fbpx

‘I don’t like my Veneers anymore’ – GF005

You place some veneers and your patient leaves in tears of joy. Imagine getting a letter a few weeks later to tell you that the patient now HATES her veneers and would like a full refund. That is soul destroying stuff, and it’s NOT about the money!

Dr Rhode to the Rescue!

Need to Read it? Check out the Full Episode Transcript below!

Within the context of this specific scenario where 6 veneers were placed, we discuss:

A. How this could have been prevented

B. How to handle the veneers that are ‘bulky at the gumline’

C. How to handle this refund request…!

I want to thank Dr Manrina Rhode for yet again adding so much value for the Protruserati

You can check out her course on Designing Smiles website

If you liked her episode and want a full hour of Veneers from preps to Temps, check out Everything Veneers with Manrina Rhode

Click below for full episode transcript:

Opening Snippet:

You pour your heart and soul into a treatment. You like study extra, you go on extra courses, you want to give your patient the best they can get so when it comes to like cosmetic dentistry, veneers remember your first couple of veneer cases like you really think about it. You really go that extra mile to make sure your patient is ecstatic at the end and then you get a letter saying that I would like a refund for my veneers like that crushes you right?


Jazโ€™s Introduction:
ย 
So this my friends is something that was experienced by one of the Protruserati. Sheโ€™s going to remain anonymous and I really wanted to help her. So Iโ€™m recording here on Sunday as in like an emergency episode I message Manrina Rhode, veneer queen who else right? About how to tackle this scenario.

So the scenario is basically you do some, you place six veneers for a patient and sheโ€™s really happy, she approves the try-in, she approves a mock-up even, she signs your consent form, she leaves really pleased on the day that you fit the veneers and then you get a letter and you think this letter is going to be a thank you letter but actually itโ€™s letter say that I have gone and got a second opinion from so-and-so dentist pg, dip aesthetic dentistry and implant density blah blah and we both agree that the veneers are too bulky.

So the main complaint was actually I think by the gum line theyโ€™re too bulky and I donโ€™t like them anymore without actually telling the dentist. They just wrote in like out of the blue right? And I would like a full refund of all the treatment. So this dentist wrote to me to say that sheโ€™s really upset that this has happened and she followed the whole protocol and she worked so hard and sheโ€™s a really awesome progressive forward-thinking dentist who has put a lot of time and money into her education so I felt really crushed for her because of one sentence she said that sheโ€™s really lost confidence in herself. And we will all lose confidence in ourselves in some procedures throughout our career.

It happens itโ€™s inevitable and I want to make this episode to help her out and so that we all as a group can learn because we all have patients, veneers patients in particular right because Iโ€™m happy to say that patients who come seeking veneers theyโ€™re all a little bit crazy letโ€™s face it. Theyโ€™re a little bit crazy I think and we have to be wary of body dysmorphia. So I pitch this scenario to Manrina Rhode, how would she advise handling a scenario A) had to prevent this from happening in the first place that you donโ€™t have an unhappy patient. B) now that a patient has complained of bulk veneers, is it okay to prep them down? How do you manage that? and C) should this dentist give the money back to the patient? What does Manrina think? I actually felt bad about asking Manrina this last question because very tough question to ask. I really twisted her arm at the end so anyway I hope you enjoyed this group function and I hope you gained value from it thank you so much.

Main Episode:
Veneer queen, Manrina Rhode, welcome back again to The Protrusive Dental podcast, how are you?

[Manrina]
Iโ€™m good, Jaz. How are you?

[Jaz]
Iโ€™m amazing thank you so much for coming at short notice to really help this dentist but I thought this would make a really great group function to help all dentists because we either have all been in some kind of a similar scenario where a patient is unhappy and or wants a refund or itโ€™s something that we can find similarities and or avoid certain the situation for the future for any dentist who can learn from this.

