Gingival recession or bad lab work: what do you think?
Dear Friends,
I am a dental technician and completed this 8-unit implant supported fixed partial denture with implant abutments in #5,6 [maxillary right first premolar and canine; 14,13] Â and 11, 12 [maxillary left canine and first premolar; 23, 24] with pontics in #7-10 [maxillary right central and lateral incisors and maxillary left central and lateral incisors; 12,11,21,22]. Â The framework fit the abutments. Â But the soft tissue adaptation is bad. Â Very poor aesthetics. Â The doctor called and said he was not paying his bill because of laboratory errors in fabrication of the fixed partial denture. Â He even sent these photographs of the case in the mouth. Â I think he sent old impressions and made a temporary bridge that was poorly adapted to the gingiva and produced the gingival recession. Â Look at my working casts. Â The case has had a poor result because of the dentist’s work, not the technician. I did not cause the gingival recession. Â Do you agree with the above? what to do?
material sent to Dr
job in mouth
job in mouth
job in mouth
24 Comments on Gingival recession or bad lab work: what do you think?
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Dr. Alex Zavyalov
4/20/2012
Unlike photos taken by the dentist, your pothos are not related to the subject of the discussion. If pictures of your mounted models (only with gingival mask) had been taken from the same angle/viewpoint, you would have been able to prove the dentist’s mistake. The possible remedy is to add some amount of pink porcelain.
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incisor
4/23/2012
Dr. Alex, thank you for your observation. Please note; I photograph every job I receive and every job I send in order to keep track of materials sent and received. noramly I use photos Dr.'s send back after placing jobs for show case etc because objective of any job is final result in mouth and not on model. It is the first time this kind of situation arrises. For this client I will start taking photos from various angles. note: I would never send out a job with this kind of problem. all my work has 4 years full guaranty and I replace jobs at no cost if necessary, so I must have a lot of rigor and quality controle.
ALI ASADI
4/21/2012
Don,t be angry.it can be solve by cooperation of both doctor and technician.I think for salvage of this problem it,s better to use FP3HYBRID model for covering of black spot.
incisor
4/23/2012
Dear Ali Asadi,
Thank you for your comment, I will resolve this job with pink porcelain or with a removable flexible orthosis. all I need is that he sends the job back or new impressions.
dr ulloa
4/22/2012
hahaha.... the papilla lost is caused because the implants are very close each other.... not for the lab technique. Any way, you must solve the case with pink porcelain.
good luck and sorry for this kind of colleagues that emend his mistakes to lab expense
camilo
incisor
4/23/2012
Dr. ulloa, thanl you for your comment. If you look close at the photos, it is visible thaty the exposed metal on cervical is grey, ie: Ti... and not a polished metal colar. I think he kept this impression at his office for a few months and patient had only temporary anterior crowns and had no posterior temp crowns on implant or more probably he had baddly executed temp crowns on the implant that caused rapid gingival recession. notice how my anterior crowns have a perfect adaptation and correct emergence profile (besides the excess ciment visible). it looks like 2 diferent technicians made the job. I think he just doesn't want to pay... but it is a pitty because I don't charge for corrections or eaven substitution. I believe niether the patient nor the dentists want to repeat a job unless it is absolutely necessary, that is why I give 4 years guaranty, no charge...
Dean Tanaka
4/23/2012
If there was an embrasure shadow at the time of cementation, the dentist should have taken a new mold of the tissue reprovisionalize and have you fix. (maybe the provisionals were too big... i donno). If the dentist cemented it anyway, it's still the dentists fault. Must be frustrating for you since its' hard to lose this person's business, but it's an obvious fault of the dentist. Good Luck!
Richard Hughes, DDS, FAAI
4/23/2012
This case should be remade. There is a lack of proportion with the cuspids and bicuspids. The anatomy is improper for all the teeth. This case can be saved with a proper remake and perhaps pink porcelain. The papilla may be an issue. It would be nice to see the case with the patient smiling and without retraction. Cement or screw retained is the doctors preference.
Peter Cabrera
4/24/2012
I believe the problems for this case began with the surgical planning. As a periodontist, I can tell you that the facial bone and tissue are somewhat thin, especially on the right side. Your occlusal photo of the models show this. Without appropriate bone and tissue, it will be impossible to develop an acceptable emergence profile for the restorations. Without a good emergence profile, the contour of the restorations will always look bad.
You cannot grow bone and tissue in the lab. Pink porcelain may help improve the situation, but will not correct a surgical deficiency. You can mask certain things, but you cannot correct them . Porcelain in the wrong spot will make it impossible for the patient to clean and will create a different set of problems.
Before proceeding with anything else, make sure you sit down with the doctor and identify the issues, tooth by tooth and what your laboratory modifications can realistically accomplish.
Simply redoing the case without specific expectations will lead to disappointment and frustration by all.
I give you a lot of credit for presenting this in public.
Good luck.
incisor
4/30/2012
Dr. Peter Cabrera
thank you for your opinion. I managed to convince my clients assistant to take an impression (in alginate) of the job in mouth and she sent it to me. I proceded to manufacture a nilon (flexible pink) removable mask to engage on vestibular and have sent it back with request for photo of job in mouth and payment. till now no answer...
David Broughton
4/24/2012
If the fixtures are supra gingival, the the technician has very little chance of providing a good aesthetic result. Either produce as is, with poor aesthetics, or provide pink porcelain to mask the fixtures, in which case hygiene is compromised. Also it is very difficult to make pink porcelain fused to metal have any chance of being aesthetically pleasing.
