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View from the Chairside: Comprehensive Management of Restorative Endeavour of a Patient with a Cleft Lip and Palate

It is always a pleasure to welcome Dr. Paul Belzycki, general dentist from Toronto, who volunteered a number of clinical cases that will be presented on Oasis Discussions. Dr. Belzycki’s experience spans over 38 years of clinical practice in which he treated several complex cases that have required a combination of periodontal, endodontic, and prosthodontic treatments. 

Dr. Belzycki shared his thoughts about the art and science of dentistry in a previous post that you can view by following this link.

I hope you find the case presentation valuable. Should you wish to ask Dr. Belzycki a question or to share your feedback, please do so by emailing us at oasisdiscussions@cda-adc.ca

Chiraz Guessaier, CDA Oasis Manager

Highlights

In this case presentation, Dr. Paul Belzycki discusses one of his complex cases. As he progresses through his diagnosis and treatment plan, Dr. Belzycki explains in detail how he approached the various restorative challenges and issues that presented using his learned and acquired clinical skills.

The patient had extensive crown and bridge work that was functional and esthetic for quite a period of time, but presented with failed bridgework on the upper left and right. The first order of business was to retreat the endodontically-treated abutment teeth and place a provisional bridge.

At the next appointment, the temporaries were removed. The underlying tissues were inflamed and the margins extended deep into the gingival sulcus. Crown lengthening surgery was performed to achieve a better restorative outcome.

After a two-month period, the provisionals were removed. Amalgam core-buildups with pins were placed in #24 and cast post cores were fabricated for the central incisors and cuspids. Once the cast post cores were finalized and cemented permanently, another impression was taken for fabrication of the final prostheses. The first set of dies are separate metal copings which are tried in individually and high spots are adjusted, as needed. The metal copings were then luted together using acrylic powder/liquid. These copings are then fitted onto a second set of dies which are joined together using sticky wax and set in dental stone to fabricate a solder jig.

These extra steps ensure an accurate fit of the crown and bridge work for the patient.

Upon final insertion, the prostheses fit accurately with good, healthy tissues. After a 12-year follow-up period, the bridgework still has good esthetics and function and there has been minimal tissue rebound.

Full Case Presentation (31.24″)

 

3 comments

  1. Hello Dr. Belzycki,

    Thank you for taking the time to share your feedback. We closely and carefully monitor all feedback we receive and act upon it whenever it is within our abilities. To rectify the situation of the image used in yesterday’s CDA Oasis Bulletin, we will be sending another bulletin today with an erratum and an apology. Please monitor your email for the updated version of the bulletin.

    We appreciate your contribution to CDA Oasis and thank you for volunteering your time and expertise.

    CDA Oasis Team

  2. Wow, this is a phenomenal case! I love the careful thought and planning in the case. The telescoping post and core was excellently executed. I would have never thought this to be a possibility or solution.

    The big question is how you would fairly fee out the case. How would you manage the fees as an office to fairly remunerate the office yet stay fair to the patient? Would you charge the patient a layaway before starting the diagnostic component? Would you also charge for the work in the temporaries, as opposed to single unit crowns in which GP don’t generally charge? Is there a master fee that you have in mind and then find the codes that would help support the fee? We don’t want to just be adding up what we charge for individual fees and then charging that, or do we? If we code up every fee possible, isn’t that not enough or even too much for the patient? I have to admit there is a financial challenge of doing cases that are not in the norm of GP practices.

    I did like the comment about doing it old school. To expand on that, digital technology has their hidden costs in which the patent holders want the cut of the pie. In the past laboratories were screwed with paying for this technology, but now dentists are in the cross hairs. So many of my colleagues are being seduced to buying 50-60k scanners, this doesn’t include the CEREC buyers. In addition, I like the comment about how intraoral scanners simply can’t pick up the post impression. The only change as of 2017 is to use a zirconium framework. Since you have control of the abutments with the cast post and core, it may be a great solution. It would also nice to reduce the weight of the prosthetic.

    To be honest, I would love to see part 2 on how you took care of some of these financial components. Even a discussion on how you would change as of 2017, the execution of the case. It is thrilling to see the possibilities and how to solve some of these cases; it is what keeps me coming back after a round of defeat.

    • Reply by Dr. Paul Belzycki

      Brian W., thank you for the kind words regarding the clinical management of the case.

      Regarding fees, I know I have used the phrase ‘Old School’ in my presentation. Quite frankly, I’m not fond of that phrase as it may invoke an image that it is somehow less than ‘New School.’ As far as I’m concerned, there’s only One School and that is ‘Good Dentistry.’ Here, I define Dentistry as the whole package of how we address our patients’ clinical, psychological and financial needs.

      In the old days, treatment planning went as follows. A patient would come in and claim “I need teeth fixed.” I would have a look, decide on a treatment plan, very quickly and all on my own. Then, I would say “okay let’s get started.” This would take all of about 10 to 15 minutes. No multi-page letters of informed consent, no multiple treatment options, and no Dr. Google.

