THE INCI-DENTAL BLOG

dentists helping dentists to succeed

Blog update

Mar 7

Posted by ChrisO'C in Blog news

I just thought I’d write with a quick blog update:

This week has been the best in terms of hits we’ve had for a while with over 130 hits a day. I take it this means that people like seeing my clinical work. I will therefore try to keep adding it when I can. However I am very aware of the need to consent patients properly and to discuss cases tactfully. As Matt said in a recent comment we must not criticise the work of others too much and must be honest about our own abilities and limitations; I hope that so far we have done this.

It’s a fine line to walk and I did consider making the clinical pages members only. I guess I just feel that we have nothing to be ashamed of and that I would welcome the public reading this blog. I hope if they understand dentistry more they will appreciate the importance of it and seeing a dentist with your best interests at heart. I hope that I am proved right in this but I would ask all readers to help me sensor the blog and  let me know if ever the conversations become inappropriate.

You may also notice I’ve taken down the courses page from the top of the site. This is becasue most courses being added were links to porn sites or casinos (Yes I blame Zaid too but I just can’t stop him). Instead I’ve updated all the link section (right toolbar) from the blog to include them and will add more as needed. I’ve also updated business sites and blog links.

I hope you don’t mind me saying this again but I don’t accept any money for putting links on the site they are there as a useful reference alone and if Ive included them it’s becasue I think they are worth a look. Oh and by the way you cheeky gits I have actually been offered some sponsor money once or … well once but I don’t go looking for any or I’m sure I would!

Finally I’d like to invite you all to join the rather wonderful incidental facebook fan page… 180 members and counting. Just one of the many (4 ways) you can get updates on when the blog changes (but you have to come here direct to see the comments), see the subscription options on the right tool bar for more details.

Also check out the Inci-dental musings on the right tool bar for hilarious (ly bad) audio blogs I make from time to time.

Please especially listen to the Thanks readers Link, as I really do mean it. I love writing the blog and have been doing so for nearly 10 months now but, i think, even a complete looser like me would find it hard to keep going without any interaction.

All the best

Chris

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Whitening teeth

Mar 7

Posted by ChrisO'C in Conservation

Here is the pictures from a completed at home whitening case. Isn’t the result amazing???

Before:

Baseline

After:Baseline 4

HA, Fooled you this is the same pictures of the baseline situations the only difference is the way the flash has lit up the scene. I’ve also not photo-shopped the light on these at all but I think from this you could see how easy it is for whitening manufacturers to fool patients. The best way to show/ prove whitening is to take pictures next to a shade tab. Here the closet shade to the case was A4 but the teeth were actually darker than this. I therefore took all the following photos with this tab against them. The sequence shows the patient at baseline, 2 week and 6 week check up.

Baseline high light2 weeks on 3 (4)Post op tab

If your interested the other work you can see that is my work is the 14 buccal composite and the 45 large composite build up. I root filled the tooth a few months ago and I’m set to crown it now the whitening has been completed.

I think this is a pretty good result and I really believe you need to be getting this kind of doccumentation for your whitening cases so you can monitor progress, relapse and protect yourselves.

DT obturate 3 months post op

You need a good written consent for gingival irritation, relapse and sensitivity. Then I like to start the patients on a low concentration agent for 2 weeks. I only give them 2 small tubes and tell them they have to make that last for 2 weeks night wear. This ensures they are not overfilling the trays. After checking there is no sensitivity and progress I then introduce a much stronger agent to wear for the next 2 weeks to speed the whitening up a little, I then typically lower the dose again for the last 2 weeks (night time) to maintain the shade reached. Reviews are at 2 and 6 weeks and again in the middle if the patient has any problems. I then recommend occasional night wear of the low concentration agent to prevent relapse. Just 2-3 nights every 3 months or so.

The regime works well for me and is a good mix of speed and keeping the concentration low over a longish duration which has been shown to reduce relapse rates.

The patient was really happy with this result and had no sensitivity. All the research I have read suggest tooth whitening in this way is safe and effective as long as it is done in a controlled way. If any patients are reading this blog then please remember that you need very close fitting trays that only a dentist can make and good quality whitening agents to get a good result. You also need to be aware that some staining will not be helped by whitening and should be checked by a dentist, you should also be reviewed regularly. If you want whitening done then I’d say go for it, but find someone good to do it, someone safe. I’ve seen some of the horror stories when it has been done in a unsafe way so please be careful.