In this case, a simple removable acrylic mask, which just engages into the undercuts around the abutments, hides the gaping spaces, and would be more translucent than the bonded porcelain, would improve the aesthetics around the canines and premolars, and the dentist should have realised this before sending to the lab.Since clearly the dentist did not appreciate the problem, then it would have been prudent for the technician to communicate this to the dentist.(Wise after the event!)
The emergence profiles of the incisors show good understanding of aesthetics, but no chance with the units over the fixtures.
It is the patient who has been compromised here.
If the dentist took such an aggressive attitude with me as a ceramist and implant technician, without realising his own shortcomings, then I would expect him to either pay up, or return the bridgework.
In the absence of good communication between dentist and technician, and if the technician cannot become the magician the dentist expects him to be, then the technician is better off without that particular dentist!
David Broughton
incisor
4/30/2012
Dr David Broughton, thank you for your reply. I made a removable pink nylon mask, to engage on vestibular and I think it will compensate aesthetics. I also sent a note for the patient about how to remove and clean because I don't think this client will inform patient correctly (given his attitude to date). I also offerd to repeat the job if necessary with no aditional cost. My only concern is with the patient and my reputation. I send back jobs to clients with a written 4 year guarantee for patient to stamp at the clinic every 6 months at check-up, but patient can go to another clinic and this new potential client will look at this job and think this is my normal work.
That is why I would like to repeat or receive photos with mask in place for me to evaluate and "rest this case".
ktau
4/25/2012
Dear Incisor,
I'm glad you take such pride in your workmanship.
Whilst I think the 'black hole' between the implants is due to loss of tissue and hence not your fault, the anatomy of the incisors, in fact all the teeth, is a little wanting. Perhaps you could improve them in future cases.
franco
4/25/2012
If the doctor (and/or the patient) is not happy with the job, then he must return it to the lab and complain ! OR cement it in patient's mouth and NO complaint.
incisor
4/30/2012
and pay...
Dr. Samir Nayyar
4/26/2012
Hello
Doctors are not always right and one should have the guts to accept the worngs done by them. Definitely if the doc has any problem he/she should not cement it & send the patient as it is. If the doc sent the patient as it is & got all the for his work then he doesn't have the right to say like this. Every problem has a solution but that has to be found out in a proper way.
Its very nice that you posted this case here. If you are right then no one can suppress you. Just add pink porcelain or it would be best to repeat the framework again.
Best of luck buddy.
Baker vinci
4/26/2012
The limitations associated with this type of dentistry are significant. If function is acceptable and access for oh, appropriate, then you have given him a good product. It's a shame your referring doctor doesn't understand that attached mucosa, or papilla will not grow where bone doesn't exist. Bv
J
5/8/2012
I dont think none of us have enough information to really know whose fault this is, however, in relation to the laboratory work I would like to say that the contouring of the restorations is far to be ideal. There is definitely a lack of tissue architecture but the problem could have been diminished with longer contact points, a more natural emergence profile and proper buccal anatomy. I wouldn´t be happy with this prosthesis either. If a laboratory sent me these restorations I would pay them but never use that lab again.
incisor
5/11/2012
Dear J, if you notice the cervical of anterior crowns, you will see (especialy in last photo) that he did not remove excess cement before taking photo. you can not evaluate the emergence profile, if the cervical of the crowns are coverd with cement.
I give all my clients a printed 4 year guarantee for all the jobs I make. all he would have to do is send me new (up to date) impressions and I would repeat the job with NO COST. If he didn´t like the job he should send it back and I would cancel this invoice.
Please note, I received primary model with this job to copy position and anatomy of anteriors, so what you see is very close to what patient was used to.
I agree that aesthetics could be better, but Zircon substructure takes up some space and leaves little for good depth of shade and translucency. needless to say that patient accepted the job because he liked what he saw in the mirror, ie: anterior crowns.
It's not easy, but I never refuse to try better a job. I believe that neither the patient nor the Dentist have any interes in adjusting or repeating unless it is necessary.
The answer to this problem is team work. if the Dentist is only interested in saving money, then we have an unbalanced situation. I don't avoid costs to repeat a job if necessary, but I don't accept that he does not return the job or pay... it is not correct. I would eaven accept he leave my job as temporary, while he sends work to another lab, but after placement he must send me my job back.
Thank you for your comment, and I apologise for my tone, but I don't like unjustice and incorrect prepotent atitudes. he would be right if I refused to solve the problem.
Baker vinci
5/10/2012
If the hydrodynamics and function are sound, why is the esthetic emmergance profile important. No one is looking under the patient's lip, except the patient and the doctor. You suggest there is not enough information, but you are throwing this man's work in the trash? Function and ability to clean are essential for successful posterior implant dentistry. I would have to assume the contact points are a result of the implant position and the tech.s attempt to not overload "them". Bv
incisor
5/11/2012
I requested new photos from the dental assistant, with the removable flange in place, but only if it does not jepordise her situation.
This solution for me is still a plan B because the job shold be remade to avoid food impactation and resulting problems.
I think it was wrong to send him the vestibular flexible gingiva mask, because I just incurred aditional costs...
CRS
5/15/2012
Without an xray, It looks like there was inadequate buccal plate and connective tissue. The case should have been grafted prior to implant placement. It may be possible to perform a soft tissue CT graft, I doubt that bone can be added. Why was this cemented? The graft could have been done with a closed flap for healing.
Jace
5/20/2012
Poor implant placement and tissue management. There is no keratinized tissue and implants do not form papillae when they are placed next to each other. Crowns are fine.
Lawrence D Singer, DMD
6/12/2012
this is clearly poor implant site placement and planning. Look at the height on the models and the spacing. There was no attention to ridge or soft tissue development. This is a classical case of underestimating the complexity of the issues at hand and not pre dicing the biological response of the tissues. Otho first would have been best. Ridge development was necessary prior to implant placement for a better outcome.