Terri Lively

	You have a diagnosis. You have a treatment plan. You have a referral to an oral surgery specialist who can help make it happen.

	You have everything you need to treat your patient - except for his or her treatment acceptance. It turns out, your patient has his or her own ideas.

	Here’s what to do when your policy of “the patient is always right” goes wrong.

	“In my seminars, I say, ‘Your patient is always right; they just don’t have to be your patient.’ I didn’t invent that, but I think it’s a fabulous statement,” says Mark E. Hyman, DDS, MAGD, an adjunct full professor at the University of North Carolina School of Dentistry and an international lecturer.

Trending article: 3 pieces of infection control equipment you're using improperly

	Young dentists have a harder time turning patients away, however, particularly when they’ve invested hundreds of thousands of dollars in complicated, high-tech equipment. Dr. Hyman teaches his young doctors to get out of debt as soon as possible.

	“It’s tough to treatment plan with integrity if you’re thinking, ‘I’ve got to pay for $400,000 of dental school,’” Dr. Hyman says. “If a patient asks you to do something that is not in your skill set or not in their best interest, it’s okay to say, ‘Let me help you find somebody that will do that for you.’”

	Jason Goodchild, DMD, director of clinical affairs for Premier Dental Products Company, says the rapport that you’ve built up with these patients can help you to reassure them about your plan to refer. He tells his patients that the treatment they need is something the specialist does all day, every day.

	“I would say things like, “Well I could probably do this, but it might take me an hour, and it will take the other guy 15 minutes,’” Dr. Goodchild says.

Dr. Goodchild’s advice for dentists is that through self-reflection, if you feel like you can do what the patient wants, then that’s one thing, but don’t be badgered into doing something.

	“I don’t care if it’s like, “Oh doc, I know this tooth is broken down, but can’t you put a filling in it to make it look like a tooth?’” Dr. Goodchild says. “You’re trying to please the patient. At the end of the day, all that ever does is go badly. So, you do the right thing, and you’ll never have to explain why it didn’t meet patients’ expectations.”

	Edward Kusek, DDS, is a private practice dentist in Sioux Falls, South Dakota, with 34 years of experience. He tells dentists they have to stand their ground when the patient wants something that will be detrimental.

	“You have got to be able to stick up for yourself,” Dr. Kusek says. “It’s hard for the younger dentist to understand because they have to keep the production up. Sometimes they may force themselves to do things that they’re not ready to do right away.”

	Knowing what feels comfortable to you is vital so you can keep your practice within your comfort zone. When doctors get outside their comfort zone, Dr. Goodchild says, in his experience, that’s when the bad stuff happens. 

More from the author: How to set proper denture expectations

	Sometimes the patient-is-always-right policy goes wrong after the treatment is done. Instead of focusing on how far the case has come and the level of improvement the treatment has provided, the patient is concentrating on other details and feeling unhappy.

	Sarah Jebreil, DDS, AAACD, a private practice dentist in Newport Beach, California, who specializes in cosmetic dentistry, says having a physical record of where the patient started can be helpful in these situations.

	“Documentation is huge,” Dr. Jebreil says. “A lot of patients forget what they came in looking like or what their chief concern was. The photo brings them back to reality.”

	The visual record is often sufficient to manage the patient’s expectations. However, some patients are never going to be satisfied. Dr. Jebreil says you should make your peace with that. She also recommends talking to the patient’s previous dentist to get an idea of his or her personality type.

	“Any redo case, there’s already so much baggage that comes along with it, and there are just some people that are never going to be happy,” Dr. Jebreil says. “You have to be okay with that.”

Articles

How to treatment plan when your patient has his or her own ideas.

When the ‘patient is always right’ policy goes wrong

	Dr. Shirin Khoynezhad, director of second-year pre-clinical dentistry at the University of Alabama, is a prosthodontist that lectures on denture materials and computer-aided design and computer-aided manufacturing (CAD/CAM) dentures. She explains that bite registration records how the teeth articulate or come together. Next, the record  transfers to the articulators or casts for treatment planning.

