diagnostic...

[2thm8kr]

This a very complex case. There is an incredible amount of wear of both linguals of upper anteriors as well as lower incisal edges.The upper anteriors have over erupted . It seems the gingival heights of centrals and laterals are at the same level. The wear on posteriors is quite severe. I would suggest ortho first to bring teeth back to proper heights them work from there. This is really a case for a prosthodontist and his team. You cant just go and open up the pin willy nilly. There is a lot going on here. If you just go ahead and make 6 anterior crowns you are in for disaster. This is not a case to rush. I see at least a years worth of ortho before any restorations can be done.

Never going to get this patient (or most others) into ortho. There is also no record of "proper heights" to work from or to.
As far as opening the pin willy nilly, what opening or closing of the vertical is official?
I agree that doing the anterior 6 is trouble, but we are talking a full mouth rehab here. You will make the occlusion and guidance with proper form and function
as the guide.
Put the patient in a deprogrammer for several days to get an accurate CR recording and do a DX. This is no different than any other rehab case.

 

[sidesh0wb0b]

Do you have photos of the patient smiling, at rest, profile, etc?

Scan both arches and do it digitally. Save the original scans as pre-op and merge to the working jaws. Use the virtual articulator and set at average values, but flatten the condylar angles to 20°. I extract the teeth virtually and in free form make sure that I have the buccal/lingula dimensions wide enough to accommodate the future preps. I would covertly open the bite. I find most times I open the bite I end up closing it back down most of the way.

Save your design and print the models so they can be used for the temps day of surgery. After you get the prep models register to your original design.

just got off the phone w the Dr. rushed conversation but better than nothing....i will have a retracted photo sent over...he doesnt have any resting that would do any good, she doesnt show any tooth.
will def be doing it all digitally. will mount on the panadent and make it all much easier to work with. also got permission to open vertical some, but he wants to be careful. patient is 78yrs young so more than likely these will be teeth for a lifetime. my head is still in a fog due to being under the weather but i feel like i have a bit more clarity than i did before.

 

[sidesh0wb0b]

This a very complex case. There is an incredible amount of wear of both linguals of upper anteriors as well as lower incisal edges.The upper anteriors have over erupted . It seems the gingival heights of centrals and laterals are at the same level. The wear on posteriors is quite severe. I would suggest ortho first to bring teeth back to proper heights them work from there. This is really a case for a prosthodontist and his team. You cant just go and open up the pin willy nilly. There is a lot going on here. If you just go ahead and make 6 anterior crowns you are in for disaster. This is not a case to rush. I see at least a years worth of ortho before any restorations can be done.

pt has some sleep apnea and other sleep habit issues. which in turn is causing perio issues on the mandible. pt is 78yrs old. ortho wont happen.

 

[sidesh0wb0b]

Mount first and make custom guide incisal table.
After spending hour waxing and knowing you can't do what the patient wants,
throw the case against the wall and go home to rest.

always words of wisdom charles.

 

[sidesh0wb0b]

Never going to get this patient (or most others) into ortho. There is also no record of "proper heights" to work from or to.
As far as opening the pin willy nilly, what opening or closing of the vertical is official?
I agree that doing the anterior 6 is trouble, but we are talking a full mouth rehab here. You will make the occlusion and guidance with proper form and function
as the guide.
Put the patient in a deprogrammer for several days to get an accurate CR recording and do a DX. This is no different than any other rehab case.

i had similar thoughts. def will NOT be doing just anteriors. thats a recipe for disaster and i will not be accountable for that!

 

[Affinity]

78 years old? Whats the problem? Isnt this what FCZ is for? Make her a nice smile so her grandkids wont think shes an old witch, next...

 

[sidesh0wb0b]

78 years old? Whats the problem? Isnt this what FCZ is for? Make her a nice smile so her grandkids wont think shes an old witch, next...

lol nice. i did just get this info. man you're harsh! can't wait to make your old man teeth one day hahahaha

 

[rkm rdt]

Tooth cowboys.

 

[PDC]

Lots of good suggestions here. Judging by what I see with the study models,it looks like this patient has a very restricted envelope of function which is causing the wear facets and chipped incisal edges. It sounds like the patient is more concerned with esthetics than her “real” issues of occlusion. I would hope the doctor would take a little time to explain this to her. If it involves opening her vdo, then so be it.

