Hi all… I’d really like you to read the recent interview I gave with apex magazine. It’s featured in this months magazine.
It pretty much sums up my current thoughts on UK dentistry for young associates and I would love to hear what you think about it!
Also as you know things are kind of busy at the moment so struggling to put up all the recent cases I’m finishing. In the mean time I really enjoyed hearing Neal’s thoughts on Class 2 composites below. I would just like to take the opportunity to reaffirm that the blog is always looking for new contributers and if you are keen to write and be part of what we do here then get in touch!
Still hopefully you will be glad to know that the 3 wear cases I put up a while ago should all be finishing in a few weeks. That means I will finally finish my guide to wear cases i started.
I actually just wrote one of them up for my VT case report so I can steal some text from that…
I’ve put a couple of pictures of one of the cases below showing the patient before and after provisional restorations. I built all these with direct composites free hand and a quick acrylic denture. However due to the sheer amount of composite and the amount of staining being picked up (heavy smoker, that acrylic shade was taken from the composite!), I’m moving the chap into upper PFM crowns and a precision attached denture.
These have now been in place 4 months (getting darker) so I’m happy with the occlusion and now getting in to the crown work. I show the results when i get them but so far so good. In brief the stages for this case are. Make a level incisal plane and decide how much to increase the VD by. Here I’ve let the aesthetics of the lower incisors and 13 contact determine the VD. I always over build the lower incisors just slightly so i can take them down a touch if I’m struggling with anterior guidance.
Then build the upper anteriors for maximum aesthetics, I build one without bond before the dam is placed and adjust this then I dam build the others and take the temp off. Obviously you can pay for wax ups if you want a quicker procedure but I like doing them free hand. It’s certainly cheaper for me right now and improves my knowledge of occlusion. It also means no record errors from articulators get incorporated. I overbuild the palatal surface slightly then I painstakingly grind in the anterior guidance. This takes on average for me 45 mins.
That is the flip side of doing things free hand; time. The reason I didn’t get the 22 and 23 completed first visit was that I’d already been working for 2 hours and a half! Still its a great way to work as a VT and keep your lab bills down and it’s also just pretty fun!
Please feel free to debate about putting the case into crowns. I debated with myself about it for a long time but I made my decision for maintenance reasons (that and the never ending stain). I appreciate the conservative point of view and certainly I have left several patient in composites but I think we have a duty to meet our patients long term aesthetic expectations and I don’t feel I have here entirely (even when i chnage the denture shade!).
Actually there is a good dental update article on this if you want more info.
Have a great week!
Chris
#1 by Jim Lafferty at May 4th, 2010
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Ah, the joys of VT – 2.5 hours for zero UDAs! I’ll bet you don’t do this as an associate or practice owner!
#2 by ChrisO'C at May 4th, 2010
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Hi Jim… Point taken and I have to accept that current primary care NHS payments make this treatment very difficult at the moment.
However, I have no intention of working in the NHS primary care next year or the forseeable future. Therefore I can promise you I will be doing this type of work as an associate and a practice owner as I believe in it.
I also know that if I was working as an NHS GDP next year I still would do a few cases like this a year. Sometimes you just can’t win on every treatment plan and this type of work is part of why I became a dentist. It keeps you turned on and keeps you alive while you work. It is my aspiration to become the best dentist I can, not make the most money. This type of work is soul food.
I also think it would be a huge shame to refer all these patients after VT. I mean to say if we can do them then why make patients wait 18 months to see a hospital junior staff member. What would you do instead?
Also there are other ways to treat this case and make it profitable/quicker:
1) Charge by the hour (I also might get quicker you never know)
2) Use the lab more and get the patient to cover it. Suck down splints, wax ups etc
3) Prep the teeth for crowns and fit shim temps as provisionals
But finally yes it IS the joys of VT. This is a cheap way for young guys to try these cases without massive lab bills for their trainers. It’s also really safe way to try an occlusal change as any work can be removed at any time without causing damage. And most importantly you will be doing these patients a great service, providing them with better function and aesthetics than they have known in years.
Go out and give them a go while you can people. Get your trainers advice or a written treatment plan from the hospital if it helps. VT is not about just getting quicker at placing amalgams.
#3 by Pete Buchan at May 5th, 2010
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A really good case with a really good result.
Welldone.
Building all 4 anteriors in one go would be a lot to get right. So splitting then into 2 sessions is a good idea.
A wax up with stent to guide you in the build ups would help.
Lots of people reffer this kinda case cos they either
1 lack the confidence to open the bite.
2 don’t understand occlusion.
3 consider it uneconomical.
Often considering the case uneconomical is the way to avoid some interesting / challenging / stimulating / beautiful dentistry that forces you to move out of your comfort zone.
Pete
#4 by Neal at May 5th, 2010
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Great case Chris. Reminds me of the sheer enthusiasm and effort you put into things when doing GPT, much to your boss’ dispair.
I still think you will do stuff like this as an associate – I still do. There has to be stuff that is non-profit or even loss making in order to keep you interested and test the skills now and again. Nice to be really proud of doing something like this once in a while. I have a couple of cases like this on the go at the moment and I really look forward to work on these days.
It’s no different than getting a 15-year old lad in that needs 3 root canals and a full mouth of interproximal restorations and some serious time needing to be spent to show him how to use the correct end of a brush.
You can’t refer that lad so the difference is that the wear case is interesting and keeps the brain ticking over!
#5 by ChrisO'C at May 9th, 2010
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Sorry all I just fixed the link to the article hadn’t checked it but it just went to pubmed home page
#6 by dentist at May 21st, 2010
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this the problem with the new contract, it does not work in the patients interest from a health perspective. yes it can save them money if their cheap, but that;s the problem. It encourages patients to not seek dental treatment until they’ve got a bunch of teeth that need treatment and then they can come in and get fillings and all sorts of traetment at a capped rate and under one course of treatment. Where’s the logic in that.
#7 by john valentine at June 15th, 2010
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really good work
#8 by jack at June 28th, 2010
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It is really a nice article regarding Dental..i just want to know that is there any other technology for Dental implants or titanium metal are used in every case
thanks
#9 by Toronto Dentist Blog at June 29th, 2010
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Great work.
Here’s a shortcut if you’re doing future crowns…
1. Take an impression of your waxup (I use clear material for this – Crystal).
2. Polish etch and bond the teeth (no anaesthetic).
3. Fill the tray with the temp material and insert.
4. Cutback and adjust (waxups rarely transfer perfectly).
5. Take photos and a new impression of your customized long-term temps (so you don’t have to start from beginning if something breaks).
The patient can wear those customized temps for months to adjust to the new occlusion. You can replace in segments when the time comes to switch to full coverage.
I feature a case like that on my site at http://www.RoyalYorkDental.com – look under Smile Makeover.
Toronto Dentist Blog´s last blog ..Dentists are Tooth Carpenters -amp Dental Hygienists are Gum Gardeners
#10 by Lucy Daniels at August 3rd, 2010
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Nice post! Check out this interesting dentist blog post as well! Veneers