So if you donโ€™t mind, Iโ€™m just going to go straight in to the main question but for those of you who havenโ€™t listened to Manrinaโ€™s episode on veneers yet, it is one of the most listened to podcast episodes on my podcast. It was episode I think it was 19 or 21 so I think around about that sort of that time and itโ€™s on YouTube and itโ€™s got like over a thousand views and Iโ€™ve always get great feedback from people actually listen like on the way to work when theyโ€™re placing veneers just because they want to learn for those last few nuggets from Manrina. So that was, if you like the ones with them lots of value in them you should definitely check that out.

So Manrina, the scenario is thereโ€™s a young dentist, a really really caring sweet dedicated young dentist who really cares about what sheโ€™s doing she took on a veneer case and sheโ€™s always asking for advice stuff, always happy to help people like her who are so interested and keen and what happened is that the patient has now told this young dentist that I donโ€™t like the veneers anymore because theyโ€™re too bulky at the cervical region and I want a full refund so thatโ€™s the long and short of it.

In what we donโ€™t see in the background is the fact that she had fantastic consent form that was personalized to the patient. She did a smile trial, she didnโ€™t take any shortcuts. She did everything step by step by step and the sad thing is that she said in her message to me that she feels like sheโ€™s lost a lot of confidence and she feels really like broken which is really sad so Manrina, I think if you break it up into three components, number one how to prevent your nuggets to, how to prevent being in that scenario? So should we tackle that one first.

[Manrina]
Yes, letโ€™s do that. So thereโ€™s got to be a lot of stages that you go through before you get to your final veneers and it sounds like this lady did go through a lot of them. So the first one that I use is photoshop that I use initially to show the patient what they should expect theyโ€™re going to achieve. I think in this case she was closing a diastema.

So particularly in diastema closure itโ€™s really important to use photoshop because you want to use it to decide how many teeth you need to involve in the process to create your plan. So also I guess she would have given orthodontic options thatโ€™s really important in diastema closure depending on whether you want to make the teeth bigger when whether the teeth are already quite small and you want to make them bigger and so maybe orthodontic options arenโ€™t as relevant or they are relevant but you donโ€™t want to close the space fully so you want to be familiar with smile design so youโ€™re making sure that youโ€™re keeping golden proportion, youโ€™re keeping the right 1 to 0.8 ratio for that central incisor.

It all starts with the central incisor and then it all goes back from there with smile design so and also to check that theyโ€™re happy with diastema closure whether they would want full diastema closure, whether they donโ€™t. I know in this case that wasnโ€™t the issue. Well she says it wasnโ€™t the issue but maybe part of this is the fact that we were closing a diastema and so maybe things look a little bit more bulky than they would otherwise depending on how much the dentist prepped the patient.

So thereโ€™s so many things going on in my head right now regarding this case but so basically I would start at the very beginning with some sort of imaging software and thereโ€™s lots of imaging software at the moment out there I use photoshop and thereโ€™s dsd and Iโ€™ve started playing with ivory smile recently from ivaclar and thatโ€™s been thatโ€™s really good as well. Actually Iโ€™m definitely going to be talking more about that on my instagram page and on my veneer course.

And then once youโ€™ve kind of had a play with that and shown the patient okay if we just close the diastema we just veneer the front two teeth then this is the result that youโ€™re going to get but the front two teeth are going to look a bit bulky and so that can be shown on photoshop, that can be shown with just a composite mock-up in the mouth and then you start getting and then when it when you do that if you do for example a composite mock-up in the mouth, you would then take a photo of what you mocked up and show it to the patient and they can take it away with them so they can start getting their head around the fact that maybe two veneers isnโ€™t enough and maybe they need to, if theyโ€™re looking at veneers and they donโ€™t want ortho then maybe theyโ€™re looking at four veneers.

