One critical step to transform your smile design cases for your patients.

I wanted to write a blog post to teach you about a critical step that I feel will really transform your smile design cases for your patients.

When I look back at all of the beautiful smiles that I am fortunate to create for my patients I concluded that one of the steps in my system that has been critical to success is the provisional evaluation appointment.

We all know that the provisional restorations are critical for the ceramist to use as the guide when creating the final porcelain restorations. The potential for a problem happens because the provisional is the last step for the preparation appointment and if you are running out of time can be rushed or not properly evaluated. This is compounded by the patient having a lack of natural lip mobility due to any remaining local anesthetic and fatigue from the entire preparation, impression and provisional process. At this stage of the appointment, many patients just want to get out of the chair.

With all of this in mind I added a provisional evaluation appointment as a critical step in my system for smile design and rehabilitation cases.

I have been using this appointment for the last 18 years and it has allowed both myself and the patient a more relaxed and ideal time together to evaluate not only the occlusion but the esthetics of the provisional results.

This appointment is the time to make any changes in the occlusion design and incisal edge position BEFORE the ceramist starts to build the final restorations.

My system is to have the patient return anywhere from 1 to 2 weeks after the preparation date and evaluate the provisional results and make any desired changes to the case. If the provisional looks great or the changes are minor I will take a final provisional impression, bite records and digital photo series of the provisional results.

If the changes are significant I will have the patient go a few more weeks to evaluate the changes and then have a second provisional evaluation appointment.

I would like to share a recent case with you that illustrates a good lesson.

This patient was treatment planned for 7 Emax restorations for the maxillary anterior.


The first step after the functional analysis and treatment planning was to alter the gingival tissue levels.


After healing a new maxillary model was taken and mounted on the Sam 3 articulator to complete the diagnostic wax-up.


The patient came into the office for the preparation appointment and the old restorations were removed, new core build-ups placed and the final preparation impression and provisional restorations were created.


The patient returned to my office 2 weeks later for the provisional evaluation appointment. Due to traffic issues the patient was very late for this appointment but he told me that he was very happy with the results of the provisional restorations.

With this in mind I took a quick look at the results and decided it looked good to me as well. I checked the occlusion, discussed the shade and took the digital photo series. I then left the case with my assistant to take the final impression of the provisional.


The next day I was looking over the models and photos of the case preparing everything to send to my master ceramist, Harald Heindl. At this point I realized that I missed the fact that the incisal edge position was slightly canted and down on the right side. Even with the patient being late I should have taken more time on the provisional evaluation appointment.

The patient told me the day before that he was happy with these results but when I reviewed them I realized that this could be dramatically improved.

The decision was made to bring the patient back for a second provisional evaluation appointment so I could shorten the right side and level out the incisal edge position.


In a case like this one where the change is not that extensive I will shorten the incisal edge on the right side with Soflex XT discs, reevaluate the results and retake the provisional records.


The case was then sent to Master Ceramist Harald Heindl and completed with layered Emax crowns.



PIC 10

The moral of this story is that a critical evaluation of the provisional restorations is important for our cases even if the patient is late or you are behind and have a patient waiting in another chair.

Let me know if you have any questions or comments using the link above this post and if you like the written blog post format.

Thank you again for being a member of my online community and remember, you can do this kind of dentistry! Beautiful dentistry with precise fit and occlusion is not just for the gurus.

All the best, Stephen

Dental Excellence Video 7: Tooth Preparation Guides and Stents

This is the seventh video from my Dental Excellence Video Series. In this video I share with you the different tooth preparation guides and stents that I use in my dental practice.

Remember. You can do this kind of dentistry and that beautiful dentistry with precise fit and occlusion is not just for the gurus!

My next class for Occlusion Design is opening for registration in April. If you would like to join the early bird list, use the link below and I will send you early access with a special bonus offer for those who register early for Occlusion Design.

Click Here to join joined the early bird list for the next class of Occlusion Design.

Dental Excellence Video 6: Critical Patient Risk Factor

This is the sixth video from my New Dental Excellence Video Series. In this video I share with you the Critical Patient Risk Factor that can destroy your cases.

Watch the video below to find out more.

Remember. You can do this kind of dentistry and that beautiful dentistry with precise fit and occlusion is not just for the gurus!

Dental Excellence Video 5: Equilibration For The Porcelain Veneer Patient.

This is the fifth video from my new Dental Excellence video series. In this video I share with you my thoughts about Equilibration For The Porcelain Veneer Patient.

Watch the video below to find out when I would equilibrate a patient before placing porcelain veneers.

Remember. You can do this kind of dentistry and that beautiful dentistry with precise fit and occlusion is not just for the gurus!

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? Immediate Vs Delayed Implant Placement -Part 1

In the last blog I presented a patient that had a non-restorable maxillary central incisor.  She was treated with an immediate post-extraction implant placement and a custom provisional crown to immediately support the soft tissues.

Unfortunately, we can not always provide this form of treatment to all patients.  When should we separate treatment into phases?

I had mentioned that we must take into consideration the shape and dimensions of the labial bone, the existing soft tissue profile and the amount of apical bone.

Immediate post-extraction implant placement requires ideal bone volume. The immediate implant is anchored into the apico-palatal bone.  If the bone is this area is compromised, then implant stability may not be achievable.  In addition, the bone on the facial supports the soft tissue profile.  Thin bone or large dehiscences are a risk for future gingival recession. A patient with inadequate facial alveolar bone should not receive an immediate implant.

This next patient I will present also had a non-restorable failing maxillary central incisor. As a teenager, this tooth was traumatized during a sports injury.  It was endodontically treated and crowned.  Ten years later, this tooth required apical endodontic surgery. The patient is now 40 years old, and presents with a fistula at the apex of the central incisor. The patient consulted with members of our team, including an endodontist.  After reviewing his options, he requested to have this tooth replaced with a dental implant.

From the clinical exam, we can determine that the soft tissue profile for this failing tooth is more coronal than the adjacent central incisor, which has slight gingival recession.
We have a very favorable soft tissue position prior to surgery, so soft tissue augmentation may not be necessary.

Further clinical evaluation we note a fistula at the apex of #9(FDI #21).  On the radiographs, we determine that there is a peri-radicular lucency that extends to the floor of the nose.  Since this is the area that I depend on for implant stability, it is unlikely that I can predictably place the implant at the time of extraction.

So how should we manage this site?  How do we extract, debride and graft the alveolar ridge?

My approach follows a sequence of steps, intended to both correct and maintain the alveolar dimensions.

After extraction, I observed that the crestal bone on the facial aspect of the socket was intact and at a favorable level.  However, the lesion had resorbed the overlying bone in the apical zone.

So to gain good access to the lesion, I made a C-shape incision around the apical fistula.  In addition, this allowed access for placement of the bone graft and membrane.  By avoiding flap reflection in the crestal half of the ridge, I was able to maintain the blood supply to the alveolar facial bone.  The ridge was grafted with allograft bone and the socket closed with an epitheliazed graft.

In the next blog, we will discuss implant placement and restoration.

Note Large Apical Lucency

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

Provisional And Final Restoration

Initial Presentation

Occlusal View Of Socket

Apical Lesion Debrided

Alveolar Grafting Completed

Alveolar Ridge Graft Healed

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.

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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.