Hope this blog brightens… or whitens your Monday morning blues!

Chris Clinical disclaimer.bmp

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Sectional Matrix

Mar 4

Posted by ChrisO'C in Conservation, Endodontics

I’ll be honest I’d never heard of a sectional matrix until Zaid wrote his blog about them on June 9th 2009. I probably should have done but the knowledge  must have just slipped though my fingers.

Well, the picture Zaid put up is here. Just look at it a beautiful rubber dam, lovely sharp contact point, excellent moisture control and contoured to the box beautifully. I look at that picture and I just want to grab some composite and get painting. You can really have fun with your aesthetics when you have that kind of control with your matrix.

Here is something I’ve realised: control= aesthetics. Control the environment and you then have the time to control your aesthetics.

Since the day I saw that picture I have been obsessed with gaining that kind of control and it has been a difficult journey. Your first thought is that no one can possibly work like that all the time, surely it takes too long, it’s too expensive, too fiddly and technically difficult. I also had to get hold of the kit, get better placing rubber dams, placing normal matrix’s and generally get better at placing composites to make this worthwhile. One of my rules is that I need to try and master all the basics before I pay out on expensive new kit or it won’t be worth the while. Get good for cheap before I splash out on fancy pants stuff, I’m not good enough to use.

It felt like a mountain to climb but I am determined to get their eventually.

Well this week I placed my first sectional matrix, it feels like a big moment and I thought I’d share the case with you. I’ve also finally worked out how to save our digital radiographs as J-pegs so I can finally show some root fillings. I’m not always sure showing root fillings is very exciting, you just know the person showing them only ever puts up the good ones. Well my root fillings are not always perfect and I’ll try to show some ups and downs as I go but generally the standard of this case is what I’m aiming for (at the moment) but I know there is room to improve.

The Case

So this case is on a 40 ish year old lady who was having some pain from her upper right tooth, she also had some food packing in the area and was not especially happy with her old dentist. When I examined the 14 tooth had a large defect I could probe right into distally and was tender to percussion. I could flex the distal portion of the tooth a little and I summarised that the tooth had a oblique vertical fracture, caries and acute apical periodontitis.

pre opWorking length

I was pretty worried that the fracture may run a long way subgingival so I made a deal with the patient that I’d remove the decay and fracture and see how deep it was. If I though I could restore it, I would. If not we’d have to look at other options but these were far from great: implant too expensive, didn’t want denture, 13 very poor root filling/ suspicious looking screw post. No chance of RBB from the 13, I didn’t fancy doing a fixed fixed on that 13 so a conventional cantilever off the 15 would probably have been the only option but I wouldn’t love the sound of that. So all in all I was pretty keen to try to save the tooth!

Post op

so next appointment we went in and removed the caries and fracture thankfully it was  alot higher than I feared maybe 1 mm below the gingival margin and well within my comfort zone. I root filed the tooth both canals were narrow so I prepared the taper using my standard endo technique to a size 25 6% taper. The obturation is with AH Plus and matched points all done under rubber dam of course. Once I’ve sealed the canal I always condense vertically with just a glick instrument (I’m saving up for a system B), I then seal the tooth with vitrabond another material clever old Zaid taught me about and which I love to use to instantly get a good coronal seal even if I then temporise the tooth before final restoration.

However I was a bit nervous of just temporising this tooth as the margin was so subgingival and I wasn’t sure I could control my GIC there. I also didn’t want to have gingival overgrowth and poor cleaning as I was planning to crown the tooth later. Finally the patient had a complaint of food packing and when you look at the 15 amalgam it’s easy to see why. I wanted to replace this restoration. Ideally before I crowned the 14 so I could get a nice contact and to do that I’d ideally need something to build against.

So all in all it was time for the sectional matrix. I whipped off the dam added 2 new holes and took the dam back to the 16, added my sectional matrix and hey presto. I know it’s not as good as the one from zaid’s blog but it’s a great start. I had great moisture control in a difficult area, a good curve on the matrix and tight adaption sectional Martix longto the margins. Only about ten minutes ago I did, however, realise that I’d got the sectional matrix ring the wrong way round but you live and learn (and it still worked)!!