The significance of bite registration in dentures

	The bite registration is crucial for all types of oral rehabilitation, per the 

Foundation for Oral Rehabilitation (FOR.org)

. Without this critical measurement and documentation, dentists and dental lab technicians cannot create accurate occlusal relationships for the patient’s prosthesis.

	Centric relation (CR) is an important factor in bite registration. However, there are many definitions of what it means. Per an article from 2017 in the Journal of Prosthetic Dentistry, CR is a spatial relationship that is clinically determined by the relationship between the mandible and the maxilla that is a physiological position both repeatable and independent of tooth contact.

Related reading: 4 tips for creating well-fitted dentures

	CR is also a starting point for vertical, lateral or protrusive movements and is restricted to a “

pure rotary movement about a transverse horizontal axis.

 It is a repeatable reference position for both mounting casts or, at a determined vertical dimension, the development of functional treatment occlusion.

That said, the article also suggested that the CR might vary a bit depending upon the recording method.

	“Without a correct centric relation (CR), the denture you build will disturb the normal function of the masticatory system,” Dr. Khoynezhad says. In other words, whenever the patient bites down they'll have premature or interruptive contact between the dentures.

	“The dentures should come together all at once because they sit over soft tissue,” she says. “In a regular denture, everything sits on soft tissue which is movable, so everything should come together at once. Otherwise the denture will have instability inside the mouth.”

	This “rocking” of the denture causes the prosthesis to become unstable and can interfere with function in the short term. In the long term, Dr. Khoynezhad says, it can cause joint problems that range from headaches to joint pain, clicking or popping in the joints. In some cases, the denture patient can develop temporomandibular disease (TMD).

	Dr. Khoynezhad compares this to balancing tires on a car. If you don’t have a proper balance, you will have more pressure on one tire. This causes premature wear and vibration problems that shorten the life of the tire. The same kind of wear can occur in the mandibular joint of a patient with an unbalanced denture.

	“You will have initiated disease in that joint,” Dr. Khoynezhad says. “The CR bite registration is very important in denture patients.”

Advice for capturing accurate measurements in bite registration  

For.org offers the following treatment guidelines

 regarding complete denture maxillomandibular relations:

			When treating edentulous patients, one of the most significant goals is to reinstitute the jaw in crosswise and sagittal dimension encompassing acceptable facial height.

			Wax rims fashioned on the master casts are the most successful way to determine the jaw relations and capture accurate bite registration with these patients.

			The wax rims set up the vertical dimension and define the patient’s lip line, mid line, smile line and occlusal plane.

	When making a restoration, clinicians analyze both static and dynamic occlusion. The static occulsion is how the upper and lower teeth come together when the jaw is closed and is recorded when the teeth have the most contacts. The dynamic occlusion is how the teeth connect when the jaw is moving in all directions and depends on both the teeth and the temporomandibular joint (TMJ) shapes.

	The correct bite registration for the static occlusion requires the following, per 

			The teeth are closed and positioned where they meet best.

			The posterior teeth bear the load of the bite evenly throughout.

			The anterior teeth take very little weight of the bite.

			The tip of the tongue can touch the back part of the oral palate.

			The overall position of the bite is attainable once the patient swallows.

	Once these parameters are met, the bite registration is recorded. Sometimes the interocclusal relationship is captured in bite wax strips or plates. However, one criticism of bite waxes is they can be less stable than other materials.

	Many times, the bite is recorded in impression material for a conventional bite registration. Once the material sets, the bite record is sent to the dental lab or scanned into a CAD/CAM system.

, the ability to capture these images of the impression material digitally can save time and increase accuracy for dentists. These scannable bite registration materials are vinylpolysiloxanes. Ivoclar Vivodent has a Virtual CADbite registration material with a vinylpolysiloxane base. The fillers in the material were designed to help prevent the light scattering that can occur when scanned by a laser scanner.

