Sometimes You Have To Zag by Dr. David Sherberg

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.

Fig. 1a

Fig.1b

Fig.1c

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.

Fig.2a

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.

Fig. 3a

Fig. 3b

Fig. 3c

Fig. 3d

Fig. 3e

Fig. 4a

Fig. 4b

Fig. 4c

Fig. 4d

Fig. 4e

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.