I don’t have a post op as I ended up running a bit late the composite looked good, you can sort of make it out on the post op radiograph?! It’s just a simple one shade composite (flow-able at the very bottom of the box) but well adapted and I hope it will last well!

Next visit I’ll replace the 15 filling but looking at that obturation picture it doesn’t look too clever endodontically. Also what would you do with the symptomless 13 the patient has previously wanted it changed for aesthetic reasons but was put off by one of colleagues which I think was fair enough but what would you do? Finally would you, having done that nice composite, crown the tooth? I regret to say hugely that I didn’t reduce the 2 cusps and take the composite over them (stupid I know). If I had would you leave it?

I’d love to know your thoughts?

I’d just like to make one more point. I read a lot of geeky dental books and I always think “wow it would be amazing to work like that” but that’s not real life dentistry. But then you start watching and talking to people who really do work like this everyday, all the time and once you know that it’s possible and you believe in the techniques…. I just have to challenge myself to use them everyday, all the time.

The trick is to get quick enough at them to make them everyday, fast and efficient. I really do think it’s possible; I’m working more and more under dam, polishing cavities before filling, bonding crown preps pre impression and other great ideas. You have to get efficient and find the time to make them part of your routine and not an extra hassle.

Maybe you already do all this stuff: to these readers I’d like to say, “I salute you, and ask you to please let me shadow you, I want you skills!” To others I urge you to give them a go, if you beliTR sectional matrix sideeve in them of course.

Chris

Clinical disclaimer.bmp

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Direct Composite Wear Case: 2 weeks post-op photos

Mar 1

Posted by ChrisO'C in Conservation

I’m enjoying writing the series on managing wear but it is pretty tricky to write and is taking some time. I’m about halfway through the next blog/essay (lol) but I won’t finish it tonight.

I have however been cropping photos for the feature and wanted to put some up as a taster. I’ve just taken some post ops today and I’m pretty pleased with them. Yes, there are things I would change and maybe I will over time but as a 2 week review of a big case like this I’m just happy that 1) They have all stayed on proving that the occlusion is good and 2) That the patient is made up with them.

I’ll go through the case in more detail as and when but basically these are free-hand composite build ups of upper 3-3, with an immediate acrylic denture providing provisional posterior support. It’s not the end of treatment; that will require a cobalt chrome denture, possibly changing the composites for aesthetic reasons and maybe, if the patient wants them, some crowns but I hope you think there is an improvement.

RCP beforeOpen before

Overall the case is going pretty well so far, I’m pretty happy with the composites and very happy with the new occlusion. You will never get quite as aesthetic a result with composite as you can with porcelain (in my hands anyway) but I think these are pretty good and I’m getting better all the time. There has been almost no prep apart from caries removal for any of these build ups though and that counts for something and in the mouth when they are not dried out they look even better.

I’m most pleased with the contact point I’ve made between the upper right lateral and the right central incisor.It took some doing, first shaping a matrix to get the emergence nice then another martix to build the tight, narrow, contact. With such a large cavity present I think the end result is a pretty good achievement.

On the down side, the left central incisor is just a bit flat near the incisal edge so it reflects the light in an unpleasant way, also the denture shade could be better and the denture doesn’t quite contact on the left premolar but hey it’s still not bad for under 4 hours work and a very cheap lab bill.

NB: I used  Burkard Hugo’s matrix technique, under rubber dam for all the build ups as described in this blog.MS 2 weeks closedMS 2 weeks open

On a side note can I just say thanks to all the people who have told me they are enjoying the managing wear series, it means a lot; I will try to get more up asap. Unfortunately I’m just really busy at the moment with key skills, a new play I got cast for, The BDA event, MFDS part 2 in May and starting a scary rotation on oral surgery (for which I really need to do some reading).

I absolutely love it all today though, so happy with my job, my life and my dreams

Have fun and enjoy your dentistry

Chris

p.s. Pride can come before a fall, I really want to learn and I’m more than happy to take critique on the case but please read my clinical disclaimer and tred softly on my dreams. :) Clinical disclaimer.bmp

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BDA event 27th March

Feb 21

Posted by ChrisO'C in Blog news

Slide1

Hey I hope I’m not overpromoting this event. This will be the last reminder promise. Ticket sales are going well so please email to reserve your space and get your cheque sent in asap. We will then send out your e-ticket.

