Dental Excellence: Accurate Master Models

This is the third video from my new Dental Excellence video series. It is critical to have accurate opposing models which make a huge difference to the fit and finish of restorations when finalizing the occlusion for your patient.

Watch the video below to find out more and see some tips to add precision to your dentistry. Remember that you can do this kind of dentistry and that beautiful dentistry with precise fit and occlusion is not just for the gurus!

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.

Transcription and Slides: Dental Excellence Video 1

I’m Dr. Stephen Phelan and welcome to Dental Excellence.

With this series of videos my idea is to create a series of shorter 10-15 minute or less videos where I’ll present one or two clinical techniques or tips or perhaps a case that I’m working on in my practice and get the word out across the various social media platforms like Facebook, Twitter, YouTube, maybe even my blog. I’m planning to post these videos on my blog, and then ultimately I’d like to create a podcast for these videos.

My goal here is to get the word out about one of my core beliefs in dentistry and dental education and that is that beautiful dentistry with precise fit and occlusion is not just for the gurus.

You know, I say this all the time but I truly believe this and if you’re watching online videos about dentistry, you know that you can do this kind of dentistry also. Because you’re investing your time and effort in online education so, you know, ultimately the next step is just having the patients come into your practice or having the patients in your practice understand that you can do this kind of dentistry for them.

And so this series of videos is meant to help inspire people about what they can do in their practice and just see what we’re doing in my practice because I have a pretty much everyday, full-time clinical practice, but I’m good at documenting cases. So, because I like to take a lot of photos and videos and I document my cases, I can share what kind of dentistry can be done in an everyday practice.

So for this particular video, the launch of dental excellence, I’d like to share with you a case that I’ve posted onto Facebook and talked about a couple of times. And it’s basically a veneer case and it illustrates another concept that I believe in my practice, and that is I’m dedicated to creating long-term results for my patients. So wherever possible, long-term clinical results, and we’ll talk about this a lot in our dental excellence videos.

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If you look at this particular patient, these are photographs I shot in September and this patient had four porcelain veneers placed by me and these are the ten-year post-op photographs for this case. So ten years post-op and when I posted these on Facebook, people thought it was amazing to have such wonderful results after ten years and I’ll tell you, again, this is what we can do in everyday practice. You know, this is not just for the gurus, this is what we can do with good lab support, good clinical techniques and really great planning and thought about how you design the occlusion.

So, here are a couple of other views. You know, you can see the tissue looks good because we’ve had proper management of the tissue. The restorative tissue interface at the time that I placed the veneers, meaning I removed any excess cement that was all over the margins and I polished it properly and I had a good interface for the tissue to adapt to. The patient’s done his part by keeping his teeth nice and clean, coming in for really regular maintenance, flossing and, obviously, just having a good overall starting position or condition of his tissue to allow this kind of result to happen.

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If you look at the preparations, this is a primary key that I talk about in all of my training programs when we discuss porcelain veneers, and that is that you want to prepare the case to leave the majority of enamel on the tooth. You know, I don’t want the majority of the enamel disintegrated into vapor– I want the majority of the enamel left on the tooth so that then I can bond my restorations to a preparation surface that’s almost all enamel and if you can do this, you’ll have very, very few veneers de-bond, even at the ten-year mark, even, maybe, at the fifteen-year mark. If you can do this, you can get really great, long-term success for your patients.

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The mistake I see is patients coming in telling me they have veneers and they’re falling off and the thing that they have is 3/4 crown preps. It’s not veneers, it’s 3/4 crown preps. You know, the facial enamel has all been prepared and the

inter-proximal reduction has been completed to break through the contact. So if you do that, you have much less enamel to bond to, clearly, and the dentin bond, despite all the great adhesives we have, degrades at a much faster rate than the enamel bond. So at the five to ten to fifteen-year mark, you start seeing these de-bonding. So not fracturing, just de-bonding and then you have to try and re-bond them but it’s all kind of a mess and it’s hard to re-attach to this over-prepared dentin.

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I’ve had a couple of patients come in with old veneers in their hands that were treated somewhere else and, you know, I basically re-bonded them but I told them, “I don’t know how long this will last.”

So my primary goal, when I’m teaching and talking about porcelain veneers, is to leave as much enamel as possible and if you look through the dental literature, that’s echoed through a lot of different research papers, retrospective papers, longevity papers, etc. The main goal is leave as much enamel as possible, that’s something I really like to drive and drive home and wherever possible, when I’m treating a veneer case that is what I do.

