One Critical Mistake I Almost Committed

I am so glad I caught this. I almost made a critical mistake with the provisional restorations for a case I completed earlier this year.

The upper provisional was completed, I thought it looked excellent and went to take a few pictures of it before seating and right there through the camera viewfinder I saw it.

Can you see what is wrong with this provisional?

I left the gingival embrasure between the central incisors closed!

This could have blunted the papilla and left a black triangle at insert (along with an unhappy patient).

Now, as we know from Dr. Dennis Tarnow if the contact point of the restorations is 5.0 mm or less from the interdental peak of bone the papilla will reform.

That is great long term but the patient would not be happy short term. Therefore, I recommend in my trainings to design and contour the gingival embrasures of the provisional to provide space for the papilla. 

Here is ideal papilla contour after the removal of long-term provisional restorations. The cement you see on the preparations is Durelon. I use this for long-term provisional restorations but it adheres to tooth structure a little and I remove it with an ultrasonic scaler. 

Several different instruments can be used to create ideal gingival embrasure form with your provisional restorations. I like the Vision Flex discs from Brasseler and/or a 7901 carbide to carve the ideal embrasure form.

These ultrathin discs are excellent to define precise embrasure form.

I recommend you instruct your dental assistants to be careful how they handle them for cleaning and sterilization because they are expensive and if they get even a small bend on one corner they do not cut with the same precision and are basically useless. 

So, with this new case, I saw the poor embrasure form while I was taking pictures and corrected it.

Here is the final provisional contour the day I seated them.

Here is an composite image showing the initial provisional with the poor embrasure form first. The middle image represents the adjusted provisional embrasure form after shaping with the 7901 carbide and the final seated image shows the provisional with a knife edge type of embrasure form created from the Vision Flex disc.

Here they are a few weeks later when the tissue was healed.

Here are the final restorations immediately after bonding.

Here are the final restorations after 4 months of healing. Note the excellent tissue health and contour. I am glad I caught that mistake I almost committed with the provisional restoration.

The ceramics were created by Master Ceramist Harald Heindl. 

If you would like to see this new case in detail with examples of the preparations for Occlusal Veneers, Veneer Crowns, and Onlay Veneers please register for my new webinar while it is still available.

Click Here to register for this New Webinar.

During this new webinar, you will learn:

  1. Where to start your analysis when a severe wear patient presents into your dental practice. I have a system for this that will help to clarify the confusion surrounding helping these patients.
  2. How to identify the risks involved with wear patients. Both risk of treatment and the risk of doing nothing. 
  3. How to design and test a new occlusion for these patients. What happens if they cannot tolerate this new Occlusion Design?
  4. How to manage muscle forces with a wear patient so you can achieve longevity with their restorations.
  5. How to choose the best restoration design for individual teeth in an erosion or attrition patient. Should you choose crowns, onlays, veneers, occlusal veneers or veneer crowns?

I hope you enjoyed this new email training and look forward to connecting with you during the webinar.

 

 

Strong Restoration VS Strong Tooth

 

As clinicians we are often faced with the dilemma of trying to balance material and lab needs with the desire to be conservative.

Would you prefer to be safe and provide the lab with plenty of reduction so the material is strong and the resulting thickness makes it easier to create a desired esthetic result?

Here is a picture for the ceramics from a recent case I completed. 

Notice the thickness of the central incisor crowns compared to the lateral incisors!

The central incisors were originally prepared by a different clinician with a more traditional preparation design and a butt joint margin.

Unfortunately, this leads to what I would refer to as Strong Restoration VS Strong Tooth.

Notice the lateral incisor crowns. These are prepared with a different philosophy that I would refer to as Strong Tooth VS Strong Restoration.

Here is the preparation photo.

The important question to ask is, “can we have both?”

I believe the answer is yes. I feel with the predictable ability to either bond directly to enamel or use IDS to predictably bond to exposed dentin you can achieve Strong Tooth AND Strong Restoration!