	In some rare cases, a clinician can record a digital bite registration for use in conjunction with a CAD/CAM system. The system uses a scanner or camera to capture the antagonist bite registration.

More from the author: 3 reasons to be excited about dentures in 2019

What about when the patient doesn’t have any teeth?

	This explains what to do when recording a bite registration when the patient has teeth. However, the edentulous patient doesn’t have any teeth. They cannot establish the vertical dimension needed for the prosthesis.

	The answer for an edentulous patient is that the bite record comes from what remains, the patient’s muscles and TMJ.

	Dr. Khoynezhad explains that a proper bite registration needs to capture the bite while the mandibular jaw is in a repeatable position, meaning it can hit the mark over and over again with few misses. When you record the bite in a position that cannot be repeated easily and then fabricate the prosthesis based on that bite registration, the denture will not fit.

	The problem with using the muscles to capture the bite, Dr. Khoynezhad says, is they are not reliable. Moreover, they can contract in different positions. If there is a difference in the contraction of the muscles of the jaw, it can change the position of the lower jaw.

	So, without teeth and because the muscles are unreliable for a repeatable position, clinicians are left with the joint position to record the bite. Dr. Khoynezhad says seating the condyles in a repeatable position is crucial in edentulous cases to capture the most accurate bite registration.  

	“We need to take the centric relation for bite registration, so you set the condyle in the most superior anterior position. That's where the disc of the joint is the closest bone-to-bone contact. It’s repeatable because there is no cushion of the joint between the condyle and the joint,” Dr. Khoynezhad explains.

	Different techniques exist for capturing centric relation. The new digital world of dentures is exciting for clinicians and patients alike. For patients with teeth, you can capture the bite both conventionally and digitally. However, for edentulous patients, Dr. Khoynezhad recommends still capturing the bite conventionally and then scanning it into the computer to assemble the information and design the prosthesis digitally for fabrication.

	“Because we are dealing with the soft tissue and joint, we have to do it manually on the patient to be able to find the most comfortable position,” she says. “You can guide the patient to the CR position and then scan the arch to be able to fabricate some tools to get the correct registration. Capturing the bite registrations purely digital is not happening for the edentulous patient.”

	Dr. Khoynezhad recommends two main things to ensure excellent fit and stability for the denture. First, capture the muscles by border molding to get an accurate impression of the ridge and mobile tissue around it so the denture will stay in place. The second is getting the CR bite record.

	“It's a crucial part of fabricating dentures,” she says. “There are many ways to do it, but clinicians have to take time and double check to make sure they got the CR bite before they proceed with the fabrication of dentures. That's the most important thing.”

 , Volume 120 , Issue 1 , 114 – 122. From Web. 9 March 2019. < 

https://www.thejpd.org/article/S0022-3913(17)30708-4/pdf

. “Complete Denture - maxillo-mandibular relations.” 

. Web. 9 February 2019. < https://www.for.org/en/treat/treatment-guidelines/edentulous/treatment-procedures/removable-prosthetics/complete-dentures/complete-denture-maxillo-mandibular-relations>.

 A closer look at bite registration, a crucial part of denture fabrication for fit and wear, and how to capture the position you need when treating an edentulous patient.

What you should know about bite registration

	One of the most common complaints by dentists about dentures is that the fabrication and adjustment process takes a long time. However, new technology streamlines the denture process, reducing the number of appointments necessary to achieve an excellent fit and wear for patients.

	Dr. Shirin Khoynezhad, prosthodontist and director of second-year pre-clinical dentistry at the University of Alabama (UAB) says the average timeline from seeing the patient for the first time till the time that they deliver a conventionally fabricated denture is about one month. Several appointments are required for conventional dentures. 

, the global nonprofit organization that advocates for science, education, and humanity in oral rehabilitation partnering with Nobel BioCare, the clinical objectives of a complete denture protocol are best met with a routine protocol. They recommend that the conventional timeline includes the following steps:

			Making an impression in stock trays to build a stone diagnostic cast. Before impression taking, the doctor should restore soft tissue to a healthy state.

