By Lee Ann Brady, DMD 

Balancing Benefits and Risks in Restorative Dentistry 

As restorative dentists, our commitment to providing high-quality, lasting care is unwavering. Ideally, we’d offer our patients restorative solutions that last a lifetime without needing repair or replacement. However, in reality, no restoration is permanent, so balancing the benefits and potential risks is essential in choosing the right solutions for each patient. 

What Makes Resin-Bonded Bridges Unique? 

Among restorative options, resin-bonded bridges may not be the first to come to mind, yet they serve as a unique solution for specific cases. Resin-bonded bridges are known for their conservative approach—they don’t require extensive alteration of the surrounding teeth and can often be placed without surgical intervention. For young patients, in particular, this minimally invasive option has a range of benefits. 

Preserving Alveolar Ridge Development in Young Patients 

One of the reasons resin-bonded bridges are favorable for younger patients is their flexibility in preserving the natural development of the alveolar ridge. By delaying more permanent options, such as implants, patients can avoid the potential complications related to ridge development and aesthetics that could arise years later. These bridges also offer an unobtrusive alternative, especially for patients who need a solution but may not be ready for an implant due to age or other factors. 

Setting Realistic Expectations with Patients 

Recommending a resin-bonded bridge requires a balanced approach to patient communication. These bridges are more likely to become loose over time, demanding a higher level of care and caution from patients. They must be aware of dietary limitations, avoiding hard or sticky foods that could disrupt the bond. Educating patients on the longevity and maintenance requirements of resin-bonded bridges helps set realistic expectations while ensuring they understand the care involved. 

A Conservative Yet Valuable Solution 

Despite their potential for detachment, resin-bonded bridges remain a valuable choice when the clinical situation calls for it. They offer patients a pathway to maintain oral functionality and aesthetics without the invasiveness of traditional restorative methods. Especially in younger individuals or those with adjacent unrestored teeth, this solution balances the need for stability with the importance of conserving natural tooth structure. 

Up Next in Part 2 

Part 2 of this series will discuss how resin-bonded bridges compare with other restorative options, such as traditional fixed bridges and implants. By understanding these options more fully, we can better guide our patients toward the solution that best fits their unique needs and preferences. 

Christopher Mazzola, DDS 

The purpose of looking at recent research data is to see how we can improve our clinical success. Different scholarly journals inform us of ways to decrease risk and hopefully increase the longevity of the services that we’re providing to our patients. In this article, I’ll summarize what I’ve learned from recent research literature about the various types of zirconia we receive from our dental laboratories and properties of zirconia that influence the quality and longevity of the dentistry we do. I found these facts fascinating from the perspective of wanting to know how to use zirconia optimally.  

Composition: There are three primary compositions of zirconia on the market: 3y, 4y, and 5y. The Y in the composition descriptor refers to Yitria or Yttrium Oxide (Y2O3). The more Yitria the zirconia contains, the more translucent the crown will be. Adversely, the more Yitria the crown contains, the less flexural strength the crown has. The 3y zirconia can handle adjustments better than 4y and 5y in terms of both strength and optical properties. 

Color: The marketplace offers zirconia that is prestained and zirconia that is not prestained. In the case of prestained zirconia, we have about a tenth of a millimeter in reduction capability before we notice a color change. Knowing this is important when we need to adjust a restoration, so we can manage adjustments to deliver the shade of restoration our patient expects. 

Wear on Other Materials: If zirconia is rubbing against other zirconia there is less wear than if zirconia is rubbing against lithium disilicate and softer ceramics or composites. When you’re setting up an occlusion or you are looking at a hybrid denture versus a normal denture, you must take this into account. If a patient has an upper fixed-hybrid denture, zirconia is going to wear those denture teeth relatively fast. Knowing this, we can best prepare our patient for the wear that is likely to occur. 

Zirconia Removal Burs Vs. Restorative Diamond Burs: In an in vitro study, the burs that are marketed specifically for adjusting zirconia restorations did not perform better on 3y, 4y, or 5y zirconia, and they did not generate less heat. 

Note About Polishing Zirconia: When we are polishing high-strength ceramics like zirconia and lithium disilicate, we must be careful not to push too hard, and we must use a continuous cooling spray of water. Otherwise, we risk nerve damage due to thermal irritation. Also, if we generate too much heat, we will overheat the glue that bonds the fine diamond particles on the bur and are likely to render the bur useless. 

By Daren Becker, DMD 

A 16-year-old girl presented with the worst case of ectodermal dysplasia I had ever seen.. She was missing all of her lower teeth except for her 12-year molars. She presented with a lower denture (made by a previous dentist) on two temporary implants in the canine position.  She had only a few maxillary teeth that were malformed; some of these were still her primary teeth.  The appearance of her smile made her look like she was a 9 year old child. 

