.00017.x

Patient–Dentist–Technician Communication
within the Dental Team: Using a Colored Treatment
Plan Wax-Up
LUKE S. KAHNG, CDT*

ABSTRACT
Communication among the restorative dental team must include the patient. The patient wants
to know the details of the anticipated restorations; but because a patient is not aware of many
dental innovations, care must be taken to provide them with a clear explanation of all antici-
pated treatment parameters. Many patients have little understanding of today’s advancements in
restorative procedures, and they may or may not understand all of the possibilities.
Through effective communication, the patient gains confidence in the dental team and better
understands the proposed restorative treatment. Patient satisfaction is significantly enhanced
through effective communication.

CLINICAL SIGNIFICANCE
This article describes the use of a diagnostic wax-up to facilitate optimal communication
between the dental team and the patient.
( J Esthet Restor Dent 18:185–195, 2006)

INTRODUCTION cemented it in place. But, for what- ultimately finds that it is important

A patient looks to the dental pro-
fessional to restore his or her
teeth to ideal health, function, and
ever reason, he or she is not happy
with the result. The dentist may
have tried many laboratories and
to work with the dental technician
at the treatment planning step,
especially with regard to complex
esthetics. Upon arrival at the dental have experienced similar results. He cases. Establishing optimal effective
office, a team is created. The or she begins to question himself or communication and teamwork with
restorative team consists of the den- herself and wonders what is wrong. the dental laboratory technician
tist and the dental technician. In The preparation guidelines met the helps to build confidence for all
order to achieve all expectations, it materials specifications, so that was cases and helps ensure consistent
is important that the team work not the problem. The directions on and successful results.
together and establish optimal com- the prescription slip were followed,
munication with the patient. so that was not the problem. Possi- Communication among the restora-
bly the dental technician was not tive team is imperative and must
A situation may occur where the involved in the initial steps of treat- also include the patient. Often, the
dentist may have made an impres- ment planning, and this lack of patient explains to the dentist what
sion, sent it to the dental labora- communication may have been he or she is expecting. The dentist in
tory, received the restoration, and partially to blame. The dentist turn will attempt to communicate

*LSK 121 division of Capital Dental Technology Laboratory, Inc., Naperville, IL, USA

DOI 10.1111/j.1708-8240.2006.00017.x VOLUME 18, NUMBER 4, 2006 185

PATIENT–DENTIST–TECHNICIAN COMMUNICATION

this to the dental technician. How- provisional restorations as the blue- a positive psychological impact as
ever, many patients have little print for the definitive well.
understanding of today’s advance- restorations.1 This article describes
ments in restorative procedures, and the use of the treatment plan wax- Although the needs may differ from
they may or may not understand all up, which is a detailed three- patient to patient, the treatment
of the possibilities. Psychologically, dimensional full-color wax-up of plan to achieve the objective of a
through informative communica- the proposed restorations and a proper restoration should not. The
tion, the patient gains confidence in valuable tool for the dentist. With treatment plan wax-up serves as a
the dental team and the restorative this realistic wax-up, the patient valuable template via a matrix for
proposal. The patient wants to can see and understand what is the provisional restorations and
know the details of the restorations, being proposed and what can be shows the patient a virtual blue-
but dentists need to remember they achieved. The patient may have lit- print of the finished restorations.
are talking to a patient with limited tle understanding of the specific The provisional restorations there-
dental knowledge and not someone restorative possibilities. The wax- after can be adjusted in the patient’s
in the dental industry. up is a powerful communication mouth, and adjustments can be
tool for increasing case acceptance relayed subsequently to the techni-
Many patients have the general per- and obtaining the best esthetic cian via impressions of the provi-
ception that restorative dentistry is result for the patient. Each patient sional restorations.
expensive. Therefore, it may not be presents an individual challenge
the patient’s inclination to immedi- and will communicate his or her PATIENT HISTORY