Also at that stage you need to have the conversation that if you are looking at four veneers to redistribute the space then that canโ€™t be done with a very minimal prep or no prep type veneer because you need to remove from the distal of the ones to mesialize the veneer to make the centrals not look too wide and redistribute the space to those laterals and even then sometimes you can end up looking, it can end up looking a bit bulky at the front if the rest of the teeth are small. And so sometimes unfortunately in these cases you need to do even more.

So you then need to involve canines and premolars and do an eight unit case to really get a nice space distribution and you need to be aware of that because patients are always going to want the minimum number of ceramics and us as clinicians we want to do the minimum number of ceramics as well because itโ€™s better for the patient, treat your patient as you would treat your own mouth or the daughter test as you would treat your own child if you have one.

But also you donโ€™t want the patient to get stuck like you donโ€™t want to be so trying to be this really great dentist and doing the minimum number and then only doing two ceramics and then theyโ€™re not happy and then you end up in in a situation perhaps similar to this although this is not exactly what happened there.

So first thing is before you do anything is really consenting and not only with a great consent form but having that conversation, giving the patient visual aids either using computer generated images or in their mouth so that they can really understand. You can also do a trial smile and I think you said that she did that so you could have an additive wax up made from the lab.

[Jaz]
So she did the trial smile and she took a photo of it. So at that point do you maybe itโ€™s just a thought cut to my head at that point you get the patient to sign off something that you know what I like this trial smile. At any point is that something that you advocate to your students?

[Manrina]
Yeah I think the more you get patients to sign off at every stage the better it is. I definitely think you need to get a sign off at the temporary stage so not quite at the trial smile. So the problem with the trial smile and I donโ€™t do them as often now as I used to do and the reason for that is because if theyโ€™re not additive if theyโ€™re made exactly how the smile is going to be then the patient will have shine through of their own teeth because youโ€™re not necessarily always adding and then itโ€™s difficult for a patient to understand what it is that youโ€™re trying to show them because they donโ€™t understand that the teeth are shining through oh Iโ€™ve got yellow patches shining through is that what youโ€™re trying to do here.

And if you get the lab to make an additive wax up just for the purpose of this trial smile so itโ€™s all being stuck on then the trial smile is going to look really bulky and then you need to explain to them oh it looks bulky but the real thing wonโ€™t be this bulky and so thereโ€™s limited benefits to a trial smile. Definitely I think that that stage is better achieved using some sort of digital imaging software.

But moving on from that say you use your digital imaging software and then you decide youโ€™re going to do however many youโ€™re going to do four veneers for example which I think is what this.

[Jaz]
Letโ€™s go with six because she did six so letโ€™s use the example of six as we move forward.

[Manrina]
Oh she did six okay fine I didnโ€™t know okay fine. So six immediately in smile design weโ€™re taught to always be wary of doing six veneers and the reason for that is the way that a veneer even with the most the top ceramics that that I work with and theyโ€™re amazing. Inevitably, the way that a veneer reflects light is slightly different from the way a tooth will reflect light. Itโ€™s porcelain as opposed to enamel and when you do six you only go as far as the corner of the mouth and then you have a different reflection of light from the front of your smile to the back or to the side and sometimes that can make the premolar region look less obvious or look different from so these just look more obvious or bulkier even if they arenโ€™t necessarily because youโ€™ve gone to the corner of the smile.

So I advocate or I was taught that you really want to do two, four, eight or ten. Not to say I havenโ€™t done six veneers in my career. I have done six but itโ€™s again the more information youโ€™ve got the more these sort of nuggets take today, keep them in your head. Come on my course. Come and learn them. And the less problems youโ€™ll have because I think it is harder to get a natural result with six than it is with four or eight because immediately theyโ€™re going to look different from the bit bulky at the front of the smile.

So okay she did six, so if you go on to okay youโ€™ve done your digital design, youโ€™ve done your preps and youโ€™ve used a stent and put the new smile on in temporaries so the patient can try out and you smile. Itโ€™s that stage thatโ€™s really super important and I will never move a patient from that stage until theyโ€™re 100% happy. If theyโ€™re even arming and eyeing slightly about I donโ€™t know they kind of look bulky okay maybe theyโ€™re okay Iโ€™m not moving from that stage because of this very reason I donโ€™t want to refund anyoneโ€™s treatment at the end of it and Iโ€™m not, itโ€™s not even about the money itโ€™s about the stress of it.

