The Restorative Case That Still Haunts Me

Case #1: Grinding the Crowns

International speaker and mentor Ankur Gupta, DDS, a general dentist in private practice in North Ridgeville, Ohio, constantly strives to provide the best possible solutions for his patients. As a result, he enjoys fierce loyalty from his patients. His Be Better Seminars help other dentists learn how to avoid failures and achieve success with step-by-step strategies to attain the goals dentists want for their practice. However, even Dr Gupta has cases that haunt him, including this one from 5 years ago.

• The Problem:
  The patient presented to the office initially to achieve improved esthetics after years of nocturnal and daytime bruxism had caused severe occlusal attrition. At that time, because of financial limitations, the practice agreed to only restore her upper teeth by using posterior porcelain-fused-to-metal crowns to increase occlusal vertical dimension (OVD). This was followed by lithium disilicate anterior crowns. The practice provided the patient with daytime and nighttime occlusal guards, but she had a difficult time with regular adherence.
  
  A long-time patient, aged 37 years, presented with a complaint that her teeth didn’t show enough when she smiled. A self-described bruxer, she asked whether Dr Gupta could fix it.
  
• The Solution:
  Dr Gupta thought he could put crowns on the back teeth to open the bite and regain some of the lost vertical from the grinding. He then planned to put zirconia crowns on the front teeth to improve esthetics but no crowns on the bottom front teeth because they didn’t show when she smiled (and to make the treatment more affordable). Finally, he would prescribe a night guard for maintenance to prevent any damage to the crowns.
  
• The Next Problem:
  A mere 2 years later, the upper restorations had decimated the lower teeth. The occlusal wear on teeth 23 to 26 was so severe that it had extended to the pulp and resulted in periapical pathology.
  
  Not long after the completion of treatment, the patient returned with a new problem. The bottom teeth that hadn’t received zirconia crowns were ground down to what Dr Gupta described as pancakes. In addition, teeth 24 and 25 had developed pulp pathology.
• The Next Solution:
  Dr Gupta crowned the lower incisors (23 to 26) with zirconia and made a bridge, again intending to increase the vertical lost to grinding.
  
• The Next Problem:
  Although the new lower restorations looked nice, it didn’t take long to determine that they would decimate the upper crowns. “Rather than determining the etiology of her severe bruxism, made the unwise decision to simply increase her OVD with posterior lower crowns and thereby provide the room for a lower bridge,” Dr Gupta says.
  
  The patient returned later with significant wear on the original upper crowns from grinding against the lower crowns. Dr Gupta describes the whole case as a disaster. “Imagine this patient. She has dumped so much money into this treatment and put so much trust in me, and I haven’t delivered for her. That’s what haunts me,” Dr Gupta says.
  
• What He Would Have Done Differently:
  Looking back, Dr Gupta thinks he oversimplified the solution to the bruxing problem and related esthetic concerns. The first thing he would have done differently was to determine why the patient ground her teeth, a discussion they never had.
  
  “I had a 37-year-old [patient] who had ground her teeth down into tiny nubs, and I wanted to fix her problem,” Dr Gupta says. “I’m guilty of what a lot of dentists are guilty of. It will occur when we fix problems without assessing why that person had that problem.”
  
  The second thing he would have done differently was not relying so much on an occlusal guard. Some patients might receive an occlusal guard, wear it as directed, and have it for the rest of their lives. However, some patients might not be this adherent. Still others might try to wear it but remove it (consciously or unconsciously) in the middle of the night if it isn’t comfortable for them.
  
  In this case, the night guard wasn’t enough, he said. “That’s a big problem I never took the time to solve,” Dr Gupta says, adding that he might have given her an easily replaceable clear plastic retainer that would have been more comfortable. “It’s important for us to realize that they won’t follow all the rules. So, it’s up to us to give them as many tools as possible.”
  
  Additionally, Dr Gupta would have altered his occlusal design so that the brunt of occlusal forces would have focused on the posterior teeth, which would have meant either base metal or gold occlusal surfaces. That way, if the patient had worn through the metal or gold crowns, he could have replaced the posterior crowns rather than remake them in the esthetic zone.
  
