Interdisciplinary Treatment and the Study Club Dynamic
Fostering success with collaborative patient care
Michael C. Verber, DMD
Interdisciplinary rehabilitative dental treatment requires strong patient relations paired with open, timely communication among colleagues. Because the dental industry has traditionally been characterized by isolated practitioners and small group practices, many dentists have struggled to realize the full potential of interdisciplinary teams. A structured restoratively driven study club, however, can provide a sense of fellowship and a forum conducive to interdisciplinary perspectives.
The Dawson Academy Study Club package gives groups of doctors resources to experience shared continuing education. It also provides tools and opportunities to present and treatment plan in a group environment. The Central Pennsylvania Dawson Academy Study Club serves as an example of how cooperation among colleagues can foster extraordinary patient care. The case described below illustrates the combined efforts of seven members of this study club.
Stephen Canis, DMD:
Case Presentation
General dentist Stephen Canis shared with members of the study club a case in which he recognized signs and symptoms of occlusal disease. Initial treatment had begun, but Canis was developing a comprehensive treatment plan prior to any final restoration.
The patient was seeking to restore his posterior edentulous areas with fixed implant-supported prosthetics. The mandibular incisors, canines, and premolars and the maxillary anteriors were retained, as were teeth Nos. 15 and 18 (Figure 1). While awaiting osseointegration, Canis reflected on the case and proposed the following questions:
• What occlusal scheme best suits the patient’s mix of natural dentition and implants?
• Should the implants be splinted?
• What restorative materials should be considered?
• Would screw-retained or cement-retained prosthetics be more advantageous?
• Is the number of implants placed sufficient?
Michael Verber, DMD:
Comprehensive Examination, Records, and Functional Esthetic Analysis
After initial discussion and an implant integration period, the author was invited by Canis to see the patient at his office. With the aid of the Dawson Diagnostic Wizard™ software (www.dawsonwizard.com), they performed a complete examination of the soft tissues, teeth, muscles, joints, bone, and airway. Records taken included a facebow, models with implant analogs, photographs, and a centric relation (CR) bite registration. The models were mounted on a semi-adjustable articulator (Denar® Mark 320, Whip Mix, www.whipmix.com), and the photographs and data were entered into the Diagnostic Wizard. This software not only aids in the collection and organization of data, but also provides virtual tools to diagnose, design, and plan treatment. Its visual impact promotes patient education and case acceptance, and its online portability facilitates communication within the interdisciplinary team. The application is included with a Dawson Study Club membership.
During the exam the patient expressed cosmetic concerns related to the deterioration of existing anterior composite restorations. The patient also desired esthetic correction of diastemas and shade (Figure 2) and reported a history of bruxism.
Using the bimanual manipulation technique, the condyles were seated in CR and comfortably loaded.1 A posterior interference was noted on remaining molars Nos. 15 and 18. The interference created movement from the CR position into maximum intercuspation as characterized by a Dawson type II occlusion.2 The temporomandibular joints were quiet upon Doppler auscultation, indicating healthy, properly aligned condyle-disk assemblies.3
Treatment planning began with a 2D functional-esthetic analysis checklist, looking at the articulated models, photographs, and a summary report of the exam findings. The case was examined for the requirements of occlusal stability4: equal intensity stops; anterior guidance in harmony with the envelope of function; and immediate disclusion of posterior teeth in excursive movements. None of these functional criteria were met. The posterior interferences, in particular, offered an explanation for the patient’s bruxism. While implants will restore the posterior teeth, they lack the proprioreception of the natural dentition. The sensory feedback from the patient’s retained anterior teeth can be used to create anterior guidance and reduce or eliminate parafunctional muscle activity.5
Global and macro esthetics were considered. It was found that the mandibular plane required correction to establish an acceptable curve of Spee. In addition, the position of the maxillary anteriors violated the parameters of golden proportion (Figure 3).
Corrections to the shape, size, and position of the teeth were visualized while working through a 3D checklist on the Diagnostic Wizard and articulated models. After considering surgical, restorative, equilibrative, and orthodontic options, a treatment plan was developed and accepted by the patient.
Edward Hilton, DMD:
Achieving Occlusal Goals with Virtual Orthodontics
Bringing a wealth of experience to the study club, orthodontist Ed Hilton has consistently produced case results meeting the requirements of occlusal stability. The patient was referred to Hilton for orthodontic treatment to reposition the teeth to achieve golden proportion and anterior guidance, allowing for minimally invasive restoration.
Using the virtual CAD tools available with the Invisalign® system (Align Technology Inc., www.invisalign.com), the team was able to design outcomes to meet the parameters set by their 2D and 3D checklists. Spaces were left to accommodate planned tooth size and contours that would be created with the addition of restorative material. The Invisalign treatment was scheduled to proceed.
