My patient wasn’t satisfied with the esthetics and feel of her previous restoration. Detailed planning enabled me to deliver a beautiful, functional result. Here is the conclusion of this case and placement of the new six unit anterior bridge:

Failed Restoration: Provisional

After the treatment planning was completed, I removed the patient’s existing anterior bridge and replaced it with a bisacryl provisional derived from the orthodontic wax-up. I sectioned it specifically to enable tooth movement while I restored the pontic sites. This meant sectioning between the maxillary central, the upper left lateral and central, and the upper right canine and lateral.

I then cemented the provisional with Rely-X luting cement. Doing so decreased displacement secondary to the orthodontic forces. Next, the patient went through orthodontic therapy over three months. Following this, she was ready for periodontal surgery. Crown lengthening was done on the upper right canine, in addition to placing connective tissue grafts in the pontic sites. This ensured ovate pontics could develop.

Failed Restoration: Equilibration & Placement

Equilibration was the natural next step. It was used to achieve the necessary anterior guidance with posterior disclusion, as well as freedom in the anterior and no centric occlusion slide to maximum intercuspal position.

I prepped off the orthodontic provisional and refined the preparation. For the margin design, I went with a shoulder and rounded internal line. This could accommodate the all-porcelain restorations.

We weren’t worried about the reduction of 1.5 mm because of the original tooth reduction, but we did go forward with placement of a third plane of reduction. This was necessary for final incisal edge placement in a AP dimension.

Venus from Hereaus was used to create the six unit provisional from upper right to upper left canine. This also allowed tissue development to occur in the pontic sites.

After taking final impressions three months later, the six unit bridge was made using E.max. I placed the patient’s direct composite veneers on the upper first molars and bicuspids. Shade matching to the anterior bridge was one advantage of this approach. Also, the patient could choose to move to porcelain at some point in the future.

My patient was finally happy with her smile. All in all, it took dedicated teamwork between myself, the ceramist, orthodontist, and periodontist to exceed her expectations. 

Replacing a failed restoration starts with a careful examination of the patient’s needs, desires, and current oral health. My patient in this case presented with a six unit anterior bridge, decay, and many esthetic issues. After an esthetic evaluation and comprehensive exam, it was time to move on to treatment planning.

Failed Restoration: Treatment Plan

To treatment plan this case, I relied on an advanced facially-generated treatment planning system for communicating with the rest of the team. Communication is essential to a reliable outcome.

First, a diagnostic work-up was generated. Then, the interdisciplinary team together developed a final treatment plan and sequence, with the incisal edge position of the upper right central as reference.

We chose orthodontic extrusion of the upper teeth to handle proclination in the anterior and the gingival discrepancy. Additionally, we treatment panned the maxillary right canine for over-extrusion by 2 mm. This was done to achieve adequate restorative ferrule through crown lengthening, not to mention re-treatment endodontic therapy with post and core.

We talked about implant therapy, but ultimately it was not a workable solution. Root proximity on the upper right and the gingival tissues meant it wasn’t ideal as a first option. For the final treatment, we decided on placing a six unit anterior bridge. I then discussed the outcome with the patient and she decided conservative therapy for the posterior esthetics of direct composite veneers was best. This enabled us to create consistent contour and shade.

Next up was the lab, which made a pre-orthodontic wax-up based on periodontal surgery and planned tooth movement. I gave them the proper information by using PowerPoint and digital photography with the proposed tooth positions. After this, the post and core endodontic re-treatment was done for the upper right canine.

To be continued…

What’s your approach to treatment planning? 

A comprehensive exam is the first step in a long line of decisions that can end in case success or failure. For this case, my patient presented with a litany of problems and dental concerns.

Failed Restoration: Patient History

When I first encountered the patient, she had a six unit anterior bridge with temporary cement. She came to my practice because she was unhappy with how her dental work looked and was interested in a permanent restoration that would truly suit her goals.

She had a checkered dental history beginning with orthodontic treatment for a diastema between the maxillary centrals and a left maxillary lateral that fractured down to the root and had to be removed. After a FPD was placed for the tooth removal, her diastema reopened and the right maxillary was also lost to fracture.

That wasn’t even it for the patient’s woes. She was given a bridge that made her very unhappy and also had to have endodontic therapy on the upper right canine. Despite multiple placements, the restoration was never to her liking.

Esthetically, the patient wanted to remedy her uneven gingival margin, the length of the upper right canine, the relative size of laterals and centrals, and the color match. The latter was difficult to remedy because of tetracycline staining from her childhood. Finally, she was also displeased with the thick feeling of the bridge.

All of this together painted a picture of a patient in need of serious help.

Failed Restoration: Evaluation & Exam

My esthetic evaluation confirmed many of her concerns. I completed it intraorally and with diagnostic photographs. The patient presented with tooth proportion asymmetries, inadequate tooth display at rest on one central, an uneven incisal plane, and gingival discrepancies.

