Solving Dilemmas in Clinical Practice

In a "perfect world," we welcome a new patient to our practice, diagnose, treatment plan, educate, and present our recommendations; then we treat the patient, the fee is happily paid, and that patient becomes a source for many referrals. Sounds great, but we don't live in a "perfect world!" It behooves us to be able to deal with the many dilemmas we face in daily clinical practice. A dilemma is defined as a situation requiring a choice between equally undesirable alternatives or any difficult or perplexing situation or problem.
     Challenging situations arise for many reasons. First, the actual dental condition of a patient's mouth may suggest multiple treatment plans, none of which we would consider "ideal." When we create one or more treatment plans that we deem acceptable, but the patient cannot afford any of them, the situation can leave us scratching our heads and wondering how to proceed. If a patient enters a practice with complaints about a past dentist and the care that was given, how do we deal with this? Perhaps a patient is so fearful of dentists that the emotional baggage carried makes rendering the care we feel is best impractical, if not impossible. These are some of the scenarios that can make our work far more challenging. There is more to the clinical practice of dentistry than just the technical aspects of a case.
     As a clinician, I face these situations regularly. As a lecturer, I'm often asked by attendees how to deal with cases where no treatment plan seems to be an ideal one, or when the patient cannot afford the optimal treatment plan. Sharing this kind of information with my audiences is very gratifying. To quote Albert Einstein, one of the most famous educators and brilliant minds of all time: "The value of a man should be seen in what he gives and not in what he is able to receive."
     And if we look to another great mind for guidance and inspiration, Kahlil Gibran said, "A little knowledge that acts is worth infinitely more than much knowledge that is idle."
     With this in mind, the purpose of this article is to show different situations that presented in our office and how my team and I dealt with each. The first case illustrates a medicolegal and ethical dilemma, and the second case illustrates a clinical dilemma involving an implant in an unfavorable position. Similar situations could have presented in your office and your answers may have differed. There is no "perfect solution" that solves each challenge, and that is the point. These are dilemmas, and hopefully, how each case was solved might be helpful when shared with you and your team.

CASE 1
Background

Figure 1. Smile showing veneers placed that morning by a previous dentist.

Figure 2. Release of liability statement.

The phone call from Gina came around 11:30 am. She was sitting in her car in the parking lot outside our office and said, "Please, can you see me today? I just had veneers put on and I can't walk around like this." My office manager, who took the call, told me she sensed desperation in Gina's voice. Of course, red warning flags went up with this phone call and yet, being sensitive to the caller's well-being, my office manager told Gina to come in and we'd see what we might do to help her.
     After calming her down, we wanted to know what prompted her to call us. We found out that she left her dentist's office that very morning, and then called the orthodontist who cared for her as a teenager. Gina pled her case to him and appropriately, he suggested she go back to the dentist who put the veneers on. She described her situation, said, "I can't go back there," and begged the orthodontist for another dentist's name. After a long conversation, he reluctantly gave her mine.

Examination and Analysis
A problem-focused examination of the anterior teeth with the aforementioned veneers that were placed just a few short hours ago was completed. No x-rays were taken on this day, and a comprehensive examination was not appropriate at this time. The questions to be answered were simple but the answers were not. What was wrong? What could be done? If something was wrong, how would I convey that to the doctor who treated Gina that morning? Should I consider doing something and assume the responsibility/liability that would occur immediately after touching the veneers? Do I send Gina back to the practitioner who placed the veneers? This was a medicolegal and ethical dilemma.
     Examination revealed improper axial inclinations, open margins, poorly shaped veneers, and gross cement excess (Figure 1). I went into my private office, called the treating dentist, and discussed the situation. I described what I saw and he said I should send her back to see what he could do. I told him I would suggest that and the decision would be hers to make. I felt I had fulfilled my obligation to a colleague; however, I had mixed feelings about it. I was troubled because I had already seen what he had done. When I spoke with Gina, she refused to go back. Now what? As you see, this is a true dilemma; you observe technically substandard care and yet do not want to be held liable if you touch the previous dentist's completed case.
     I empathized with this young woman and wanted to help her but at the same time protect myself from liability for what another practitioner had done. I wrote a simple statement describing the situation, what I would do on an emergency basis, and that this care was not a substitute for a comprehensive examination and future treatment to correct the problems. I concluded this statement with Gina, agreeing I would not be responsible if the laminates were to chip or break when I adjusted them. She signed the statement in the presence of my clinical assistant, who witnessed it. The "release of liability" statement I created is in Figure 2.
     Without belaboring the point, the deficient margins and residual cement are some examples of what I saw (Figure 3). With some recontouring and repolishing, I was able to improve the existing veneers somewhat by correcting the shapes and axial inclinations, allowing Gina to go out without feeling embarrassed. The poor margins were not addressed at this time. A few days later, we took a complete history and performed a complete evaluation. This included a visual oral cancer screening and examination of all soft and hard tissues. A subsurface examination for abnormal tissues was performed with the VELscope (LED Dental). Periodontal evaluation was done with a 3-6-9-12-mm probe (Premier PerioWise [Premier Dental]), a full-mouth series of x-rays was taken, and diagnostic model impressions were made using an alginate substitute (Position Penta Quick VPS Alginate Replacement [3M ESPE]) in a stock tray (Originate Disposable Impression Tray [AXIS Dental]).
     It was apparent that this lovely young woman had many problems that needed care, in addition to her smile. However, she opted to deal with her veneers before taking care of the other necessary restorations. In order to determine what Gina wanted her smile to look like, we spent time reviewing photos of various smile designs, tooth shapes, and discussed shades and incisal translucencies. Dental terminology was avoided and a simple "I like it" or "I don't like it" from Gina helped me to understand what her preferences were. A diagnostic aesthetic wax-up for 8 new veneers was created based on the information gathered during our conversation. She reviewed the wax-up and said she liked it.

