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Implantology Supporting Your Practice View From The Chairside

View from the Chairside: Teeth “Made to Measure” by a Tailor’s Son – Implant Cases Series

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We present to you Episode 4 of Dr. Paul Belzycki's implant series in which he speaks about how to plan, design, and restore implants. In this episode, Dr. Belzycki emphasizes the importance of margin design in the success of implant restorative treatment.

I hope you you enjoy this masterfully crafted presentation. We always look forward to hearing your thoughts and receiving your questions and/or suggestions about this post and other topics. Leave a comment in the box below or send us your feedback by email.

Until next time!
Chiraz Guessaier, CDA Oasis Manager

Watch Previous Episodes

Dr. Belzycki's Thoughts

The Benchmark of Excellence in Dentistry is Margin Design

In my mind, the benchmark of excellence in restorative dentistry is the management of restorative margins. The proper interface between artificial materials and the living host tissue is critical to the long-term survival of the restoration we place. The exactness of a marginal seal, i.e. the fit and finish of materials used, is but one aspect. A second overarching aspect is the placement of that margin in relation to the Biological Width…that delicate complex of tissue that forms around each tooth and implant to seal off the “inside world” from the microbes that inhabit the oral cavity. The tissue complex around implant vs. tooth may be different, but one truth remains constant…that complex must not be violated. This presentation concerns itself with a comprehensive case to illustrate criteria and techniques used to attain that elusive perfect margin.

Oasis Moment (2.23")

The Patient's Perspective (3.38")

Full Presentation (59")

Case Update (4.56")

3 Comments

  1. Doug Cowdrey January 28, 2020

    Dear Dr. Belzycki, I just reviewed Videos 1-3 before watching #4. Very thorough, I have a few questions, I may have missed some of your points in the video?
    1. wrt the 13 endo and the “temporary” composite place during the course of BW investigation, I think you suggested the seal of the CR was not to worry, what about sepsis and endo treatment, if the restoration is leaking, then what about bacterial ingress?
    2. On the root proximity issue 26-27, post root amp, do you “retro restore the obliterated canal”, or is the crown prep into the embrasure anatomy such that the DB canal is sealed with the crown? I have done a few of these, often I find there may be future perio issues wrt bone resorption post DB root amp, have you experienced the same?
    3. On the Restoration of 21-27 natural/implant combined case, what occlusal scheme was designed into the restorations please?
    4. Final case is beautiful, “biocorrect” I am sure, in retrospect would have you considered other options wrt exposed margin -tooth interface on 22B?
    5. Old school works fine by me. i PLAY ON THAT TEAM.
    I thank you for the time invested in your presentations, it is always great to have a “checkpoint” to see if “old school” is still in play. I will retire before I buy a scanner sir. Thank you D Cowdrey 8T2

    Reply
  2. Dr. Paul Belzycki January 29, 2020

    Hi Doug.

    Answer 1. Doing these presentations is talking to a laptop all alone in my office pretending there is an audience. I do not read from a script and have learned to just tell a story so-to-speak…of how I have handled a case. When I was going over that particular slide, I instantly thought “someone is going to take me to task over moisture control with the placement of a composite”. So, to preempt that, I made the statement you are referring to. So, my instinct was correct. Here is my answer…Of course I am concerned about bacteria. Hence, without a rubber damn in place, in the presence of a flap, I did the best I could to control moisture. Had 2 suction tips going. Even though the cavity prep was clean, I am sure his breathing created a fine layer of moisture on the composite as it was introduced. But my overriding concern was getting to the endo and closing the flap. So, I weighed the risks/benefits and felt comfortable that whatever seal had resulted would be sufficient in the short term, and this proved to be the case.

    The statement “I am not worried” was cryptic for “I am aware of lack of definitive moisture control, but it will suffice for the short-run until I can treat tooth definitively, which was the case.

    Question 2, I entomb the entire complex with a crown/retainer down to soft-tissue. I have done many of these over the years and have no greater incidence of recession that around adjacent teeth. Perhaps because I wait several months for complete healing before moving ahead with final restoration.

    Will address Question 3 later when I have time.

    Question 4. The little dark-line is a non-issue as the patient has not brought it to my attention. He does not care and neither do I . I could do CT graft and have done in the past…see my post on that subject. Even with his biggest forced grin…that margin is not visible.

    Thank you for your interest in this case. Much appreciated.
    Dr. Paul Belzycki

    Reply
  3. Dr. Paul Belzycki January 29, 2020

    Hello Doug,

    Here’s my answer to your question 3:

    This patient had no TMJ issues or findings whatsoever.

