Transcription and Slides: Dental Excellence Video 2

Hi there. I’m Dr. Stephan Phelan. Welcome to Dental Excellence.

For this video I want to point out one of the themes that I follow when I’m teaching about more complex dental cases or aesthetic dental cases and that theme is the wax up is the blueprint. I really believe that you need to “begin with the end in mind”, to quote Steven Covey, if you’re going to be thinking about doing more complex dental or aesthetic cases.

I designed my diagnostic wax up communication form to enable my ceramist to really have the vision that the patient and I have for the case. I did share this with a lot of people when I was promoting my occlusion design online course a couple of years ago and I think it was really well received. People really liked the concept and I wanted to add this to my Dental Excellence video series.

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The concept of creating an additive diagnostic wax up, as well, is something that I first heard from Pascal Magne and Michel Magne when I went to the first course that they hosted at IDEA about ten years ago. It was a fantastic course; it really made me think about aesthetics at a really higher level just because of the level of beautiful dentistry that the Magne brothers produce.

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And so, when I spoke to Harald, my ceramist, Harald Heindl, about the cases, we talked about additively contouring the porcelain restorations based on the wax up and the wax up additively contouring to the teeth so that we could, again, preserve more tooth structure and more of the patient’s own enamel. Even with crown cases, I like to preserve as much tooth structure as possible and as much enamel as possible so that if something were to break, I’d rather the porcelain, veneering porcelain, break than the tooth break at the gum line. So we try to preserve as much tooth structure as possible. So if you can, within the confines of the patient’s overall smile design, if you can create an additive contour wax up, that allows you to preserve more tooth structure.

So additive contour wax up is a really great concept. I would Google Dr. Pascal Magne and read some of his articles about this that he’s written with his brother, Michel Magne and this is a case that we did next to the case report from the Magne brothers.

And I’ll just share with you this case briefly. It’s a patient that came into my practice with a lot of erosion, attrition and tooth wear. The result is the teeth are already somewhat prepared because of the amount of erosion and attrition on the teeth. There is no need for me to excessively prepare these teeth, there’s no reason to. We need to additively build up the tooth structure.

And you can see the before model next to the diagnostic wax up and appreciate the amount of volume of tooth structure we’re adding with this wax up. We then use that as the blueprint to make the provisional restorations, which are then the blueprint to create the porcelain restorations. So the wax up is the key, it’s the foundation for creating these restorations.

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So here’s the patient again, occlusal view, you can see all the wax being added to the before model. It’s an additive wax up concept. And the wax up is the blueprint.

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Here’s this particular patient and if you look at his before pictures, you know, we didn’t have to prepare the teeth a lot; the erosion and the attrition have prepared the teeth already. I had to prepare the teeth interproximally, so the jacket crowns would go over the teeth because I felt there was too much facial erosion to really prepare these teeth for porcelain veneers. But jacket crowns, conservatively prepared, are a good option for a patient like this with this much facial and incisal erosion.

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So you look at the different views– here he is before. Again, end–to-end occlusion from the wear and the movement of the teeth as the teeth wore. He developed a more end-to-end occlusion as opposed to any kind of over jet and over bite. So we are going to open the vertical to create over jet and over bite so he has a more normal functioning occlusion and it helps with the survival of our restorations as opposed to having our restorations contact in an end-to-end occlusion.

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There are a lot of good teaching points on this case and I will talk about this case in a few future Dental Excellence videos, but the bottom line for this video is the wax-up is the blueprint.

So you look at the before pictures. Looks like Bruxism, if you were to look at how the wear facets line up. The wax-up, again, was the blueprint to create the diagnostic provisional restorations.

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So if you look at the provisional restorations, we’ve changed the length of the teeth, the tooth volume and we’ve changed the occlusion design. We’ve opened the vertical, created some over jet and over bite and maintained a pretty flat occlusal guidance scheme. And so, look at the before and after change just by adding plastic– additively in the mouth, with the provisional restorations.