			Creating a custom impression tray and final impressions based on the diagnostic cast. From the final impression, a definitive stone cast is made.

			Making and adjusting wax occlusion rims to capture occlusal plane, the vertical dimension of the patient’s occlusion, and smile and lip lines.

			Registering the maxilla-mandibular relation record and articulator mounting.

			Choosing and arranging teeth for the try-in prosthesis.                                    

			Evaluating the try-in clinically for fit, centric relation, and esthetics.

			Placing the final denture, adjusting for comfort, function and esthetics.

			Fine-tuning again post-placement of the prosthesis and repeating as necessary.

	“In general, it is five or six visits with the conventional method,” Dr. Khoynezhad says.

Every step is essential for a proper prosthesis using the conventional method

	Dr. Khoynezhad says you can bypass and combine the first two visits in some cases, using moldable trays and taking the final impression in the first session. In many cases, however, the dentist will first get a diagnostic impression to make the study cast.

	“There are plenty of muscle attachments around the upper and lower ridges that activates when patient functions (easts, speak, etc.). So, capturing these muscles in action is very important using a custom tray so that the denture will be stable when patient functions with it,” Dr. Khoynezhad says.

Trending article: What you should know about digital impressions for dentures

	Making conventional impressions takes up the first two visits in a traditional denture fabrication method, per Dr. Khoynezhad. However, most dental professionals and technicians agree impressions are critical appointments.

	“We have to see the patient first to get the diagnostic impressions, and then fabricate the cast in stone. We study it and fabricate the custom tray over it so we can get the final impression,” Dr. Khoynezhad says. “So, the final impression is the second visit in the conventional method.”

	On the second visit, after you fabricate that custom tray based on the diagnostic impressions, the doctor takes the master impression.  From that impression, the clinician makes the master cast for the next step.

	The third visit is getting bite registration and the vertical dimension. Finding the correct vertical dimension requires consideration of a few parameters.

	“For conventional dentures, we make something that we call records base and wax rims over the master cast, and then we adjust it inside the patient's mouth to get the centric relation (CR). Also, we take the vertical dimension. We can open and close the jaw, but there should be somewhere in between where the teeth come together. So, we establish that in the patient’s mouth,” Dr. Khoynezhad says.

	Also, in this appointment, the clinician establishes the lip supports. Dr. Khoynezhad says that when patients lose their teeth, the lips will be collapsed, so they build that back out and mark the midline, the smile line, and others. This data gives the clinician guidelines for when the patient is not there to setup teeth.

	The fourth visit is the try-in with the teeth set up in wax. The doctor is looking to see if the denture works in the patient’s mouth, if the midline is correct and the patient’s smile looks correct. If not, the clinician will adjust it.

	“After everything is perfect, we send it out to the lab to process it,” Dr. Khoynezhad says. “The wax gets replaced with acrylic.”

	The last visit is where the clinician delivers the denture after processing. There is another try-in to ensure the bite is the same as the wax try-in.

	“A lot of times it's not, because acrylic shrinks and it moves the teeth a little bit. So, it’s very important to double check and adjust the teeth after processing,” Dr. Khoynezhad says.

	Dr. Khoynezhad says sometimes clinical remounting is necessary. The dentist will get the bite registration again in the patient's mouth and the CR. It is then sent to the laboratory and adjust the teeth so that that they come together all at once in this centric relation.

	“The process of the conventional denture is not ideal. There are limitations that we have with the materials,” she says. “However, both digital and computer-aided design and computer-aided manufacturing (CAD/CAM)processes have helped simplify all of those steps.”

Related reading: How to set proper denture expectations

Digital dentures reduce the steps and streamline the process

	In addition to her position at UAB, Dr. Khoynezhad also lectures on denture materials and CAD/CAM dentures. With CAD/CAM fabrication for conventional dentures, there are only two or three appointments. Dr. Khoynezhad says the first appointment is where they get impressions.

	“And at the second visit, you deliver the denture to the patient,” Dr. Khoynezhad says.

