Essential Photos to Achieve Predictable Outcomes - Lab Communication

Have you ever been frustrated with a diagnostic wax-up or final restoration returned by your laboratory? There could be several underlying reasons the result was not the one you expected.

There are several questions you can ask yourself when troubleshooting what might have gone wrong. Did you comprehensively complete the prescription form? Did you provide photographs in addition to the written information?

There are three times during comprehensive care or esthetic treatment when clear and concise communication is essential. One of the best ways to improve communication is with accurate photographs. I suggest you provide photographs at the following three phases of treatment.

Diagnostic Phase

The essential photographs to be sent to the laboratory during the diagnostic phase of treatment, are preoperative images. They include:

1. Portrait with lips in repose - lips separated by 4.0 mm

2. Portrait with maximum smile

3. Portrait with lips retracted and anterior teeth separated by 2.0 to 4.0 mm

4. Portrait of the patient with the facebow

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5. Intraoral close-up image (1:2) with shade tabs of current shade and expected shade if different from the current condition. The shade tabs are positioned at the incisal edge of the teeth to the incisal edge of the tab, or if the technician prefers, the gingival third of the tab next to the incisal edge of the teeth. I suggest using Vita Classical and Master shade guides.

Treatment Phase

The essential photographs to be sent to the laboratory at the time of final restoration fabrication, are images of the provisional restorations. They include:

1. Portrait with lips in repose - lips separated by 4.0 mm

2. Portrait with maximum smile

3. Portrait with lips retracted and anterior teeth separated by 2.0 to 4.0 mm

4. Portrait of the patient with the facebow

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5. Intraoral close-up image (1:2) with anterior teeth separated by 2.0 to 4.0 mm

6. Tooth preparation with shade guide/prep guide next to the teeth

7. Intraoral (1:2) preoperative shade of teeth and shade tab, and expected shade

8. If the treatment requires the technician to fabricate a restoration to replace soft tissue, a photograph of the pink ceramic shade guides next to the gingival tissue is required. The shade guide should be from the manufacturer of the pink ceramic the technician will be using.

If Esthetic Adjustment Is Required

The recommended photographs will be taken of the restoration tried on the prepared tooth using try-in paste. The try-in paste bridges the space between the restoration and the prepared tooth. This is the only way to evaluate the final shade with translucent restorations.

In the case of an anterior single restoration, the photos needed are:

1. Full face portrait with patient in maximum smile
2. Full face portrait with lips retracted and anterior teeth separated by 2.0 and 4.0 mm
3. Intraoral close-up image (1:2) with anterior teeth separated by 2.0 to 4.0 mm
4. Intraoral close-up image (1:1) of restoration
5. Intraoral close-up image (1:1) of contralateral tooth
6. Intraoral close-up (1:2) of restoration with shade tabs in view (original and possibly new shade tab)
7. Intraoral close-up (1:2) of contralateral tooth with shade tabs in view (original and possibly new shade tab)
8. Intraoral close-up (1:2) of tooth preparation with shade tabs in view

In cases where multiple teeth are involved (anterior only or anterior and posterior), and occlusal planes need to be evaluated, the photographs needed are:

1. Portrait with lips in repose - lips separated by 4.0 mm
2. Portrait with maximum smile
3. Portrait with lips retracted and anterior teeth separated by 2.0 to 4.0 mm
4. Intraoral close-up (1:2) with the original expected shade tab and the new requested shade tab, if a shade adjustment is required
5. Intraoral close-up (1:2) of the tooth preparations with shade tabs and/or preparation guide tabs. This new photograph of the teeth is suggested because the original photograph of tooth preparations may have been inaccurate due to color changes caused by dehydration.

Including photographs with your laboratory prescription should lead to a decrease in remakes, and improve the overall esthetics of your cases.

Robert Winter, D.D.S., is a member of Spear Resident Faculty.