By: Dr. Lee Ann Brady, DMD
This topic originally appeared on Pankey.org. Dr. Brady granted permission for igniteDDS to share with our readers.
Dentistry is a life-learning career, and everyone encounters some cases through their career that challenge their clinical skills. That’s a positive thing, it motivates us to explore more and advance our skills further, since doing the same procedures and not trying something new for our patients, will eventually cause us to stagnate and become complacent.
To excel in our job, it’s important to always learn new techniques, collaborate with our colleagues, or even ask for second opinions when needed. Â
Even an Expert Has Something More to Learn
This patient that came into my practice is a perfect example of why collaboration is so important. No matter how much I think I know about the techniques for tricky restorations, I’m always surprised by how much there truly is left to understand or adjust.
It’s important to discuss with our peers and lab partners for case breakthroughs and insights. They can see things from a different perspective and help you to provide an exceptional outcome for patients. Sometimes just talking through impressions on a patient’s circumstances can lead to unexpected outcomes.
Patient with Extreme Parafunction
This case frustrated me for quite a while before I understood how to solve it and decided something needed to be changed.
The patient presented with upper and lower implant hybrids from another dentist. An examination revealed the problem she had visited my office for, which was the fracturing of the upper right lateral denture tooth.
She was no stranger to the irritation of fractures. She shared with me that she had a long history of wearing down and fracturing her teeth. I was immediately interested in taking the time to understand the cause of this consistent fracturing.
The patient had multiple single-unit implants placed for the replacement of individual teeth. Her condition then worsened to the point where she had her remaining teeth removed. Implants were used for dentures with locator attachments, but this didn’t last long. The problem persisted and resulted in the need for more implant placements.
Upper and lower hybrids were created, yet still she went through 4-5 replacements of upper lateral and canine denture teeth. After seeing me, she and I had to replace upper anterior denture teeth several times over a year. That meant removing the hybrid and replacing the screws each time.
I planned an intervention that would last her a longer period of time. After looking at the mounted models and evaluating her history of extreme parafunction to determine what we should do next. I recommended resetting the upper hybrid, opening her vertical, and both shallowing and balancing her occlusion.
These adjustments would hopefully make a big difference in her ability to maintain dentures for longer. There wasn’t much space to open the vertical dimension, but with the little we had we managed to lengthen the time between fractures from months up to once a year. That was a huge achievement on its own, but we knew we could do more. We had also made her an occlusal appliance that went over her upper hybrid. She consistently wore it, which was beneficial.
I shared this story with Wiand of Wiand lab and he was able to give me an important breakthrough. He asked me how high her smile line was and I told him it was very low. He had an idea that made all the difference. We took upper and lower impressions of the hybrids, bite records, facebow, and fixture level impression on the upper arch, and gathered shade information.
Wiand Lab removed everything from the original bar. Then, I had them send the entire case to Gold Dust Dental Lab. There, they waxed the upper to full contour over the bar. After this, the case was returned to Wiand, where an injection-molded composite was used to fabricate a one-piece upper over the patient’s original bar.
This seems to have finally done it for keeping my patient out of the dental chair. No maintenance has been necessary since. By relying on the advice of my fantastic partners in both dental labs, I was able to help a tricky patient. The lesson here is that patients who are hard on their teeth will be hard on restorations. Similarly, implants aren’t going to magically resolve issues for occlusally high-risk patients.
In Conclusion
Excited to explore the intricacies of comprehensive treatment plans? Read more of my blogs on The Pankey Institute website to master these challenging cases or explore our courses for advanced dental education. Gear up to handle any situation with expertise. Head over to Pankey now for more insights!
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