Treatment

After evaluating all diagnostic materials, it was clear that endodontic therapy was needed on tooth No. 10, and also possibly on tooth No. 9 (Figure 4). Root canal therapy (Smart Endodontics rotary system [Discus Dental]) was completed on No. 10 (Figure 5) and several weeks later, when it was deemed necessary, on No. 9. The defective veneers were removed with a high-speed air-driven handpiece (GentleSilence Lux 6500B [KaVo America]) and an 856-01C coarse diamond (SS White). Preparation depths for new veneers were established with depth cutting burs, Nos. LVS1 and LVS2 (Brasseler USA), and the axial preparations done with 2-grit chamfer burs Nos. LVS3 and LVS4 (Brasseler USA). The retraction cord was easily placed (Ultrapak 000 retraction cord [Ultradent Products]) with a specially designed cord packing instrument with a serrated end (Fischer's Ultrapak Packer 45° Small [Ultradent Products]) (Figure 6). After 3 minutes, the cords were removed and Impregum Penta Soft Quick Step Light Body (3M ESPE) injected. A prepared stock tray (COE Plastic Disposable Tray [GC America]), previously coated with adhesive and dried, was filled with Impregum Penta Soft Quick Step Polyether Medium Body (3M ESPE) mixed in a Pentamix 2 Automatic Mixing Unit (3M ESPE). The filled tray was then seated and held in place to set according to the manufacturer's instructions.
     After the impression was removed, a very thin layer of Vaseline was painted on the composite on tooth No. 9 so that the temporary veneers would not bond to that composite. Temporary veneers were created by injecting Luxatemp Fluorescence (DMG America) into a Position Penta Quick (3M ESPE) impression of the aesthetic wax-up which Gina had approved. The provisional material was allowed to cure on the teeth. After setting, the flash was removed gently from the gingiva. Final trimming of the margins of the temporary veneers was done under magnification (Dimension-3 Dental Loupes [Kerr Orascoptic]) with a very fine finishing diamond (392-016VF Mosquito [SS White]). A thin coat of a liquid polish resin (Lasting Touch Nano-Technology Liquid Polish [DENTSPLY Caulk]) was brushed on following the manufacturer's instructions and light-cured to give the temporary veneers a high luster (Figure 7).

Figure 3. Deficient margins and remaining residual cement was obvious clinically.

Figure 4. Periapical pathology on tooth No. 10.

Figure 5. Endodontic therapy using Smart Endodontics completed.

Figure 6. Preparations completed with No. 000 cord (Ultrapak [Ultradent Products]) in place.

Figure 7. Temporaries were delivered. Note the high luster provided by applying a clear light-cured resin (Lasting Touch Nano-Technology Liquid Polish [DENTSPLY Caulk]).

Figure 8. Postoperative smile.

Figure 9. Preoperative full face.

Figure 10. Postoperative full face.