She was embarrassed by her smile and realized she would need implants and restorative dentistry down the road. At the time, she was too young. Our hearts went out to her. 

Another dentist had recommended direct bonding, which certainly could have worked, but I thought that we could get a better aesthetic result for her with significantly less time in the chair. So, we captured preclinical digital impression scans with our iTero scanner and along with Matt Roberts at CMR Dental Lab in Idaho, we designed a digital wax-up for an improved occlusion and smile. From there, we had milled PMMA (Polymethyl Methacrylate) overlays created that we direct bonded onto the existing dentition as a long-term temporary solution. We did not need to prep any teeth, and we quickly gave her a broad beautiful smile that looked natural and age appropriate. 

She was in tears. We were in tears. Her mom and sister were in tears. It was the best day ever! 

Soon after, she got a part as an extra in a series filmed here in Georgia, and is thinking about a career in acting. Seeing her life change with simple, comfortable clinical procedures has been priceless. 

By Kelley Brummett, DMD 

A situation occurred in my office when I was working with a patient who needed a 30-year-old PFM crown replaced on #8. I was struggling with the shade because the adjacent teeth were an in between color. What I did was take a shade photo of the brightest one, which was B1, and then I took a shade photo with A1–because those were the two shades that matched the best. They weren’t what we were looking for. So, I made a provisional out of the A1 shade and a a provisional out of the B1 shade. I took the extra time to place both of them onto the tooth and let the patient look with me and help me decide. The patient chose the A1 shade. 

After I placed the A1 provisional, we sent  photos to my lab. These photos included the first shade photos of B1 and A1 alongside the tooth, photos of the B1 and A1 provisionals, and photos of the provisional I placed on the tooth from various aesthetic views. I then talked to the lab over the phone while we viewed the photos together so they could create the right in-between shade.  

At the end of the process, my patient expressed gratitude for taking the extra steps and meeting her expectations for a beautifully blended smile. 

Kelley Brummett, DMD 

After you do a crown preparation, do you tell your patients that you’re going to make them a temporary or a provisional?  

Provisionals are more than temporary restorations. They are part of a process. They’re the dress rehearsal to the final outcome. They are the prototypes for the final restorations.  

The “provisional” process is an opportunity to gain trust with the patient while modifying the length of teeth, the shape, or the color. It is also a way to communicate with the patient how their functional and parafunctional findings may have contributed to the destruction of their teeth. 

As the patient comes back to have their bite checked and to talk about what they like and don’t like, we are building trust. We’re involving them in understanding what they feel and think. We’re listening to improve their conditions. 

I’ve had patients who were fearful about moving forward with extensive treatment because they couldn’t envision the transition from the prep appointment to the final. What would those temporaries look like? What would they feel like? How would they function?  

So, when I am discussing a case with a patient, provisionals are all part of one treatment fee. We talk about the prep process, the provisional process, the lab process, and the final seating process—all as one process for which there is a fee. We discuss how the provisionals will guide us in optimizing the lab plan to achieve the desired comfort, function, and aesthetics.  

Whether it’s a single tooth or whether it’s multiple, I encourage you to help the patient understand that what you are providing in the interim between a preparation and a seat of a restoration is called a “provisional.” 

A provisional protects the underlying tooth structure. It keeps tissue in place. It helps the patient feel confident. It allows us to understand what might be going on functionally. It helps us communicate better with the lab. It’s more than a temporary restoration. It’s a guide on our journey toward predictable and appreciated relationship-based dentistry. 

Gary M. DeWood, DDS, MS 

Many dentists believe that provisional restorations don’t really matter. After all, they are not really a stand-in for the final restoration. I would respectfully disagree. I am a proponent of creating functional, durable, and highly esthetic provisional restorations, every time. They have the potential to impact your dental practice a lot more than you might think. Whether you print them, form them, or free-hand them, a GREAT temporary is a great billboard for your practice. 

1. Make the provisional as Esthetic as the final restoration.

I contend that the more your provisionals look like what you are hoping for when you seat the final restorations, the more people will talk about them, AND you. 

I was able to build a referral restorative practice by creating provisionals that made patients want to come to my practice and specialists want to send people. For much of our career, almost the entire team of the oral surgery office we worked with, and many of the team members from the other specialty practices we worked with, were our patients in Pemberville, Ohio. 

Front teeth or back teeth, when you make them look like teeth, people will like it and they will show and tell other people. “This is just the temporary?!” was not an uncommon question or exclamation from our patients.  