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So here he is with his provisional restorations. What I said earlier is that we create the final restorations based on the provisional restorations. The provisional restorations were created based on the diagnostic wax-up. So we are, again, using the wax-up as the blueprint.

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So here are the final restorations, these are Lava Zirconia crowns, layered Lava Zirconia crowns. You know, this case was completed about four years ago. My ceramist Harald Heindl from the Seattle area creates the restorations; he’s a German Master Dental Ceramist. Beautiful anatomy, beautiful layering of the porcelain but for me the keys are beautiful fit and beautiful occlusion– beautiful fit and occlusion. Those are the keys to make my life easier as well as the beauty and the aesthetics.

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So there are the before and after photographs of the close-up view and, you know, it’s a huge change for this patient, it’s a transformational change, really. When you look at what this does to the overall appearance of the person it makes almost everybody who has a before and after change like this look tremendously younger. You can’t help it because you’ve changed the whole part of the face that people look at the second-most; they say that people look at the eyes the most and then secondly the teeth and smile. So, you know, this is transformational.

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These photos were taken a while ago with the three-year post ops, you can see the case has held up exceptionally well but he did have very nice occlusal design, very precise and well thought-out occlusion design for this particular case. I talk about the occlusion design and the different things that we look at with over jet, over bite, angle of guidance, pathway of guidance as well as degree and width of guidance.

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Here are some more views. Natural-looking aesthetics, these are Lava Zirconia restorations but layered in such a way that they can look very natural.

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And I’ll just end by saying that you can do this kind of dentistry. I have an everyday practice, I just really document well and I work with a great ceramist so I’m fortunate that way, obviously.

You can do this kind of dentistry. Beautiful dentistry with precise fit and occlusion

Dental Excellence: The Wax-up is the Blueprint

In this second video of my new Dental Excellence video series , I discuss a theme that I follow when I am treating complex dental cases or aesthetic dental cases and that is The Wax Up Is The Blueprint.

Watch the video below to find out more and see another great case from my practice and always remember that beautiful dentistry with precise fit and occlusion is not just for the gurus!

If you are not a member of my email list join today and receive a free video about implant esthetics.

Dental Excellence: Longevity of Porcelain Veneers

I have created a new series of Dental Excellence videos that teach clinical techniques and case studies from my practice.

In this first video I explain the most important factor for the longevity of porcelain veneers. A 10-year old porcelain veneer case is used to illustrate the concept.

You can ask a question or comment using the link above and don’t forget to Like, Share or Tweet this video.

Thank you again for being a member of my online community and remember, beautiful dentistry with precise fit and occlusion is not just for the gurus.


Altering The Gingival Levels For Anterior Dental Implants

I wanted to create a follow up post for the series of articles I created last spring that discussed techniques to treat a hopeless central incisor. If you recall I left the series with the dental implant placed using a flapless technique with a Surgiguide created from the Simplant treatment plan. I created an immediate implant provisional crown but I left the facial emergence profile really flat during the initial healing so I would not stretch the tissue too much post surgically.

The post surgery results were very good and the interdental papilla level was excellent but its shape and the free gingival margin were located too far incisally. This gingival asymmetry leads to a result that makes the implant provisional crown look too short compared to the adjacent natural central incisor.

There are two techniques that will correct this problem.
1.    Adjust the gingival tissue surgically.
2.    Adjust the provisional crown contours.

I thought about which option would work better for my patient and because the initial provisional crown was slightly under-contoured I decided the best option was number 2.

Adjusting the subgingival contours of an anterior implant provisional will have a dramatic effect on the free gingival margin. If the free gingival margin is slightly too far apically you can try to flatten the emergence profile to encourage the gingival tissue to migrate incisally. If the free gingival margin is too far incisally, such as this case, you can add to the provisional contour to encourage the gingival tissue to migrate apically.

