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Supporting Your Practice

Designing a Smile for a Case of Severe Attrition

Dr. Paul Belzycki's Thoughts
General Dentist, Toronto

I have often made the analogy that SUCCESS is similar to a linked CHAIN, where the links of the chain represent the conceptual and technical criteria that must be properly considered and orchestrated to result in a restoration that will withstand the test of time. Experience has taught me that each case has a weakest link and that the ultimate strength of any chain rests on that weakest link. Our challenge is to identify and manage this critical link to the best of our abilities.

Some of these links are what we as dentists bring to bear; our knowledge, skills, ability to properly manage the laboratory phase, and ultimately our dedication to details. The remaining links are contributed by the patient; their physiology, psychology and commitment to treatment, particularly when that treatment is extensive in scope.

The present case involves many critical technical links that resulted from the patient’s resistance to act on treatment options early on when problems initially presented. That chain-link, the patient’s psychology, is not wholly controllable by a healthcare provider.

The patient in this case presentation has been under my care for 20 years and is a wonderful gentleman in every regard, except for his reluctance to accept treatment earlier rather than later. The patient has consented to the use of the case and the content presented in this case.

We hope you find the conversation useful. We welcome your thoughts, 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!
CDA Oasis Team

Full Conversation (30.30")


  1. david February 12, 2021

    Dr Belzycki, how did he go for months with an upper temporary only, where presumably, based on the occlusion pre-op, he would only be occluding on the lower anteriors (which are worn to sharp inciso-lingual line angles to boot). How did he handle this? Or did he have posterior occlusion and I’m missing something?

  2. david February 12, 2021

    OK, now that I have watched to the end (guess I should of done that before my previous question!) it’s a single arch case, and the lower anteriors are not as exdtruded as they often are in such deep bite wear cases. Do you agree that if this was the case, you would have a harder time, and likely would have to be a double arch case? Also, what if the patient decides they want the lower anteriors treated in the near future, the bite would have to be opened further, correct? Thank you!

  3. Dr. Paul Belzycki February 13, 2021

    Here are my thoughts on occlusion, based on four decades of providing extensive restorative dentistry. Specific causes linked to specific effects are illusory. I have treated patients with Joint/Facial pain that have what appears to be wonderfully intact dentitions. At the other end of the spectrum, I treated patients where no two opposing teeth come together properly and yet they are pain free with regards to Joint/Facial pain or symptoms. This gentleman is representative of this group. I am fully aware that there are devoted disciples of various “Occlusal Gurus” that might claim some occlusal discrepancy is the route cause of the wear and tear demonstrated by this case. Perhaps, but there is plenty of evidence showing that we really do not know exact causes bruxism. Clearly it is present in this case and is a “critical link” that must be managed to achieve long-term success.

    Thus a properly constructed provisional bridge is a key component to restore form and function. It this case, I am giving him a ‘new bite” with provisionals that are to be worn for several months…even without pandemic. During this phase, symptoms are monitored. As I have said in all the cases presented on Oasis, “I want a patient to test drive my design in the provisionals”. Adjustments are made accordingly and this is why methyl methacrylate powder liquid acrylic is used for provisional fabrication. It adds to itself an innumerable number of times. Once a design has proven itself successful, it is vital to have the lab replicate that design. This is how the case played out.

    It terms of posterior support, obviously it is lacking. I have asked him to consider implants, but he is not inclined to do so. Folks do quite nicely from bicuspid to bicuspid occlusion.

    I did want to restore both arches at once, as this would allow for many options with regards to dental anatomy in terms of esthetics and function. I pleaded with him. He refused. So I will get around to it when he has pain in the lower arch. It ain’t a perfect world. And yes, I will need to open the bite yet again. In this case, given his huge range of motion and lack of symptoms, my gut instinct is he will not notice a thing. Just as he was unaware of the problems he initially presented with.


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