I do not believe we need excessive reduction of healthy tooth structure to achieve our long-term goals. We can bond a thinner thickness of ceramic leading to less reduction of healthy tooth and stronger remaining teeth while still achieving excellent esthetics and predictable results.

This leads to some exciting preparation designs even with erosion patients like you see in the picture below.

We can use Occlusal Veneers, Veneer Crowns, and Onlay Veneers to help restore a patient like this with severe erosion in a more conservative manner.

If you would like to see this new case in detail and examples of Occlusal Veneers, Veneer Crowns, and Onlay Veneers please register for my new webinar while it is still available.

Click Here to register for this new webinar.

This new webinar will feature a detailed new case study for a patient with severe erosion I treated this year with a partial rehabilitation.

If you have wear patients you are unsure about or you have avoided treating you should watch this encore webinar.

Here are a few slides from the webinar presentation. As you can see below I use a variety of preparation designs for this case to produce a Strong Tooth AND Strong Restoration! 

 

During this new webinar, you will learn:

  1. Where to start your analysis when a severe wear patient presents into your dental practice. I have a system for this that will help to clarify the confusion surrounding helping these patients.
  2. How to identify the risks involved with wear patients. Both risk of treatment and the risk of doing nothing. 
  3. How to design and test a new occlusion for these patients. What happens if they cannot tolerate this new Occlusion Design?
  4. How to manage muscle forces with a wear patient so you can achieve longevity with their restorations.
  5. How to choose the best restoration design for individual teeth in an erosion or attrition patient. Should you choose crowns, onlays, veneers, occlusal veneers or veneer crowns? 

Click Here to register for this new webinar.

I hope to connect with you during the webinar.

 

Dental Excellence Video 21: Occlusal Veneers to open the vertical dimension with wear patients

This is the 21st video in my Dental Excellence Video Series.

In this new video, I talk about occlusal veneers to open the vertical dimension for wear patients that may not require full coverage restorations for the molars.

During the video, I share with you images from two cases I completed in my practice. The first case was finished 13 years ago but I saw him this week during his hygiene appointment and I included new 13-year post op photos taken Wednesday.

The second case was completed this year in my practice.

 

Thank you again for being a member of my online community and remember…

You can do this kind of dentistry!

I believe that beautiful dentistry with precise fit and occlusion is not just for the gurus.

All the best,

Stephen

P.S. If you are interested in this kind of dentistry, I believe you would enjoy my Online Seminar. Altering the Vertical Dimension Case Studies.

This seminar will feature 3 detailed case studies teaching a different vertical dimension concept for each case. These case studies are from patients that I have successfully treated in my own practice over the past 21 years.

The first case study is the 13-year-old case from my new Dental Excellence video so you can be confident these techniques work in a regular clinical practice. 

Click Here to register for this seminar.

During this online seminar, you will learn:

  • The one thing you NEVER want to do when you alter the vertical dimension!
  • The starting point to assess if the vertical even needs to be altered.
  • Three different options to alter the vertical and when to use each.
  • Should I test out the new vertical with a splint first?
  • Will my patient be able to speak properly after I alter the vertical?
  • What should I do if my patient has speaking issues after I alter the vertical?
  • Can I predict if my patient can tolerate an alteration to the vertical dimension?
  • Will my patient have pain after if I alter the vertical dimension?
  • How stable is the new vertical dimension?
  • How should I design the anterior guidance to work with my new vertical dimension?

Click Here to register for this seminar.

 

Dental Excellence Video 19: Dental Implant Adventures

This is the 19th video from my Dental Excellence video series.

A couple of weeks ago I was prepping a rehabilitation case and we had a bit of an unexpected implant adventure. This new video will tell you all about it and offer a very nice solution.

 

Thank you again for being a member of my online community and remember.

You can do this kind of dentistry!

I believe that beautiful dentistry with precise fit and occlusion is not just for the gurus.

All the best,
Stephen

Dental Excellence Video 18: Specific Detail for Porcelain Veneer Preparations

This is the 18th video from my Dental Excellence video series.

