Overcoming patient objections to deliver desired results – Dr Richard PollockFeatured Products Promotional Features
Posted by: Dental Design 4th December 2018
Dr Richard Pollock shares a complex case that required a multidisciplinary approach in order to achieve the result the patient was looking for.
I saw the patient several years ago – she’d had 24 Lumineers placed and 19 of them were defective after nine months (Figure 1). She had a 2mm midline shift to the left (Figure 2), which caused the canines to be very asymmetrical. This was the patient’s main complaint, despite the fact that so many of the Lumineers were chipped, broken or de-bonded
Fig 1 Fig 2
The patient initially struggled to understand the need for orthodontic treatment in order to align the teeth to achieve good symmetry by correcting the midline shift. She therefore declined orthodontics and we proceeded with a compromised treatment plan using a standard smile design protocol, which took about three months. Veneers and crowns were suggested from 5-5.
This treatment was a significant improvement but offered limited compensation for the asymmetry. By applying the smile design protocol to the shape, inclination and proportions, the asymmetry appeared minimised. The patient made several trips to the lab technician and we placed, replaced and removed several provisional restorations by changing one canine then the other several times to her prescription. Obviously this never completely solved the problem. She chose everything down to the extent of translucency and mottling on the restorations, and was relatively happy with the result in the end, but still felt slightly disappointed by the canines. Having made the adjustments she requested in the provisional stage each time, this had resulted in her being happy with one canine, in turn causing the other to look worse in her mind. Ultimately, what the patient was asking for was unachievable in the way she wanted, and while this was explained, she wasn’t prepared to undergo orthodontics.
Two years passed and the patient returned to my practice with a bag of archwires and Damon Braces on her teeth. She said that her dentist in Brazil had advised her to ask me to change the archwires every two months. This was not something I was happy to undertake. The patient therefore proceeded to travel back and forth between the UK and Brazil every two months in order to complete the orthodontic treatment. On completion they also carried out some restorative work to try and improve the result of the midline shift correction that had not been successful. However, the patient had developed gum disease and caries between the teeth. The orthodontics had created a little space – just enough to trap food in, which had led to decay (Figure 3).
De-bonding the brackets caused chipping of the veneers, some were quite significant defects. The patient therefore asked me if I would change them. She didn’t like the shade any more or the characterisation she had selected herself and was adamant that she wanted bright, pure white teeth. I was hesitant initially to proceed based on previous treatment and experience with this patient – I also don’t like unnatural white – but I agreed to using the MyCrown system (Fona) and ensured this time that the patient understood exactly what she was asking for and what the challenges would be.
I started with the UL5, UL4 and UL3. I used MyCrown NatureShape Individual Design function to create slightly larger crowns so that the teeth would appear to have moved along the arch. Reduction of the distal aspect of the upper left lateral incisor. The effect of this was to move the left canine around in order to correct the symmetry. A week later, I worked on the right hand side. The UR5 was an original smile design crown on an implant and while I advised the patient to replace the crown in order to achieve the result she wanted, she declined at this point. The UR4 and UR3 restorations were therefore replaced with similar but slightly smaller crowns, moving the UR3 distally by 1mm, again to enhance the symmetry of the canines. Sirona Blocs in bleaching shades were used for all the restorations. The patient didn’t want the anterior veneers/crowns glazed as she desired no translucency – just very white teeth.
A small amount of composite was bonded onto the upper laterals and upper centrals to adjust the shape to correct the midline. A NatureShape Copy scan using the MyCrown system was then performed to replicate the modified centrals and laterals with corrected midline (Figure 5 -8). This copy function is very accurate, giving a reliable duplicate of the existing restorations (Figure 9).
A scan of the lower jaw and a buccal registration scan are not normally necessary when using the copy function, but I opted for them in this situation. The first proposal was very close to what we wanted – only a small adjustment was needed using the design tools to create the ideal new restorations (Figures 10 & 11).
The patient was generally very happy at this stage of treatment, we had solved the canine asymmetry and the patient immediately saw this. However, this drew her attention to the UR5 – the implant crown was now too dark and not long enough so she requested this be changed (Figure 12)! I used the Aquamarine Laser (Fona) to re-contour the gingivae around the UR5 implant. I also performed some gingival re-contouring on the UR2 in order to raise the gumline and optimise aesthetics (Figure 13). A Vita Enamic block was used to create a new implant crown, because of the thickness around the margin of the existing implant abutment (Figure 14).
The patient was ecstatic with the final result achieved in this case (Figures 15 & 16). While it took a little longer than it might have due to the patient’s hesitation to undergo orthodontic treatment, we got there in the end. The case demonstrates the benefits of the MyCrown system – the anterior veneers/crowns were done in just two and a half hours. The NatureShape Individual function was used for the left and right hand side restorations, as I needed to be able to modify them to improve their position, contour and emergence angles, using the copy scan as a template. Overall, we were able to meet the patient’s expectations.
For more information, visit www.my-crown.co.ukor call 03339 873007
Dr Richard Pollock qualified from University of Dundee in 1999 and moved to London after qualifying. Richard aspires to the highest standard of dentistry with cutting edge technology using the latest techniques. Richard treats many patients following the safe mercury removal protocol. He has lectured on CAD/CAM dentistry in Europe and the Middle East and frequently trains new users to CAD/CAM systems. Richard has a specialist interest in orthopaedic and interceptive orthodontics treating both children from the age of 7, and adults using a variety of appliances from fixed braces to invisible braces. Richard has completed the certificate in implantology and is experienced in placing and restoring implants from single tooth implants to “teeth in a day”. He is a member of the IDDA (International Digital Dental Academy) IAOMT (International Association of Oral Medicine and Toxicology), the BSEM (British Society for Ecological Medicine) and the BSMSD (British Society for Mercury Safe Dentistry).
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