Becky Fox, DMD:
Digital Dentistry
When it was determined that the patient lacked the necessary anchorage to orthodontically position the anterior teeth, the team turned to Becky Fox, an advanced CEREC® (Dentsply Sirona, www.cereconline.com) user and trainer with expertise in digital impressioning, digital design, and in-office milling, for a solution. By placing scan bodies on the implant analogs in the pretreatment diagnostic models, she was able to digitally impress and articulate the dentition. Using IPS e.max® CAD lithium-disilicate blocks (Ivoclar Vivadent, www.ivoclarvivadent.us), she milled screw-retained crowns to serve as anchorage devices (Figure 4). The crowns were designed out of occlusion and with open contact to allow for the anticipated tooth movement.
Robert Myers, DMD:
Bone, Implants, and Cloud-Based Communication
Oral and maxillofacial surgeon and implant specialist Robert Myers provided initial treatment for the patient that included ridge augmentation and bilateral sinus lifts with platelet-rich plasma. Six maxillary and two mandibular posterior implants were later placed and exposed using a two-stage protocol. A final implant was eventually added in the No. 31 position.
To help streamline and share information among doctors, technicians, and staff and advance standards of care, Myers has developed a cloud-based application to allow providers to upload and access files to and from a patient history. PatientWeb (www.patientweb.com) also allows doctors to message, create referrals, provide treatment updates, and draft lab prescriptions.
Through the course of this case, at least two dozen instances of online communication took place. Photographs, x-rays, treatment prescriptions, reports, and Diagnostic Wizard data were electronically managed by connecting the entire team to a single HIPAA-compliant platform.
Melinda Whire, EFDA:
Team Approach in the Restorative Operatory
Understanding and participating in all phases of treatment from diagnosis to delivery allows an EFDA to provide valuable recommendations and support. With proper training and an expanded scope of practice, the role of many dental auxiliaries is shifting from basic assisting to partnering with doctors to ease much of the restorative burden and improve care.
At the completion of the patient’s orthodontic treatment, Melinda Whire, a licensed extended function dental assistant, took a new set of records for final restorative design. She also managed whitening treatment to lift the shade on the lower incisors. The laboratory work associated with the models, mounting, and whitening trays was all handled by laboratory assistant Erickia Rynard, EFDA, who also created reduction guides and a temporary matrix from the diagnostic wax-ups.
All the teeth receiving indirect restorations were prepped, and Whire fabricated provisional prototype restorations with a self-curing bis-acryl composite material (Telio CS C&B, Ivoclar Vivadent). After a few weeks of wear, the prototypes were refined, records of the temporaries were completed, and a final impression with a centric relation bite registration was taken. Final porcelain crowns were luted with Variolink Esthetic (Ivoclar Vivadent).
Craig Yoder, CDT:
Technician-Guided Planning
Craig Yoder, a ceramist and manager of Thayer Dental Laboratory (www.thayerdental.com), gives the study club group an appreciation for the role a knowledgeable technician can play in the treatment planning process. Rather than having to make esthetic and functional compromises late in treatment, ideal outcomes can be achieved with early laboratory guidance.
After reviewing the articulated models and the Diagnostic Wizard, Yoder completed diagnostic wax-ups. He and his team were then able to advise on material choices, prosthetic design, and implant components. The anterior and lower premolar restorations were done with e.max Press (Ivoclar Vivadent) crowns by Thayer ceramist Harold Diedrich, CD (Figure 5).
The mandibular single-unit implant restorations were fabricated with zirconia crowns retained on custom titanium abutments with zinc-phosphate cement. The maxillary posterior implant restorations were designed as screw-retained hybrid-type restorations. The milled zirconia prostheses were based off of scans of provisional prototypes created in-office by Rynard. Cut-backs in the final restorations allowed for the layering of porcelain to maximize esthetics of the teeth and pink gingival areas (Figure 6).
Discussion
Through the support of colleagues, one can find motivation, shared knowledge, and perspective. Dawson Academy Study Club members examine the latest scientific and management trends through modules that feature industry-leading researchers, clinicians, and management consultants. The tools and benefits included with membership are valuable treatment aids. The perspectives offered by colleagues inevitably provide valuable wisdom and have a positive effect on patient care. By sharing the principles of complete dentistry and gaining mutual understanding of interdisciplinary treatment goals, strong bonds are formed between treatment teams.
Disclosure
Michael C. Verber, DMD, has no relevant financial relationships to disclose.
References
1. McKee JR. Comparing condylar positions achieved through bimanual manipulation to condylar positions achieved through masticatory muscle contraction against an anterior deprogrammer: a pilot study. J Prosthet Dent. 2005;94(4):389-393.
2. Dawson PE. Classification of occlusions. In: Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby Elsevier; 2007:107-109.
3. Piper MA. Piper’s Classification of TMJ Disorders. Piper Education and Research Center website. http://www.pipererc.com/tmj.asp. Accessed June 22, 2016.
4. Dawson PE. Requirements for occlusal stability. In: Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby Elsevier; 2007:345-348.
5. Kerstein RB, Radke J. Masseter and temporalis excursive hyperactivity decreased by measured anterior guidance development. Cranio. 2012;30(4):243-254.
About the Author
Michael C. Verber, DMD
Faculty
The Dawson Academy
St. Petersburg, Florida
Private Practice
Camp Hill, Pennsylvania
