Interesting Worn Dentition Case Part 2

Hi everyone,

I wanted to start off by thanking all of you for the excellent ideas and comments related to my last post. Many of you had excellent thoughts about how this wear evolved over the years and how you would help this patient. Today I would like to share with you the etiology of the wear and the actual treatment plan that the patient selected.

As I stated in the last post this particular patient came into my practice with a significant amount of tooth wear but he had no TMJ or muscle symptoms and has good bone levels around his teeth.

There are a number of correct answers to the question I asked about the etiology of wear for a patient like this and if you look in the comments section of the first post you will see many great ideas from the people that participated.

Examination of the tooth wear revealed that the wear facets were present on tooth surfaces that were not in occlusal contact. Attrition requires the wear to be derived from tooth to tooth contact so this wear appears to be predominantly from erosion.

This patient was aware that he had significant wear and when questioned about the etiology he let us know that he consumed one 1.5 liter bottle of Coca-Cola per day for the last 20 years. With a pH of 2.48 Coca-Cola consumption of this magnitude and duration would certainly lead to this amount of erosion and tooth loss.

During the functional analysis large centric relation interference was discovered on the palatal cusp of 17 and the buccal cusp of 47. This interference was also located and verified with the 2 sets of the CR mounted study models that were made with the 2 CR bite records. I take 2 sets of CR bite records and make 2 mountings to verify the accuracy of the bite records and the mountings. I am looking for the 2 sets of bite records and the 2 sets of mountings to be the same.

I then verify that the point of initial contact on the mountings matches what I found in the mouth. If all of this is consistent then I feel that the CR bite records and the mountings are accurate and can be used for the diagnostic wax-up.

As you can see with the photograph of the 2 sets of mountings they match each other and the point of initial contact that I found during the functional analysis.

For this case the patient recognized that he needed significant restorative dentistry to be restored to a more healthy functional and aesthetic condition. He did ask if I could figure out a treatment plan that would fit within a reasonable budget and avoid a full mouth rehabilitation. With this in mind I treatment planned to open the vertical dimension to the point of initial contact and restore the upper arch from first molar to first molar and the first bicuspids and first molars on the lower arch. This treatment plan would lead to a 16 unit partial rehabilitation and I planned to use direct composite bonding to restore any erosion that is present in the remaining dentition.

I also planned to alter the gingival levels of 11 (8) and 21 (9) to improve the gingival symmetry as well as the retention and resistance form.

If you place the study models from this case on the Sam 3 articulator and close to the point of initial contact you can see the vertical dimension that the case will be waxed up to. This technique will open the vertical dimension in most cases more than enough for the restorative material requirements without increasing the contracted length of the elevator muscles.

For this patient with his MI position he had no room for the restorative material due to extensive erosion and tooth eruption that has led to an end-to-end anterior tooth relationship. If you tried to restore him to his MI position you would compromise the structural integrity of the upper anterior teeth.  This can be solved with either orthodontics or opening his vertical dimension.

I have completed the crown lengthening with my Waterlase MD dental laser and the case is now being waxed up with the initial preparations scheduled in 3 weeks. I hope these posts have provided you with some interesting ideas about treating this type of case. As usual you can add any questions or comments using the link above.

Anterior Teeth Before Gingival Adjustment

Anterior Teeth After Gingival Adjustment With The Waterlase MD Laser

2 Sets Of Mounted Models

Models At The Point Of Initial Contact

Models At The Point Of Initial Contact

Models At The Point Of Initial Contact

Models At The Point Of Initial Contact


Interesting Worn Dentition Case

Hi Everyone,

For this weeks blog post I thought I would share with you an interesting worn dentition case. During the last few years I have noticed that we have seen a real increase in the number of patients entering my practice with significant tooth wear seeking help.

I don’t know about the rest of you but it seems to me that with the improvement in periodontal care, patients are keeping their teeth longer which is leading to many different forms, patterns and degrees of severity of tooth wear that patients are presenting to our dental practices.

This particular patient came into my practice with a significant amount of tooth wear and the resulting occlusal changes but he had no TMJ or muscle symptoms and has good bone levels around his teeth.

I have completed a functional analysis, complete exam and treatment planning consultation with this patient and I will tell you that the tooth wear has a clear etiology.

I thought it would be an interesting learning exercise to find out what everyone believes are the possible causes for this pattern of tooth wear and what your treatment plan would be for this patient. There are a number of correct answers to these questions and next week I will share with you the etiology of wear for this patient and the treatment plan that we have decided to follow to restore him to a more healthy functional and aesthetic condition.

