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

Jaz’s Introduction: 
So this my friends is something that was experienced by one of the Protruserati. She’s going to remain anonymous and I really wanted to help her. So I’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 she’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 it’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 they’re too bulky and I don’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 she’s really upset that this has happened and she followed the whole protocol and she worked so hard and she’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 she’s really lost confidence in herself. And we will all lose confidence in ourselves in some procedures throughout our career.

It happens it’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 I’m happy to say that patients who come seeking veneers they’re all a little bit crazy let’s face it. They’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 don’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]
I’m good, Jaz. How are you?

[Jaz]
I’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 it’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 don’t mind, I’m just going to go straight in to the main question but for those of you who haven’t listened to Manrina’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 it’s on YouTube and it’s got like over a thousand views and I’ve always get great feedback from people actually listen like on the way to work when they’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 there’s a young dentist, a really really caring sweet dedicated young dentist who really cares about what she’s doing she took on a veneer case and she’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 don’t like the veneers anymore because they’re too bulky at the cervical region and I want a full refund so that’s the long and short of it.

In what we don’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 didn’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 she’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, let’s do that. So there’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 they’re going to achieve. I think in this case she was closing a diastema.

So particularly in diastema closure it’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 that’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 aren’t as relevant or they are relevant but you don’t want to close the space fully so you want to be familiar with smile design so you’re making sure that you’re keeping golden proportion, you’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 they’re happy with diastema closure whether they would want full diastema closure, whether they don’t. I know in this case that wasn’t the issue. Well she says it wasn’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 there’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 there’s lots of imaging software at the moment out there I use photoshop and there’s dsd and I’ve started playing with ivory smile recently from ivaclar and that’s been that’s really good as well. Actually I’m definitely going to be talking more about that on my instagram page and on my veneer course.

And then once you’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 you’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 isn’t enough and maybe they need to, if they’re looking at veneers and they don’t want ortho then maybe they’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 can’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 it’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 don’t want the patient to get stuck like you don’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 they’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 it’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 don’t do them as often now as I used to do and the reason for that is because if they’re not additive if they’re made exactly how the smile is going to be then the patient will have shine through of their own teeth because you’re not necessarily always adding and then it’s difficult for a patient to understand what it is that you’re trying to show them because they don’t understand that the teeth are shining through oh I’ve got yellow patches shining through is that what you’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 it’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 won’t be this bulky and so there’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 you’re going to do however many you’re going to do four veneers for example which I think is what this.

[Jaz]
Let’s go with six because she did six so let’s use the example of six as we move forward.

[Manrina]
Oh she did six okay fine I didn’t know okay fine. So six immediately in smile design we’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 they’re amazing. Inevitably, the way that a veneer reflects light is slightly different from the way a tooth will reflect light. It’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 aren’t necessarily because you’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 haven’t done six veneers in my career. I have done six but it’s again the more information you’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 you’ll have because I think it is harder to get a natural result with six than it is with four or eight because immediately they’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 you’ve done your digital design, you’ve done your preps and you’ve used a stent and put the new smile on in temporaries so the patient can try out and you smile. It’s that stage that’s really super important and I will never move a patient from that stage until they’re 100% happy. If they’re even arming and eyeing slightly about I don’t know they kind of look bulky okay maybe they’re okay I’m not moving from that stage because of this very reason I don’t want to refund anyone’s treatment at the end of it and I’m not, it’s not even about the money it’s about the stress of it.

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

So once they’re in temporaries that’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 didn’t feel like they were bulky that she was happy with the way that the temporaries were so that’s that.

Then you go on to your finals, it depends what lab you’re working with. If you’re not able to charge the prices that maybe I charge or other some other dentist charge then maybe you also can’t work with the labs that charge what my labs charge because obviously it’s all relative and maybe if you’re working with having to work with a less expensive lab maybe they haven’t got the skill set to not create bulky veneers. They’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. She’s a master ceramist I’ve worked with her for 18, 19 years now and she’s wonderful and if you look at my instagram page there’s such a variety of cases that she’s done for me from very natural to very Hollywood to blocky to very minimal and according to the patients you know she’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 it’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 don’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 doesn’t have the skill set to remove enough at the gingival third and I’m not saying this about this dentist at all because I don’t know but sometimes dentists don’t remove enough there and then for it’s not the lab’s fault, it’s the dentist fault that they don’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 they’ve prepped the margin it’s starting to look like a bit of a heavier prep, they’re scared that they’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 I’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 you’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. Let’s just tackle part two now which is-

[Manrina]
Even if you have to give up the case, if can’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 you’ve got that lab bill associated and you’ve got that final thing stuck in their mouth you know you’ve gone too far so this is this is really a very important appointment.