Email ad is: youngdentistsnc@googlemail.com

Please invite friends etc

All the best

Chris

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Reflections and Resolutions

Feb 18

Posted by ChrisO'C in Personal Blog

I’m feeling reflective today having got the day off to myself. I was supposed to be heading home to see my mum but I forgot I was going to see Hot Chip tonight, so I’ve been a little at a loose end.

I’m afraid I don’t feel like writing about dentistry much today. I had one of those days yesterday where the job got me down and I’ve been stewing on it all day.

Mind if a share my stewing about yesterday?

Well at first there was a patient with a terminal upper bridge and lower denture worn to nothing. Last visit I suggested he really needed to move to an upper denture and get a new lower one. Yes I appreciated £198 was a lot of money but the bridge really was on the very last legs and I didn’t think he could keep getting it re-cemented every month. Yesterday I attempted to take primary imps and do a full exam. Question “could you take the denture out please sir”, answer “I haven’t been able to for 4 months and it has only been out twice since it was made.”

Well the horror must have showed on my face as I resorted on trimming back the slimy denture in the mouth to release it and expose the most unbelievable path of insertion I’ve ever seen. I then had to scale all the teeth fully take impressions and adjust the denture to something reasonable, running miles late in the process. None of that bothered me but it was the overriding feeling that the patient thought I was ripping him off. That the work was not needed, that I’d conned him into having new dentures and insulting the old dentist by trying to correct the current set. “Your a very good salesman” he told me when I first convinced him to get a new set, “A good salesman but a lousy dentist” was how it sounded now.

Then later a set of complete dentures at try-in, I’d been asked to make a new set by another dentist at the practice after he’d struggled twice to match the ladies expectations. I’ve done the works on these dentures and had some trouble with the lab but I thought they were going well god fit, excellent extensions, occlusion spot on, yes the upper needed a wash impression as the cast had a large air blow but they were a pretty good. “Not happy” said the lady “the lower denture moves” she said thrusting her tongue forward. And that was when it hit me… I could never match this ladies expectation of what a complete denture could achieve on almost no ridge. I tried to explain and make her understand the limitations but then I heard “well if I’d known that I wouldn’t have paid you to let you try to make a new set”. The miscommunication was my fault, I’m sure, and I still hold out hope of wowing her when they are finished.

What hurts is despite all the effort I make with dentures, the books the greenstick and the time I take, she still felt I’d ripped her off. Even though the cost of the dentures had already far outweighed her cost, even though I thought I’d explained at the start the limitations, she still felt I’d ripped her off.

I’m sure you have felt like this in your job. I was ready for a holiday, tired and exposed and took it too personally. I see that know and I’m over it, I’m going to do my best to amaze them next time I see them anyway: perfect dentures all round. But if not I’ll tell them the truth; that I’ve done my best, better than some would do and that I’m sorry I couldn’t do more.

I wish that was easy for me to do. I want every patient to be delighted with treatment I provide to understand how I’ve excelled when it’s finishe, but that is an unreasonable aim. They are not dentists; they want “no pain” and speed, not beautiful posterior crown margins. I need to stop trying to show off to them when I get in a sclerosed canal after 20 minutes hard slog. It’s too important to me to do my best for me to change how I work but I need to toughen up mentally, improve my communication skills to ease these situations, stop seeking constant approval and have more confidence in what I’m all about.

I have therefore decided today to make this goal for myself:

I am going to develop an inner confidence in what I do and be proudPoem of that. Proud enough that I do not need the constant approval of others or to favorably compare myself against others in order to remain proud.

Maybe you already have this. Insecurity is my least favorite weakness I see in myself from time to time and I hate how it affects my relationships and mood. I’m not saying I’m a complete arse, or at least I try not to be, however I acknowledge there is certainly room for improvement.

So in the spirit of my new resolution I’d like to share something personal with you all. This is a poem I wrote when I was 18. I’ve given it a little rework recently and it was supposed to be part of a larger collection that never really took off. I wrote about 5 poems in all and sent them to this little competition. Having failed miserably to even get some feedback I sort of stopped writing. This was my favorite from the failed venture and I’m still a little proud of it and now I have an excuse to share it. I am nervous to share it, like the first time I blogged, or put up clinical photos and that usually means it’s a good thing to do.