As usual you can leave your comments using the link above this post.

Part 4: Would you extract this tooth or not?

Hi everyone, once again I would like to start off by thanking all of you for the excellent ideas and comments related to last weeks post and let you know that if I have not responded to your comments yet I will in the next week. It really is great to see everyone’s ideas about treating a case like this and I enjoy all of the comments and suggestions.

Today I would like to share with you how I handled the implant placement and provisional issues that this case presented with. As you know from last weeks post I elected to graft the socket and delay the implant placement for three months for the bone to heal and the soft tissue to mature around the provisional crown.

For the implant placement I had a Simplant Surgiguide made from CBVT scan of the case. The Surgiguide is a steriolithographic stent, which was constructed on the stone model of the patient’s mouth with the central incisor removed. This particular Surgiguide was made with a 5.0 mm Straumann sleeve that will guide the implant placement with depth control build into the system.

The first thing I needed to do was to remove the provisional crown that was bonded to the adjacent teeth. I did not want to damage the unprepared adjacent teeth so I used a thin Axis Dental KS0 cylinder diamond to cut through the old crown leaving a little of the flowable composite on the adjacent teeth. I then polished this composite with composite polishers and assessed the remaining ridge and the fit of the Surgiguide. As you can see by the photos I took after the provisional removal the ridge and soft tissue displayed excellent healing from the socket grafting procedures.

At this point the decision needs to be made if you flap or punch the tissue to place the implant. In this case because of the ridge preservation procedures the site does not need any contour augmentation and the soft tissue profile looks excellent. I also have a CBVT scan of the site and a Surgiguide to guide the implant placement so the most logical treatment approach is to punch the tissue and use the guide to drill the osteotomy.

I used a 4.0 mm rotary tissue punch through the Surgiguide to remove the soft tissue prior to drilling the osteotomy.  As a general rule I remove the punched tissue with a scaler and save it in a sterile bowl with saline in case I need it for contour augmentati

on after the implant placement. With this patient the tissue was not needed due to the preservation of the soft tissues with the grafting technique.

I proceeded to prepare the osteotomy using the Surgiguide and the Straumann Guided Surgery Kit, taking a radiograph after the initial 2.2 mm and the final 3.5 mm twist drills to confirm the location, angulation and depth of the osteotomy.

The implant, a 4.1 mm RC Bone level implant was placed to a depth of 3.0 mm below the CEJ of the adjacent central incisor. I used the adjacent central incisor because the grafting technique left the free gingival margin of the implant site slightly coronal to the natural central incisor. I then tested the stability of the implant with the Osstell system and the ISQ measurement indicated that the implant had excellent primary stability and should be suitable to place an immediate provisional.

The next step was to create a screw retained immediate provisional with fairly flat contours and emergence profile to avoid placing too much pressure on the soft tissue at the surgical site. I adjusted the provisional so it did not contact in centric and shortened the Incisal edge so that it would not contact in protrusive.

The patient has now completed healing after the implant placement and it appears that we have excessive tissue at the free gingival margin. This is a good problem to have but I would like to know what all of you would do to complete the treatment of this case. Would you remove the excessive tissue with a laser or push it apically by adjusting the contours of the provisional implant crown? We will also need to consider the Incisal wear and provide the patient with some form of protective appliance.

Please let me know If you have enjoyed this blog series, and also if you have any suggestions for future blog topics because I would appreciate the feedback.

If you would like to really boost the fun and profitability in your dental practice you should consider learning more about guided dental implant surgery. Take a look at my new seminar Interdisciplinary Aesthetics for Implants and Teeth hosted at the Niagara Fallsview Casino and Resort on Sept 30th and Oct 1st, 2011. You can click on the link here to learn more about this entirely new seminar.

Final Implant Site Development

Final Implant Site Development


Straumann Guided Surgery Kit

Implant Site Tissue Punch

Implant Placed into the Tissue Punch

Osstell Placed on Implant

Testing the ISQ with the Osstell

Adjusting the Meso Provisional Abutment

Completed Provisional Abutment

Completed Provisional Labial View

Completed Provisional with Flat Emergence Profile

Completed Provisional Palatal View

Before Treatment

Implant Provisional in Place

Part 3: Would you extract this tooth or not?

