You Only Treat What You See...

Consider this patient who did exactly what her dentist suggested; she cracked her lower left second molar and it split in half and had to be extracted. Her dentist told her she didn’t need to replace it and she went for a couple of years until she decided that she didn’t like the way the space felt to her tongue. She went to a different dentist who had an implant placed by an oral surgeon and a subsequent crown. A crown was also placed on the first molar since it was cracked. He suggested the crown would prevent further damage. Three years later, she entered my practice and learned that both of the crowns had fractured and that there were other teeth in her mouth that were severely worn and were also cracked. I am certain the dentists who treated her had only the best intentions and I am certain they treated what they saw. The issues arose with what they didn’t see.

In the second image you’ll notice that both the upper left first and second molars supraerupted after the lower second molar was extracted. The implant was restored with a crown cemented on a stock abutment; most likely the shortest one available. The end result? The final restoration had the abutment exposed in order to have restorative room.

Had the dentist looked at a set of articulated casts he might have seen the shortage of space. I am going to take a guess here, since I’ve done the same thing, that this was probably one of the first implants he restored and was relying on the oral surgeon to guide the process.  There was a lot of bone and the implant seemed like a slam dunk, so it was placed and integrated successfully and sent back to the dentist to restore. The dentist, after sending the case to the lab, got a call from his ceramist and was told there wasn’t enough room for an abutment and a crown. He responded by telling the lab to do the best they could do. The working models were likely the first models taken, and probably the first time the restorative space was evaluated by the technician. As I said, I am guessing here, and I have done the same thing, either out of pure ignorance or for fear of looking bad in the eyes of my patients, peers or ceramist. Today, I would evaluate a set of articulated models, communicate with the patient about everything I see and what I believe to be the cause of the conditions present. Then I would suggest all of the options. If I am doing a procedure for the first time, I ask all the people around me who have done the same procedure and ask for their help in planning it. Even then things go wrong, but they usually are fixable because they have been anticipated. In this case, an orthodontist could have intruded the upper molars to create room; they could have been restored and shortened or the implant could have been restored with a screw retained restoration on a bone level implant to create more restorative space.  If I didn’t have experience with a restorative process, I might not even consider these options. Asking other people helps me see what I don’t see. I think this case shows the true value of study clubs, since they provide the opportunity to ask for help from colleagues who have been there before.