During my first few years of practice,
I read as many dental magazines as
I could to learn the nuts and bolts
of this profession. I found their articles so
amazing, so inspiring! They portrayed case
after case of beautiful smile transformations
performed flawlessly by master practitioners
whose hands seemed anointed by
the Almighty himself. The photos in these
articles showed surgery being performed
seemingly without any bleeding, amazing
tertiary anatomy placed on second molar
restorations and patients whose deep satisfaction
was only rivaled by the depth of
their wallets. One day, I thought, I was going
to be that great, and my patients would
adore me for it.
Now that I’m older (yes), wiser (hopefully)
and balder (definitely), I’ve come to
realize such dental perfection is rare in everyday
practice. There are too many obstacles
in our way preventing magazine-level
success. The reality of practicing dentistry
is one of compromise. It’s doing your best
with limited resources. It’s creating a meticulous
treatment plan while understanding
you may need to zag in the middle of
it. The following case is such a zag.
The patient presents
This patient (Figs. 1a–1c) presented
with the very innocent chief concern of
wanting whiter teeth. I had recently completed
a full-mouth rehabilitation on her
fiancé, and she was unhappy his teeth were
now whiter than hers.
Periodontally, she was healthy except
for a few areas of mild recession. One area
of Class II decay was noted, which I filled
with a composite resin restoration, and
orthodontically she was Class III with an
anterior open bite, likely because of tongue
thrust. Palpation of her lateral pterygoids
revealed some discomfort and after a load
test using a leaf gauge, the patient exhibited
symptoms of tension and tenderness
in her TMJ musculature. At this point the
patient revealed that she often woke up
in the morning with headaches and TMJ
discomfort. I proceeded to deprogram her
chairside with cotton rolls placed between
her maxillary and mandibular posterior teeth for 15 minutes, and upon trying the
load test again, no discomfort was noted,
indicating the symptoms were limited to
the TMJ musculature and not the disc/
bone of the joints themselves.
Because her teeth were healthy and
already a B1 on the Vita Shade guide,
my first treatment recommendation involved
some whitening gel with or without
Invisalign orthodontic treatment. The
patient immediately shot down this plan
because she had tried whitening in the
past, but her teeth did not become “white
enough.” Furthermore, she did not want to
deal with the maintenance associated with
at-home whitening. She wanted her teeth
to be as white as possible, which meant
bonded porcelain was the only realistic
answer.
To be sure, I created a couple of graphical
smile previews using DTS Pro software
to give her an idea what the various treatment
options would feasibly look like. I
love this software for treatment presentations
because it is quick and inexpensive
and lets pictures say the thousand words
I can’t. I was able to show with reasonable
accuracy what a combination of Invisalign
and whitening (Fig. 2a), instead of maxillary
and mandibular porcelain restorations
(Fig. 2b), could do for her smile.
When the patient saw the graphical
mock-up of the porcelain work, she
exclaimed, “That is what I want! That is
what I’m looking for!” A treatment plan
had been accepted, and it was now time to
obtain records and get to work.
Fig.2a
Fig. 2b
The dentist plans …
I, like just about every dentist in the
United States, would describe myself as a
conservative dentist, so my treatment plan
involved comprehensive Invisalign therapy
to straighten her teeth and allow for conservative
veneers and onlays with minimal
tooth structure removed.
Once the orthodontic phase was completed,
I planned to make sure the patient’s
joint and occlusion were stable through
splint therapy and equilibration as needed.
Impressions were made for Invisalign treatment,
aligners were delivered, attachments
bonded and interproximal reduction (IPR)
was performed between her mandibular canines,
premolars and first molars. Months
of satisfying tooth movement via aligner
therapy could now begin.
… and God laughs
“Get these things off. Get them off
now !” The very next day, the patient was
back in my chair, demanding the attachments
be removed. She did not like how
they looked or felt. She demanded I fill in
the spaces between her teeth where IPR
had been done. Exasperated, she stated,
“I just wanted whiter teeth, not all this.”
Drat! Time to regroup, time to zag.
These are the moments that truly test
your dental grit. I could of course fill in
the IPR spaces with Class 2 composite
restorations and tell the patient, “Adios,
please fi nd another dentist to deal with
these ridiculous demands,” but I started
to realize a plan for porcelain was still
possible.
- Yes, the patient had TMJD, but
she was comfortable in her current
occlusal scheme.
- Yes, CR dentistry is ideal, but given
that we weren’t changing her VDO
for this case, restoring in her habitual
MIP wasn’t out of the question.
- Yes, minimal prep is ideal, but
her current tooth position still
allowed for relatively conservative
restorations. Also, serendipitously,
IPR had already been performed on
the lower posterior teeth that would
be receiving conservative crowns
anyway.
The zag
With all this in mind, I decided to skip
the orthodontics, go straight to wax-up,
limit any changes to her occlusal scheme
in an effort to not poke her TMJD dragon,
and hope we would be popping champagne
at the end of all this.
