This is a fairly complicated case that was managed over a lengthy period of time. As is customary of Dr. Paul Belzycki, he chose to show this case because it is loaded with good clinical information and learning pearls. It is fairly lengthy and that’s why we divided the clinical presentation into two parts. However, we sincerely hope that you will enjoy it and benefit from it.
For those who watch Dr. Belzycki’s work for the first time, Dr. Belzycki is a Toronto general dentist; and he regularly shares four decades of clinical experience with his colleagues.
During the presentation, we spoke about Dr. Andrew Moncarz’s collaboration in this case and we mentioned his presentation on CDA Oasis. As promised, here’s the link to that presentation:
Dr. Belzycki’s Thoughts
Yes, the devil is in the details! That is an idiom that refers to the importance of finding the key element that is hidden in a complex problem. That element which may seem simple at first sight and which ends up sucking more time and effort to successfully complete than expected. This has been my everyday experience in Dentistry. I have said it before: “every case has a WEAK LINK.” Failure happens when that element is not identified and/or is mismanaged. Every skilled craftsman, including dentists, must live by the following creed: Measure twice, cut once.
If you want to provide long-lasting restorations, you have to fight for every detail. If there are 10 steps involved, you do nine perfectly and one is not so great, it will come back to haunt you. So, it’s not that it requires a lot of brain power and it’s not that anything is overly difficult. It’s just a lot of simple tasks that need to be executed to an exacting manner to end up with a good restoration.
View Part 1 of the Presentation (33.10″)
View Part 2 of the Presentation (35.32″)
Dr. Belzycki is clearly a very good technical dentist, but there is a fundamental problem here. These patients he has discussed are all victims of occlusal disease. The teeth fail because there is a problem with the occlusion. The failing restorations are a clue. The tori are a clue. “Lack of TMJ symptoms” is a red herring. First off, many of these patients ARE in pain but they’ve lived with it for so long they think it’s normal. (when you get them stable, it’s fun to see them acknowledge the fact). One has to get beyond the point that “symptoms” are a guide, and look at what’s happening in the mouth. The teeth are failing because it’s an occlusion problem.
I strongly disagree with the whole approach. When you see a patient with occlusal disease, the LAST thing you should do is major dentistry, orthodontics or whatever. You need to establish a stable centric FIRST, then re-diagnose the malocclusion, and THEN treatment plan the case.
He shows a patient with a LOT of restorations done over a long term. I would offer that, if the CAUSE of the occlusal disease was addressed in the first place, many of those restorations never would have needed to be done in the first place. I do not look at this kind of case as a success. Rather, I consider these kind of cases a failure of dentistry to understand occlusion.
I see this time and time again in my practice. Patients with decades of patchwork dentistry – which still ultimately fails because the etiology was never addressed. None of these dentists were “bad”, and no doubt they all felt they could “save” the patient. A recent patient had 10 implants, 13 crowns, some more endo and she presented to me in pain. After decades of dentistry and tens of thousands of dollars of expense. We put her onto a full time splint, deprogrammed the muscles, established a stable centric, and lo and behold she is a big Class II that was posturing into some form of unstable CO. All this dentistry was done on a foundation of sand. That’s just sad.
The best dentistry in the world will fail if you have not addressed the cause of the occlusal disease.
The fundamentals of occlusion new. McCollum and Stallard were working on this almost 100 years ago. Charlie Stuart and PK Thomas were heralds who carried the torch forward. A lot of the principles of functional occlusion were established in the 50s and 60s. Bill McHorris was probably the first that recognized that one had to stabilize a patient before the instrumentation and restoration so that you could properly diagnose (and then treat) the malocclusion. Lundeen and Gibb ultimately illustrated that the anteriors needed to be the right length to create nociceptive feedback during function to prevent lateralized chew patterns, which are fundamentally destructive in the long term. But all these principles seem to have been lost somewhere along the way.
Never in this case presentation was the issue of the occlusion truly addressed. All the photos and radiographs in the world don’t make up for not actually mounting the case to see what was going on. Or establishing a stable centric before launching into a restorative program.
There is so much more we can offer our patients with a little more knowledge. I urge the readers out there to learn. Spend the money and time and take courses by Spear, or Kois or OBI or whatever. There is a lot of “preventable dentistry” out there if we truly understand occlusion and manage our patients accordingly, rather than patchwork dentistry being repeated until it’s too late.
Unfortunately, this comment probably won’t get published. Which is sad in and of itself.
Kois, Spear, Neuroromuscular goggly gook, can’t do dentistry without it, haha….
Paul you rule, love seeing all that amalgam, must make their eyes water.
Wow. What an astute comment. I’ve been in the game for 40 years too, pal. But there is none so blind as he who will not see. But I can’t say I’m surprised.
I don’t know if correcting occlusion alone will prevent decay and fallout after.Paul’s approach of treatment is methodical to address problems in day to day dentistry.
Dear Yogi. Thank you for your comment. In addressing this case, it remains my opinion that with an absence of TMJ/TMD symptoms, there were no occlusal issues to alter other than how to best secure the teeth in a harsh environment.
And, yes an occlusal appliance was delivered on completion of the case to help dissipate the destructive forces generated by bruxism. I was remiss in not stating this
But, I remain skeptical of claims that it is repeatably possible to eliminate bruxism, or “romance the condyles” to some idyllic position, or “recapture” chronically displaced discs with a block of plastic, irrespective of its design or designer. It is my understanding that the peer-reviewed literature substantiates my skepticism.
Dr. Paul Belzycki, DDS
I was interested in your reason for splinting crowns of posterior RCT’ed treated teeth —-is it your 35+ yrs experience that you feel this is best or do you base this on some published literature? Just curious.
As I have claimed on several past posts, whenever possible I will place splinted crowns. I routinely employ Full Metal or PFM crowns for strength and durability; and hence splinting is an option. I routinely splint crowns on multiple implants as well. The motivating concept is strength in numbers. This is vitally important with endo treated teeth anywhere in the mouth. It is hoped that forces of occlusion are dissipated and shared among several teeth/implants. As my perio colleague Jon Adam has claimed, I tend to over-engineer.
In addition, splinting crowns negates the opening of contacts. Over a long career, I have observed that this does occur. Patients with heavy parafunction tend to move teeth and these are the very patients that require crowns. So, I feel I gain strength and security and loose nothing.
I know of no formal studies that support this viewpoint. But I was advised by an old engineering professor that my clinical experience should “stand for more” than research carried out on a lab bench.
As demonstrated, there is an extra step to try-in metal and solder-index to assure accuracy of fit and embrasure design and the fee is adjusted for this.
All in all, I and patient sleep better a night. Perhaps that is the best reason.
Dr. Paul Belzycki, DDS