     On insertion day, the veneers were tried in individually for overall fit and marginal integrity. All veneers were then tried together to be sure the contact areas were properly designed with no excess pressure that would disallow any veneer from seating properly. A water-soluble try-in gel (Prevue [Cosmedent]) was used to ascertain the shade of resin cement (Insure [Cosmedent]) used for cementation of the veneers. When Gina and I were satisfied with the preview, the veneers were removed, all try-in paste was washed out, and the veneers thoroughly cleaned. A prehydrolyzed silane ceramic primer (RelyX Ceramic Primer [3M ESPE] was brushed on the pre-etched inner veneer surfaces and allowed to dry. A thin layer of resin adhesive (Adper Single Bond Plus Adhesive [3M ESPE]) was brushed onto the silanated veneer surfaces and air-thinned. The selected shade of resin cement was placed in each veneer in an incisal-gingival direction and all veneers were placed in a covered storage container (ResinKeeper Mixing and Storage Palette [Cosmedent]) to keep the resin cement from setting prematurely.
     The temporaries were removed and the teeth cleaned with pumice (Consepsis Scrub [Ultradent Products]) in a prophy cup. Floss was used to remove any remaining prophy paste interproximally. A final surface cleaning was gently performed using a microetcher (MicroEtcher IIA [Danville]). Then, the prepared teeth were etched with a 35% phosphoric acid gel (Ultra-Etch [Ultradent Products]), rinsed, and dried. A thin layer of the resin adhesive was brushed onto the teeth, air-thinned, and cured. It is this author's preference to insert both central incisor veneers simultaneously followed by 2 or 3 veneers at a time on one side, then the other side. Each veneer was tacked in place for 2 to 3 seconds with a halogen curing light (Optilux 501 [Kerr Demetron]), gross excess cement removed, and final curing for 60 seconds was done on each veneer. The gingival margins were cleared of any excess.
     Because Gina had expressed a desire for "more rounded corners" while wearing her temporary restorations, the incisal angles were gently rounded with a very fine diamond (888-012VF [SS White]) and polished (Jazz P3S Porcelain & Metal 3-Step Polishing System [SS White]) to bring the porcelain back to a high luster. Her completed smile is seen in Figure 8, and even more telling are the before and after images seen in Figures 9 and 10. This case started out as a medicolegal and ethical dilemma, but ended with an excellent result that satisfied the patient, giving her a renewed sense of trust.

CASE 2
Background

Eli's chief concern related to an implant-supported crown on tooth No. 8. The crown had previously come off many times. When he entered our practice, he told me, "Not only did my cap come off, but the post underneath also came out. I've had to have it banged back in more times than I care to remember." He was referring to a PFM crown that was placed over an abutment placed on an implant. On this day, the crown had come off and the abutment had loosened but was still in place. The abutment he had placed was a "locking taper" implant, also known as friction, as explained by Bicon Dental Implants (bicon.com/ product_info/pi_faq.html). It should be reiterated that I inherited this implant. This author's preference is for implant systems that utilize screw-retained abutments such as Replace Select (Nobel Biocare), and many other systems too numerous to mention. For a listing of many implant companies, you can visit implantdentistry.com/man.html.

Examination and Analysis
Clinical examination revealed a very slight shade variation between the crown on tooth No. 9 and the natural teeth Nos. 7 and 10. This was of no concern to Eli. The abutment on No. 8 was too short (Figure 11), and the implant itself was positioned more to the palate than I would have liked (Figure 12). Based on the patient's account I sensed that, in addition to the inadequate length of the abutment, there were forces that contributed to dislodging the crown in excursive movements, similar to undesirable forces on a cantilever bridge. Considering that the crown and abutment loosened multiple times, it seemed inappropriate to repeat the same remedies that had been used before. The quote that comes to mind to best describe this dilemma is, "Insanity is doing the same thing over and over again but expecting different results." (This statement has been attributed to Benjamin Franklin, Albert Einstein, and an old Chinese proverb. However, it seems that one Rita Mae Brown first said it in her 1983 book Sudden Death.)
     What were the possible solutions to this dilemma? The existing implant could be removed and a new implant placed in a more favorable position. After osseointegration, a new screw-retained abutment with adequate length could be placed and a new crown made. Eli was not excited about this option. Could something different be done using the existing implant to improve the chances for abutment and crown retention?

Figure 11. Excessively short abutment.

Figure 12. Abutment was placed too far palatally.

Figure 13. New abutment was short in apical direction.

Figure 14. Retraction cord in place.

Figure 15. Metal alloy primer used. (Alloy Primer [Kuraray]).

Figure 16. Temporary crown extended over the abutment.

Figure 17. Extensions (Majesty Esthetic [Kuraray]) with healed gingival.

Figure 18. A shade photo was sent to the dental laboratory technician team.

Figure 19. Porcelain-fused-to-gold crown (Shofu Vintage Halo porcelain [Shofu Dental]).

