I recently received a gift from one of my patients with a note on the front that said not to open it until I got home. When I got home, I opened the card and in a box was a small angel. On the foot of the angel was the date 11/08/08. The card said, “I wanted you to have this because without you, I would have never had the courage to move forward with my dental treatment. After hearing your story, you made me feel that I had found the right dentist and team.”
The date on the angel’s foot was the date of the patient’s preparation appointment and the start of their new life. I knew at that moment that I had to share my experience with my dental colleagues, in hopes that they will understand how we must show compassion and empathy toward our patients. Sometimes the best way to do that is to share with them our own dental experiences so they know we truly understand what they are going through.
I sustained head trauma and a green line fracture to the jaw 15 years ago (1995) in a car accident caused by a drunk driver. That accident also caused teeth #14 and #15 to break, and I needed root canal therapies, core build-ups, and full-coverage crowns. Several years later, full direct resin restorations were-placed on teeth ##5-12, and the previously treated tooth #14 had to be extracted due to fracture. Four weeks after that, however, the lateral and canine teeth broke and were subsequently repaired. Eight months later, porcelain veneers were placed, along with a 3-unit bridge restoration across teeth #13-15.
Switching from being chairside to being in the chair gave me greater empathy toward my patients-as well as a far greater understanding and appreciation of the respective procedures I underwent-I was still experiencing my own “dental story,” but I wasn’t fully aware of why. One-and-a-half years after receiving the porcelain veneers, I began experiencing migraines, the veneer on tooth #7 broke and was replaced, and an older crown restoration on tooth #31 broke. By the time I presented to Dr. John Cranham, the migraines had continued for five more years and the root of tooth #7 had fractured.
Clinical Case Presentation
When I began working for Dr. Cranham in 2006, I had been experiencing migraines, facial pain, and toothache in the maxillary molar areas. I couldn’t understand why my teeth hurt and had been for some time. Dr. Cranham immediately initiated complete records gathering. This comprehensive examination consisted of obtaining a full series of radiographs, a panoramic view, full mounted study cast, a facebow transfer, Bio-JVA (Joint Vibration Analysis) is based on simple principles of motion and friction, and centric relation (CR) bite record. He had a difficult time obtaining a CR bite record, and it was then that the decision was made to put me in a splint to deprogram the elevator muscles.
I wore the splint that first night and, upon awaking the next morning and removing it, could feel my teeth hit in areas I’d never felt before. I was instructed to wear the splint for a full three days. The anterior deprogrammer was designed to separate the posterior teeth and deprogram the muscles to find centric relation. Dr. Cranham was able to load test my joints without any signs of tension or tenderness. Centric Relation was verified. A new CR bite was taken and the casts were remounted. The treatment plan would not be as simple and straightforward as I had anticipated (i.e., I thought I would just need some equilibration and some restorations replaced). Rather, Dr. Cranham informed me that something wasn’t right, and he referred me to Dr. Albert Konikoff, a local periodontist, for a cone beam 3-D dental imaging scan (ICAT) to get a better look at the teeth that were bothering me. The ICAT revealed the need to extract teeth #3 and #15 due to root fractures. Dr. Konikoff explained that he would need to place bone grafting material in the extraction sockets, allow time for the bone to heal, and then perform inferior sinus lifts while placing the implants. The next day we worked up my treatment plan.
The diagnosis was unbalanced occlusion in centric relation, combined with a restricted envelope of function due to the presence of thick/steep lingual contours on the previous esthetic restorations. The poor occlusion caused fractured porcelain, headaches and muscle pain, and three fractured roots that led to the loss of three maxillary molars which was due to a flawed occlusal design combined with parafunction which generated the root and ceramic fractures.
Ironically enough, I had all of the signs years ago. I broke so many teeth and never knew why. I would assume it was outside factors, such as the materials that were used for my restorations, but did not consider my bite as the cause. As for the migraines, I attributed them to stress and my diet. I just didn’t know what I didn’t know.
When I looked at preoperative photos, I liked my smile, but I knew there would always be a compromise. I didn’t feel that the pontic on my bridge matched, and my mandibular teeth were a little darker than my maxillary teeth. Although it doesn’t seem that long ago, we didn’t have the porcelains then that we have now that imitate the optical properties of real tooth structure (e.g., opalescence and fluorescence).
While the size and shape of the previous restorations were beautiful, the maxillary incisal edges were slightly incline facially, causing some issues with the “feel” of the teeth. The teeth felt dry, making it difficult for the lips to come together. Tucking the maxillary incisal edge lingually toward the inner vermillion border of the lip would be all that was required and worked out in the provisional stage. Additionally, the mandibular lower incisors were thick from the occlusal view. These would be made thinner for esthetic and functional reasons. It is important to note that thick maxillary lingual contours in conjunction with thick mandibular incisal edges can have a devastating effect on patient’s occlusion. These bulbous contours restrict the natural functional envelope of the mandible. This common error will lead to fractured porcelain, mobile anterior teeth, diastima openings, and distalized condyles. Any of the problems ultimately lead to failure.
