Sometimes You Have To Zag by Dr. David Sherberg

Sometimes You Have To Zag 

What’s a doctor to do when a patient opts out of previously accepted ortho?

During my first few years of practice, I read as many dental magazines as I could to learn the nuts and bolts of this profession. I found their articles so amazing, so inspiring! They portrayed case after case of beautiful smile transformations performed flawlessly by master practitioners whose hands seemed anointed by the Almighty himself. The photos in these articles showed surgery being performed seemingly without any bleeding, amazing tertiary anatomy placed on second molar restorations and patients whose deep satisfaction was only rivaled by the depth of their wallets. One day, I thought, I was going to be that great, and my patients would adore me for it.

Now that I’m older (yes), wiser (hopefully) and balder (definitely), I’ve come to realize such dental perfection is rare in everyday practice. There are too many obstacles in our way preventing magazine-level success. The reality of practicing dentistry is one of compromise. It’s doing your best with limited resources. It’s creating a meticulous treatment plan while understanding you may need to zag in the middle of it. The following case is such a zag.

The patient presents

This patient (Figs. 1a–1c) presented with the very innocent chief concern of wanting whiter teeth. I had recently completed a full-mouth rehabilitation on her fiancé, and she was unhappy his teeth were now whiter than hers.

Dental veneers case
Fig. 1a
Dental veneers case
Dental veneers case

Periodontally, she was healthy except for a few areas of mild recession. One area of Class II decay was noted, which I filled with a composite resin restoration, and orthodontically she was Class III with an anterior open bite, likely because of tongue thrust. Palpation of her lateral pterygoids revealed some discomfort and after a load test using a leaf gauge, the patient exhibited symptoms of tension and tenderness in her TMJ musculature. At this point the patient revealed that she often woke up in the morning with headaches and TMJ discomfort. I proceeded to deprogram her chairside with cotton rolls placed between her maxillary and mandibular posterior teeth for 15 minutes, and upon trying the load test again, no discomfort was noted, indicating the symptoms were limited to the TMJ musculature and not the disc/ bone of the joints themselves.

Because her teeth were healthy and already a B1 on the Vita Shade guide, my first treatment recommendation involved some whitening gel with or without Invisalign orthodontic treatment. The patient immediately shot down this plan because she had tried whitening in the past, but her teeth did not become “white enough.” Furthermore, she did not want to deal with the maintenance associated with at-home whitening. She wanted her teeth to be as white as possible, which meant bonded porcelain was the only realistic answer.

To be sure, I created a couple of graphical smile previews using DTS Pro software to give her an idea what the various treatment options would feasibly look like. I love this software for treatment presentations because it is quick and inexpensive and lets pictures say the thousand words I can’t. I was able to show with reasonable accuracy what a combination of Invisalign and whitening (Fig. 2a), instead of maxillary and mandibular porcelain restorations (Fig. 2b), could do for her smile.

When the patient saw the graphical mock-up of the porcelain work, she exclaimed, “That is what I want! That is what I’m looking for!” A treatment plan had been accepted, and it was now time to obtain records and get to work.

Dental veneers case
Dental veneers case
Fig. 2b

The dentist plans …

I, like just about every dentist in the United States, would describe myself as a conservative dentist, so my treatment plan involved comprehensive Invisalign therapy to straighten her teeth and allow for conservative veneers and onlays with minimal tooth structure removed.

Once the orthodontic phase was completed, I planned to make sure the patient’s joint and occlusion were stable through splint therapy and equilibration as needed. Impressions were made for Invisalign treatment, aligners were delivered, attachments bonded and interproximal reduction (IPR) was performed between her mandibular canines, premolars and first molars. Months of satisfying tooth movement via aligner therapy could now begin.

… and God laughs

“Get these things off. Get them off now !” The very next day, the patient was back in my chair, demanding the attachments be removed. She did not like how they looked or felt. She demanded I fill in the spaces between her teeth where IPR had been done. Exasperated, she stated, “I just wanted whiter teeth, not all this.” Drat! Time to regroup, time to zag.

These are the moments that truly test your dental grit. I could of course fill in the IPR spaces with Class 2 composite restorations and tell the patient, “Adios, please fi nd another dentist to deal with these ridiculous demands,” but I started to realize a plan for porcelain was still possible.

  • Yes, the patient had TMJD, but she was comfortable in her current occlusal scheme.
  • Yes, CR dentistry is ideal, but given that we weren’t changing her VDO for this case, restoring in her habitual MIP wasn’t out of the question.
  • Yes, minimal prep is ideal, but her current tooth position still allowed for relatively conservative restorations. Also, serendipitously, IPR had already been performed on the lower posterior teeth that would be receiving conservative crowns anyway.