	With CAD/CAM dentures, the study cast is unnecessary so you can skip the diagnostic impression taking. Instead, the clinician jumps to the custom-tray step of conventional dentures.

	“There is a special tray that they put in the warm water, and they are moldable so we can mold them intraorally,” Dr. Khoynezhad says.

	In that same initial appointment, the doctor gets a conventional final or master impression, as well as the CR Record, vertical dimension, and other measurements from the first three regular fabrication method appointments.

	Today, the impressions are still traditional for a full conventional denture over digital impressions because of limitations of the scanning technology. It cannot yet capture the soft tissue and muscle attachments well enough for a system to fabricate a denture that fits. 

	Also, at this initial appointment, the doctor and patient can choose the teeth and the suitable teeth mold for the patient. Then, they send all of that data to the lab.

	Dr. Khoynezhad says once you have the impressions, records and the related measurements, you ship them to the lab, which usually takes about a week. The lab scans in the impression, designs the prosthesis, and ships it back to you.

	“Now, there is no teeth try-in with CAD/CAM. You can ask the company to send back the teeth to try- in the patient’s mouthto see if it works and then process it or finalize it,” she says.

	The try-in denture from the CAD/CAM process has an acrylic base. However, it has sockets for the teeth that are set in wax so the teeth can adjust if necessary.

More from the author: 3 reasons to be excited about dentures

	Some clinicians have the patients bring in foods they like to eat to test the denture. Dr. Khoynezhad says they give the patients chewing gum so they can chew with the denture. The wax is only in the sockets so the denture won’t fall apart when the patient chews.

	“But in general, with the two-day process, we don’t do the try-in,” Dr. Khoynezhad says.

	The lab makes the prosthesis based on the first appointment. At the next visit, the doctor has the actual denture for delivery and adjustment. Dr. Khoynezhad says that CAD/CAM dentures are more accurate than conventional dentures. Part of that has to do with how the acrylic is processed; the digital method does not have the volumetric changes that occur in a traditional process.

	“Acrylics in CAD/CAM dentures are poured in either a disc or cylinders and they undergo shrinkage before they mill the denture out of it. The actual acrylic doesn't shrink after they mill the denture. There are fewer changes in the denture compared to the conventional methods. It's more accurate,” Dr. Khoynezhad says.

	However, the CAD/CAM process doesn’t mean you don’t have to have the same skill level as you would with conventional dentures. The preparation for the lab requires precise measurement and accurate capture of the patient’s bite.

	Getting the record is crucial, and that relies on the clinician’s expertise either conventionally or digitally.,” Dr. Khoynezhad says. “To find the correct spot that you want to re-establish your patient’s teeth is very important.”

 “Complete Denture Clinical Protocol.” 

https://www.for.org/en/treat/treatment-guidelines/edentulous/treatment-procedures/removable-prosthetics/complete-dentures/complete-denture-clinical-protocol

New technology reduces the process and time necessary to achieve ideal fit for denture patients.

How to streamline the denture process

	Shade matching is an area with no shortage of difficulties for clinicians. Mimicking nature with a manufactured material is challenging. However, with experience and the continued improvement of restorative materials, you can prevail with excellent outcomes.

	Shade matching natural teeth is complicated. There are dimensions of color that every dentist needs to consider in the shade matching process. They include hue (color), chroma (intensity) and value (brightness).

 These dimensions can be subjective and influenced by outside factors.

	Also, natural teeth have properties of translucency, fluorescence and opalescence. Translucency is how much light the tooth allows through it, while fluorescence is how teeth absorb and radiate light back at the observer. Opalescence describes how teeth can appear to display varying colors.

 Materials must be able to mimic these qualities while also providing strength and durability to the restoration - a tall order.

