iatrogenic issues in
Fred H. Peck, DDS, AAACD
WHEN DENTISTS EMBARK on cosmetic improvements for our patients,
our goal is to improve the patient’s appearance, self-confidence, and dental
health without causing additional problems. One of the hardest tasks we
have as professionals is when a patient presents with a situation that was
directly caused by previous dental treatment, whether our own or someone
else’s. A delicate conversation follows: we should assure the patient we are
there to help, but we should not comment on the past dental treatment if
we do not know all of the facts. If we caused the issue, we should just
correct it for the patient. If it was done elsewhere, we should keep the
discussion to the facts and correcting the patient’s issues.
A 52-year-old female patient presented to my office with recent porcelain
restorations that had been placed on her upper six anterior teeth.
Besides her complaint of the bite feeling different, her main concern
was that her speech was off, especially her s sounds. She stated these
problems occurred after the final crowns were placed. Further questioning also revealed that she was unhappy with color and shape ( figures
1–3). A full examination was completed, including x-rays and photographs, and periodontal, TMJ, occlusion, and dentition evaluations.
She had excellent oral health and her dental issues were all related to
her occlusal and esthetic complaints.
My diagnosis was that the final anterior restorations induced an
anterior constriction. Her mandible was forced posteriorly from
overcontoured excess lingual porcelain on teeth Nos. 7–10. In addition,
her tongue did not have enough room to move forward for proper speech
enunciation, especially with her s sounds. The initial treatment involved
placing the patient in a Kois Deprogrammer appliance. 1 This would allow
her mandible to move in a position dependent on the muscles and remove
the interferences caused by her dentition and the excess lingual porcelain.
The patient returned one week after wearing the appliance and stated
that she felt great, her jaws were comfortable, and she liked their position.
Diagnostic models were taken in her centric relation position with the
appliance in place and mounted on a Panadent articulator. A diagnostic
equilibration was completed on the models. The final equilibration would
be completed after an additional three weeks.
SCIENCE & TECH
Figure 1: Anterior smile view of the patient’s original restoration
Figure 2: Anterior retracted view of the patient’s original restoration