Hope you enjoy it but if not don’t worry, I’ll not lose sleep over it :)

Now I am officially ready for the floor!

All the best

Chris

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Teux Deux

Feb 15

Posted by ChrisO'C in Personal Blog

Since I started the blog I have become the king of the to do list. I can’t keep on top without them.

Prioritise into A) urgent, B) Priority and C) low priority and  start ticking them off!

I found this website off a Seth Godin blog ages ago and I’ve been using it for at least 3 months.

I love it: It’s called Teux Deux and I have it is probably my second most used bookmark. I strongly recommend it to all busy people to get their lives in order!

Chris

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Pulpal Diagnosis

Feb 15

Posted by ChrisO'C in Blog news, Endodontics

Having been working on the Dental emergency clinic for the past few weeks I have noticed that a lot of students are getting their pulpal diagnosis mixed up.

This is a nice flow chart I stole from the rather fantastic endo blog that might help you figure them out. Getting this provisional diagnosis right will make your final diagnosis far easier. You will know what to look for in the mouth, the radiograph and what treatment to offer.

Ideally you should know what pulpal diagnosis you’d expect to see from your history and what kind of situations to look for.

Reversible:  Sharp transient pain with hot/cold. Usually for a few weeks before patient gets it checked, often in a well kept mouth. It can be interproximal caries, a loose filling, lost filling or fracture. It can even be a cracked tooth presentation so check with tooth sleuth or cotton wool to test it.

Cotton wool test is bite hard as possible on cotton wool roll then let go quickly: if painful suspect crack.

Irreversible: Severe pain, spontaneous or after a cold/hot drink. Lasts for about an hour after it starts. Unable to locate source of pain but feels one side rather than the other. Painkillers ease pain. Worse at night (this is because lying down the blood pressure rises in inflamed pulp). At late stage cold can actually help as it restricts blood supply to pulp.

This is likely to be a recently placed deep filling, filling lost a few months ago, deep interproximal caries (these are the sneaky ones). Check with ethyl chloride and radiograph!

pulpaldiagnosisperiapicaldiagnosis

Please note you should reach a provisional diagnosis before taking your radiograph and it should be one of the above. If there is a huge swelling and a chroinc apical abscess you don’t need to tell the person you present to the tooth is necrotic it will be obvious. The disease is already a few more rungs down the ladder of disease progression.

Also I still call symptomatic apical periodonitis, acute apical periodonitis and I think most people do. It probably means we’re out of date but better to be out of date and have the people who mark you understand than not!

Also for fun here are some additional features.

Reversible pulpitis only occurs if there is fairly significant primary decay so you really need a radiograph to exclude it. It is too easy to think they might have a dentine hypersensitivity.

Irreversible pulptits can be easily located to the correct side but often confused upper or lower so get your ethyl chloride out and try both arches. Take radiographs and be sure. If it is irreversible it will need an access don’t join the ledermix liner brigade. Basically if you do you kill the pulp slowly (mainly painlessly) making a future inevitable sclerotic root canal in 3-5 years very difficult.

Don’t forget about perio. This can cause tenderness; spreading pain and even sensitivity like symptoms if it doesn’t fit check the gums. If it isn’t the tooth it’s often the gingiva. Get your BPE probe out and check them, it will save you a lot of heart ache.

Hope this helps!

Chris

P.S If any 5th years have any questions they want to go over on the blog then let me know (Or if your at Newcastle you will find me on DEC until April)  and I’ll try to get round to covering them. I know you’ve all suddenly got very interested in dentistry… I wonder why!

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Dead like Harry

Feb 8

Posted by ChrisO'C in Personal Blog

Sorry to go very off topic but I just want to share this website with you.

A while ago I went on holiday with my best friends two of which are in a band. They made a great album, funded it by helping build the studio they recorded it in and are really tallented song writers.

Their problem was that record companies are being squezed at the moment and they couldn’t get a good distribution deal. The other problem is everyone is downloading all the music for free and the record business doesn’t know what to do. We need to change the way the game is played.

We mulled it over on holiday and got discussing a certain Seth Godin and a free-volution. We agreed that hard core fans would always support bands and want the hard copy of CD’s and come to gigs. What the band needed was more hard core fans. Answer to get them, distribute: give the album to everyone for free to download and get it out there.

