I was interested in this course held in March 2017 since it looked at how complex cases are addressed by the Clinic for Fixed and Removable Prosthodontics at the University of Zurich in Switzerland.

Complex cases are those where the  patients come into the surgery with their mouths in rather poor condition, but who are nevertheless prepared to invest time and money in obtaining a healthy, good-looking and properly working set of teeth, and who are also committed to doing what it takes to ensure that their new mouth is kept in good condition.

It is essential to make a complete study, with photographs of the patient’s face, mouth and teeth from different angles, also taking moulds for plaster casting and studying how the teeth are articulated. X-rays should also be taken as necessary.

A study must be made of the gums, tooth mobility, fillings and root canals required. The dentist must also decide whether certain pieces should or not be extracted. Orthodontics may similarly be required to align certain teeth for the purposes of fitting a fixed prosthesis or implants.

There are generally several possible treatments, of differing complexity and cost.

In these complex cases, at the University of Zurich, and in our San Sebastian dental surgery, we start by cleaning and treating the gums, making any essential extractions and proceeding with the necessary odontology treatments (fillings and root canals).

The quality of the oral hygiene subsequently required will be studied with the patient. This is followed by a study of the different treatment options. The symposium speaker called this Sequential Treatment.

The different possible treatments are devised according to the result we wish to and can obtain as regards both aesthetics and functionality. Sometimes we proceed with a Diagnostic Wax-up and a Mock-up. The diagnostic wax-up consists of mounting resin teeth on wax gums in a mould taken from the patient’s mouth, copying their teeth and showing what the resulting shape, colour and articulation of the new teeth would look like.

The Mock-up is a copy of the above, in the shape of resin veneers joined to one another, which are placed over the patient’s natural teeth to give an idea of the treatment result.

Once we know what we want to and can do, we will shape the teeth or fit implants, crowns or porcelain veneers, guided by the models and the desired final result. This is what’s known as Inverse Planning, where we work to a pre-established result.

During complex treatment, just like renovating a house, we may come across surprises which oblige us to adapt or extend the treatment. That’s why careful planning and the patient’s collaboration in maintaining their dental hygiene throughout the different stages of the treatment are essential.