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.

And The Winners Of The Dental Products Are…

The winners for the Phelan Dental Seminars Sponsors contest are …

Click the video below to find out if you have won….

The winners will receive their prizes at the seminar.

1. 3M ESPE RelyX Veneer Cement Kit – Winner – Dr. Tim Sellner
2. National Dental FlashMax Curing Light – Winner – Dr. Michel Brunet
3. CRD Heatwave and Quad Tray Intro Kits – Winner – Dr. Uyen Ahh Nguyen
4. Henry Schein Dentsply SmartCem 2 Kits – Winner – Dr. Louis-Rene Dubois
5. Henry Schein Axis CeraGlaze Kit  – Winner – Dr. Brian Croppo

Congratulations to our winners and I look forward to seeing you at the seminar. 

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: http://www.dailymail.co.uk/news/article-1366155/Japan-earthquake-tsunami-4-month-old-baby-girl-father-reunited-Ishinomaki.html#ixzz1GugjleK3

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.

Cheers,

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.

Cheers,

Dr. Stephen Phelan

And The iPad Winner Is …

The iPad winner for the Phelan Dental Seminars pre-registration contest for the April Occlusion seminars is …

Click the video below to find out if you won the iPad and remember if you are not the winner you could still win by joining our online community by entering your name and email address on the webform on our blog and by liking our Phelan Dental Seminars facebook page. You can also have another chance to win an iPad by liking  Dr. Stephen Phelan facebook page.

Congratulations to our winner and best of luck to everyone else for our future contest.

OPENING THE VERTICAL DIMENSION

How would you test out a change in the occlusal vertical dimension?

This week I would like to tell you about a technique that I use to test altering the vertical dimension without preparing any teeth. Changing the vertical dimension is an important tool that we use with large cases to create the room needed for restorative material but there is some concern about stability and the ability of the patient to adapt to the alteration.

Today I wanted to share with you a nice and simple technique to alter and test the new vertical dimension on unprepared posterior teeth.

I will talk more about the 5 areas of concern we have when altering the vertical dimension as well as the techniques that I use to determine the vertical in my new seminar this April, Functional Occlusion and Full Mouth Rehabilitation. I have also created a detailed review of vertical dimension for the restorative dentist in my new occlusion DVD series.

The technique that I want to share with you today depends on having an accurate diagnostic wax-up created on study models that were mounted on an articulator.

Once you have a duplicate model of the wax-up you can create a vacuum formed shell and use it as the matrix to create the provisional restorations. In my practice we use a Biostar positive pressure thermal forming device to create really accurate shells using 0.8 mm Hardcast material.

I can then take this shell to the mouth and seat it on the unprepared teeth to verify the fit and accuracy. With my technique, I will load the matrix with Protemp Plus provisional material and let it set on the unprepared teeth that have been coated with Vaseline. I will remove the matrix and Protemp Plus provisional and place it on a model of the teeth. In this case, I created a pretreatment model using Permadyne impression material that was a little more flexible then stone to facilitate any corrections or additions I would make to the overlay provisional.  Another material that works well for this technique is Mach 2 Die Silicone.

After I have tried in and confirmed the fit of these restorations, I will cement them into place with RelyX Unicem Self-Adhesive resin cement. When I am testing out the new vertical dimension, I prefer to have the overlay provisional locked onto the teeth so that the patient does not have any issues with them.

To complete the change I will address the anterior teeth. In this case, the patient had a very steep angle of guidance so I decided to develop the Incisal edge position of the anterior teeth with composite resin. I used an Incisal putty matrix from the diagnostic wax-up and built the teeth up individually using plumber’s tape as isolation.

With the completion of the lower arch using this technique, the case can now be segmented and treated as a series of smaller cases at the new vertical dimension.

For example, you could now complete one posterior quadrant using really conservative porcelain onlay preparations. You could also complete the anterior porcelain veneers, or you could complete the entire case. This technique provides you with many different options as a restorative dentist.

You can see some of the case photos from my keynote presentation attached to this post. I hope this post helps you to think outside the box about creative ways to address some of the problems we face in restorative dentistry. To see more details about this case and many other complex dental cases, don’t forget to attend my new seminar in April.

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

RISK ASSESSMENT FOR COMPLEX CASES

Take some of the mystery out of complex dental cases!

This week I would like to tell you about a new approach to treatment planning complex cases that I will be presenting at my new seminar FUNCTIONAL OCCLUSION AND FULL MOUTH REHABILITATION. This will be a completely new topic that will be presented during the seminar this April in Toronto and Montreal.

I had the inspiration for this idea when I was at the Masters Course in Esthetic Implant Dentistry at the University of Bern last month. During the course, Dr. Buser presented a form from the ITI Treatment Planning Guide that outlined Risk Factors for Esthetic Implant Cases.

I really liked the way that Dr. Buser integrated the concepts from this form into his case presentations and was inspired to develop a similar approach for complex dental cases with esthetic and occlusal problems.

I decided to develop a form that would integrate the 4 main areas of concern we encounter when we treatment plan these types of cases. The Risk Assessment for Complex Cases form has 14 risk factors listed that cover these 4 areas of concern and each risk factor can be categorized as low, medium and high risk. I have designed the form so you can color each risk factor either green, yellow or red depending on the level of risk that the patient presents with to your practice.