2. A GREAT guide makes a GREAT provisional restoration.

Your wax-up** cast/model serves as your vision, as your preparation guide fabrication device, and as your provisional former. When the preparation is appropriately reduced for the material selected, the temporary can mimic the restoration. 

** The wax-up might be created with wax then duplicated with impression material and stone to create a cast, or it might be scanned to be duplicated with resin and printed or milled to create a model. 

3. 3. Use that provisional to highlight the talents of your team members.

You might LOVE to make those provisionals, but if your assistant is equally excited when it comes to recreating nature for the patient to appreciate, then it could be an opportunity for patients to see that your assistant does much more than set-up, clean up, and hand you an instrument. My dental partner, Cheryl, (who is also my wife) and I actively sought out things that could help our patients experience our team as much more than our helpers. 

As we all know, dental assistants are an integral and vital part of what the practice is and are a powerful force in how and why patients ask for dentistry. Assistants who fabricate provisionals have an opportunity to be seen differently, and we were always looking for ways to create partnership with them in our treatment. 

4. 4. Take pictures of them.

Photographs of the temporary will make it easier for the lab to design the outcome. They will be able to see what you are thinking, able to visualize what you want, AND maybe even more importantly, see what you do not want. With anterior provisionals, I have frequently noted to my ceramist, “Please put the incisal edge in exactly this position vertically and horizontally in the face, then use your artistry to create the tooth that belongs in the face you see in the photographs of the patient before, prepared, and temporized.” 

There were many times when the technician was able to see and create effects that I might have not recognized as being “just the thing that would make these teeth extraordinary.” And don’t forget to show the patient the photograph. 

5. 5. Love the material you make the temporary with.

The better the provisional material is at holding tooth position and functional contact, the less adjustment we’re going to have, so using a high-quality material is important. There are a lot of them out there. I like bis-acryl materials that polymerize with a hard surface, have little or no oxygen inhibited layer, and can be polished easily. The polish is more about feeling smooth than about the shine. Ask you patients how their provisional tooth “feels” when you are done, so they sing your praises. 

6. 6. Use high-quality core material.

When you use a good core material the prep will be smoother, making it easier to fabricate nice provisionals. Ideal prep form goes a long way toward better provisionals. 

7. ASK your patient to tell people.

As noted above, when you can elicit an emotional response about the awesomeness of your provisional, ask the patient to tell other people, “….and this is just the TEMPORARY!” 

Trying to match the color of the cement between the abutment and the dental implant crown in the anterior can be very frustrating. Here’s a trick that works well for me. 

A while back I was struggling to match the color of the cement between the abutment and an anterior implant crown. I always try-in the abutment and the crown and try to confirm the shade before they are put together. We do this because the laboratory can’t redo the shade once they’ve bonded the crown and the abutment for screw retention without trying to separate the cement, which is difficult. 

Over the years, it was a challenge to replicate the opacity of the cement used to connect the titanium abutment and ceramic crown. I’ve tried using some of the opaquest try-in paste on the market. 

In the case I referred to above, we thought we had it. My lab cemented it together and I put it in. I could see the opacity of the cement through the restoration. So, we had to take it apart and try again. My laboratory technician shared with me a trick that he had learned from one of his other dentist clients. And that was to simply go to CVS, Costco, or Target and buy good old fashioned liquid white out.  

Now, I put a very tiny amount of whiteout on a micro brush and paint it on the inside of the labial surface of the crown on the intaglio surface. Then, I use a bit of translucent try-in paste to seat the crown. 

The whiteout works well because it is basically titanium dioxide and water with preservatives—the same white compound that is in super white sunscreens. In my opinion, it is relatively safe to use, and I can see what the implant will look like when the pieces are cemented together. 

Why Use an Essix Retainer Versus a Flipper During Dental Implant Therapy 

Lee Ann Brady, DMD 

When it comes to choosing a provisional during implant therapy in the anterior aesthetic zone, we have two removable options. One is called a “flipper.” It’s an interim partial denture composed of an acrylic base and a denture tooth. The other is an Essix retainer.  

There is no question that both options are taxing for the patient for the three to five months that the patient is edentulous and must deal with having this removable device to replace the tooth. So, I always tell my patients that they are going to have to manage the provisional for that time, but it’s worth it because, in the end, they have replaced the tooth with an implant with all the benefits of an implant versus an alternative prosthetic solution. 

In my practice, I use Essix retainers in nearly 100% of the cases. Why? Because an Essix retainer is tooth-borne. The pressure is placed on the teeth and not on the surgical site. In the case of a flipper, the prosthesis is primarily tissue-borne with a little pressure placed on the adjacent teeth. We really don’t want any pressure on the surgical site while it is healing. Pressure can induce biological problems in bone grafts and connective tissue, which affect the long-term outcome. From an aesthetic perspective, the most challenging thing about anterior implant aesthetics is replicating the size, shape, and position of the tissues of the alveolar ridge and papilla. I want to do everything I can to eliminate pressure on the healing tissue. 