The technique that I use in my practice is to mark the free gingival margin right on the provisional in the mouth with a pencil. I then unscrew the provisional crown and add flowable composite resin to the portion of the provisional below the pencil line. You want a screw retained provisional for a case like this because the tissue will resist seating the over-contoured provisional.

Once you are satisfied with the contour of the provisional you will  screw it back into place and assess the results. If you have added enough flowable composite to change the gingival tissue levels you will see a fair amount of blanching of the tissue. I will leave this in place for about 5 to 10 minutes and then reassess the tissue colour and position.

If the free gingival margin is still too far incisal I will remove the provisional and add more flowable composite subgingivally and then try it in again.

If the free gingival margin is too far apically, I have added too much flowable composite so I will remove the provisional and remove some of the composite. I will then try the provisional into place and reassess the tissue levels.

As you can imagine all of this takes a little trial and error and time. This is the reason my fees for anterior dental implants are so much more than for molars. I feel that I need to spend this time to make sure that the tissue levels are ideal BEFORE the final custom porcelain restoration is created.

Once you are satisfied with the final gingival tissue levels you need to assess the tissue colour. If the tissue is still blanched I will continue to wait until the colour returns to normal which can take up to 30 minutes. I prefer not to dismiss the patient if the tissue is blanching because you may have stretched the tissues to far and run the risk of creating a pressure necrosis.

I would also recommend that you take a radiograph of your provisional in place and make sure that it is not too close to the bone.

In the next post I will share with you some of the techniques that I use to communicate the exact provisional and tissue contours to my ceramist. As always feel free to add any questions or comments using the link above this post.

Tissue levels prior to alteration.

First addition with flowable composite.

Tissue result with first addition. The level needs to be raised apically.

Second increment of flowable composite is added to the provisional.

Tissue result from this addition. The free gingival margin is better but the papilla contour needs more development.

Final addition of composite to the mesial papilla area.
Final addition of composite to the mesial papilla area.

Final addition of composite to the mesial papilla area.

Final tissue contour is better but slight tissue blanching remains.

Ten minutes later the tissue blanching is resolved.

Final Result 2 weeks later.

How Do You Treat A Non-Restorable Central Incisor In Your Practice? Immediate Vs Delayed Implant Placement -Part 2

After complete healing, the alveolar ridge appeared favorable for a flap-less implant placement approach.  This can be a challenge to position the implant platform at the ideal level.  If the implant is positioned too shallow, there will be insufficient room to create a proper emergence profile and crown form.  If the implant is too deep, it may be a risk for future recession or inflammation.

I was very careful with measurements made clinically from the existing gingival margin and the new planned gingival margin as well as checking with radiographs.  Using a computer-generated guide is another option for these cases, but will still require good clinical judgement.

The implant was positioned with the platform 3 mm from the future gingival margin to accommodate a favorable emergence profile. It is important to note that the interproximal bone must be modified to create space for the future restoration; otherwise, it may be a challenge to seat the restorative abutment and there is possible risk of developing bone necrosis due to excessive interproximal pressure. (See radiographs)

Interproximal Bone Adjusted At Time Of Surgery To Provide Room For Future Restoration

Provisional And Final Restoration

The gingival recession on the adjacent central incisor #8 (FDI #11), was improved by a semi-lunar coronally advanced flap.

After the implant has osseointegrated, it is time to shape the abundant soft tissue from that of a circular healing abutment to that of a triangular tooth form.  The provisional restoration is fabricated with a sub-gingival profile that will create tissue support and an ideally positioned height of contour to move the gingival margin to the desired level.

After a couple of months, the tissue form created by the provisional restoration can be duplicated by using a custom impression coping during the impression procedures.  The final crown should follow these sub-gingival contours to maintain this soft tissue form.

The restorative phase was completed with a custom cast gold abutment and a cemented PFM crown.  The crown form was slightly flatter at the mesial line angle than the provisional restoration and we can see the change in the soft tissue form.  Overall, the treatment sequence insured a predictable outcome for this patient.

