Today we move between the digital and the analog world to accomplish the goals of aesthetic dentistry. A mock-up is a key tool in helping patients want aesthetic dentistry and visualizing what the changes will accomplish.

Lots of us have learned from masters like Dr. Susan Hollar how to hand-lay composite on the patient’s teeth so the patient can see their possible new smile. This trial smile technique is a fabulous way to motivate patients. It’s also a great way for us to learn what might be possible.

For many dentists, that technique is not natural for us, and it takes chair time. Another way we can model possible changes is through digital technology. In our office, we are using digital smile design as follows.

1. We do our initial records, which includes facial photos and an intraoral scan using our digital impressions intraoral scanning system.

2. Either on the software in our office or at the lab, a 3-D version can be designed of what the new smile approximately could look like.This doesn’t have to be a definitive wax-up. Remember, we call it a diagnostic work-up. In fact, this is oftentimes where we discover the need for gingival changes and/or orthodontic procedures in order to achieve the desired outcome. I find this extremely helpful in communicating with the patient as I can show them what the compromised outcome would be if they choose not to correct the gingival levels or align the teeth if that is in fact appropriate.

We’ve learned it is very efficient to collaborate with the lab, the lab creates the 3-D design, and the lab emails us the STL digital file of the design. Alternatively, the lab can send printed models, matrices, or even milled/printed PMMA shells of the design.

3. On the 3-D printer in our office, we print the model from the STL file.

4. We make a matrix from that, either in a suck down material or a putty matrix, and we take that to the mouth, fill it with our temporary material (usually bisacryl), and seat it right onto the teeth.

5. After letting it set, removing the matrix, and peeling off excess material, the patient is wearing their trial smile. This last step takes all of two minutes.

Using this process enables us to do the lab work between appointments, and when the patient returns, they can very quickly preview the possibilities.

It is a wonderful communication tool, because the patient can look in their own mouth, not at a picture of someone else, not at pictures of other shapes of teeth, and say, “I like that,” or “I thought they would be shorter (longer, fatter, narrower…).” You can go in with your handpiece and reshape the temporary material or add material with flowable to make something more pronounced.

Patient participation in the tweaking of the design draws the patient into deeper engagement with and commitment to the smile they want. Now, we can scan the corrected and approved trial smile while it is in their mouth and take photos to send to the lab to help them as we move into the definitive design phase, including working out the occlusion and function.

Staying in the question — staying curious about what more you can learn about each dental patient and the intention to help each patient be more curious about their own situation, enables dentists and dental hygienists to be more effective in helping their patients.

What Do You Think You Know?

The next time you are reviewing the chart of a patient you are frustrated with, try this exercise. Instead of going too quickly to thinking, “What is wrong with this person? Why don’t they get it?” – ask yourself these three questions:

1. What do you know about this patient and their situation, specifically because they told you this? They actually said it.
2. What do you think you know? This has to do with the guesses you have, your intuition about what is going on. What do you think the patient has implied by what they said? Recognize which of your thoughts are guesses because those assumptions might or might not be true. If you act based on what is not true, you may miss opportunities to learn more about what is important to your patient. Asking yourself what you think you know is a way of challenging your assumptions.
3. What do you want to know? What are you curious about? How can you take some of your “think you know” thoughts and move them into the category of “what you do know” about your patient.

The more you do this exercise, the more you become aware of the difference between what you know and what you think you know, and the more curious you will become about your patients. The more I have done this exercise, the more I have come to know that what I do know is small compared to what I do not know. I sometimes I realize I know very little about what is important to them.

Is the Patient Curious to Learn About Their Situation?

I have come to realize that the first question the patient asks is just the first step in their learning process. Sometimes they need help framing some of their more important questions. Or sometimes, a question is their attempt to share a little of their story, their struggles, their fears, their embarrassment. Often, I realize they have emotional discomfort I can address with empathy. In that moment, empathy is more effective in helping and leading the patient to higher health than the clinical information I could provide them.