I made impressions, used a Kois dentofacial
analyzer to mount her models on a
semiadjustable articulator and proceeded
to wax the case myself. Though time-consuming,
I find waxing cases necessary
to help truly get a handle on what is possible.
From the wax-up I created a PVS putty
stent, which I would use to flash on the
wax-up as an aid in reduction and fabrication
of the provisional.
The plan was to prep first molar to
first molar with veneers and crowns on
two consecutive mornings. Because these
appointments can be three to four hours
long, I used oral conscious sedation via a
combination of diazepam and lorazepam
to keep the patient comfortable.
On the first prep day, I prepped the
maxillary teeth and provisionalized via
a shrink-wrap spot-bond protocol using
TurboTemp bis-acryl composite (Danville)
and Surpass bonding agent (Vista Apex).
The mandibular teeth were prepped the
following morning, and for those I provisionalized
with cemented bis-acryl posterior
crowns and shrink-wrapped anteriors.
Occlusal coverage for the mandibular posterior
teeth makes sense from a cosmetic
standpoint in these cases because the occlusal
aspects of these teeth can be seen during
laughter. Final impressions were made for
both sets of teeth utilizing a heavy and
light-body PVS material.
Over the course of the following week,
the patient had time to analyze her “trial
smile” and see what she did and did not
like about it. Because of the translucency
of the provisional material, her smile was
not “white enough” in her opinion, so I reassured
her that we would go whiter with
the final restorations.
As I expected, because of her somewhat
unstable occlusion/TMJ, she experienced
some discomfort in excursions that
required adjustments of the provisionals,
and a few veneers popped off in that first
week and required rebonding. Eventually,
though, we provided her a comfortable,
stable occlusion in her provisionals.
At this point, impressions were made
of the provisionals, a Kois dentofacial analyzer was taken of them as well, and
occlusal records were made in MIP using
a Blue-Mousse bite registration. This gives
the lab enough information to create final
restorations that mimic the appearance
and function of the approved provisionals.
Furthermore, the patient demanded no
characterization of the restorations. After
showing her case photos of heavy, little and
no staining, she maintained her position.
Nothing but white it is!
The final result
I used Arrowhead Laboratory to complete
this case and provided all the records
with a detailed lab script. I always request
photographs of the wax-up, including occlusal
markings, before moving forward
with the restorations for final approval
(Figs. 3a–3e). The entire case was
done in medium translucency E.max,
Shade 0M1 from the Vita Shade guide. We
bonded the restorations over the course of
two mornings, one arch at a time, using
Surpass bonding agent, Interface Ceramic
Dental Primer (Vista Apex), and NX3
Nexus Third Generation white light-cured
resin cement (Kerr). Equilibration was
once again performed via a leaf gauge, but
because there was no VDO change and
the case had been accurately mounted,
only minor adjustment was necessary. One
more small occlusal adjustment was performed
a week later at the patient’s request,
and she reported no additional TMJ comfort
after delivery. I could finally breathe a
sigh of relief.
Fig. 3d
Fig. 3e
Hugs were shared after finishing this
case (Figs. 4a–4e), and of course I acted as
if this had been all in a day’s work. But the
reality is a combination of planning, skill,
freestyle jazz and a bit of luck allowed this
case to come together. Whenever I finish a
case I feel went well, I always take an extra
beat to let the gratification wash over me.
I’ll chat with the patient a bit longer and
relish in how much joy my work gave him
or her.
Fig. 4d
Fig. 4e
Our job is often a series of compromises,
half measures and Band-Aids. It’s
very easy to focus on what went wrong and
mentally skip right over a case that went
right. Taking the time to enjoy the little
moments of positivity in the office is the
fuel that I need to handle that next dental
zag, which is inevitably waiting one operatory
over.
Learn more
about restorative dentistry
and earn 1.5 CE credits!
“Principles of Visual Perception, Smile Display
and Functional Longevity,” Dr. Lane Ochi’s latest
online CE course for Dentaltown, focuses on a
systematic approach using classic concepts to make
restorations aesthetically pleasing and long-lasting.
To take the course for the chance to earn 1.5 CE
credits, click here.
Dr. David Sherberg graduated from the University of Connecticut School of Dental Medicine, then
pursued an Advanced Education in General Dentistry residency at Virginia Commonwealth University.
Sherberg, who has received extensive dental implant continuing education, is a certified DOCS Education
member. He is certified in moderate sedation and is an oral surgery volunteer at Remote Area Medical in
Florida. An avid researcher, he is also a fellow in the Academy of General Dentistry. He lectures nationally
to dentists and is a faculty member of the Phelps Institute. He has received numerous “Best Dentist”
awards throughout his career, including Best Dentist in Tampa Bay, and has been featured on ABC News,
News Channel 8, Vibrant Living and the Wellness Hour.