Hi everyone, once again I would like to start off by thanking all of you for the excellent ideas and comments related to last weeks post.

Today I would like to share with you how I handled the extraction, socket grafting and provisional issues that this case presented with, but first I would like to address the question about immediate or delayed implant placement.

As you could see by the CBVT images the buccal plate was fairly thin in the coronal half of the ridge with volume of less then 1.0 mm thickness. I spent a week at IDEA in San Francisco 2 years ago at a course presented by Dr. Dennis Tarnow about aesthetic implant techniques and he taught us if in doubt to follow the principle of doing one miracle at a time.

With this in mind if the buccal plate is missing or very thin the most predictable treatment option is a delayed implant placement. In this particular case we started out with excellent gingival architecture and a fairly high smile line so I wanted to design the treatment strategy to preserve and protect the pretreatment contours.

The 2 options if you are considering a delayed implant placement are to extract the tooth and not graft the site followed by an early implant placement at 6 weeks. This is the technique advocated by Dr. Danny Buser and he generally preforms a contour augmentation of the ridge at the time of the implant placement with a GBR technique.

The second option is to remove the tooth, graft the socket and support the soft tissue profile with the provisional restoration. This is followed with the implant placement at 3 months using a minimally invasive surgical technique.

In this case because the tissue architecture was ideal before the extraction I decided to follow the second option because if you remove the tooth without grafting and soft tissue support you loose most of your ideal tissue architecture. The overall tissue architecture then needs to be rebuilt with the GBR technique and later with the implant provisional.  I believe the first option with the GBR technique is best utilized when the patient starts out with less than ideal tissue architecture that will need to be rebuilt regardless if you graft the socket or not.

My point with all of this is that if you have excellent tissue contours before the treatment starts you need to plan your therapy to preserve these contours with your treatment strategy.

For this case I started by extracting the tooth using a periotome elevator and an atramatic technique. One of the most important concepts you need to keep in mind is that you cannot raise a flap to remove these teeth and expect to maintain the tissue architecture. If you raise a flap to extract the tooth you are going to loose most of the soft tissue architecture and likely the buccal plate of bone.

In this case I did my best to remove the tooth without surrounding trauma and then I accessed the socket. The buccal plate was intact but appeared fairly thin so I grafted the socket with Puros cancellous particulate allograft and placed a BioMend Extend barrier membrane and sutured the membrane into place with 6-0 polypropylene monofilament sutures.

To create a provisional restoration that would support the soft tissue architecture I cut the old crown from the tooth and bonded the endo access that would face the ridge with composite resin.

The next step was to attach the crown to the adjacent teeth and this patient has a deep overbite so I decided to bond the crown to the proximal contacts of the adjacent teeth. To facilitate the placement of the crown in the correct location I made an Incisal putty matrix on the pretreatment study model. I placed the adjusted crown into the correct location on the putty matrix and boded it to the adjacent teeth using Optibond adhesive and flowable composite.

As you can see by the photos I have included from this case the overall tissue architecture has been effectively preserved using this protocol.

To continue the conversation this week I would like to know if you would raise a flap to place the implant and if you would place an immediate provisional.

Graft and Membrane Sutured Into Place

Preparing to Bond the Provisional Crown

Provisional Crown in the Putty Matrix

Provisional Crown Bonded into Place

One Week Post Surgery After Suture Removal

Final Implant Site Development

Part 2: Would you extract this tooth or not?

Hi everyone, I wanted to start off by thanking all of you for the excellent ideas and comments related to last weeks post. Many of you had excellent ideas about how you would treat this patient and today I would like to share with you the actual treatment plan the patient selected.

As I explained last week, I listed the options that I thought were reasonable for this case and the patient let me know that she wanted a predictable long term solution and that she did not like the grey that was showing through her gingival tissue. I have attached a full smile photograph this week to illustrate the extent of the grey shadow that is seen in her smile.

The idea of orthodontic eruption is an excellent one except for the tapered shape of the root, which may leave the patient with mobility post treatment. The option of crown lengthening a single central incisor in the aesthetic zone can lead to compromised papilla and an uneven gingival architecture. If the patient was planning to restore the remaining anterior teeth, crown lengthening the 4 incisors could lead to a more even result but we are still left with the dark color and low value of the remaining root structure for this central incisor.

With this in mind the patient decided to have a dental implant placed to replace this structurally compromised tooth. With the final restorative option decided we needed to determine how we would execute the treatment. There are 3 basic options when you are planning to replace a compromised anterior tooth with a dental implant.