The goals of treatment would include stabilizing the occlusion; creating harmony between the temporomandibular joints, muscles and teeth; and providing uncompromised esthetics. Because implants would play a significant role in restoring the posterior teeth, proper sequencing was of paramount importance in this case. Therefore, the case was restored in the following manner, which was also significant to stabilizing the occlusion.
Teeth #3 and #15 were extracted and the sockets grafted to preserve the form of the ridge.
Once the bone had matured, the sinus augmentations were completed and three Nobel Replace Select Implants were placed in a one-stage procedure #3 under provisional- 14 and 15.
During integration, teeth #21-28 were prepared and provisionalized while the remaining dentition were equilibrated and contoured.
The mandibular veneers were placed, and the maxillary teeth ##5-12 were prepared, impressions taken, and these maxillary teeth were provisionalized.
The restorations for teeth ##5-12 were delivered, and the maxillary posterior teeth were prepared, impressions were taken, including for those that were implant-supported, and the maxillary posterior teeth were provisionalized. Vertical was increase by 1mm 1/2.
The maxillary posterior restorations were delivered, and the mandibular posterior teeth were prepared, impressions were taken, and then these teeth were provisionalized.
The mandibular posterior restorations were delivered.
Postoperative adjustments and final equilibration were performed
(Figs 8 & 9).
As part of the treatment sequence outlined above, I was in provisionals for almost two-and-a-half years, so I know personally that temporary materials can appear very natural looking and lifelike. I received laboratory fabricated provisionals for the implants (Bayview Laboratory), and bis-acrylic temporaries (Venus; Heraeus Kulzer, Armonk, NY) for the other teeth. The veneer temporaries were placed using a shrink/lock-on technique and bonding resin; the crown provisionals were placed using provisional cement (Ultratemp; Ultradent Products, Inc., South Jordan, UT), which provided more strength.
The definitive veneer and onlay veneer restorations were cemented with Rely-X Veneer Cement (3M ESPE, St. Paul, MN), while all other restorations were cemented using a universal resin cement (Multilink, Ivoclar Vivadent, Amherst, NY).
Key to the treatment plan was restoring the dentition with a material that would be strong and provide optimum esthetics across a combination of different restorations. The choice of materials for the definitive restorations would be critical to the success of the case esthetically, functionally, and occlusally. Material selection therefore involved a collaborative discussion between Dr. Cranham and Shoji Suruga (Bayview Dental Lab), the laboratory ceramist who fabricated the restorations. According to Mr. Suruga, based on this collaborative discussion-which I was also involved in-it was clear that all-ceramic restorations would ideal.
However, when fabricating a full-mouth reconstruction using different restorations and potentially different materials, matching shade and value can be a challenge. The anticipated restorations would include a bridge with pontic, implants, veneers, onlay veneers, zirconia-based, and full-coverage crowns. Recent improvements in materials would enable the restorative team to deliver thinner, properly contoured restorations that would demonstrate the proper strength, fit, and esthetics. A universal all-ceramic system that incorporates zirconia CAD/CAM and lithium disilicate pressable techniques (IPS E.max, Ivoclar Vivadent, Amherst, NY) was chosen for use in fabricating the restorations outlined in Table 1.
When it was introduced, the IPS e.max® system provided dental professionals with a simplified way to prescribe the all-ceramic restorations they need for their highly esthetic cases. IPS e.max Press, a lithium disilicate glass ceramic that delivers the fit, form, and function expected from pressable ceramics, demonstrates increased strength and optimized optical properties. The IPS e.max all-ceramic product line also enables CAD/CAM fabrication techniques with the use of its IPS e.max ZirCAD milling block. As a result, laboratories can use a single restorative system for a variety of indications, making it ideal for combination cases such as this. Emax offers custom lab mille substructure potential use for 3 to 4 unit FPD (fixed bridge), and ability for ceramics for superstructure.
Sometimes the best way to be empathetic toward a patient is to know first-hand what it’s like to experience what they’re experiencing. While I am grateful that I have a beautiful new smile, I am also overcome that I no longer have headaches, muscle and joint pain, and that my occlusion and overall oral health has never felt this good. It is a great experience that I now relate to patients.
But as a dental professional, perhaps the most important thing I have learned from this experience is to listen to your patients. If they tell you something isn’t right or doesn’t feel good, listen. Sometimes, being in the role of dental expert, we might talk too much and listen too little. I also believe that we must be aware of signs. If a patient is breaking restorations and fracturing teeth at the root, something is definitely wrong. Without having undergone a thorough and comprehensive records gathering process (e.g., mounting study casts, facebow, ICAT, etc.), I may never have known exactly what the problem was. OH
Shannon Pace Brinker, CDA CDD, Editor in Chief-Contemporary Product Solutions, Member, Board of Directors, American Academy of Cosmetic Dentistry, 309-A 26th Street, Virginia Beach, VA 23451. Shannonlpace@aol.com, www.shannonpace.com
Oral Health welcomes this original article.
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The author would like to thank Shoji Suruga and Buddy Shafer from Bayview Dental Lab for fabricating the restorations for her case and for providing information about their creation for this article.