You want to keep your life stress free, you donโ€™t ever want to feel like you donโ€™t want to do a smile makeover again because youโ€™ve got all this stress at work this is supposed to be a treatment that gives you a lot of pleasure because itโ€™s really enjoyable transforming someoneโ€™s appearance and giving them that joy and so letโ€™s not involve any stress in it.

So once theyโ€™re in temporaries thatโ€™s when you want them to sign off and so really you need to have that conversation and I assume that she did have that conversation and I assume that at that stage the patient didnโ€™t feel like they were bulky that she was happy with the way that the temporaries were so thatโ€™s that.

Then you go on to your finals, it depends what lab youโ€™re working with. If youโ€™re not able to charge the prices that maybe I charge or other some other dentist charge then maybe you also canโ€™t work with the labs that charge what my labs charge because obviously itโ€™s all relative and maybe if youโ€™re working with having to work with a less expensive lab maybe they havenโ€™t got the skill set to not create bulky veneers. Theyโ€™re definitely ceramics have a style and they have a shape that they like teeth to be.

So one of my favorite ceramics Nikki from precision dental. Sheโ€™s a master ceramist Iโ€™ve worked with her for 18, 19 years now and sheโ€™s wonderful and if you look at my instagram page thereโ€™s such a variety of cases that sheโ€™s done for me from very natural to very Hollywood to blocky to very minimal and according to the patients you know sheโ€™s diverse but she still has a style. She still has a style that she likes to go to that I know like that I can recognize her work and itโ€™s very subtle but having done over 12,000 veneers with her I get it I can see it and I also I know about different labs and the different pros and cons that I have from each one of those people having their individual style.

So and the problem sometimes with the less expensive labs is that they make these bulky veneers they because they donโ€™t have the skill set to make them very thin at the cervical margin but still put the correct anatomy on and potentially the dentist doesnโ€™t have the skill set to remove enough at the gingival third and Iโ€™m not saying this about this dentist at all because I donโ€™t know but sometimes dentists donโ€™t remove enough there and then for itโ€™s not the labโ€™s fault, itโ€™s the dentist fault that they donโ€™t have the space to make a thin veneer in that area and then they end up looking more bulky because dentists can be a bit scared of theyโ€™ve prepped the margin itโ€™s starting to look like a bit of a heavier prep, theyโ€™re scared that theyโ€™re getting too deep into things and so they kind of leave it but then you end up with it with a bulkier, a bulky veneer.

[Jaz]
Well Iโ€™m just going to say because in the interest of time and I really want to squeeze as much out of you in this valuable but small amount of time I have with you so I think the take home message really for that first bit is temporaries. Make sure you absolutely nail it in the temporary and I remember in the episode you talked about youโ€™re happy to keep them on temporaries for as long as it needs to be until the patient is absolutely ecstatic and I remember that so I think that is one main takeaway from part one. Letโ€™s just tackle part two now which is-

[Manrina]
Even if you have to give up the case, if canโ€™t get them happy in temporaries and you need to give up the case at that stage, much better to give up the case at that stage than go on to finals because once youโ€™ve got that lab bill associated and youโ€™ve got that final thing stuck in their mouth you know youโ€™ve gone too far so this is this is really a very important appointment.

[Jaz]
Brilliant and now letโ€™s tackle the bit where letโ€™s imagine to help purely to help this because I really want to serve this dentist. She has the complaint of the cervical area by the gum line is too thick and too bulky and thatโ€™s the main complaint the patient saying. What is the best way to manage that? Is it a matter of just starting again? Is it a matter of just prepping away some of the ceramic? How to handle that in just a couple of minutes because I want to ask you one more thing after that.