ately buy into a comprehensive esthetic, phonetic, or occlusal prob- The patient, a woman in her fifties,
treatment plan. The patient may lems.2 The dentist and the dental presented with two fractured maxil-
need time to consider the extent of technician understand concepts of lary anterior porcelain units. After
the treatment he or she is willing to anatomy and function and will a comprehensive examination, it
pursue or how much they can address the patient’s concerns in the was noted that the patient exhibited
afford. By presenting a complete context of the treatment plan. After posterior malocclusion resulting
and understandable proposal of patient consultation, the dentist will from premature loss of posterior
what is achievable, it is more likely review special requests from the molars, resulting in posterior bite
that the patient will accept the patient and discuss them with the collapse. The patient would not
entire proposed treatment plan. dental technician. Necessary alter- smile because of the appearance of
Presenting a treatment plan that ations for phonetic or esthetic con- her front teeth.
offers realistic options is best in siderations may include revising
helping the patient understand the incisal edge position and length.3 INITIAL TREATMENT PLAN

possibilities they are to consider. The treatment plan may include The first phase of the treatment
This can be facilitated by optimal procedures that address anterior plan was to pursue orthodontics to
communication with the dental guidance, incisal length, centric correct the occlusal plane, upright
technician and is enhanced with the stops, posterior occlusion with cus- the tipped posteriors, and achieve a
treatment plan wax-up. pid disclusion, tooth reduction, or better curve of Spee and curve of
preplan necessities such as gingival Wilson.5 Provisional restorations
A traditional rehabilitative tissue recontouring.4 The esthetic (Figure 1) were placed on the
approach is to use acrylic resin changes are a vital part in creating involved anterior teeth. The

© 2006, COPYRIGHT THE AUTHORS
186 JOURNAL COMPILATION © 2006, BLACKWELL MUNKSGAARD

KAHNG

Figure 1. Preoperative view. Provi- Figure 2. Full view of the treatment Figure 3. View showing the emergence
sional postorthodontic treatment; the plan wax-up. profile. The different colors are used as
provisional was in the mouth for over a teaching tool to identify the travel
2 years. paths of the opposing cusp.

programmed articulator can mini- wax was added to replicate tissue.
mize articulator-generated occlusal The pink wax gives a realistic
errors. (Figure 4) and more natural
appearance to the restorations,
It is not only form-function ele- which helps promote case
ments that develop the important acceptance by the patient.
structural components of molar
relief in the shaping of enamel PREPARATIONS AND IMPRESSIONS

Figure 4. Protrusive view shows func- labial line angles, triangular beads, The provisional restorations that
tional and nonfunctional areas.
auxiliary line angles, and fissures. were worn during orthodontic
Everything is brought together treatment were evaluated. Excessive
orthodontic treatment was com- under the essential mechanical prin- wear was seen and the provisional
pleted in just over 2 years and ciple of the mortar-pestle type restoration had worn quite thin on
resulted in repositioning the canines adjustments. the maxillary right canine. Because
in a more optimal position. the provisional restoration was so
The right posterior mandibular thin in this area, it was important
Following orthodontics study, casts quadrant (Figure 3) was fabricated to compensate with the tooth
were made. Bite registrations (cen- using colors for teaching purposes. preparation.
tric relation and protrusive func- Differences can be seen early in
tion) were made, as well as a cusps (buccal and lingual) as well as All the restorations must have ade-
face-bow transfer record. A treat- in teeth. After evaluation, it was quate tooth structure reduction to
ment plan wax-up (Figure 2) was decided that unless minor adjust- allow for marginal placement to be
generated to help ensure a success- ments were needed, the mandibular positioned at or below the gingival
ful outcome. anterior teeth would be untreated. margin. After removing the provi-
The maxillary posterior, mandibu- sional restorations, the existing
When fabricating a treatment plan lar posterior, and maxillary preparations were slightly modified.
wax-up, variables that may influ- anterior teeth would be restored. In the preparation of the teeth
ence the outcome of the occlusal Because the patient was worried (Figure 5), to ensure proper
morphology must be addressed. A about the esthetic appearance, pink anatomic form, the preparation

