Dental Photography Mirror Tips

Do you get watermark stains on your mirrors after you sterilize them?

Watch the video below to find out the best tip to get rid of the watermarks for good!

Two Keys For Matching A Single Implant Crown

I thought I would create a blog post to share with all of you the results of the implant case.

I placed the final crown a couple of months ago and I am pleased to report that the crown was inserted on the first attempt. I can’t really say that this happens to me all of the time with a single central incisor restoration. There are cases that I am not satisfied with the results and I return it to the lab to modify.

I think the key to nailing one of these restorations on the fist attempt lies with excellent lab communication. Harald Heidl, a master dental ceramist from Seattle, fabricated this case. The case consisted of a custom Etkon Zirconia abutment and an IPS e.max layered ceramic crown. In this case I also used some limited bonding to improve the shape and form of the adjacent central and lateral incisor and recommended a bite splint to protect the restorations from future attrition.

Due to the distance involved, Harald never was introduced to the patient in person so we communicated with digital photography. I have discovered over the years that excellent digital photography can replace the need for the patient to drive to the lab for a custom staining appointment. The system that I follow is to send a series of shade photos that I take using my Nikon D3s camera using the Nikon Micro 105mm lens and the Nikon RICI Micro flash kit.

I find that this body, lens, and flash system produces excellent results but I have also tested the Nikon D7000 body with this set up and it offers great results at a lower price point.

I will share with you two different tips for excellent shade photos.

The first tip is to pick the shade tab that you feel is closest to the tooth you are matching and photograph that tab as well as one with higher value and one with lower value. For an anterior tooth I typically shoot shade photos with 3 different shade tabs from two different angles but sometimes I can use 5 or 6 shade tabs if the tooth in question has a complicated shade map.

The second tip is that I would recommend that you angle the lens and flash of your camera so that it is not perpendicular to the teeth and shade tabs that you are photographing. With this tip, you will find that the teeth and the shade tabs have less reflection on the surface and you can diagnose the shade more effectively.

If you follow these two tips and set your camera up correctly with proper exposure and white balance you should have great results matching even the elusive central incisor.

If you would like more detailed photography training feel free to check out my Mastering Digital Dental Photography DVD set. As always if you have any questions or comments feel free to use the link above.

Remaining tooth before extraction and implant site development.

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Shade photo with the provisional implant crown and the surrounding dentition.

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Shade photo with the provisional implant crown and the surrounding dentition.

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Shade photo with the provisional implant crown and the surrounding dentition.

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Shade photo with the provisional implant crown and the surrounding dentition.

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Shade photo with the provisional implant crown and the surrounding dentition.

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Shade photo with the provisional implant crown and the surrounding dentition.

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Final crown and zirconia abutment.

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Final crown and zirconia abutment.

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Zirconia abutment seated on the dental implant

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Final restoration.

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Final restoration.

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Final restoration.

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Replicating The Gingival Levels Of A Dental Implant Provisional In Your Impression

I wanted to follow up last weeks post with a quick article to demonstrate how I would replicate the soft tissue contours in a final impression.

When I left last weeks post I had just spent a significant amount of time to create and perfect the provisional crown contours that would produce the soft tissue outline form for my final implant restoration. The question now becomes how would I transfer that information to the dental ceramist?

You have two options if you are going to take a final implant impression.

1.    You can use a stock open or closed tray impression transfer.
2.    You can create a custom impression transfer.

Some of you may be thinking why would you bother spending the time to create a custom transfer? I will answer that I feel when you have spent time and effort to create a specific soft tissue form that the extra time you spend to create a custom transfer is worth the effort.

You may think that a standard transfer will capture the tissue contours well enough but I would argue that when you remove your provisional the soft tissue will not be supported and will collapse slightly. This may not be an issue with a molar but with a central incisor I think it is a huge concern.

So, for arguments sake lets assume that you want to make a custom impression transfer for anterior cases and you will use a standard transfer for molars and decide on the need with bicuspids depending on the case. Let me share with you a fairly simple way to create a custom transfer.

The first thing you need is an impression analog and for a number of years I would just hold them in a hemostat but for the past six months I have them mounted in a plaster cup and ready to use for cases.

I remove the provisional from the patient’s mouth and screw it onto the analog that is mounted in the plaster. I then inject Mach 2 Die Silicone around the cervical half of the provisional and let it set.

The next step is to remove the provisional from the analog and if you look at the result you have an exact replica of the soft tissue form created by the provisional in the Mach 2 Die Silicone.

I will then screw the appropriate impression transfer onto the analog. In this case a Straumann RC bone level implant was used with the Straumann closed tray RC impression transfer. The final step is to fill in the space between the transfer and the silicone with flowable composite resin and light cure.
When you remove the impression transfer from the analog you have a customized surface created by the flowable composite that is an exact copy of your provisional contours.

I hope this post helps to clear up how I create this transfer with a technique that is simple and easy to use in your dental practice. As always thanks for reading and feel free to add any comments or questions using the link above.

Best regards,

Dr. Stephen Phelan

Completed soft tissue outline form.

Completed soft tissue outline form.

Standard impression transfer in place with the soft tissue starting to collapse.

Provisional seated on stone mounted analog.

Injecting the Mach 2 Die Silicone.

Provisional with the die silicone setting around it.

Completed soft tissue outline form replicated in the silicone.

Completed soft tissue outline form replicated in the silicone.

Creating the custom transfer with flowable composite.

Completed custom transfer being removed from the silicone mould.

Comparison of the custom provisional and custom impression transfer.

Custom impression transfer in place.

Custom impression transfer in place.

Final Permadyne impression.

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Nikon D7000 Review For Dental Photography

For this weeks blog post I thought I would share with you a product review for the new Nikon D7000 Digital SLR. Clinical dental photography is a really valuable tool for patient communication, lab communication and personal education. In the video below I share with you some of the D7000 features and I also show you some settings to use for clinical photography; such as,  your image size, white balance, picture control and colour space.

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

Panorex

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

Surgiguide

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.