That was not even 4 months ago and I’m so proud of the band, they have embraced the Godin. I’m keeping my fingers crossed for them but the new website is fantastic, launched tonight and I couldn’t be more proud of them. If I made a dental website it would be like this. All the ideas we dental marketers talk about.

Sticky homepage, moving images: tick

KEDO (knock em dead offer) -Free album: tick

Links to social media: tick

Gets people on the mailing list: tick

Easy to navigate and full of suprises: tick

Great product: thats for you to decide, I’m biased but I think they are great!

All they need now is the album to go viral. Please give it a go and pass on the link if you like it.

Go on give it a go!

DEAD LIKE HARRY

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Part 2: Managing wear: Establishing a position

Feb 7

Posted by ChrisO'C in Conservation, Dental Blog

When managing wear I split the treatment plan into 3 sections:

1)      Establishing which position to restore to

2)      Deciding how to manage anterior teeth and create stable occlusion

3)      Long term provision of posterior support

Which position should you restore to?

Pretty much no matter what the wear is like you only have a few options of where you can actually restore the bite to.

1) Conforming to the occlusion:

The intercuspal position (ICP) or Centric occlusion: is the occlusion a person makes when they close their jaw and fit their teeth together in maximum intercuspation. This position is rarely useful in restoring wear cases as the ICP is often in a protruded position. There will also be very little room in this position to replace tooth tissue, in fact there will be the minimum space as there is maximum intercuspation.

The only wear case I can think you might restore into ICP off the top of my head is a serious erosion case on the upper anterior which has progressed quickly so that the lower anterior teeth have not compensated and filled the space lost by the erosion. In this case you would just rebuild the palatal surface of the upper teeth in ICP with the material of your choice.

However outside wear situations ICP is the most likely position to restore to. In most simple crown work or trauma cases we always conform to the original occlusion and accept whatever slide from RCP to ICP that is present.

2) Setting occlusion to the Retruded contact position (RCP or centric relation):

When some people bite they have an initial contact and then slide into a position of maximum intercuspation (ICP). For most people this slide is small and non consequential. However in certain people it can be marked. Sometimes the initial contact is a real interference and the wear may be caused by the patient trying to grind past this initial contact into a more even occlusion. These patients are potential TMD sufferers and if the initial contact is on the tooth you’re trying to crown/ restore then beware as they are high risk for repeated fractures of your work. However I digress this will have to be the subject of another blog.

Sometimes in wear cases you can take advantage of the space between the RCP and ICP to give you a little room to restore in. Where you can do this you get advantage over increasing the Vertical dimension. That advantage is that you already have some contacts in this position which will help maintain the occlusal changes and reduce the amount of teeth you need to restore.

3) Increasing the vertical dimension:

In cases where you can’t use the ICP or get enough space in RCP then you only really have one option left? That is to restore the teeth to an increased vertical dimension. This can be relatively straightforward in mouths without posterior support but can be far trickier where a Dahl appliance or posterior shims are needed. I would say in general the more units you have to restore the harder it becomes.

With this technique you are making a new ICP wherever you like; the only rule is the new position has to be the RCP so picking this new ICP position is pretty easy. The difficulty is recording that position and translating it to your restorations.

When we increase the vertical dimension we can increase it by any amount we like, many studies and experience shows us that patients can tolerate pretty much any increase we choose. We therefore set the increase on two factors the anterior aesthetics and the amount of posterior disclusion we will leave. Therefore your aim would be to have the best anterior aesthetics with minimum posterior disclusion, N.B. The closer together the posterior teeth are the more likely Dahl compensation is to occur and the easier they will be to restore.

Our only limit to creativity is that the new ICP must be on the retruded arc of closure. That means with the condyle in its most superior position on closing. The reason we do this is that we want the new occlusion, wherever we choose it, to be in an RCP relationship (i.e. RCP =ICP). The reason is simple; If we are creating a new occlusion why would we want to have an RCP- ICP slide? Why risk TMD, interferences and potential loss of restorations if we don’t have to. It is by far the safest and best to make our new ICP a nice firm position and the first contact when we close.