VOLUME 18, NUMBER 4, 2006 187


Figure 5. Preparations for the three- Figure 6. From duplicate models, clear Figure 7. The flexible clear stent is used
unit fixed partial denture and the single hard surgical and clear flexible stents as a preparation guide.
units in the maxillary anterior region. are made.
The maxillary left central incisor is an
endodontically treated tooth.

agement, management of blood or sional restorations, one may lose
saliva contamination, and correct shape or experience some distortion
size of the impression tray. But if from the excess provisional acrylic.
the dentist is not comfortable with The harder-type stent will exhibit
the material or technique, he or she less distortion. The harder stent,
will lose accuracy that is so impor- when positioned over the inner
tant. The vinyl polysiloxane impres- more flexible stent, will result in a
sion accurately captured the tooth more precise contour and shape
Figure 8. Provisional is made using preparation. that is not achievable with the
the flexible stent placed inside the hard
surgical type stent. This will be used flexible material alone. However,
as a template for the provisional. The PROVISIONAL RESTORATIONS it is important to have the flexible
hard surgical-type stent will have less
distortion. Instead of using a silicone matrix of material stent used inside of the
the wax-up for the fabrication of harder outer stent, as it is much
consisted of placing a shoulder the provisional restorations, a easier to remove the provisional
preparation of 1.0 mm, at a 90- to duplicate model was made of the material from the inner flexible
110-degree angle. Facial and lingual wax-up and a flexible clear stent stent. The hard stent, if used
reduction was at least 1.5 mm and was fabricated (Figure 6). The stent alone, would stick to the provi-
the incisal resolution was 2.0 mm. was also used as a reduction guide sional acrylic and be difficult to
in generating the preparations remove.
The impression was made with a (Figure 7). The clear stent also can
vinyl polysiloxane impression mate- be used as a matrix for the fabrica- The provisional restorations were
rial (Examix, GC America Inc., tion of the patient’s provisional made with a bisacryl material. The
Alsip, IL, USA). Making an accu- restorations, but to avoid distor- patient was pleased with the
rate impression requires selecting a tion, a hard surgical stent (Figure 8) appearance, and no modifications
technique with which the dentist is was fabricated and placed over the were needed. The provisional
comfortable. The dentist must take clear stent to afford support. restorations (Figure 9) were worn
into consideration appropriate The clear stent is a flexible mater- for 4 weeks until delivery of the
tooth preparation, soft-tissue man- ial. When fabricating the provi- final restorations.


KAHNG

LABORATORY PROCEDURES patient how the restorations resem- In the best interest of the doctor
Treatment Plan Colored Wax-Up ble the wax-ups (Figure 16). The and the health of the patient, it is
The treatment plan colored wax-up colored wax-ups are valuable to the dental technician’s responsibility
is a full-contour wax-up of the the dental technician as well during to be educated in the latest materi-
restorations. The colored wax is the porcelain build-up and contour- als, techniques, proper function of
hard enough to withstand try-in in ing stages of the restorations. occlusion, and the longevity proper-
the mouth (Figure 10) for the indi- ties of the materials to be used. This
vidual crowns and the fixed partial information should be shared and
denture. The wax try-in (Figures 11 Material Selection discussed among the entire team:
and 12) allows the dentist to check Material selection is crucial in the doctor, patient, and technician.
midline, size, shape (Figure 13), and success of any restoration.6 In After this team meeting, the final
pontic tissue adaptation (Figure choosing the right material, one decision as to which restorative
14); it also allows the dentist to factor to consider is longevity. No materials are used rests with the
show the esthetic qualities of the matter how esthetically beautiful dentist.
restorations to the patient. If the the restorations are, if they do not
patient requests changes, the dentist last, it is inconvenient for the The material chosen in this case
can change the wax-up immediately patient, the clinician, and the dental was Captek (Captek, Altamonte
to achieve the desired contour laboratory. Springs, FL, USA). Captek is a thin
(Figure 15). Upon completion of gold coping that is internally rein-
the final restorations, the dentist Preparation design factors will forced. It is not a cast alloy, and it
can interchange them to show the determine the material you choose. is not a foil. The system is nonoxi-

