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

How Do You Treat A Non-Restorable Central Incisor In Your Practice? Immediate Vs Delayed Implant Placement -Part 2

After complete healing, the alveolar ridge appeared favorable for a flap-less implant placement approach.  This can be a challenge to position the implant platform at the ideal level.  If the implant is positioned too shallow, there will be insufficient room to create a proper emergence profile and crown form.  If the implant is too deep, it may be a risk for future recession or inflammation.

I was very careful with measurements made clinically from the existing gingival margin and the new planned gingival margin as well as checking with radiographs.  Using a computer-generated guide is another option for these cases, but will still require good clinical judgement.

The implant was positioned with the platform 3 mm from the future gingival margin to accommodate a favorable emergence profile. It is important to note that the interproximal bone must be modified to create space for the future restoration; otherwise, it may be a challenge to seat the restorative abutment and there is possible risk of developing bone necrosis due to excessive interproximal pressure. (See radiographs)

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

Provisional And Final Restoration

The gingival recession on the adjacent central incisor #8 (FDI #11), was improved by a semi-lunar coronally advanced flap.

After the implant has osseointegrated, it is time to shape the abundant soft tissue from that of a circular healing abutment to that of a triangular tooth form.  The provisional restoration is fabricated with a sub-gingival profile that will create tissue support and an ideally positioned height of contour to move the gingival margin to the desired level.

After a couple of months, the tissue form created by the provisional restoration can be duplicated by using a custom impression coping during the impression procedures.  The final crown should follow these sub-gingival contours to maintain this soft tissue form.

The restorative phase was completed with a custom cast gold abutment and a cemented PFM crown.  The crown form was slightly flatter at the mesial line angle than the provisional restoration and we can see the change in the soft tissue form.  Overall, the treatment sequence insured a predictable outcome for this patient.

Coronally advance flap #8(FDI #11) and flapless implant placement #9 (FDI #21)

Implant Placed According To Future Gingival Margin

Provisional Restoration

Provisional Restoration

Provisional Restoration At Placement

Provisional Restoration After Tissue Shaping

Final Restoration

How Do You Treat A Non-Restorable Central Incisor In Your Practice? Immediate Vs Delayed Implant Placement -Part 1

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

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

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

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

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

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

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

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

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

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

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

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

Note Large Apical Lucency

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

Provisional And Final Restoration

Initial Presentation

Occlusal View Of Socket


Apical Lesion Debrided

Alveolar Grafting Completed

Alveolar Ridge Graft Healed