Understanding that most patients have some level of anxiety about their oral health and oral health visits, I have learned to pause and ask a question before plowing ahead with information they may not want or need — or may not “hear” if they are anxious.

For example, if I see wear patterns on teeth when I do an examination, I could tell the patient what I see. I could say, “I see you grind your teeth.” But that type of statement is often perceived as accusing, not empathetic. What I have found to be more effective is to show the patient what I see. If the patient does not say anything that indicates she would like more information, I might ask her, “How long has that wear pattern been there?” or “What do you think has caused it?” I never want to deprive her of information. I want to give information when she has a little more curiosity — when she wants to know it and will hear it.

Sparking curiosity with a question often leads the patient to ask a question that reflects what is most important to them at that time. Discovering what is most important to them enables us to optimally make use of our time during that visit. We can provide information that is important to them, that they want. Or we can focus on providing the empathy they need to develop a relationship of trust.

In my dental practice, we often use mounted models for diagnostics and restorative treatment planning. Three years ago, we began 3D printing these models.

One of the benefits of printed models is their higher durability compared to stone models. Also, long term, we do not need to save the printed models because we have the digital models saved in the patient’s file. But the greatest benefit has been the efficiency gained in mounting models on articulators. As a result, we have decreased our overhead and increased our mix of services.

What made this mounting efficiency possible is software called “Blue Sky Plan” from Blue Sky Bio. Blue Sky Plan is advanced dental treatment planning software used for milling and printing dental products. One of its applications is printing surgical implant guides, but it has many dental and medical applications for anatomical modeling, surface editing, and offsetting. It allows for CT scan importation and analysis, and export to STL format for 3D printing.

When dental models are printed, the interior can be hollow with a waffle pattern on the back that makes articulator mounting super easy. The process is as simple as opening the software, going to editing, importing your scan, and then selecting a hollow model with the waffle base. To print the waffle base on the model, you need to scan the entire pallet.

The art of helping our patients develop ownership of their present condition and their desires for their dental health is built on the foundation of listening. But much of the time, we do all the talking and provide all the information.

Several years ago, my friend and I were coaching a young hygienist when her patient asked how she could get her teenage son to spend more effort caring for his teeth. I was ready to dazzle them with all the tips I had learned over my 20+ years in Hygiene but my friend Linda cautioned us to “stay in the question.” She was curious to know what the mother in the chair was really asking. That was the first time I became aware of the concept of staying in the question.

The model I learned in my clinical training—the model of teach and tell, really isn’t enough to help patients make choices about their dental care. And over the years, I learned that when I assumed I knew what a patient meant by a question and gave information I thought they wanted… I was wrong. My assumptions got in the way of my ability to really help my patients.

Are our patients asking for help or for information?

When I learned to combine the ability to stay in the question with my knowledge about dental health and dental care, all my conversations became a bit easier. I have come to realize that that mother with a teenage son, like so many of our patients, was asking for HELP but not information.

Today I can think of several questions I might have asked that mom before I jumped in to giving her information. I might have asked, “Well, what have you tried so far?” Or I might have asked, “What motivates your son in other areas of his life?” I might have asked, “What is he doing to care for his teeth?” I might have asked all those questions but asking even one of those questions, might have enabled me to better help.

Sometimes asking just one question before offering information is enough to open the door to real learning.

Staying in the question is both a skill and an attitude.

We need to skillfully ask authentic questions that are not designed to manipulate people into doing what we want them to do. If the questions help us understand our patients better, they are authentic questions. If the questions help them talk through and move through any barriers they perceive, they are authentic questions. If the questions open their minds to possibilities, they are authentic questions.

But staying in the question is not just about asking questions. It’s about an attitude of curiosity, of coming to the conversation with a desire to know more. It’s about releasing the attitude that we know everything we need to know to help the patient move forward.

Staying the question requires a genuine belief that our patients have information that we need to help them better.