    So, it is my task to replace what is pre-existing and make the occlusal table and vertical dimension to match the right side. I do not obsess over cusp/fossa angles of inclination. Give me solid stops in “centric”, on as many teeth/implants as possible with freedom to translate in any direction. Given the replacement of the cuspid was implant-supported; I wanted to have some guidance from this crown. Hence, I splinted the two crowns together (23 and 24) for strength, given the implants were the smaller “narrow-neck” variety. This to me is a common-sense approach.

    However I know full well that I will get comments stating I missed the boat completely because those patients with no TMJ symptoms are the worse cases and because their joints are so deranged as to hide the “Ticking-Time-bomb” that will explode the second I finish the case. Further, that a multiplicity of occlusal appliances should have been used to reposition the condyle in some prescribed “ideal relation to the fossa”. In 40 years, I am still waiting for “bombs” to explode.

    In my presentations on Oasis, I rely heavily on photographic evidence of past clinical experience to demonstrate that I stress, really stress, over the details of every case I treat (hence the title of one of my previous posts, The Devil is in the Details).

    However, the factor that causes me the least amount of stress is occlusion. If a sufficient number of teeth are present, I build to that centric occlusion (maximum intercuspation) as this is a repeatable position that can be shared between the patient, myself and the lab. If landmarks are lacking, I will build to something vaguely repeatable and that happens to be the “centric relation”. Note vaguely repeatable. The TMJ is a visco-elastic biological complex which means a precise condylar/fossa relationship is illusory. The amount of fluid in the joint differs from morning to evening. I would not be surprised if these differences arise even during the course of a long dental appointment. Commonsense tells me I have little control over this. Therefore, I aim for restorations with solid flat occlusal stops that provide freedom for the patient to move in function, or for that matter, in parafunction without awareness. I am hopeful that a patient’s powers of accommodation, both physiological and psychological, contribute to the success of our restorations as we are keenly aware of the tolerance of error.

    Philosophically, “Seek no more precision in a system than it may admit to.”

    1. I never bring a case to completion in the presence of symptoms. Any symptoms!
    2. We have seen dentitions where no two opposing teeth properly come together and yet the patients remain asymptomatic for life.
    3. We have seen and treated patients with various types of joint/facial symptoms and their occlusions and radiographic TMJ images appear as normal textbook features.
    4. Bruxism/parafunction cannot be cured, only managed. Factors unrelated to occlusal articulation and joint anatomy may be at play. Put another way, how the teeth come together is not a predictable causal factor in joint pain, or bruxing or TMD.
    5. The proposition that a singular concept, Occlusal Disease, is the occult cause of all that fails in dentistry demonstrates the adage “If all you have is a hammer, then every problem is a nail”. Alternatively, “If all you see are nails…get the hammer”. Let the reader choose which is most appropriate.

    Having said this, would I insert a restoration that is not harmonious with a repeatable asymptomatic occlusion or some concept of centric position? Of course not. That is just Good Dentistry. It’s a no-brainer goal that does not require a guru.

    Have I alleviated symptoms by grinding down balancing-side interferences? Yes, and I certainly looked like a genius.

    Have I repeated this on a second patient and not succeeded in alleviating symptoms? Yes, and I looked not so genius.

    Do I employ occlusal splints? Yes. But I explain to the patient that their individual results will vary. It has been my experience that TMJ problems are sporadic and typically self-limiting. Folks have gotten better with merely suggesting relaxation, self-awareness, soft diet, use of moist heat, and NSAIDS. Let us see what Mother Nature can do for us with a common-sense, low-cost, non-invasive approach.

    Patients who are provided with an appliance are informed that if it works, I will take all the credit. If it doesn’t, I will accept no blame. We really do not know why or how occlusal splints work when they do. We have guesses and here is mine. Somewhere in the deep recesses of a patient’s mind, the presence of a block of plastic in the mouth somehow modulates neuromuscular activity. I am certain this is a huge over-simplification and the cerebral pathways are complex and vary extensively between individuals. I will state that the effect is partially placebo! I am sure this may be the case in some folks, and this too is honestly explained to the patients I treat. Perhaps it is merely the laying-on of hands. The rendering of diligent and compassionate care may in and of itself reduce heightened stress and anxiety that is part of pain appreciation.

    Here is my message to young and seasoned clinicians. Gurus are in the business of being gurus. And they are good at it as their lectures are typically well attended. Obviously, knowledge in occlusal management is vitally important, as is everything else we do in Dentistry. But, be warned, as considered skepticism is required to integrate efficacious knowledge. One needs to carefully consider their guiding sources before providing irreversible treatment to “reposition” condyles, provide orthodontics, and/or grind away enamel in the name of “occlusal disease”.

    This is especially true when no pre-operative symptoms were present in this case.

    Dr. Paul Belzycki

    Reply

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