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Sometimes more is less and sometimes less is more. But appropriate is always appropriate. There are often different ways to solve a puzzle; some simple, some complex. This case illustrates that comprehensive care does not always mean more dentistry; it may mean less. A complete, thorough comprehensive examination and workup will always give you the opportunity to present appropriate care.
Barb (not her real name) is a dental technician who works in a lab I have been using for almost 10 years. She has seen my work; we have discussed cases and learned much together over the years. She chose me to fix her smile.
At first glance, veneers seemed to be an obvious answer. However, my training and successes have come not from knee-jerk diagnoses and treatment planning, but from comprehensive examinations and careful interdisciplinary workups.
Barb was pretty set on who she wanted to take care of her and what she needed done. So I did not argue; I just asked questions. I invited her to experience a complete and thorough examination as I would do for any new patient. She agreed.
Barb has had several different bitesplints made over the years. All had been made in her maximum intercuspal position without regard for the condylar position. She had muscle pain, wear, craze lines, and a history of stress-related headaches. I relined and adjusted the best of her splints in an effort to get her more comfortable before doing some esthetic work. To Barb's surprise, her headaches almost completely disappeared. After new models, a face bow, and a centric relation record, I set about "working up her case." Periodontally, she was sound. There was decay on a lower molar that would need a crown. Orthodontics might be a consideration. We would have to do the trial equilibration and wax-up to survey the full extent of treatment necessary to meet her esthetic and now functional needs.
I told Barb I also wanted to help her have a more solid bite relationship, like she felt on the splint — with all the teeth hitting evenly when she closed in hinge axis, and the front teeth making the back teeth come apart when she moved from side to side or forward. This would provide more stability and longevity to our restorative plan as it unfolded. She agreed and was excited to have her teeth feel as solid as they did on the splint. Barb had become occlusally aware since our splint adjustments and was anxious to have it feel the same all the time. I described what we would do in terms of reshaping the cusps and fossa so they would allow her to touch more evenly. I then told a kind of half-truth. I explained how we would reshape some of the guiding edges along the anterior teeth and might need to add some composite to a couple of surfaces to achieve evenness as well; maybe even close the diastema to see what it would look like in the veneers.
Well, you know what transpired. I did an equilibration and added some composite to two teeth to provide a more esthetic finish to the anterior odontoplasty. The reshaping was primarily a functional adjustment done with a secondary esthetic undertone.
The results were spectacular. Not perfect. But spectacular. We could get a small esthetic improvement with indirect restorations as Barb had first prescribed for herself. But the invasive nature of that restorative course did not balance out when weighed against the esthetics we did accomplish. We had successfully executed a minimally invasive comprehensive restorative plan. Sometimes more is less, and this was most appropriate.
Mark Murphy is a featured presenter for the National Dental Network and the National Lab Network. He lectures internationally on a variety of dental clinical and behavioral subjects. Dr. Murphy practices part time in Rochester Hills, Mich., and is the director of professional relations at The Pankey Institute. You may contact him by e-mail at [email protected] or visit mtmurphydds.com.