I introduced the form this past weekend at my Occlusion Workshop to use for treatment planning the cases that the dentists who attended brought for the group to evaluate. The dentists in the workshop really liked the way the form organizes the risk factors involved in treating their cases and we used small colored stickers to categorize each patient’s risk factors. The goal is to prevent you from missing an important area of potential risk when you are treatment planning a complex case. I believe the form will also be helpful to present to the patients at the consultation appointment to help them develop ownership of their dental problems.

I have attached a photograph of the form from one of the cases we treatment planned and a sample of the master from as well.

If you would like to have copies of this form and learn how to integrate these concepts into your dental practice, make sure you attend the new Functional Occlusion Seminar this April. I am developing a totally new presentation that will explain the form and each risk factor and you will receive copies of the form as well as a detailed course binder when you check in the first day of the seminar.

This week is the last week to register and have a chance to win the 64 GB iPad and receive $100.00 discount on your tuition and an additional $100.00 discount if you order my new occlusion DVD series.

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

My Favorite Cements for Porcelain Veneers, Part 2

What luting composite am I using for porcelain veneers.

This week I would like to tell you about the luting composite that I turn to the most frequently in my dental practice for porcelain veneer cases.  As I covered in last weeks post, I would like a luting composite that is light cured, has a matching try-in gel, cleans up easily and has excellent physical properties.

With all of these factors in mind, the luting composite that I turn to first is the 3M ESPE RelyX Veneer Cement System. I like this kit for a number of reasons but one of the most important factors for my practice is that the try-in gel matches the shade of the cured resin cement really well. With the referrals I receive in my practice, I tend to see patients that have high esthetic expectations so it is critical that I have an accurate preview of the results before I commit to the final shade.

I also like the shade selection for this kit with a white, B0.5, A1, A3, and translucent shades. The shades that I seem to use the most are the white, B0.5 and the A1. If anyone needs A3, I have a large collection of that shade for sale! 🙂

This luting composite also has a nice viscosity for porcelain veneers that helps facilitate an easy clean up and excellent physical properties.

I have included some photos from a 6 unit veneer case that I completed a few years ago that was bonded into place with the B1 shade of RelyX Veneer Cement. Take a look at the shade match between the cuspid veneers and the natural bicuspids. The ceramics for this case and the case from last weeks post were created by Master Dental Ceramist, Mr Harald Heindl. Next week, I will talk about the other 2 kits that I have in my practice and when I choose to use them.

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

My Favorite Cements for Porcelain Veneers, Part 1

What should you look for in a luting composite?

I have received a number of e-mails during the last few weeks asking me what cement I am using for porcelain veneers. I thought this would be an excellent topic for a series of blog posts that would cover the materials I am using when I am bonding in a veneer case.

The first thing that I would like to point out is that I actually have 3 different kits of veneer luting composite in the practice that I like to use for different cases. Each kit is from a different manufacturer and each has a different amount of viscosity and opacity along with different shades for me to select from. The reason I have 3 kits is that there are some patients when I cannot find the correct shade or opacity of resin cement to match the surrounding dentition. In these cases, I will turn from my primary kit to one of the other 2.

The kits I use all have been designed with two areas in common. The first commonality is that each kit is designed as a light cured only system. I prefer to have complete control when I am bonding porcelain veneers into place. To maintain control the cement is only cured when I am 100% confident the restoration is seated in the correct orientation and all the margins are closed. This is only really possible with a light cured only luting composite. If you are a little slow with a dual cured system you may not have the restoration completely seated when the cement starts to set and you will be left with a poorly fitting restoration and open margins. I also prefer to spot cure my veneers into place and clean the interproximal excess before curing the overall body of the veneer.

Another benefit of using luting cement designed to only be light-cured is that the cement itself does not contain the unreacted amines necessary to react with the peroxides in the catalyst needed with a dual-cure cement. The bottom line is that this makes the cement much more color stable. The dental literature reports a potential color stability problem with cements that are designed to be both light-cured and dual-cured when used with the dual cured catalyst. This may not be a problem with a larger porcelain onlay but with a thinner porcelain veneer any change in the luting cement color over time may result in a change in the veneer and an unhappy patient.

The second important area in common with the 3 kits is that they all have a water-soluble try-in gel that allows me to test out the selected shade of luting composite before I commit to bonding the restoration into place. I feel this is a very important feature to have with any kit designed to lute porcelain restorations because the luting composite will affect the value and color of the veneers.

The next area you will want to look at are the actual physical properties of the materials. The manufacturers are providing us with many excellent products in the dental field but my preference with porcelain veneers is to use materials that have a number of years (preferably 5 years, check out the pictures below from a 4 unit veneer case that was 6 years old last month) of clinical evidence supporting their use. I would like a color stable material with a low film thickness and excellent compressive, flexural and tensile bond strength that is easily polymerized in the 400 to 500 nm wavelength.

I would also like a material that will clean up easily around the porcelain restorations

Next week, in part 2 for this series I will let you know the kit that I use for the majority of my porcelain veneer cases. Can you guess what this kit is?

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