[Manrina]
Yeah so youโ€™re breaking up a little bit, Jaz but I think I got what youโ€™re saying that how weโ€™re going to manage this now. Now weโ€™re at this situation sheโ€™s cemented it. So first of all at the cementation stage just really be very be wary of that try in. So before I at the cementation appointment I always say to my patients nine out of ten times Iโ€™ll go ahead and cement your veneers today but one out of ten times I wonโ€™t and thatโ€™s because theyโ€™re not perfect for me and if theyโ€™re not perfect for me theyโ€™re not good enough for you so just to let you know if theyโ€™re not perfect Iโ€™m not going to cement them.

So you also need to be aware as a dentist and look at that stage. Thatโ€™s another stage where you could get the patient to sign off so sometimes Iโ€™ll put them in with a try and paste and Iโ€™ll still get them to sign off saying that theyโ€™ve seen their veneers that theyโ€™re happy for me to cement. So thatโ€™s another stage that you can put in there and sometimes theyโ€™re not. Sometimes even Iโ€™m happy with them but the patient will look at them be like no the laterals look like theyโ€™re slightly different length so I really donโ€™t want that and so much better at that stage to catch that than later on. So Iโ€™m not sure if this dentist did that but good to show them and at that stage if she thought they were bulky the lab could have adjusted that for her.

Okay but anyway we get to where we are, weโ€™ve cemented them and then the patient feels like theyโ€™re too bulky. For sure prep your veneers like you would prep enamel. I do it often. Iโ€™ll go and recontour a veneer and sometimes patients come to me who have had veneers done by someone else and they donโ€™t like them and I can see why they donโ€™t like them, I can see what needs to change and Iโ€™ll just be like you want me just to contour them for you rather than changing them and theyโ€™re like yeah go for it and Iโ€™ll just prep their veneers.

Obviously you have to be a little bit careful itโ€™s easier when youโ€™re changing it incisally but when youโ€™re prepping the labial aspect you donโ€™t want to if you start getting shine through and it gets very thin and youโ€™ve got the tooth shining through youโ€™ve got a real problem. So just very gently, very carefully contour the porcelain. Obviously itโ€™s not ideal to do that Iโ€™d rather the lab did it because when you do that you remove your glaze and so you remove some of the shine from the ceramic and thatโ€™s what I think happened with this lady. So then you can polish it. So thereโ€™s lots of polishing kits available out there porcelain polishing paste and porcelain polishing burs that go on the slow handpiece and theyโ€™re full kits that vary in color and you start with the darkest color and you move your way through from gray down to pink or whatever the shading is for the brand that youโ€™re using and so go to any brand that youโ€™re familiar with I think I was talking to her about Kerr.

She messaged me on me on instagram as well to ask about how to polish this porcelain and yeah I sent her a link to a Kerr polishing kit and also feel free to call the reps at Kerr and say I want to polish this porcelain and they can advise you how to best use their kit like whether it should be used with water whether it shouldnโ€™t you know and all the little tips that they have to get the best result and really you can get quite a nice shine from polishing that way.

[Manrina]
Amazing. Very good and itโ€™s great to learn that because yeah a dentist myself included would be would be not so confident in prepping the ceramic but I think when you have the good kits that you use and the experience that you have then it becomes easier and easier but itโ€™s something that naturally I think a lot of dentists are worried about prepping especially someone elseโ€™s work and the whole show through issue that could happen if the veneers are thin in any one area but I think you raised a fantastic point.

The last question now is what should she do? The patient wants a full refund, I donโ€™t know. This is such a tough one but I know I realize itโ€™s probably one of the toughest questions Iโ€™ve ever asked a guest on my show but what do you advise?

