By Lee Ann Brady, DMD 

One of the most common ways that we temporize a patient who is having maxillary anterior implant dentistry is with an Essix retainer. Some patients will wear it 24 hours a day and others for less. Hopefully they are taking it out to rinse, brush, and floss, but the reality is they are wearing a removable device that covers all of the tooth surfaces for a lot of hours every day, and we’re increasing their risk of caries, decalcification, and gingivitis. 

In addition to discussing the normal oral hygiene to be done at home, in our practice, we typically dispense a product like Clinpro 5000 from 3M or MI Paste from GC America. These are high calcium and fluoride products that provide fluoride treatments inside the Essex retainer. 

• If a patient is sleeping in the Essix, the instructions are to brush and floss the teeth and then use a toothbrush to spread a little bit of Clinpro or MI Paste on the inside of the retainer before going to sleep. 
•  If they are not wearing the Essix during sleep, the instructions are the same but to wear the Essix for up to an hour every evening before removing it to go to sleep. 

If the patient’s caries risk is high, I prefer using 10% carbamide peroxide gel instead of Clinpro or MI Paste. This is the active ingredient we us in perio trays to help prevent gingivitis. This is also the means by which patients can whiten their teeth while wearing an Essix retainer. 

To prevent damage to the Essix, instruct patients to rinse it with cold water and, when not wearing it, to store it in the provided container.  

A patient presented to my practice with upper and lower implant hybrids and a long history of fracturing. I myself struggled with needing to replace her dentures regularly up until the point I decided something had to change.

Parafunction, Occlusion, and a Low Smile Line

The patient clearly needed some type of intervention. I looked at mounted models and evaluated her history of extreme parafunction to determine what we should do next. She had been restored in her hybrids with canine guidance and relatively steep anterior guidance. In light of all these factors, 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 periods of time. There wasn’t much space to open vertical, 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, 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.

It’s impossible to go through a dental career without continuously encountering cases that challenge our clinical skills. Nor do I think that would be a good thing, as stagnation and complacency can lead down a slippery path to less optimal dental care. Even an expert has something more to learn.

The case I’m going to discuss here is a perfect example of why collaboration is so important in the dental practice. 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 rely on our peers and lab partners for case breakthroughs and insights. They can see things from a different perspective and give you exactly what you need to provide an exceptional outcome for patients. Even just the act of talking through impressions on a patient’s circumstances can lead to unexpected realizations.

A Case of Fracture, Wear, and Parafunction

This case frustrated me for quite a while before I understood how to solve it. 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 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 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 the course of a year. That meant removing the hybrid and replacing the screws each time.

To be continued …

Dive into this case for a look at Dr. Owen’s thought process and treatment protocol leading to porcelain restorations. 

Angela was 27 when she came to us asking about options to improve her smile. She was getting married within a year. She hated the appearance of the bridge #3-6 that had been placed in high school. It was repaired at the buccal margin of #6 the day of delivery. She also said she wanted to avoid implants because of time issues and she didn’t want more crowns.

Patient Background

Angela was congenitally missing #4, 7, 10, 12, 13, 20, and 29. In the past, she had implants to replace the lower bicuspids and said the process took too long. Her previous dentist had placed two upper bridges – #3-7 with pontics on #4 and #7 and #14-10 with pontics on #13 and #10. The space for #12 did not exist.

Treatment Plan

I noticed her narrow central incisors compared to her laterals and the general contour and color of the bridges. I knew we could improve her smile with all porcelain restorations. Implants to replace missing teeth and veneers on the centrals would make a difference. We did a wax up that she took home to study, comparing it to the model of her existing restorations. She visited the periodontist who would do the implants and I showed her lots of photos of other cases similar to hers.

Creating Porcelain Restorations

Ultimately Angela agreed with our plan. She had implants replacing #7, 10, and 13. We used Zirconia abutments and e.max crowns, as well as an e.max crown for #14. She opted for a Zirconia bridge #3-5. While she was healing, we made provisional bridges, including the cantilevers for the laterals. She was hesitant about the veneers on #8 and #9, but before we began I removed the bridges and created a trial restoration with the wider veneers and proper bridge contours. I took photos and let her think about it before she agreed. She got married with a beautiful new smile.   

What interesting cases are you currently working on? 

Approaching implant reconstruction as an all or nothing situation ignores the reality of future patient needs. Often it is too expensive for patients, who will not be able to proceed fully with treatment. They then receive only part of the complete treatment plan.

For example, with an edentulous arch the difference between a lower denture with two implants and locators as opposed to five implants with a fixed restoration is significant.  Alternately, it’s common for patients with two implants and a lower denture with locators to be dissatisfied with their function and esthetics. They may wish to move to a fixed restoration if they can now afford it. But does the clinical situation make this possible?