The zag

With all this in mind, I decided to skip the orthodontics, go straight to wax-up, limit any changes to her occlusal scheme in an effort to not poke her TMJD dragon, and hope we would be popping champagne at the end of all this.

I made impressions, used a Kois dentofacial analyzer to mount her models on a semiadjustable articulator and proceeded to wax the case myself. Though time-consuming, I find waxing cases necessary to help truly get a handle on what is possible. From the wax-up I created a PVS putty stent, which I would use to flash on the wax-up as an aid in reduction and fabrication of the provisional.

The plan was to prep first molar to first molar with veneers and crowns on two consecutive mornings. Because these appointments can be three to four hours long, I used oral conscious sedation via a combination of diazepam and lorazepam to keep the patient comfortable.

On the first prep day, I prepped the maxillary teeth and provisionalized via a shrink-wrap spot-bond protocol using TurboTemp bis-acryl composite (Danville) and Surpass bonding agent (Vista Apex). The mandibular teeth were prepped the following morning, and for those I provisionalized with cemented bis-acryl posterior crowns and shrink-wrapped anteriors. Occlusal coverage for the mandibular posterior teeth makes sense from a cosmetic standpoint in these cases because the occlusal aspects of these teeth can be seen during laughter. Final impressions were made for both sets of teeth utilizing a heavy and light-body PVS material.

Over the course of the following week, the patient had time to analyze her “trial smile” and see what she did and did not like about it. Because of the translucency of the provisional material, her smile was not “white enough” in her opinion, so I reassured her that we would go whiter with the final restorations.

As I expected, because of her somewhat unstable occlusion/TMJ, she experienced some discomfort in excursions that required adjustments of the provisionals, and a few veneers popped off in that first week and required rebonding. Eventually, though, we provided her a comfortable, stable occlusion in her provisionals.

At this point, impressions were made of the provisionals, a Kois dentofacial analyzer was taken of them as well, and occlusal records were made in MIP using a Blue-Mousse bite registration. This gives the lab enough information to create final restorations that mimic the appearance and function of the approved provisionals. Furthermore, the patient demanded no characterization of the restorations. After showing her case photos of heavy, little and no staining, she maintained her position. Nothing but white it is!

The final result

I used Arrowhead Laboratory to complete this case and provided all the records with a detailed lab script. I always request photographs of the wax-up, including occlusal markings, before moving forward with the restorations for final approval (Figs. 3a–3e). The entire case was done in medium translucency E.max, Shade 0M1 from the Vita Shade guide. We bonded the restorations over the course of two mornings, one arch at a time, using Surpass bonding agent, Interface Ceramic Dental Primer (Vista Apex), and NX3 Nexus Third Generation white light-cured resin cement (Kerr). Equilibration was once again performed via a leaf gauge, but because there was no VDO change and the case had been accurately mounted, only minor adjustment was necessary. One more small occlusal adjustment was performed a week later at the patient’s request, and she reported no additional TMJ comfort after delivery. I could finally breathe a sigh of relief.

Dental veneers case
Fig. 3a
Dental veneers case
Fig. 3b
Dental veneers case
Fig. 3c

Dental veneers case
Fig. 3d
Dental veneers case
Fig. 3e

Hugs were shared after finishing this case (Figs. 4a–4e), and of course I acted as if this had been all in a day’s work. But the reality is a combination of planning, skill, freestyle jazz and a bit of luck allowed this case to come together. Whenever I finish a case I feel went well, I always take an extra beat to let the gratification wash over me. I’ll chat with the patient a bit longer and relish in how much joy my work gave him or her.

Dental veneers case
Fig. 4a
Dental veneers case
Fig. 4b
Dental veneers case
Fig. 4c

Dental veneers case
Fig. 4d
Dental veneers case
Fig. 4e

Our job is often a series of compromises, half measures and Band-Aids. It’s very easy to focus on what went wrong and mentally skip right over a case that went right. Taking the time to enjoy the little moments of positivity in the office is the fuel that I need to handle that next dental zag, which is inevitably waiting one operatory over.


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Author Bio
Author Dr. David Sherberg graduated from the University of Connecticut School of Dental Medicine, then pursued an Advanced Education in General Dentistry residency at Virginia Commonwealth University.
Sherberg, who has received extensive dental implant continuing education, is a certified DOCS Education member. He is certified in moderate sedation and is an oral surgery volunteer at Remote Area Medical in Florida. An avid researcher, he is also a fellow in the Academy of General Dentistry. He lectures nationally to dentists and is a faculty member of the Phelps Institute. He has received numerous “Best Dentist” awards throughout his career, including Best Dentist in Tampa Bay, and has been featured on ABC News, News Channel 8, Vibrant Living and the Wellness Hour.
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