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Prosthodontics/full mouth reconstruction

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Question
Doctor Elsafi,
My goal is to be as brief as possible while giving you information that, I hope, will  convey my concerns and present position to you with enough clarity for you to be able to assess and respond effectively.

I completed full mouth reconstruction ten months ago. All existing upper and lower teeth were crowned and right and left upper rear molars are now placed as a removal partial denture. I am planning to receive from one to three implants in the near future, and am considering sinus lifts to place implants in place of the RPD. I've held off on initiating the implants because it makes no sense to place implants and crown them to my existing occlusion, which has proven to be unsatisfactory.

I normally eat a healthy diet, consisting for example, of green salads with vinegar dressing, fresh and steamed vegetables, fruits and occasionally whole grain pastas, and have not been able to chew those foods with any degree of comfort or good mastication.

If I eat foods like beans, bread, or soft center sandwiches, I can get by, but even those foods are not well masticated. The overlying factor here is that I will not continue to eat a diet that I consider unhealthy any longer than I absolutely need to. It's already been too long.

For example; trying to eat a green salad; lettuce/cucumber/broccoli with vinegar is impossible. There is no cushioning or lubrication involved. The vinegar cleans away any lubrication effect and the green salad demands proper occlusion. If I attempt to eat these kind of foods, all I do is beat up the teeth and subject them to fracture and trauma. Plus I am swallowing un-masticated food.

Because of the structure of the upper and lower front teeth, I can not bite into an apple with enough ease to feel confidant about doing so without putting too much stress on the teeth, so instead, I sliced off a piece and tried very carefully and controlled to chew it. It took forever and was never masticated. Plus my jaw muscles felt exhausted by the attempt. The next day a lower molar had sore and swollen gum tissue and bleeding upon cleaning. I knew that with my fastidious cleaning that there could not be debris below the gum to cause infection, and concluded it was the result of the tooth being traumatized while trying to eat the slice of apple, even though I was consciously working to be as gentle as possible I attempted to chew. Three days later the tooth and gum were blood and pain free. The conclusion was no more apples or like foods. That ruled out eating and enjoying all of the foods that are a part of my normal healthy diet. I do make soups where the vegetables are boiled, and make smoothies in a blender, but that is not how I want to eat for the rest of my life, nor after the expense incurred should I be expected to.

The teeth are not properly occluding well and are unbalanced in contact. The side to side is way off. The teeth do not support their opposition through the movement. That includes movement to both directions. Trying to move side to side, and also to chew foods, generates hitting and grinding throughout the process, and does not provide reasonable mastication of the food. Only strict up and down and controlled movement, being careful to not close completely, occludes with anything close to proper occlusion.

To my understanding, one aspect of a full mouth reconstruction is that the bite will be optimal. Mine is certainly not and I am at a loss as to how to proceed.

My Board Certified Prosthodontist did not respond well to any questioning during all stages of treatment. This is very serious work, almost privileged, and should be conducted with the goal of what's in the best interest to the patient. I regret not catching this in the initial stages and either establishing a willingness to dialogue, or I would halt the treatment and find someone who was willing to treat me in that manner.

One question, for example, was in regard to my upper partial. Once the lower temps were replaced with permanent teeth, I lost occlusion of the RPD and the ability to chew. That was very early on in treatment. I tried to address this but my Dentist responded with an annoyed resentment and basically blew me off.  I have not been able to chew since that point in treatment.

I am not trained in Dentistry or Dental speak. From that point on, I decided to keep still and to trust my Dentist to deliver treatment that is to my best advantage, whether it seemed to be going well or not.

Finance was never a factor. I wanted well placed crowns in relation to the gum line that would offer protection to the tooth structure and would allow me to keep the areas clean and healthy, a good bite followed by good esthetics and speech, and was very willing to cover the expense of my Dentist providing it to me.

Upon conclusion of treatment, I made an appointment and requested that he do something to correct my bite. Specifically, number 11 which did not occlude at all, and he said that he could make it touch, but it probably would not function any better than it does now, and that he "wasn't going to chase dots!"

I understood what he meant by chasing dots, and it left me, in a word, stunned. I trusted this man completely. Was he telling me that what I have is all I'm going to get, whether it's right or not? He also said that in six months or so, my bite should feel comfortable. Even though what I was experiencing told me that the bite would not feel comfortable in six months, I decided to give it a chance, to trust him once again.

Another reason that I chose to hold off was because I was so thrown off by how he treated me that I needed time to gather myself together so I could address the issue calmly and in a controlled and effective manner.

If my Dentist is not completely willing to correct my bite, I do not want him to do anymore work on me. I don't want anyone to do anything that they don't want to do, especially when it comes to my teeth. I'd be better served to move forward and pay someone else to do it.

As previously stated, at one time, the upper temps were fine, but after delivery of the permanents, I sensed that the arch of the permanent upper teeth is too narrow, and my jaw placement was slightly forced backward, and I began to experience jaw pain and clicking.

My first concern is in regard to re-doing possibly most, if not all of the upper teeth, and possibly some lowers as well.

At this time, I have no tooth sensitivity, they look great and my speech is 99%. I am not saying that they all need to be replaced, but since the original temps occluded well, until the permanent lowers were delivered, I do consider something that drastic in nature may need to be done.

I am also concerned that the teeth were already traumatized once, and to do it to them again is not something I feel is without risk to the integrity of the teeth, especially if it's done by someone who resents having to do it.

I am not comfortable going to another Prosthodontist and having him have correct someone else's work. Probably a different Lab, possible different esthetics, but if that's my only option, then I am considering that's what I'll have to do.

And, it doesn't seem right that I should have to pay for this caliber of work twice, but if that what it takes for me to have a healthy mouth, and a healthy body, I will do it.

I have an appointment in a couple of weeks to meet with my Prosthodontist and plan to approach my issue, but I am somewhat uneasy as to how to do it in a way that will be to my best advantage.

From your perspective as a Dental Professional, what should I rightfully ask for, and also expect, from my Prosthodontist at my next meeting with him? Do you have any suggestions regarding how I should approach the issue with him?

Thank you Doctor.

Answer
Dear Mr. Jensen,
As prosthodontists, we take pride in perfecting the occlusion on our full mouth reconstruction cases and that's what makes us different from general dentists. You should not feel uneasy to address your occlusal issues and concerns with your prosthodontist. I suggest to write all your concerns and problems on a piece of paper and discuss them one by one with your prosthodontist. I am sure that he will do his best to correct them.

Good luck,
Dr. Elsafi

Prosthodontics

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Mohamed Elsafi, DDS, MS, FACP

Expertise

I am a board-certified Maxillofacial Prosthodontist. I do head and neck prosthetic reconstruction for patients with congenital and acquired defects. This also includes trauma and cancer patients. I can answer questions about prosthetic rehabilitation of the head and neck area. I am also a board-certified prosthodontist and can answer questions about dental reconstruction including crowns, bridges, veneers, partial and complete dentures and implant restorations. I can also answer questions about TMJ problems. I can not answer about surgical reconstruction.

Experience

I am a board-certified prosthodontist and maxillofacial prosthodontist and have been practicing denitstry for over 15 years.

Organizations
American Academy of Maxillofacial Prosthetics. American College of Prosthodontists. American Dental Association.

Education/Credentials
I received my dental degree from University of Southern California. I did my prosthodontics residency at University of Florida and my maxillofacial prosthetics fellowship at MD Anderson Cancer Center in Houston.

Awards and Honors
Chief Fellow at MD Anderson Cancer Center.

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