Figure 9. The provisional is completed. The patient is able Figure 10. The treatment plan colored individual wax-up
to wear what she saw in the treatment plan wax-up. (individual crowns and FPD) is tried in the mouth. The wax
try-in allows the midline, size, shape, pontic-to-tissue fit,
and esthetic values to be checked. A patient’s request for
changes can be made immediately to the wax-up.



Figure 11. The colored wax-up is checked for size, horizon- Figure 12. Protrusive view of wax-up. Maxillary left cen-
tal view, and three-dimensional evaluation. tral incisor shows a gray gingival area with internal silver
metal post/core underneath.

Figure 13. The distal of the maxillary left canine has Figure 14. The treatment plan colored wax-up—three-unit
chipped from the heavy stress forces of biting. Care must be fixed partial denture is tried in.
taken to make changes for freedom in this area.

Figure 15. Incisal view checking for centric stops, occlusal Figure 16. Colored wax try-in of the maxillary left central
pattern, lip support, occlusal table, and tooth form. incisor and canine to check the three-dimensional room for
the maxillary left lateral incisor.


KAHNG

dizing so there is no darkening that with opaque is thicker than for a ment copings with a laser welder.
occurs as with traditional porcelain Captek framework with opaque. The tacking occurs in small areas
fused-to-metal systems. Because it is This quality allows for additional on the facial and lingual surfaces in
nonoxidizing, there also is no dark porcelain thickness, because of the order to hold the pontic securely.
background that can interfere with thinner Captek frame. Additionally, The Inconnect is then applied to
the optical qualities of the porce- its warm gold color enhances the the whole joint area. The Inconnect
lain. Having a warm gold color and esthetics. is a pastelike material that will
no oxides, the material needs less seal the joint area with a solderlike
opaque, which allows for addi- consistency to create a solid con-
tional porcelain thickness. This Fabrication of the nector. This feature represents an
translates into better esthetic Captek Framework advantage over mere laser
vitality. The Captek copings and the sepa- welding, which often results in
rate pontic are fabricated. The pon- inconsistencies. It is also an
No matter what material is used as tic needs to be attached to the advantage over a post-soldering
a framework, the application of the abutment copings. Rather than approach, because no time is
porcelain is the most important step using post-solder or complete laser needed for investing.
to achieving the highest esthetics. welding (Figure 17), the new Incon-
The skill and knowledge of the den- nect (Captek) material is used. The After framework completion, nor-
tal technician and the thickness of Captek fixed partial denture with mal procedures are followed for the
the porcelain used greatly affect the the new Inconnect material allows application of UPC bonder, opaque,
esthetic beauty of the restoration. the dentist to feel comfortable and porcelain. The UPC bonder
Many ceramic restorations are very with the connectors to the pontic. (Captek) is a bonding material
esthetic but the metal framework The pontic is tacked to the abut- (Figure 18) for Captek. Because

Figure 17. Captek framework is fabricated. The pontic is Figure 18. Finished Captek framework with the UPC bon-
tacked into place with a laser welder and then attached to der applied and ready for opaque..
the abutments using Inconnect. The Inconnect works like a
solder to make a solid connector and will flow in to form a
solid joint.