Now there are some cases where the patient probably should have had orthodontics, they refuse orthodontics and you might have one area or one tooth in the arch that was out of place and should have been treated orthodontically where you’ve prepped the veneer more aggressively than you would like to and it’s more like a 3/4 crown. So what I frequently do in those cases, is I’ll have, for example, six veneers being placed, but one of the teeth that’s really out of alignment, instead of a 3/4 veneer I’ll make that a jacket crown, just because I know that we’ve removed more enamel than I’m comfortable with. So I’m just going to wrap it around the palatal or lingual and make that particular restoration a jacket crown just to try and prevent this de-bonding problem and then the rest of the teeth, if the alignment allows, will be prepared as a conservative porcelain veneer case.

So if you look at this particular case for Ross, you can see a starting condition and when we started, his teeth were not in great alignment and the one lateral incisor was really, kind of, sticking out, labially, and I would have really had to over-prepare that tooth to get it into alignment so my suggestion to Ross was what I have suggested to most of the cases that come through the practice is do orthodontics first and he didn’t want to have braces, per say, traditional orthodontics, but he did agree to Invisalign.

Dental Excellence V2 5So with Invisalign, we were able to bring the lateral incisor in and level the lower incisors much better so that at the veneer insert appointment I could just equilibrate those lower incisors and level them a little bit with Soflex XT discs, some polishing discs, as oppose to a fairly aggressive enamel-plasty that would be needed if they were left as they are here. So you can see here, with the Invisalign, I was able to line up the lower incisors quite nicely and then just enamel-plasty them a little bit to have a better contacting surface for my new incisal edge position of my upper porcelain veneers.

And so that’s another key tip, you need to set up the opposing arch when you’re doing porcelain veneers so that it’s going to work with the new incisal edge position in a protrusive and lateral guidance relationship. So often, you either have to do orthodontics, veneers on the lower incisor or cuspids, or enamel-plasty, different levels of enamel-plasty and my tip to you is you should explain this to the patient at the consultation appointment, not after the veneers are placed. Because if you start grinding on the lateral incisors after the veneers are placed, typically, the patient’s going to wonder what you did wrong and, “Why are you grinding on my good teeth at the bottom?” But when you tell them at the consultation appointment then its part of the process.

So those are just tips that I would have for you. Here is Ross finished. These probably were taken around the five-year mark, these photos. And here he is when he began. Again, didn’t like his lower incisors either, but I felt that we could improve those just with Invisalign and reshaping. The upper incisors, he had a diastema with composite resin between the centrals and he just didn’t like the triangular tooth shape that he had with those teeth so we wanted to change them to a fuller tooth shape and we did that with conservative porcelain veneer restorations.

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So another lateral view, you can see the aesthetic integration of the porcelain into the surrounding dentition. We have good surface anatomy, surface luster as well as shade and value.

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And another view. This view illustrates a point that I like to make that the porcelain veneers shouldn’t stick out, kind of protrusive; you shouldn’t have incisors that have the facial edge going to the incisal edge and kind of a facial curvature kind of surface. You want it to curve in a little bit. If you look at these incisal edges, they curve in slightly and I actually had a patient in this week– we were completing a functional analysis for her– and another dentist referred her, doesn’t like anything in her mouth. She has different restorative dentistry done at different times throughout the mouth. It’s basically going to be a full-mouth rehabilitation, but her primary concern, aesthetically, is her upper bridge. The teeth stick out on an angle and they don’t curve back in on the incisal third so, you know, that’s a fairly easy fix as long as we can find the room in the occlusion to do that. That’s a pretty effective and easy fix for me to give her what she is looking for as her primary concern, what she’s looking for resolving.

So at the three-year post-treatment, just to show you some photos as we went through the post-treatment series with this patient. I took these photos, everything looked great then. Here is a lateral view. Tissue looks great. I love the surface anatomy and luster on these restorations, they really mimic that adjacent cuspid, really mimics the adjacent cuspids and the translucency. A lot of subtle aesthetic characterizations in this case that really make it a winner and look natural. And then the ten-year post-treatment and, you know, the tissue’s maybe a little uneven– but overall I think it looks pretty darn good at ten years.

Here is another view of the ten year. And I actually video taped the entire preparation and bonding of this case, which is kind of neat, that I have all of the documentation from this case ten years ago that I video taped and edited and made into a series of DVDs, as well as, added to my online Occlusion Design membership site.

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So in the fifth module of Occlusion Design, I go through the preparation of this case, in detail, with all the prep videos.

And then in the sixth module, I show bonding in this case. So if you’re an Occlusion Design member watching this, just go back, watch module five and six and keep this case in mind because it shows what I’m teaching in module five and six on that particular case video series. You know, this has long-term post-operative results for that. From the teaching aspect ten years ago filmed with a dental microscope, the Zeiss dental microscope, all the way to the post-ops now. So it’s good to have that kind of proof of principle, so to speak, of all the different, subtle, aspects of the preparations as well as the bonding in of this case.