      How could I do this? What I try to do first and foremost is develop trust. Trust has to be earned. It is earned over a lifetime with constant effort, but lost in a fraction of a second. So I have strived to be the best I can be as a dentist and as a human being. I don’t say this to the patients. I don’t have any mission statement nailed to a wall. I don’t give out glossy brochures. I go about my day and hope patients would notice. Some do. Some don’t. The ones that do, have stayed a lifetime. And please note that like you, I too am a GP.

      Patients that have been coming to my practice for many years, trust me. When starting a complicated case such as this, they are made aware that I have a final goal in mind; to deliver a long-lasting restoration. Yes, I can envision every technical step along the way. No, they do not need to be made aware of those steps. That is of course, unless they ask…at least three times. Then, I will show them, very graphically with intraoral photos, a case similar to theirs. When the slide of periodontal surgery pops up on the screen, they typically look away and say…”Doc, just do it and don’t tell me.”

      With a new patient, I gain trust by first showing them a case similar to theirs, blood, guts and all, so they can have solid evidence to judge quickly…”Yes, this dentist knows what he is doing and he is good at it.”

      Once they make that decision to trust, the rest is easy. I typically spend an hour or so discussing treatment. I educate them by showing them several cases. My letters of informed consent are very detailed. I have no treatment coordinators nor financial arrangers. I do it all. It has been my experience that fees are rarely discussed with exact detail. Yes, they are given a ballpark figure, but they are advised that the amount may change according to clinical findings. I take treatment photographs which are reviewed with the patient, so they can see all the effort put forth and any new clinical findings that demand a change in treatment.

      New-Schoolers call this Transparency. Old-Schoolers call it plain old Honesty. In a large case, such as the one presented, our ODA fee guide is consulted, but fabrication and constant revision of the provisionals has a justifiable additional cost. Also, the management of multiple units deserves a more-than-average fee.

      And finally, patients undergoing these large cases know the cost will be significant. I urge patients to not make large decisions in my office as I do not want them to feel any pressure but commitment. “Go home and think about it.” In the presence of earned trust, there is an understanding that they will not be taken advantage of. Ethical patient management is an art all unto itself and beyond the scope of this comment, but it lays at the heart of my answer.

      As for Digital Dentistry…

      I have been investigating digital scanners. Last week, I got advice from university-based researchers currently studying this issue. I have learned that results are good for 2 or 3 crowns in a quadrant. However, full-arch accuracy is not there yet. I assume each one of us assesses accuracy of fit in the mouth subjectively and hence subject to self-deception, so I must look towards evidence-based findings. I will not trust a manufacturer’s claims nor a researcher I do not know personally.

      With time-honoured traditional methods, I secure accuracy in any size case, so why bother changing? For 50 to 60K, I can buy a shipping container full of impression material and acrylic that I know will yield an excellent fitting restoration. Last year, I spent just under $5000.00 on both. I do crown and bridge work just about every day.

      Furthermore, my lab technician, who is my patient, very skilled and honest, claims…“a defect-free impression that is properly poured is more accurate.”
      Note the caveats.

      As for Zirconia, I have had very few problems with single crowns. I have done many 2-unit splinted crowns and I believe a total of 6 small-span bridges in the anterior. The oldest is about 8 years and still going strong. My lab does have a 3M Lava milling unit, so we are more than well-versed in the protocol and have intimate quality control. The fit for small multiple units in the anterior is good and that is where I have used it, if aesthetics is the overriding concern. My experience goes back approximately 10 years with this material.

      My experience with gold alloy (full metal and PFM) goes back 38 years. I have placed crowns and bridges over that span of time that are still in service. Even today, my material of choice is a gold-based alloy, as there is irrefutable historical evidence of biocompatibility and long-term survival. That has been my experience; and therefore, I feel it is unwise and unethical to risk long-term success, especially in these extensive cases. What would you want in your mouth?

      In a previous post, I quoted Dr. Ursula Franklin, a professor in materials sciences: “Nature has an insidious way of undoing anything that man can make.”
      Initially, I too was convinced to use Zirconia due to its claimed fracture resistance. Scientific evidence is now mounting that the process of transformational toughness, switching from a tetragonal to a monoclinic phase in the presence of stress may now be its undoing. I suggest you research “Low Temperature Degradation of Zirconia” before jumping in with both feet on large span restorations.

      Even Dr. Google knows about it!

      As for weight-saving…no patient has ever complained of any perception regarding this issue.

      The oral cavity is a harsh environment. Acid attack, thermal cycling and unremitting cyclic fatigue, stress our restorations over a lifetime in ways not fully modelled on the research bench. If it were my mouth, give me Gold. That is why we have the slogan “The Gold Standard”. We are taught this in school. At least we were.

      But then again, that’s Old School.

      Again, I thank you Brian W. for expressing an enthusiastic interest in this presentation and putting pen to paper, or rather fingers to keyboard. Keep up the good work.

      Dr. Paul Belzycki

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