Captek does not oxidize, a bonder because they are a three- quadrants were then slated for
is needed to secure the porcelain. dimensional copy of the desired subsequent restoration.
restoration.
The opaque material (Initial MC, Patients have many different ques-
GC America Inc.) is applied in a Cementation tions about how their new crowns,
thin coat; thinner than would be Because Captek requires no special including: what material is used,
necessary for coating an oxidizing bonding or cementation technique, color choices, shapes, etc. What
type material. This allows for addi- the restorations were cemented they are really asking is “Will this
tional porcelain, which even in the with Rely-X Unicem (3M ESPE, St. crown or restoration look like nat-
slightest amount is helpful in Paul, MN, USA). Unicem is a self- ural teeth? Will they look like my
achieving better esthetics. adhesive universal resin cement. own teeth?” The patient has high
The self-adhesive resin helps to expectations and needs to under-
The multilayered porcelain (Initial eliminate some of the technique- stand what is available to them.
MC, GC America Inc.) build-up sensitive and time-consuming steps
technique is used to give a natural associated with traditional resin A treatment plan wax-up accurately
appearance. The colored wax-ups bonding cements. shows the patient what the antici-
are used during the porcelain build- pated new smile will look like and
up while building to full contour. ensures that their full expectations
Without the colored wax-ups, CONCLUSION will best be met. It is a three-
porcelain may become overbuilt, Optimal esthetics and proper ante- dimensional tool that, coupled
resulting in the removal of a desired rior guidance were established with with good team communication
color when adjusting the contour. the Captek restorations. The (Figure 20), is very informational
The full colored wax-ups are supe- patient was comfortable with to the patient. More importantly,
rior to a putty matrix (Figure 19), the occlusion and the posterior these realistic and thorough

Figure 19. The porcelain first bake of the maxillary left Figure 20. Completed restorations next to maxillary left
anterior teeth. The contours of the crowns are compared lateral incisor colored wax-up, showing the patient how
with the three-unit colored wax FPD (maxillary right ante- similar they are with regards to shape, contour, size, and
rior teeth) instead of using a silicone putty matrix. form.


KAHNG

Figure 21. Maxillary left anterior teeth colored wax FPD, Figure 22. Immediate postoperative view in resting
maxillary left central incisor Captek crown, maxillary left position.
lateral incisor colored wax, and maxillary left canine
Captek crown.

communicative tools (Figure 21) The case discussed is courtesy of 3. Garber DA, Salama MA. The aesthetic
smile: diagnosis and treatment. Periodon-
build confidence, which will help Rick Alwan, DDS (1292 Ricker Dr. tol 2000 1996;11:18–28.
the patient accept the proposed #144 Naperville, IL 60540; Tel.: 4. Lee R. Esthetics and its relationship to
optimal treatment plan. The better 630-717-8700). function. In: Rufenacht CR, editor.
Fundamentals of esthetics, Chicago (IL):
the team communication, the more Quintessence; 1990. p. 137–50.
successful the outcome will be for 5. Wheeler RC. Dental anatomy, physiology
REFERENCES and occlusion. 5th ed. Philadelphia (PA):
everyone involved (Figure 22).
1. Donovan TE, Cho GC. Diagnostic provi- WB Saunders; 1984.
sional restorations in restorative dentistry: 6. Spear FM. Esthetic Technologies and
the blueprint for success. J Can Dent Materials (Seminar).
DISCLOSURE AND
Assoc 1999;65(5):272–5.
ACKNOWLEDGMENTS
Reprint requests: Luke S. Kahng, LSK 121
The author has no financial 2. Chiche GJ, Pinanlt A. Artistic and scien- Division of Capital Dental Technology
tific principles applied to esthetic den- Laboratory, Inc., 940 E. Diehl Rd #100,
interest in the companies whose tistry. In: Chiche GJ, Pinanlt A, editors. Naperville, IL 60563; Tel: 1-630-955-1010;
Esthetics of anterior fixed prosthodontics, Fax: 1-630-955-2020; e-mail:
products are mentioned in this luke@lsk121.com
Chicago (IL): Quintessence; 1994.
article. p. 13–32. ©2006 Blackwell Publishing, Inc.


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