You just need to provide a nice diagnostic wax up with canine protective guidance and increase her envelope of function by redesigning the linguals of the maxillary anterior teeth to provide this. They are currently very flat without any concave contour. Duplicate your wax up after approval by doc, make a temp matrix, and let the patient wear the temps for a few weeks to make sure there are no occlusal, esthetic, or TMJ issues that might occur.

It’s interesting that the only concern expressed by the patient is increasing the length by .5 mm.....and she is going to be able to see that at 78 yrs old!

 

[slotboom.f]

I would suggest starting with a simple grinderplate to rise the bite and see the acceptance and also protect the teeth because those wear facets and chipped insical edges are there for a reason and just executing new prosthetics does NOT take that away. Reasonable expectations would be that this patient would perfectly demolish the .5 mm build op in less than a few days and the technician gets blamed for doing a crappy job.



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[sidesh0wb0b]

Lots of good suggestions here. Judging by what I see with the study models,it looks like this patient has a very restricted envelope of function which is causing the wear facets and chipped incisal edges. It sounds like the patient is more concerned with esthetics than her “real” issues of occlusion. I would hope the doctor would take a little time to explain this to her. If it involves opening her vdo, then so be it.

You just need to provide a nice diagnostic wax up with canine protective guidance and increase her envelope of function by redesigning the linguals of the maxillary anterior teeth to provide this. They are currently very flat without any concave contour. Duplicate your wax up after approval by doc, make a temp matrix, and let the patient wear the temps for a few weeks to make sure there are no occlusal, esthetic, or TMJ issues that might occur.

It’s interesting that the only concern expressed by the patient is increasing the length by .5 mm.....and she is going to be able to see that at 78 yrs old!

man you hit it spot on.
spoke w the Dr some last night. we will open her a bit, no way to avoid it and have me do the work! will probably put her into more of a group function than a straight forward canine protection. might even make the temps and let the Dr put those in and wear them for a few weeks instead of letting him make them. will prob have another conversation w him about that when i get through the waxing.

 

[sidesh0wb0b]

I would suggest starting with a simple grinderplate to rise the bite and see the acceptance and also protect the teeth because those wear facets and chipped insical edges are there for a reason and just executing new prosthetics does NOT take that away. Reasonable expectations would be that this patient would perfectly demolish the .5 mm build op in less than a few days and the technician gets blamed for doing a crappy job.



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exactly. i wasnt going to take all the risk and punishment

 

[Affinity]

lol nice. i did just get this info. man you're harsh! can't wait to make your old man teeth one day hahahaha

Dont listen to me, I thought this holiday rush might make me lose my mind and apparently Christmas came early this year!

 

[sidesh0wb0b]

well, he's taking responsibility. he wanted a flat plane for the mandibluar arch and open vertical 1mm or less. here's what i ended up with.

 

[JMN]

well, he's taking responsibility. he wanted a flat plane for the mandibluar arch and open vertical 1mm or less. here's what i ended up with.

Give yourself a raise. That's a really nice pitcher of lemonade you made out of that mess.

 

[Affinity]

Looks good! I would only shorten/flatten those long Mx cuspids.

 

[Car 54]

Looks good! I would only shorten/flatten those long Mx cuspids.

And then maybe a bit on #4, 5, too.

 

[sidesh0wb0b]

Looks good! I would only shorten/flatten those long Mx cuspids.

yeah, these are the things i see when i post pics too. makes me cringe a bit that i missed them while it was in my hands....spent so much time worrying about some of the other things i feel like i missed some simple stuff. ah well, live and learn!

 

[rkm rdt]

yeah, these are the things i see when i post pics too. makes me cringe a bit that i missed them while it was in my hands....spent so much time worrying about some of the other things i feel like i missed some simple stuff. ah well, live and learn!

Good thing you didn't deliver the case until we had a look at it.

 

[Car 54]

yeah, these are the things i see when i post pics too. makes me cringe a bit that i missed them while it was in my hands....spent so much time worrying about some of the other things i feel like i missed some simple stuff. ah well, live and learn!

Same thing happens to me. You work on case for so long, it becomes a blur, let alone with all the other distractions.
At times when I deliver a case, I look at it in the Drs parking lot before I go in
and see something I would want to tweak. Whenever I have the time
with an upper 6+ unit case, I like to get it contoured then re-look at it the following
morning. I usually see a line angel, mid line correction etc I change.