	In addition, outside factors play a role in shade matching outcomes. 

 suggests that there are frequent contributors to shade matching problems. Among them are:

		Poor lighting that doesn’t allow you to make an accurate match

		Oversaturated backgrounds that alter your perception of the shade of the tooth

		Faded shade guides that have been cleaned one too many times

		Taking too long to decide on a shade and allowing the eyes to fatigue

		Matching shade at the end of an appointment when a tooth is more dehydrated

Dental professionals must consider all of these color and light factors while avoiding the everyday challenges presented by the shade matching process. Moreover, they have pressure to do it quickly and flawlessly to provide an excellent patient experience while keeping productivity where it needs to be.

	It’s no surprise dentists describe shade matching as challenging and time-consuming. Materials manufacturers strive to simplify and streamline the shade matching process.

	Nonetheless, shade matching is a consumer-facing concern, and therefore, a significant one. Patients don’t know anything about marginal gap widths, polymerization shrinkage percentage, or whether you used a flowable bulk fill composite versus a full-bodied one. What they can tell is when their composite restoration doesn’t look quite right - and you can too.

	Shade matching is an art. We researched and spoke to experts (i.e., fellow shade matching artists) for their advice to overcome the challenges of shade matching with composites. Here’s what they had to say.

	Tip #1: Use new levels of translucency to leverage the chameleon effect

	“When I think of matching color with direct restorations, one trend that I’ve seen is making direct composite resins more translucent,” says Nathaniel Lawson, DMD, an assistant professor in UAB’s School of Dentistry’s division of biomaterials.

	When composite materials are high in translucency, they have what some people call the “chameleon effect.” Dr. Lawson describes the chameleon effect as a blending effect. It means the observer’s perception is that the two juxtaposed colors are closer in hue than when separated. In terms of composites, the chameleon effect means that the composite will blend in with the surrounding teeth.

	Higher translucency could cause some clinicians to worry that the material contained a lower filler content and therefore possess a reduced strength. However, there are other ways to increase translucency besides taking out some of the filler. Manufacturers can instead better match the way resin and fillers refract light without reducing filler content.

	But there’s a drawback to higher translucency, Dr. Lawson says. When you place translucent composite over tooth preparations that are dark, it will discolor what you see. In these cases, an opaquer should be used. The same thing can happen when you place a Class IV restoration in a tooth without a lingual wall behind it. The absence of light in the oral cavity will make a restoration look grey.

	The more a composite can blend, the easier it is to shade match, Dr. Lawson explains. It also means you don’t have to have as many shades in inventory, which is another trend in materials, according to Dr. Lawson.

	“That’s a trend that manufacturers are going for - shade clouds. So, instead of having everything different in a series, they take the A, B, or C shades and put them in a ‘shade cloud’ instead. They make it easier to shade match for posterior restorations,” Dr. Lawson explains.

	The transition between the composite and the natural tooth can be a critical area for the esthetic outcome of the restoration, particularly in the anterior. Dr. Lawson suggests that clinicians aren’t shy about using a long bevel in their direct composite restoration preps to help blend the material into the natural tooth shade.

	He also says you should shade match prior to isolating the tooth. As the tooth dehydrates, it will look lighter, he says. If the doctor waits to shade match later in the appointment, he or she won’t have the correct shade. It’s also why you shouldn’t panic upon completion of a restoration and it appears that it doesn’t match.

	“Don’t be surprised if you have finished a 45-minute Class IV composite restoration and your restoration looks a little bit darker than the tooth. It could be because the tooth is dehydrated,” Dr. Lawson says.

	Tip #2: Work with your patient to explain your composite blending process

	Les Crawford, DDS, practices in Maumee, OH, just outside of Toledo, with Namay Dentistry.  He says meeting the patient's expectations is one of the difficulties of shade matching. Many patients don’t understand that a tooth isn’t one uniform color; rather, it’s a gradient of colors, not to mention the white spots, staining, and grooves that affect the appearance of a tooth.

	With porcelain, Dr. Crawford explains, you can stain and glaze to make a restoration look a lot more natural. However, composites are one shade, and staining and glazing aren’t an option, so it’s difficult to do. To achieve the best possible esthetic on extensive anterior restorations, he’ll blend several composites.