  Perhaps most importantly, Dr Gupta would have referred the patient to a prosthodontist. He thinks a prosthodontist would have had a better understanding of occlusion than he does as a general dentist.
  
• Where Is the Case Now?
  Dr Gupta says he sent the patient for a sleep study after her top crowns suffered loss from grinding. His patient was diagnosed with obstructive sleep apnea and began using continuous positive airway pressure to improve her breathing, which was the cause of her grinding.
  
  Is she suing him? Thankfully, no. “She still totally loves me, and I don’t deserve it,” Dr Gupta says.

Case #2: Testing the Limits of a Bridge

Speaker and educator Jeffrey Lineberry, DDS, AAACD,FAGD, FICOI, owner of the Carolina Center for Comprehensive Dentistry in Mooresville, North Carolina, focuses on complex cosmetic and restorative dentistry. It’s not unusual for him to work on full-mouth restorative cases for his patients. So when a patient wanted Dr Lineberry to fix her smile, he was sure he could help. However, the way he helped her wasn’t his first choice of treatment plan.

• The Problem:
  The patient, aged mid- to late 50s, presented with missing teeth from the canines to the premolars on the upper left. She already had a removable partial denture but wanted a new solution.
  
• The Solution:
  Dr Lineberry told his patient she was a candidate for dental implants, but she refused this option. With a partial denture and implants off the table, Dr Lineberry would do a multiunit bridge abutted to the lateral on the central, replacing the canine and 2 premolars. The entire treatment, which would involve removing existing crowns and placing the bridge, would be complete in 1 day.
  
• The Next Problem:
  The patient suffered from dental anxiety, so she took Valium to help her relax for the treatment. She drove herself to the office, which was not something Dr Lineberry had advised. This situation tipped him off that the day wasn’t going to go as smoothly as he had hoped. “When your patient drives themselves to the visit—which was against our advice and not following our direction—and they seem unaffected by several milligrams of Valium, that’s a bad thing, especially when they’re already an anxious patient,” Dr Lineberry says.
  
  Once he began the treatment, Dr Lineberry saw that the patient had poor gum health and was experiencing heavy bleeding. Moreover, his patient was moving in the chair, adding to the challenge, and there were still hours to go before completion.
  
  Eventually, the bridge was placed along with all the other restorations, and everything worked out. Despite testing the limitations of the bridge and force load on the adjacent teeth, the outcome was satisfactory for Dr Lineberry and the patient. But the process? Not so much. “It was one of those 8-to-5 days of torturing yourself and the patient,” Dr Lineberry says. “It’s about the best way of describing it.”
  
• What He Would Have Done Differently:
  This case occurred early in Dr Lineberry’s career, almost 20 years ago. Dr Lineberry says he would have changed a few things about how he delivered that treatment. First, he would have offered more medication before attempting to alleviate the patient’s discomfort. Second, he would have ensured her gums were healthier and encouraged the patient to improve her oral health before initiating treatment. Finally, he might have convinced her to go with a different solution. “Each time she came in, I kept looking at the case wondering when it was going to fail, because everything you read in the prosthodontic books says it will fail,” Dr Lineberry says.
  
  Dr Lineberry also learned that with extensive case management, communication is critical. Not only will it make clear whether the patient’s desired option is not ideal, but it will also allow them to be part of the solution. With many cases (not just this one), Dr Lineberry sees that patients do not take enough ownership of their role in their oral health.
  
  “They show up in our office, and they want us to fix things, but then they don’t want to change anything that got them there,” Dr Lineberry says. “I tell them upfront, ‘If we do this, then this is how we need to manage it.’ If they don’t want to manage it and do things the right way and it breaks, I tell them they get to pay me to fix that crown again because I told them what would happen.
  
  “It’s the most frustrating thing I have when it comes to complex cases,” Dr Lineberry continues. “They don’t do what they’re supposed to, follow through, and take ownership in their own oral health, [which] directly affects the outcome.
  
  These up-front conversations often help when something breaks, Dr Lineberry says. When he reminds patients of their earlier conversation, they understand how their role played a part in the outcome.