[Jaz]
Brilliant and now let’s tackle the bit where let’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 that’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 you’re breaking up a little bit, Jaz but I think I got what you’re saying that how we’re going to manage this now. Now we’re at this situation she’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 I’ll go ahead and cement your veneers today but one out of ten times I won’t and that’s because they’re not perfect for me and if they’re not perfect for me they’re not good enough for you so just to let you know if they’re not perfect I’m not going to cement them.

So you also need to be aware as a dentist and look at that stage. That’s another stage where you could get the patient to sign off so sometimes I’ll put them in with a try and paste and I’ll still get them to sign off saying that they’ve seen their veneers that they’re happy for me to cement. So that’s another stage that you can put in there and sometimes they’re not. Sometimes even I’m happy with them but the patient will look at them be like no the laterals look like they’re slightly different length so I really don’t want that and so much better at that stage to catch that than later on. So I’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, we’ve cemented them and then the patient feels like they’re too bulky. For sure prep your veneers like you would prep enamel. I do it often. I’ll go and recontour a veneer and sometimes patients come to me who have had veneers done by someone else and they don’t like them and I can see why they don’t like them, I can see what needs to change and I’ll just be like you want me just to contour them for you rather than changing them and they’re like yeah go for it and I’ll just prep their veneers.

Obviously you have to be a little bit careful it’s easier when you’re changing it incisally but when you’re prepping the labial aspect you don’t want to if you start getting shine through and it gets very thin and you’ve got the tooth shining through you’ve got a real problem. So just very gently, very carefully contour the porcelain. Obviously it’s not ideal to do that I’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 that’s what I think happened with this lady. So then you can polish it. So there’s lots of polishing kits available out there porcelain polishing paste and porcelain polishing burs that go on the slow handpiece and they’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 you’re using and so go to any brand that you’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 shouldn’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 it’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 it’s something that naturally I think a lot of dentists are worried about prepping especially someone else’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 don’t know. This is such a tough one but I know I realize it’s probably one of the toughest questions I’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 she’s asking for a refund and what should a dentist do at that stage? So my immediate thought is don’t take the stress if she wants a refund you just contact your indemnity people you let them know what happened, she’s done everything correctly, she’s given the consent form the patient’s consented along the way she’s got all her notes and then the indemnity people will advise you.

I’m sure that if they advise that you should give a refund in this situation then actually that’s what indemnity is for and your indemnity people will pay for it so they’ll probably cover the refund and I don’t think you’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 you’ve paid the lab bill and you’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 you’re starting out and I don’t want this patient to lose confidence and I don’t want them to think that this is going to happen all the time. It probably won’t happen very much and the more she does them the less it will happen I can’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 it’s not something that happens often but it is something that maybe happens at the beginning of your career because you haven’t got all these stages in place to make sure that that doesn’t happen.

[Jaz]
So Manrina I think you’ve answered it will be unfair to because you’ve really done a good job of answering that question that’s very helpful. I want to say is where can, tell us about your course I mean is it happening now there’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 o’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 don’t know I really enjoyed it and learned a lot actually and I think what’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 that’s how we learn and that’s how we grow and none of us know everything. So it’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 don’t know, ask Manrina right? But now is an opportunity to just tell everyone who’s keen.

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

So even if you know the basic process there’s so much to be picked up from my experience and a lot of people that come on it that don’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 you’ve gone through the four days that you can go ahead and do them with confidence so even for this lady if she’s feeling like she’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, it’s called designing smiles and it’s on my website drmanrinarhode.com yeah and it’s running yeah we did one last month and we’ve got another one in June. So yeah thanks, Jaz.

Jaz’s Outro: 
Brilliant. Manrina thank you so much for giving up your time today and I think it’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.