1)   Extract the tooth and place an immediate implant and graft the remaining socket.

2)   Extract the tooth and graft the socket with a delayed implant placement at 3 months.

3)   Extract the tooth without grafting the socket followed by an early implant placement at 6 weeks.

The next decision that needs to be made is about the form of provisional that you will provide for the patient. The different types of provisional restorations that can be created for a situation like this are:

1)   Single tooth RPD or flipper.

2)   Essix type of retainer with a prosthetic tooth.

3)   Bonded Maryland type bridge.

4)   Bonded tooth or crown to the adjacent teeth.

5)   Immediate implant crown provisional.

In this particular case we decided to have a CBVT scan completed to determine the thickness of the buccal plate and ridge volume and see if an immediate implant at the time of extraction is a reasonable treatment. If you look at the slices from the scan you can see that the patient has adequate height and width to the ridge but does she have enough thickness on the buccal plate. It looks like the thickness is less then 1.0 mm in the coronal half of the root.

To continue the conversation this week I would like to know what implant placement option and what form of provisional would you choose for this patient.

I would also like to know if the remaining buccal plate would factor into you’re the timing of your implant placement. As usual you can leave your treatment choice and comments using the link above this post.

Next week I will share with you more information about the treatment the patient has received for this case.

Would you extract this tooth or not?

I wanted to share with you a case that presented to my office a few months ago and see what your opinion would be about the best approach for treatment.

With this case the patient presented with a central incisor that had previously been treated with an endo, post, core build-up and crown. The problem was that something was loose. In this particular case the margins were not supragingival so it was hard to tell what exactly was loose!

In a case like this, either the entire tooth, post core and crown is loose or the post core and crown is loose, or maybe just the crown is loose.

I really could not tell during the emergency visit so I decided to reappoint the patient a few days later when I had more time to assess the situation and provide some form of treatment.

At the next appointment I tried to remove the crown and the post, core, and crown came out in one piece. You can see by the photo that there is not very much remaining tooth structure and minimal ferrule.  The remaining root has a small amount of recurrent decay but no mobility and normal periodontal architecture.

I provided the patient the following options for treatment:

  1. Remove the remaining root, graft and place an immediate implant.
  2. Remove the remaining root, graft the socket and plan to place an implant 3 months later.
  3. Remove the remaining root, graft the socket and prepare the adjacent teeth for a fixed bridge
  4. Remove the remaining root and prepare the adjacent teeth for a fixed bridge without grafting the socket
  5. Remove the remaining root and place an RPD.
  6. Recement the post, core, and crown
  7. Crown lengthening surgery followed by a new post, core and crown

As you can imagine giving the patient a list of options like this is important for informed consent but can lead to confusion for the patient to make a decision.

In a case like this the patient will inevitable ask you what you would recommend for the treatment if this were your tooth.

What I would like to know is how you would treat this patient. I gave the patient 7 options for treatment and I would like to find out your treatment recommendation if this was your patient. You can leave your treatment choice and comments using the link above this post.

Next week I will share with you the treatment the patient has received for this case.

Back to Blogging!

Hi everyone, I just wanted to let you know that I will be back to my regular blogging schedule starting this week. I have taken a little break while I was preparing and presenting my latest seminar, Functional Occlusion and Full Mouth Rehabilitation. I would also like to thank everyone for attending these seminars and making them such a great success. I have posted a few photos from these seminars as well as a photo taken with Rick King from Kingston as I gave him his iPad2 that he won during the early registration bonus for these seminars.

I have some great ideas for the next few blog posts and I am going to try and create a new post weekly for the next few months so stay tuned. If you have any suggestions for future blog post topics please add them in the comments section using the link above.

A Touching Story From Japan

I thought with the events from the past week that are developing in Japan I would forget about writing about dentistry this week and pass on a story I received in an email from Garr Reynolds.

As you may know Garr Reynolds is the best selling author of the book Presentation Zen and a few other great books about Zen design related to PowerPoint and he happens to live in Japan. He lives in Nara, which is in Western Japan near Osaka and about 600km from the epicenter.

I like and respect his work and I am on his email list so I received an update this week about the devastation the country has endured and that each day reveals the devastation and loss of life is even worse than feared. Thousands have died, tens of thousands are still missing and feared dead. Parents have survived the quake and tsunami only to learn their children are gone. Children escaped only to learn that their parents did not. Virtually everyone lucky enough to survive in the devastated areas has lost a friend or a loved one, in addition to losing their home and their belongings. In some cases entire towns were washed away. What are the residents to do? The pain must be unbearable.

