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I spent the very end of the day into the 6pm hour remaking and adjusting an anterior provisional from the upper right canine to the upper left canine for the second time. By now for the dentists reading this your blood pressure is elevated and you may be beginning to sweat. In the early years of my career when this happened I would have gotten frustrated and called the lab and asked that they rush the case back. In this case I can’t call the lab, as we have not taken final impressions, because these provisionals were designed to test the occlusion and esthetics. Instead of getting frustrated, I ask myself what is the story the provisionals are trying to tell me. Something is flawed in my design and the provisionals are telling me what it is, I simply have to listen. True if I went to porcelain it wouldn’t fail in 48 hours, but it would fail and sooner than either the patient or I would prefer.
The first place I look when this happens is the occlusion. The patient reported waking with headaches the first two mornings after we placed the provisionals. This is a significant finding and I’ll address it in Monday’s post. I started by looking very closely at protrusive. The patient was in my opinion heavy on the centrals and laterals, so I began the process of adjusting. As I adjusted I realized he was also catching on the incisal edge in his return stroke from protrusive. I added the leading edge and trailing edge to the provisional to allow for a smoother transition. The more I adjusted, the more he came forward, not the first time I have experienced this. Ultimately I left the guidance shared between the canines and the centrals and as smooth as I could make it. Low and behold he broke the provisional again.
Today in my adjustments my goal was to shallow his guidance and begin to share protrusive with the premolars. Unfortunately due to the position and shape of his anteriors and his condylar guidance this would require major occlusal adjustment. What I need to do in order to shallow guidance is either decrease overbite or increase overjet. The incisal edge position was set esthetically, so my only option for decreasing overbite is shortening lower anteriors. In order to increase overjet I can procline the restorations. The only way to solve this issue is to work it out on an articulator. Since it was after 6pm when we finished the provisional we rescheduled to get new models, a facebow and protrusive records. With the mounted models I will work all of this out before going to the third set of temps!
Lee- Thank you for sharing this case and for your courage in doing so. This is a powerful learning experience for nearly everyone following your blog and resonates the congruence between your values and your teaching method. I would be very grateful to be your patient!
Hi Lee
2 questions
What is meant by “procline”?
How is all of this unforseen time figured into a fair fee?
Jerry,
Priceline is to tip the incisal edge to the labial. Since the gingival position is fixed, you angle the incisal edge labially. This slope will increase overheat and shallow the interincisal angle, therefore guidance.
As for the fee, in complex functional and restorative cases I estimate in time for several sets of temps plus ten percent for misc. When I estimate poorly its a great learning experience for the next case!!
Lee
Thank you for your fine discussion of functional occlusion. We need more of this in the dental profession. For these reasons, I cringe when I hear a dentist claim they can slap on 6 anterior braces and acheive functional occlusion in 6 months. Really?! In the end, no matter how fantastic the comprehensive orthodontic result is, for the best functional occlusion possible, you still need equilibration diagnosed from a set of CR mounted study models with a corrected hinge axis.
Thank you for writing this and best wishes in your pursuit of functional occlusion excellence!