Working to the retruded arc of closure also gives you the only really reproducible position for you to work to in lab. Without it there is no way you can predictably plan new position on study models and that means all wax ups would be fairly useless.

P.S.  It’s not that you absolutely can’t restore a new ICP which is not RCP the real question is why would you ever want to?! It might happen by mistake and the patient may develop an engram (jaw closing pattern) that compensates for any slide from RCP without causing TMD but that is a large risk to take. You are far better eliminating this slide and being certain your restorations will stay in place than crossing your fingers the patient can adapt favorably.

Examples of choosing restoring position:

I hope I’ve not lost everyone with that explanation of the 3 positions you can restore to. I’m hoping these 3 case examples might make the points easier to follow so bear with it. Sometimes the choice is easy to make but sometimes it is harder.

Case one:

ICP

The top picture shows the patient in ICP here the teeth are over closed with no room to restore the upper incisors. So ICP is not a useful position to restore to. However this patient has a huge slide from RCP to ICP. This has been caused by a relative loss of posterior support and the face that his RCP is so unstable.

The RCP position is shown in the bottom picture. You can clearly see that there is an initial contact between the 27 and 36 tooth but because that contact is unstable and has no chomp the patient slides forward (look at the wear groves in the 22) into the ICP.

Now when I had a good look at that RCP I could see that there was loads of space available to me in this position to restore the anterior teeth upper and lower. Obviously I’d have to provide posterior support to stop the slide to keep them but that is easily achieved with an upper denture.

RCP

Alternatively I could Increase the vertical dimension more than this if I wanted more room but why would I want to? If I do I lose this nice position I can work to and register to easily, I will need face bows and more accurate records to predict the new RCP position and worst of all I’ll have to shim or build up the 27,36 teeth to get back the contact I have at the moment.

Verdict: restore in RCP
Case 2:

This picture actually shows the patient in RCP. You can see from the wear patterns that the ICP (maximum intercuspation) would need the patient to protrude and grind to his left. I didn’t get a photo in ICP unfortunately but I think this shows pretty well that in this RCP note first contact between 13 and 43 there is not enough room to restore aesthetically.

We are therefore committed to open up the vertical dimension to a new RCP. I can choose whatever increase I want so I will level the lower incisors and make the upper incisors the correct length.  The reason this case is easier than some is that here we have literally no posterior support so I will not have to restore any posterior teeth no matter how much I open the bite.

DSC_0003
Verdict: Increase vertical dimension
Case 3:

In this case I wasn’t sure weather to restore to RCP or increase the vertical dimension. You can see from the photo that the patient has a few posterior units but he just doesn’t have any opposing pairs. That’s why he has ground down the incisors to make a chewing platform.

Again this picture is not in ICP because in ICP the patient would be protruded as he is in function grinding the teeth. The picture therefore shows the patient in RCP. I’m not sure if it’s easy to see in this photo but in this RCP there is actually a fair bit of room between where the lower teeth hit the palatal surface of the upper teeth and the incisal tip.

RCP before

This space is probably just big enough for me to add composite and lengthen the upper incisors without changing this RCP. If at this point I could provide some posterior support to stop the habitual grind forward I could maintain these restorations. However they might be a little thin.

Open before

Alternatively I could make a very small increase in the vertical dimension and build palatal shelves on the upper anterior teeth. This would only be a very minimal increase in VD but would give me more freedom to shape the teeth as I pleased and make the restorations more steady.

The final possibility is to increase the vertical dimension more add length to the worn lower teeth and add palatal shelves to the upper teeth thus improving aesthetics even more. However  it would require far more treatment and it’s not always easy to add length to lower incisors.

When the lower incisors have an even occlsual plane, unlike case 2, I often try to leave them alone providing the patient is not concerned about the aesthetics of short lower incisors (which they rarely are).

Verdict: Increase in VD (but a small one)

Clear as mud?

I’ll answer any questions if people have them but it’s a tricky subject to explain. I know I found it veryClinical disclaimer.bmp confusing in the books and having tried to write this; I can see why!

However it’s really important to get a handle on what position you want to restore to so make sure you do get this before you try a wear case. Only when you’ve worked out the position you’re going to restore to you can start to plan how you will actually do it. In the next blog in this wear series I’ll go through the treatment planning options for case 2 and what I actually did.

All the best and sorry if this is a bit long!

Chris

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