	“Depending on the size of the restoration, we use several different layers of composite to try and mimic the different shades the tooth has in it naturally,” Dr. Crawford says.

	The Namay Dentistry team believes it should treat everyone the way he or she would treat his or her own family. So, when it comes to adjusting patient expectations, Dr. Crawford says you must be honest. He has the patient hold a mirror and together they’ll assess the shade. Dr. Crawford will point out some things to the patient.

	“I'll say, ‘Here's your natural tooth. See how it's got a different color here than it has here? See these little spots here on your natural tooth? All of that is missing on this tooth you've chipped. We're going to try and rebuild it,’” Dr. Crawford says.

	Blending shades can be time-consuming. Dr. Crawford says in a best-case scenario, the patient’s tooth has a uniform shade and it’s obvious which shade to use. However, when the restoration is substantial and the color is inconsistent, you might use as many as three or four composites to make the match.

	Dr. Crawford uses 3M™ Filtek™ Supreme. He likes how when he’s layering composite there are dentin shades and then enamel shades that are more translucent. When you’re layering them, the different types of composite for the tooth structure make the restoration look more natural.

	The process begins by holding the shade guide next to the teeth. Sometimes, Dr. Crawford says, a more yellow-toned shade matches the area near the gums, and the white shades can be better at the edge of the tooth.
	“If you have a lot to replace, you have to blend shades together and try to smooth them out at the end when you polish and make it look natural,” Dr. Crawford says.

	How flat or rounded you shape the tooth can change the perception of shade as well. The shape of the tooth can trick your eye with how the light reflects off of it. Dr. Crawford explains that when the tooth is flattened, it’s going to reflect more light, and when it’s rounder, it won’t reflect as much.

	Like Dr. Lawson, Dr. Crawford also recommends using a bevel in the preparation. The gradual transition eliminates the line between the natural tooth and restoration that can draw attention.

	“You still have to pick the right shade, but at least when you bevel, there's not that abrupt transition from the filling to the tooth,” Dr. Crawford says. “As you are finishing and polishing, you can get the light out and see if you need to make any adjustments.”

	Tip #3: Mind your surroundings for shade matching

	Many factors can affect how you interpret the shade. Managing your environment is key to accomplishing the best possible match.

 the type of light you use to match the shade of your patient’s teeth can affect which shade you choose. Dr. Lowe recommends shade matching in natural daylight, preferably at midday (and with the sun to the north, to be specific). Also, he suggests matching under a second light source, to ensure you get the same result. He also discourages shade matching in operatory lights, as it could lead to poor results.

	In addition to choosing the best possible light source, Dr. Lowe has the following tips for managing elements that could influence shade selection:

		Use a neutral bib to cover the patient’s clothing.

		Remove staining on adjacent teeth, if any, first before matching shade.

		Keep the shade guide at arm’s length.

		Check the shade guide against surrounding teeth as well.

		Study the shade guide for short bursts rather than extended studies to avoid eye fatigue.

	Finally, Dr. Lowe says for doctors to ensure that whoever is taking the shade doesn’t suffer from color blindness or any other sight deficiencies that could affect the shade selection. They must be able to see the colors of the Munsell hue range, which include red, green, blue, yellow,and purple. If there are any difficulties in the perception of these colors, it will hurt the outcome of the shade match.

	1. Fondriest, James. (2003). Shade matching in restorative dentistry: The science and strategies. The International journal of periodontics & restorative dentistry. 23. 467-79. 10.1016/j.prosdent.2004.03.015. From PDF: Web 26 February 2019. < https://www.researchgate.net/publication/9006870_Shade_matching_in_restorative_dentistry_The_science_and_strategies>.
	
	2. Ibid.
	
	3. Lowe, DDS. FAGD, FICD, FADI, FACD DIADFE, Robert A. “Composite Restorations: Subtleties in Shade and Technique.” Web. PennWell. dentalacademyofce.com. October 2010. Web. 2 January 2019. https://www.dentalacademyofce.com/courses/1972/PDF/1011cei_nuance_web2.pdf.