In this new training, I share a new video I filmed with my Zeiss microscope teaching you about a specific detail for porcelain veneer preparations.

This new training will use clinical video footage filmed with my Zeiss dental microscope to teach you this simple but highly effective technique.

Thank you again for being a member of my online community and remember.

You can do this kind of dentistry!

I believe that beautiful dentistry with precise fit and occlusion is not just for the gurus.

All the best,
Stephen

P.S. We all know the importance of the diagnostic wax-up. This new Dental Excellence video uses a putty fabricated on the diagnostic wax-up that I section to guide the veneer preparations.


If you are interested in this kind of dentistry, I believe you would enjoy my new online seminar. Altering the Vertical Dimension Case Studies.

When you attend this online seminar, I have a special bonus for you. At the 5-minute mark I have created a link to download my New Diagnostic Wax-up Instructions PDF to use with your cases!

You must log in and attend the seminar to receive this download.

Click Here to register for this new seminar this weekend, Altering the Vertical Dimension Case Studies and receive this Free Download when you log in.

Dental Excellence 17: Root Extraction System

This is the seventeenth video from my Dental Excellence video series.

In this New Dental Excellence Video I will share with you a very cool root extraction system.

This new training will use extensive video footage filmed with my Zeiss dental microscope to teach you this simple but highly effective extraction technique.

Thank you again for being a member of my online community and remember.

You can do this kind of dentistry!

I believe that beautiful dentistry with precise fit and occlusion is not just for the gurus.

All the best,
Stephen

P.S. All of us have patients that suffer from tooth wear in our practices. During this new Dental Excellence video I also tell you about my Altering the Vertical Dimension Case Studies Online Seminar.

If you are interested in this kind of dentistry CLICK HERE to register and find out more about this new seminar presentation.

P.P.S. We all know the importance of the diagnostic wax-up. When you attend my new online seminar I have a special bonus for you. At the 5-minute mark I have created a link to download my New Diagnostic Wax-up Instructions PDF to use with your cases!

You have to log in and attend the seminar to receive this download.

Click Here to register for this new seminar this weekend, Altering the Vertical Dimension Case Studies and receive this Free Download when you log in.

Dental Excellence 16: Case Acceptance Systems

This is the sixteenth video from my Dental Excellence video series.

In this New Dental Excellence Video I will teach you the overall system I follow to help patients with more complex dentistry select appropriate treatment plans.

I will tell you about a new patient that I recently completed the diagnostic records for that is going ahead with a full mouth rehabilitation.

I have edited my recent Facebook Live presentation to use a multi-video camera presentation that I think you will enjoy!

Near the end of this new video I take you on a tour of my large operatory and show you my microscope, loupes, piezo, cameras and laser. This is the operatory I prepare my full mouth rehab cases in. ☺

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

All the best,
Stephen

P.S. To learn more details about presenting fees for these cases and to see the actual case presentation slides for a full mouth rehabilitation consultation join me for my Master Your Case Acceptance Webinar by clicking this link to register https://www.phelandentalseminars.com/myca-reg

Dental Excellence 15: Ultrasonic Preparation Clinical Microscope Video

This is the fifteenth video from my Dental Excellence video series.

In this New Dental Excellence training I would like to share with you a new clinical video I filmed with my Zeiss microscope teaching you how I use ultrasonic diamond tips for the precision preparation of class 2 box forms.

Near the end of this video I tell you about my new clinical tutorial: Creating Stunning Provisionals. Click here to learn more.

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

All the best,
Stephen

Dental Excellence Video 14: Precision Preparation Guides

This is the fourteenth video from my Dental Excellence video series.

In this New Dental Excellence Video I would like to share with you the stents and putty matrices that I use for the precision preparation design for everything from a 6-unit veneer case to full mouth rehabilitation cases.

Click Here to register for my new webinar that I talked about at the end of this new video.

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

All the best,
Stephen

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