With all of this terrible news Garr also included the link to a story that I found really touching and I wanted to share with all of you.

Miracle of the baby girl plucked from the rubble: Four-month-old reunited with her father after incredible rescue

Read more:

As a father myself I just can’t imagine having my daughter swept away from my arms when the Tsunami hit. It is too terrible to even comprehend but fortunately the story for this family has a miracle ending.

You can help!

Japan does need our help. One of the easiest ways to help is to make a donation through the Red Cross. If you have an iTunes account you can very easily make a donation that way. I made a donation through the Canadian iTunes store today to see how it worked and it could not be simpler. Apparently in the case of Red Cross 91% of the money goes directly to assisting people in need. You can make a donation for as little as $5.00 and I believe that every little bit will help these people in their time of need.

If you have any questions or comments, please feel free to leave them using the link above.

The Key Concept for Porcelain Veneer Preparations

Biomimetics is the study of the structure and function of biological systems as models for the design and engineering of materials. Following the principles of biomimetics and applying them to dentistry the clinician should strive to restore or mimic the biomechanical, structural, and esthetic integrity of the tooth.

When the patient and clinician’s treatment of choice is a conservative esthetic rehabilitation with porcelain veneers it is paramount to be respectful of the existing tooth structure, especially the dental enamel. The use of porcelain as an enamel substitute is an excellent application of the biomimetic principle due to the similar elastic modulus, thermal expansion, and optical properties of the two structures. When the original tooth has a thinned out or worn enamel surface and is restored to original volume with porcelain as an enamel substitute, studies by Dr. Pascal Magne and others have found that the tooth recovers much of its original structural, optical, and biomechanical properties.

Numerous retrospective studies that look at porcelain veneer longevity have also found that the veneer will have more predictable long-term success if the restoration is bonded primarily to enamel. This is especially true at the facial-axial region of the tooth preparation and care should be taken not to remove excessive enamel at this critical region.

The traditional approach for porcelain veneer preparation was to use a depth cutting diamond on the existing tooth surface and remove a fixed amount of tooth structure. This technique leads to an excessive loss of sound dental enamel with unnecessary dentin exposure especially in patients that already have wear or thinning of the enamel surface that will be restored with the new veneers.

This preparation method has been replaced by newer techniques that attempt to relate the tooth preparation to the desired final outcome as represented by the additive diagnostic wax-up.

With this in mind the Key Concept for Porcelain Veneer Preparations is that the tooth reduction should be relative to the final outside surface of the porcelain veneer, not the outside surface of the tooth that you are preparing.

During my webinar on March 10th from 8 to 9 pm EST I will demonstrate a number of techniques to relate the diagnostic wax-up to the tooth preparations in an efficient and reliable manner. I will also share with you the retraction and impression technique that I use for large porcelain veneer and full arch cases, as well as a number of other useful ideas and tips.

Now, click here to save your seat. Register Here!

I have added some images for a case that follows the Biomimetic Principle by replacing the thinned out and loss of enamel due to erosion with porcelain veneers.

If you have any questions or comments, please feel free to leave them using the link above.


Dr. Stephen Phelan

Preparation Techniques for Porcelain Veneers

Free one hour webinar to learn the system that I use to improve my tooth preparations for complex porcelain veneer cases.

I’m excited to take you on a deep dive into tooth preparation concepts for porcelain veneers, along with my proven step-by-step strategy for generating predictable, conservative and precise preparations. By attending this information-packed session, you’ll walk away with:

*  A clear understanding of the preparation design for conservative porcelain veneer restorations.

*  A strategy for preparing teeth when the arch form and tooth position is not ideal.

*  The stents that I use on a daily basis to relate my preparations to the diagnostic wax-up.

*  I will also walk you through the diamonds that I use on a daily basis to create precise, smooth and clean preparations.

This webinar will not be replayed after the live presentation, so you will want to join me live for this information packed session. The webinar will take place on March 10th from 8 to 9 pm EST.

PLUS, there will be an opportunity to win some special prizes during the webinar too! It’s going to be a packed house – be sure to register right now because I only have a limited number of spaces available!

Now, click here to save your seat. Register Here!

Any questions just let me know! I look forward to connecting with you very soon.


Dr. Stephen Phelan