Figure 20. Immediate post-op photo of the cemented crown.

After consulting with the company that manufactured the implant and abutment, I discovered that they had an angled abutment that would emerge in a more favorable location. However, the coronal portion of this abutment was still shorter in the apical direction than I would have liked (Figure 13). This meant that the crown margin would not be buried under gingival tissue, creating an unaesthetic result. If I were to use this newer abutment, what, if anything, could I do to create more length in the apical direction to allow the crown margin to be placed subgingivally? Finally, another possibility was to leave the implant buried and make a conventional bridge across the affected area.
     Clearly, we had multiple options, but none seemed truly desirable. After discussing the options with Eli, he decided to retain the existing implant and have me try to create a more favorable platform for a new crown to sit on. I explained to him that if this didn't work, we'd have to revisit his decision and try something else.

Treatment
A Stylus ATC high-speed handpiece (DENTSPLY) with an 856-01C coarse diamond was used to roughen the coronal surface of the abutment. This handpiece is air-driven with electronics inside to maintain torque that is similar to that of an electric handpiece. After sandblasting the abutment surface with the microetcher, a piece of No. 1 cord (Ultrapack) was placed around the abutment using a Fischer Ultrapak Packer 45° Regular to obtain sufficient retraction (Figure 14).
     Two coats of metal primer (Alloy Primer [Kuraray]) were then applied to the abutment metal and left to dry for a few seconds. Alloy Primer (Figure 15) is a metal primer used to increase the bond strength of composite and acrylic resins to gold, base and semi-precious metals, and titanium. This product eliminates the necessity for tin-plating and enables bonding to metal surfaces, according to the manufacturer's product description (kuraraydental.com).
     Next, 2 thin coats of adhesive resin were applied, air-dried, and cured with a halogen curing light. Clearfil Majesty Esthetic (Kuraray) was carefully added to the abutment and shaped with an IPC carver (Premier) to increase the apical length of the coronal part of the abutment and to create a more ideal incisal edge. The additions were cured and then shaped with a very fine diamond. I had no concern regarding subgingival recurrent caries because a titanium abutment cannot decay. A temporary crown was made using a polycarbonate crown (Polycarbonate Adult Anterior Crown [3M ESPE]) with a palatal extension of quick-setting, self-cured temporary crown and bridge resin (Alike [GC America]). The palatal contour of the temporary crown illustrates the actual palatal position of the implant and the severity of the situation (Figure 16).
     A few weeks later the gingival tissue was healthy and ready for the final impression (Figure 17). EXAJET Fast Set (GC America) mixed in a Pentamix 2 and EXAFAST NDS Injection (GC America) wash were used for the impression. A bite registration (O-Bite [DMG America]) was done, and a shade photo (Figure 18) was taken (Canon Powershot intraoral photography system [PhotoMed]) and sent to the dental laboratory. The porcelain-fused-to-gold crown (Figure 19) was fabricated (Shofu Vintage Halo porcelain [Shofu Dental]). After returning from the laboratory, the restoration was cemented (Premier Implant Cement [Premier Dental]) (Figure 20). Two years have passed since restoring this complex case and the crown and abutment have never loosened.

CONCLUSION
Sometimes a situation presents that has no simple solution. This may be due to technical, medicolegal or ethical issues, or patient-centered issues. When this occurs, we may have to think outside of the box in order to best serve our patient. It is my hope that the solutions for the 2 patient cases described above will offer some insight on how the dental team can solve some of the dilemmas faced in clinical practice.

Acknowledgments
For their expertise and artistry I thank the following dental technicians:
Case 1—Daniel Materdomini, CDT, and his team, daVinci Dental Studios, Woodland Hills, Calif.
Case 2—Steven Killian, CDT, and his team, Killian Dental Ceramics, Irvine, Calif.


Dr. Fier is a full-time practicing clinician and highly respected lecturer for CE courses at universities, meetings, and study clubs in the United States and internationally. He is executive vice president of the American Society for Dental Aesthetics. He has been honored with Fellowships in the American College of Dentists, the International College of Dentists, and the Academy of Dentistry International. He is board-certified as a Diplomate of the American Board of Aesthetic Dentistry, a contributing editor for REALITY, on the Advisory Board of Dentistry Today, and has been listed in Dentistry Today's Leaders in Continuing Education for the past 11 years. Dr. Fier can be reached at (845) 354-4300 or via e-mail at docmarv@optonline.net

Disclosure: Dr. Fier occasionally receives materials, honoraria, and lecture support from many of the companies mentioned herein.