In my practice, we do Essix retainers that don’t have a full solid tooth in them. Instead, we simply paint flowable on the facial so that there’s zero pressure anywhere around that surgical site after extraction, after grafting, and after implant placement.  

In addition to explaining the improved outcomes associated with using an Essix retainer, I assure my patients that the retainer will be more comfortable to wear than a denture and be easily removed by them for eating, for drinking liquids other than water that are likely to stain the retainer, for teeth cleaning, and for cleaning the prosthesis. When out in public, such as in a restaurant, patients may carefully eat while wearing the Essix retainer.  

When we identify patients, whose dental esthetics has been negatively impacted by altered passive eruption, our treatment plans are apt to include altering the gingival esthetics. One of the things we are tasked with is determining where we want the tissue to be.

We start by determining if the incisal edge is correctly positioned in the face.

For example, by looking at a lips at rest photograph and a full face image for my patient with altered passive eruption, we can see that the patient’s incisal edges are correctly positioned. If they were not properly positioned, we would next plan the position for the incisal edges.

Tooth proportion becomes the next building block in the planning puzzle. We know that beautiful anterior teeth are usually between 70-80% width to length ratio. This variability allows us to accommodate other clinical considerations, as well as patient preference. As a starting point, I begin with 75% and then look at the other parameters.

If the patient has excessive gingival display, and one of the hoped for outcomes is to minimize the amount of gingiva, we can alter the drawing to increase the length and then evaluate the esthetic result.  On the other hand, if there is excessive sulcus depth, we can place the proposed gingival margin within the confines of the sulcus and assess the esthetic result.

Patient Involvement

I create template drawings, like the one below, in Keynote on my Mac computer, but drawings also can be done in PowerPoint. I then sit down with my patient, insert a retracted teeth apart patient photo behind the drawing, and together we move the lines until the patient is happy with where the pink will be.

Once we have the final proposal, the next step is to determine the possible treatment options to gain the intended result. The information can easily be transferred to a wax-up or used to create a snap on trial smile.

How to Create and Use Templates

In Keynote or PowerPoint, take a retracted teeth apart photo of a beautiful, near perfect smile. Put it into the presentation software. Blow the image up to 200%. Using the free form drawing tool, trace the outline of the upper six anteriors. Take the photo out and save the presentation as a named template.key or template.ppt file.

When you want to do proposal drawings with your patient, open up the template, insert the patient’s photo and save the file with the patient’s name. You can copy and paste the tooth outlines onto any of the patient’s photos to propose gingival changes. If you pre-draw and save outline templates for various tooth sizes (ratios), you can quickly show options to your patient.

One of the challenges of aesthetic dentistry is setting clear expectations for patients. The more we can use visual tools over words the easier this becomes.

Over the years I have found that looking at photos with patients, both of their teeth and of the teeth of other people whose smiles demonstrate the principles I am explaining has made patient understanding much more successful. I always ask permission to show a patient the photos of their teeth as I find sometimes they are shocked by what they see. The photos can also be used to show them the changes being proposed. Drawing shapes and lines on the images communicates the information without the risk of setting unattainable expectations, which I fear using photoshop might.

The Third Aesthetic Zone Ration

The next of the esthetic zone ratios looks at tooth proportion. Upper anterior teeth look their most esthetic when the ratio comparing width to length is between 70-80%. This proportion can be measured on a computer screen in pixels using programs like Keynote or Powerpoint.  Insert the image into a slide and trace the outline of the tooth with the freehand shape tool. Once the shape is complete click on it and hold your mouse curser over the corner. The pixels for width and length will apear and you can calculate the ratio. It is also easy to figure out this ratio by measuring on a stone model with digital calipers, or from a printed image using a ruler.

(Width/Length) * 100= Tooth Proportion Ratio

What the Ratio Means

Teeth with a ratio of less than 70% appear too tall and narrow. If it is greater then 80% the tooth appears too short and wide. If the tooth has a width to length ratio that is less than 70% or greater than 80% and we are going to treatment plan changing it we have to determine where we make the length adjustments at the incisal edge or the free gingival margin. The fist step is to determine the correct position of the incisal edge in the face using a lips at repose or rest photo. From the proposed incisal edge position we can then determine the proper position of the free gingival margin using this ration.

Some simple math can be very helpful when determining the appropriate length to correct this ratio.

• 70%= width times 1.43
• 75%=width times 1.33
• 80%=width times 1.25