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And we posted this, as I said, to Facebook, I had a really great response. We posted it on the Phelan Dental Seminar’s Facebook page and I believe I posted it on the Dr. Stephen Phelan Facebook page as well. We had lots of likes, looks like we had a hundred and forty-something likes, twenty-nine different comments, a lot of engagement with these kinds of posts on Facebook and three different shares where people were sharing it with their own page or their own profile to say– I looked at some of these and people say things like, “Oh this is what I really want”, etc. to share with their friends and it’s typically– the shares are frequently on my Dr. Stephen Phelan page by patients and, as I said, saying, “This is what I’d like to see for my mouth.”

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So that’s video number one for dental excellence and if you enjoyed this video, by all means leave a comment or question below the video. Whether that’s on my blog, on YouTube, on Facebook or hit the Facebook like button or on LinkedIn.

I’m basically planning to post this video series, as I said, on the various social media platforms that I have a profile with and I’m going to do my best to answer any questions if you didn’t have your question answered, maybe post it on my blog. That’s probably the central point where I’ll answer most of the questions– the PhelanDentalSeminars.com blog page. And, you know, that’s basically it.

So I hope you enjoyed video number one for dental excellence and just to remind you, you can do this kind of dentistry– beautiful and precise dentistry with precise fit and occlusion is not just for the gurus. So thank you very much.

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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.

 

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

Flapless Dental Implant Surgery: 1 Week Post-Surgical Photos

One Week after Minimally Invasive Implant Surgery

I thought I would share some photos from the one-week post-operative appointment with the implant surgery case I posted last week in this blog. As you can see the case has healed really well at the one-week mark and the tissue looks excellent. The patient reported virtually no pain, swelling or bleeding post surgery and should be ready for the final impression next month.

If you are noticing a subtle difference in the color between the pictures in the 2 posts it is because they were taken in different rooms with different cameras. My dental hygienist Anna using a Nikon D200 camera and a Nikon 105 Macro lens with a Nikon SB 29s Macro Flash took these pictures and I took the pictures in the previous post using a Nikon D3s camera with a Nikon 105 VR Macro lens and the Nikon R1C1 Macro Flash System. I think that both sets of pictures look excellent. Can you see some slight differences between these two cameras?

Feel free to add any comments or questions using the link above.

Plumber’s tape for dentistry

Plumber’s tape can have many uses in your dental practice.

One product that is really inexpensive and useful to have around your dental practice is plumber’s tape. You can buy it for a few dollars at the local Canadian Tire or hardware store and it can be very handy for isolation.

If you look at the pictures attached to this post I have isolated the adjacent teeth with plumber’s tape so I can etch and bond the veneer preparations without damaging the adjacent teeth. This isolation technique prevents etchant and adhesive from contaminating the adjacent tooth structure, which can lead to bonding these teeth together when you insert the veneers.

Another use for plumber’s tape is to isolate the screw holes for screw retained provisional implant crowns like the ones in my exclusive video, How To Create A Custom Implant Transfer For Esthetic Implant Cases. In a case like the one in the video the plumber’s tape is used to prevent the cement or composite resin from clogging up the abutment screws and make it difficult to remove or tighten them at a later date. This can be very useful when you have provisional implant crowns that need to be removed one or two times to refine the esthetics before the completion of the case.

With the plumber’s tape you can screw the provisional into place and insert the rolled up plumber’s tape over the abutment screw and then seal the access with composite resin. When you need to remove the provisional all you need to do is drill out the composite resin to the level of the plumbers tape and then remove the plumber’s tape with a probe or explorer.

I used cotton pellets for this technique for years but I now find that the plumber’s tape is a cleaner and easier way to handle these cases.

Do you have any other ways you use Plumber’s tape in your practice?
Feel free to add any comments or questions using the link above.

Flapless Dental Implant Surgery

I wanted to post a couple of photos from an implant I placed on Thursday. The implant was a Straumann bone level implant. The surgery was completed with a Simplant Surgiguide and the implant was placed without a flap through a 4.0 mm tissue punch. I have talked about this technique on my YouTube channel http://www.youtube.com/user/phelandentalseminars and I wanted to share some photos from this case with everyone to illustrate how great the site looks post surgery using this approach. You will notice the only incision is the tissue punch and no sutures were required. I measured the stability with the Osstell and the implant showed excellent results with readings of 86 on the mesial and distal and 76 on the buccal and palatal.

I called the patient the next day and he told me it did not even feel like he had any surgery completed on the area! I really feel this technique is excellent for the patient providing you have an adequate ridge volume. Are you wondering how this ridge is so well preserved for the implant surgery? I will talk about the technique I use for ridge preservation at the time of the tooth extraction in a future post.

Feel free to add any comments or questions using the link above.

Dental Implant Problems and Solutions

I posted a new video  about a common problem we all have from time to time with dental implant components. In this video I discuss the problem of stripped screw heads and I share with you the solutions that we used to solve this and make it possible for us to complete the cases.