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Examiners’ Observations- Key Insights for Accreditation Case Type III

Examiners’ Observations- Key Insights for Accreditation Case Type III By Scott Finlay DDS, FAGD, FAACD

In Case Type III, the candidate is challenged to replace a missing maxillary incisor or cuspid to a level of accreditation excellence. The operator is given the option of replacing the missing dental components with either a bridge or an implant. If a bridge is selected, the accepted standard of excellence is the use of an ovate pontic. Replacement of a crown on a pre-existing implant is not acceptable for this case presentation.

The edentulous space must be documented pre-operatively with a radiograph. The examiner’s focus is limited by definition to the replacement tooth and any areas that that candidate has treated. It is not necessarily a case type in which comprehensive smile design criteria are heavily weighed, unless the treatment rendered encompasses a broader field in the smile zone.  The candidate must keep in mind that if a limited scope of treatment is elected, the balance of the smile zone should not be visually distracting to a reasonable extent that may otherwise indicate the need for additional management. A common modifier in this case type is underestimating the time required in establishing ideal tissue architecture.

The candidate’s case selection and abilities to treatment plan are particularly magnified in this case type. It is in the candidate’s best interest to find a patient with reasonable periodontal architecture that presents the optimal environment to create excellence. Our goal is to achieve a result that challenges the observer’s eye in discerning that a natural tooth does not otherwise occupy the edentulous space.  Working with a mentor, who has been calibrated as an examiner, is strongly recommended with every Accreditation case.

Successful management and treatment planning demands a mastery of not only prosthetic concepts, but also the parameters of health imposed by the periodontal architecture. Although some restorative dentists may provide advanced surgical procedures to their patients, in many cases effective treatment involves an interdisciplinary team.  This team would typically consist of the restorative dentist and the surgeon who may be involved in site development or the placement of the implant. Regardless of who performs the surgery if it is indicated, the key responsibility remains the orchestration of the treatment planning by the restorative dentist with a protocol that will hopefully provide predictable, durable and esthetic results.

A predictable protocol begins with a complete understanding of the options to restore the health and function for the patient. This protocol starts with a visualization of the desired solution that is then studied and modulated in 3 dimensions through the use of diagnostic models and a wax up of the intended result.  From this dental blue print, stents can be fabricated and utilized in both the surgical and restorative phases to effectively reproduce the designed anticipated results.  The restorative dentist will find great value in methodically and patiently manipulating the prototype restorations to help establish the best possible periodontal architecture.

Dr. Chan should be commended in his fine demonstration of each of these elements of case management and the final result. His conservative approach in limiting his treatment to the edentulous areas #6/11 was well within the parameters of this case type. His model analysis and diagnostic wax up allowed him to make key decisions in managing the spaces and develop the appropriate stents to be used during treatment.  His understanding of the biology of the system facilitated his planning in the ideal placement of the implant in 3 dimensions.  His attention to detail in managing the prototype insured the predictability of the tissue architecture and what appears to be a healthy and sustaining result.  His keen eye identified those elements of macro and micro esthetics that allows the restorations to invisibly disappear into the surrounding dentition.

The examiners as a group identified very limited criteria that were at fault. Most examiners awarded the case a plus one because of the excellence that it demonstrated.  The case passed unanimously.  Those criteria that accounted for minor deductions included:

Criteria 53- The opacity is slightly high in the cervical 1/3 of the cuspids
Criteria 87- Minor dissymmetry’s are noticed in the contra lateral teeth #6 & 11

The Accreditation Process represents the ultimate challenge in your growth in the mastery of dental esthetics.  Achievement of this gold standard of excellence will provide immeasurable rewards for you and your patients.

Accreditation Examination Criteria, American Academy of Cosmetic Dentistry, Madison, Wisconsin, March 2009.

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