[Manrina]
No not at all. So again it was breaking up I think the question is that if now what do they do? The patient sent a letter sheโ€™s asking for a refund and what should a dentist do at that stage? So my immediate thought is donโ€™t take the stress if she wants a refund you just contact your indemnity people you let them know what happened, sheโ€™s done everything correctly, sheโ€™s given the consent form the patientโ€™s consented along the way sheโ€™s got all her notes and then the indemnity people will advise you.

Iโ€™m sure that if they advise that you should give a refund in this situation then actually thatโ€™s what indemnity is for and your indemnity people will pay for it so theyโ€™ll probably cover the refund and I donโ€™t think youโ€™re going to be out of pocket from it and even if you are out of pocket say you need to refund it and you know youโ€™ve paid the lab bill and youโ€™re going to lose that money then I would just take it and treat it as a learning experience.

I know that these cases can be scary when youโ€™re starting out and I donโ€™t want this patient to lose confidence and I donโ€™t want them to think that this is going to happen all the time. It probably wonโ€™t happen very much and the more she does them the less it will happen I canโ€™t remember anyone asking for a refund for at least the last 15 years with me and so and I do 10 or 20 units a week.

So itโ€™s not something that happens often but it is something that maybe happens at the beginning of your career because you havenโ€™t got all these stages in place to make sure that that doesnโ€™t happen.

[Jaz]
So Manrina I think youโ€™ve answered it will be unfair to because youโ€™ve really done a good job of answering that question thatโ€™s very helpful. I want to say is where can, tell us about your course I mean is it happening now thereโ€™s covid and stuff? Is your course happening and also tell us about your clubhouse room so we can start joining them as well.

[Manrina]
Yes great so I started an aesthetic dentistry club on clubhouse so check that out and please join it as a member and I do a regular room on it every Tuesday at seven oโ€™clock. I choose different topics and different speakers to come and talk with me every week and we talk about various topics around aesthetic dentistry.

Really, really interesting ones I know Jaz we had you last week and we were talking about TMJ issues and occlusion which you would think would be not that interesting a topic but I donโ€™t know I really enjoyed it and learned a lot actually and I think whatโ€™s interesting about these rooms is getting all these different speakers in and hearing all these insights also letting people come up from the audience and hearing their insight thatโ€™s how we learn and thatโ€™s how we grow and none of us know everything. So itโ€™s a real really great opportunity to just like kind of work together and learn from each other.

[Jaz]
And your course is it happening on the covid dates and stuff? People keep messaging me saying is Manrina doing a course again? I donโ€™t know, ask Manrina right? But now is an opportunity to just tell everyone whoโ€™s keen.

[Manrina]
Thank you yeah so Iโ€™ve got my four-day veneer course. I suggest everyone does it whoโ€™s not doing a lot of ceramics even if you are doing a lot of ceramics Iโ€™m sure youโ€™ll pick up a lot from it. Obviously Iโ€™ve done more veneers than Iโ€™d say 99 dentists in the world itโ€™s all Iโ€™ve done throughout my career of veneers every day and so thatโ€™s Iโ€™ve got a massive amount of experience in it.

So even if you know the basic process thereโ€™s so much to be picked up from my experience and a lot of people that come on it that donโ€™t know the basic process because you never taught how to do a smile makeover with post and veneers at university and the plan is that once youโ€™ve gone through the four days that you can go ahead and do them with confidence so even for this lady if sheโ€™s feeling like sheโ€™s lacking that come learn you have a little support network with the people who do the course with you. You can bounce ideas of each other, itโ€™s called designing smiles and itโ€™s on my website drmanrinarhode.com yeah and itโ€™s running yeah we did one last month and weโ€™ve got another one in June. So yeah thanks, Jaz.

Jazโ€™s Outro:ย 
Brilliant. Manrina thank you so much for giving up your time today and I think itโ€™s going to serve this young lady but serve a lot of dentists who are about to have such an issue and that can avoid it or have suffered with similar issues in the past and can now really reflect together. So thank you so much for sharing your expertise today have a lovely week.

Hosted by
Jaz Gulati

More from this show

Episode 81