Implant Treatment Planning for the Future

It’s a good idea to create a treatment plan for a patient that doesn’t eliminate their ability to select different treatment in the future that could lead to improved esthetics, health or function. Certain planning decisions must be applied when placing implants to ensure necessary spacing and vertical room for a fixed restoration.

Ideally, the plan would include fixe fixtures between the mental foramina for a fixed restoration. If the patient currently wants a removable with two implants, the ideal placement can be planned for five. The 2 and 4 spots can then be used for placement of fixtures with locators.

This gives enough room for three potential implants later on that are spaced correctly. Though the placement choice can be based on a clinician’s preference for where locators would be, the 1 and 5 locations allow for ideal placement of five future fixtures. Still, many patients will have two fixtures between the mental foramina that negatively impact proper spacing for a fixed restoration. On top of this, the lower ridge position is another important factor to consider. It must be managed to account for vertical space.

The end of 2017 is wrapping up a solid year of incredible dental blogs from our talented Pankey contributors. Our posts featured everything from techniques for occlusion and orthodontics to practice management and leadership.

There are tons of useful tips and plenty of information for dentists at every stage of their career on the Pankey Gram. Here, we’re compiling five pieces of sound advice from blogs in 2017 that are sure to get you excited for another year of practicing dentistry your way.

As Pankey dentists, we continue to strive for greater learning and growth in our professional and personal lives. Revitalize your hunger for education with these thought-provoking tips:

5 Clinical Tips From 2017 Pankey Blogs

1. Consider physiologic changes that occur over a lifetime when planning restorative dentistry.

In his blog on ‘Adult Growth of the Dental Arch,’ Dr. Roger Solow explored the slow craniofacial growth that can affect dentistry throughout a patient’s life.

2. Set splint therapy fees in such a way that you can actually make money off them.

In his blog, ‘How to Set Splint Therapy Fees,’ Dr. James Otten described how to individualize splint therapy fees and more accurately estimate therapeutic time.

3. Think like an orthodontist when advising patients on post-ortho care.

In her blog, ‘How Long Should Patients Wear Their Retainers Post-Ortho?’, Dr. Lee Ann Brady laid out important considerations for dealing with questions about retainers.

4. Recognize when patients are in denial and practice empathy toward them.

In her blog on communication, ‘From Denial to Acceptance and Action,’ Mary Osborne RDH enlightened with a description of patient denial in dentistry.

5. Improve you protocol for restorations by adding another dental assistant.

In his blog, ‘6-Handed Bonding,’ Dr. Mike Crete made his case for why an extra dental assistant can benefit dentists dealing with adhesive dentistry and tricky restorations.

And there you have it folks. Best wishes for 2018! 

Successful restorative dentistry now hinges on an understanding that physiological changes occur over a lifetime. It’s detrimental to treat the dynamic relationship between dental occlusion and adjacent craniofacial structures as static.

We are all generally familiar with the fact that there is a significant change in facial profile (convex to straight) between adolescence and adulthood. Jaw growth usually ends between 17 and 20-ish years old, but 3-dimensional craniofacial skeletal growth and remodeling does not cease after adolescence.

It’s lifelong growth even though it’s slow. As a result, we can’t consider adult patients morphologically stable. This is actually a relatively new concept that we’ve become aware of because of implant dentistry.

So what does this mean for restorations? First, we need more information.

Physiological Changes and Restorative Dentistry: A Quick Overview

These adult growth changes can be seen in both a decrease and increase in the dimensions of the craniofacial skeleton. There is an increase in maxillary and mandibular anterior dentoalveolar heights.

We should also pay attention to vertical growth of the maxilla, which continues after transverse and sagittal growth end. It has been suggested that reductions seen in arch width, depth, and perimeter may be due to interstitial wear and mesial drift. The latter occurs because of an occlusal force stemming from root angulation, mesial eruption force and the direction of occlusal contact during chewing. It’s integral to consider tooth movement because it compensates for wear while maintaining interproximal contacts.

There are different patterns of growth in short-faced and long-faced people. Short-faced individuals have greater transverse maxillary growth. As they mature, their anterior teeth tip forward and enable mesial drift. This process occurs more vertically in long-faced people. Short-faced individuals experience upward buccal movement of the teeth, while long-faced individuals experience lingual movement and continual tooth eruption that supports a normal interarch relationship.

What we now know from recent research is that eruption after the tooth has reached occlusal contact is a compensatory response to occlusal wear. Eruption creates vertical growth if there is no occlusal wear.

A comprehensive understanding of the complex interplay between all of these changes in the dental arch is essential to restorative dentistry.

How do you keep up to date on the latest dental research? We’d love to hear your tips in the comments!