Shade matching can be difficult for clinicians, but with experience and improvements in restorative materials, you can produce excellent outcomes.

3 tips for overcoming common challenges of shade matching

	Flowable composite is one of many categories of dental composite. “Flowables” are known for their excellent handling properties. They’re also known for increased polymerization shrinkage and reduced mechanical properties as compared to the other composite categories.

	However, if you can count on one thing in dental materials, it’s change. Let’s take a closer look at this type of composite and how it can work for your practice. DPR spoke to three clinicians to get their take on flowable composites and how you can go with the flow in your practice.

	Flowable composites have a lower viscosity than their thicker counterparts. They can flow into the nooks and crannies of preparations that might otherwise be difficult to fill with a thicker composite. Flowable composites usually come in a syringe with a small-gauge needle to help them do their job in small preparations.

 Another advantage of the lower viscosity is flowables can form very thin layers, which prevents bubbles or voids in the material.

Related reading: A game-changing dental composite

	Of course, what makes flowables great for some restorations limits their effectiveness in others. The lower filler content of some materials can lead to more polymerization shrinkage.

 Also, when there’s less filler present, it can lead to a reduction in the composite’s mechanical properties.

	However, not all flowables are alike. Newer materials have higher filler contents than their predecessors, which improve some of the well-known disadvantages. These improved materials can be used for more than in the past and with similar results to more viscous composites.

	Flowables: suffering a bad rap from an inauspicious start?

	Nathaniel Lawson, DMD, an assistant professor in UAB’s School of Dentistry’s division of biomaterials, thinks the reputation for reduced mechanical properties is just a bad rap for flowable composites. The materials are improving in strength and wear all the time.

When introduced in the ‘90s, the first flowables were more viscous because manufacturers reduced the filler content. Dr. Lawson estimates it was in the 50- to 60-percent range, which decreased their strength and wear properties. He says that reputation has stuck with flowables still today.

	However, flowables in the post-2010s are 70 to 80 percent filled. Today, Dr. Lawson explains, flowable composites are approximating the mechanical properties of highly filled composites as far as strength and wear.

	“Flowable composite is less viscous, so it adapts better. However, to get that flow, manufacturers had to take out some of the filler particles initially,” Dr. Lawson explains.  “Now, they've manipulated the size of the particles, and that's how they've been able to obtain the different handling properties without reducing filler content. Also, that's how they've been able to maintain the strength.”

	In 2015, Dr. Lawson and his team at UAB 

. The study compared the two-year recalls of both flowable and conventional highly filled composite resin in Class I restorations. Flowables had similar clinical performance after two years to highly filled composites in restorations of this type. 

, which reported similar performance of a flowable composite as a conventional, highly filled composite in “small- to moderate-sized occlusal restorations.”

	“I'm not afraid to use flowables in posterior restorations. My hesitation in using them is if I have some area I want to sculpt because they don’t have great sculpting properties,” Dr. Lawson says.

More from the author: 3 tips for overcoming common challenges of shade matching

	However, Dr. Lawson says that some flowables have a slightly higher polymerization shrinkage percentage.

	“The wear and strength of flowables have been improved, but the shrinkage hasn't been resolved. It's still an issue,” Dr. Lawson says.

	According to the Journal of Conservative Dentistry, flowables need more study. The current literature on their success is too limited to make predictions about their long-term success.

	However, based on the research available at the time of publication (2017), the scientific evidence does suggest that flowables had similar clinical efficacy after three years to their conventional composite counterparts for both carious and noncarious lesions.

 Furthermore, they perform well for occlusal cavity preparations, as sealants for pits and fissures, minimally invasive Class II restorations and noncarious cervical lesions.

	Outside of scientific study, however, flowables have their uses in your everyday practice. Here are a few ways our clinicians shared that you can use flowables to great effect in your direct composite restorations.

Find out how you can make this type of composite work for your dental practice.