Coronally advance flap #8(FDI #11) and flapless implant placement #9 (FDI #21)

Implant Placed According To Future Gingival Margin

Provisional Restoration

Provisional Restoration

Provisional Restoration At Placement

Provisional Restoration After Tissue Shaping

Final Restoration

How do you treat a non-restorable central incisor in your practice?

How do you treat a non-restorable central incisor in your practice?

If an implant is to be placed, should we perform the procedure as an immediate extraction socket placement or should we delay the implant placement?

I am sure we have all had a patient like this walk into our practice. The patient has a history of trauma at a young age with subsequent endodontic therapy.  Years of loading further weaken the tooth.  Her dog recently bumped her in the mouth and now she feels that her tooth is loose.  You determine that the crown is fractured and the tooth has a poor restorative prognosis.

How do you plan this treatment with your team?  Should the surgeon place an immediate implant at the time of extraction?

To determine the most predictable treatment option, we must take into consideration the shape and dimensions of the labial bone, the existing soft tissue profile and the amount of apical bone available for implant stability.

From the clinical exam, we can determine that the soft tissue profile of the hopeless incisor is similar to the adjacent central.  When considering immediate implants or simultaneous procedures, I always prefer to have a favourable soft tissue position prior to surgery.  The slight crestal bone remodeling after the extraction will lead to reduced support for the gingiva with resulting recession.  So we either have a gingival level that is coronal to ideal, or our procedure must provide some additional support or augmentation.

Next we can look at the radiograph to evaluate the interproximal and apical bone.  For this patient, we note that the bone appears to be at a normal level on the mesial and distal of the root and adjacent teeth.  The apical bone is without a lesion and it is sufficient for implant anchorage.

Lastly, we will need to evaluate the facial bone.  This can be done with a CBCT or clinically at the time of surgery.  Insufficient labial bone can be a risk when attempting to place an immediate implant.  It is best to stage the procedure with alveolar ridge augmentation and a delayed implant placement.   For this patient, the labial bone had both a normal crestal level and facial thickness.

The implant was placed immediately at the time of the extraction for this patient.  In the next blog posting, we will look at how I managed the soft tissue form.

Full Smile View

Retracted View

Crown Fracture Resulting In Inadequate Tooth Structure For Predictable Restoration

Dental Implant Placed With Platform 3 mm Below The Free Gingival Margin

Dental Implant Placed Towards Palatal Aspect Of Socket With Bone Augmentation In Residual Socket

Radiographic Evidence Of Large Pulpal Chamber And Extent Of Fracture Line. There Is Abscence Of Any Peri-Radicular Lesion.

Options To Consider For Interim Tooth Replacement And/Or Soft Tissue Management

Now that the implant is placed, we have several options to consider for interim tooth replacement and/or soft tissue management.

If the soft tissue form is favorable, then an attempt to maintain or support the supra-crestal gingival tissues during the period of osseointegration simplifies the restorative process. By simplifies, I mean that the emergence profile will not need to be developed with a provisional crown.

One way to achieve this is to fabricate a custom healing abutment with the proper shape to provide support for the gingival tissues.  To replace the tooth, an interim RPD or a bonded tooth pontic can be used.

Another technique I like to use is a chairside fabricated provisional crown.  If the implant is stable at placement, and the occlusal is favorable, then a crown can be attached on the day of surgery.

In this case, I utilized the patient’s tooth.  The tooth was trimmed to create a shell crown, and then relined on the temporary abutment in the mouth.  The provisional restoration is finished on an analog to ideal contours and then inserted with finger torque.

For this patient, I also added a small piece of connective tissue, that was harvested from the palate.  This helps to increase the thickness of the facial gingiva, to minimize the development of a flat or concave contour that so often happens after normal remodeling of the alveolar complex.

The restorative phase was completed with a porcelain veneer on tooth #8 (FDI #11) and a zirconium abutment/ porcelain crown on #9 (FDI #21).

In our next blog posting, I will talk about a patient that required a staged alveolar grafting and implant placement.

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.