Her comprehensive exam revealed normal TMD joints, but also showed posterior wear. She had muscle pain and headaches yet no muscle tenderness. I put her on six weeks of appliance therapy, which led to the discovery that she had a habit of ‘power wiggling.’ I was then able to obtain an accurate centric relation bite record.

I removed the anterior bridge for radiography of the abutments. It became clear that her maxillary right canine had a lot of decay and inadequate ferrule.

To be continued…

Like with any big purchase or expensive commitment, it’s not surprising patients would want to try on a new smile before going all in. You wouldn’t expect someone to purchase a sports car without first riding it around the dealership, would you?

Think of your cosmetic treatment as a high-end experience and your patients will too. Even the most hesitant spenders will be much more interested in moving forward if they’ve gotten a taste of how beautiful their smile really can be. This is where the ‘trial smile’ comes in.

Cosmetic Case Acceptance: Let Patients Try Their Smile

There’s no need to feel daunted by the process of creating a trial smile. Patients want to find a dentist who will offer them the kind of care they feel they deserve and who are willing to give them exactly what they want. You’d be surprised how hard it can be to find someone who will listen to a patient’s expectations instead of delivering what they personally feel is best.

With esthetics, the patient should have the primary say. Invite your patients who have given indications of wanting cosmetic treatments to communicate their preferences in a very tangible manner. All you have to do is first conduct a co-discovery appointment complete with high-quality digital images and an occlusal exam as well. Then, temporarily put composite on their unprepared teeth.

With this strong foundation already in place, your patient can see the potential outcome of smile design. When you pitch a trial smile to them, you can even call it a ‘demo.’ If the patient loves what they see, it’s no problem to move on to a diagnostic wax-up using a model of their demo smile.

What case acceptance techniques do you find most effective? We’d love to know your thoughts in the comments section below!

Photo courtesy of Matt Roberts CDT, CMR Laboratory.

The Aesthetics Course taught by Matt Roberts, CDT, Dr. Frankie Shull, Dr. Susan Hollar, Dr. JA Reynolds and Mr. Michael Roberts is just the place to learn to use digital technology to help patients want an aesthetic makeover.

The question of what makes something ‘aesthetic’ or pleasing to the eye is one that often plagues dentists. We are so concerned with our patients’ perceptions of beauty that it is always on our mind.

The sense of aesthetics is an innate quality that we all carry. This sensibility is intertwined with our own internal creativity and curiosity, as well as our desire to create. Many people conflate a particular affinity for aesthetics with a lesser ability in other more technical areas, but in reality these are not mutually exclusive.

As dentists, we balance the technical and the aesthetic every single day. It can be challenging to handle the needs of both these areas in concert.

A Pankey Take on Aesthetics

Dr. Pankey had a particularly eloquent way of describing aesthetics. He clearly had a great appreciation of the world. This is why he combined his appreciation for aesthetics with the needs of dentistry, which resulted in multiple insights about the complexities of aesthetic dentistry.

Dr. Pankey’s aim was to learn the ins and outs of dental aesthetics to maximize quality of patient care. He had a vision of organizing all of the information he had acquired and making it available to more dentists.

The S Curve

An important tenant of dental aesthetics is the ‘S’ shaped curve that visually stimulates a sense of beauty. This has to do with the way it moves the eye and creates a flowing movement. The curve is a common aesthetic aspect of teeth and tissue, especially in the tips of every papilla to the zenith point.

We see the S shape as a result of the emergence profile or the angle of the entrant line of each tooth. Contour also plays a role in this specific part of the smile’s appearance. All in all, it’s important to pay attention to this aesthetic nuance in your work.

What do you think is the most important consideration for aesthetics in dentistry? 

Every patient has a story that makes their case unique. When we embrace their path to treatment and make an effort to understand their motivations, we can provide even more excellent care.

A great example of this simple lesson came in the form of my patient Anne. I knew Anne well, as she ‘grew up’ in our practice and had been a regular patient for many years. This fact added an unexpectedly challenging element to her case. I knew I needed to re-familiarize myself with her interests and background instead of taking our past relationship for granted.

Restorative Case For a Future Hygienist

Anne is nineteen and currently training to become a dental hygienist. Her personal dental experiences spurred her interest in the field. She’s excited to provide patient care that improves both oral health and self-image.

All of these details about Anne informed how I approached her treatment. Her primary esthetic concerns were a peg lateral #7 and a congenitally missing #10. She also had canted axial alignment, mottled enamel, and uneven gingival zeniths with a high smile line.

We decided on comprehensive restorative treatment approach that would correct these problems and provide her with a result she could readily show off. The treatment consisted of orthodontics, an implant for #10, and periodontal surgery to reposition gingival levels. We also moved ahead with occlusal equilibration and a diagnostic wax up.

To round out the case, we did tissue sculpting on #10 in addition to esthetic/functional testing and refinement via provisionals. Anne got beautiful e.max veneers on #5, 6, 7, 8, 9, 11 and 12. Finally, she got an implant supported e.max crown on #10.

Matt Roberts CDT handled the lab side of Anne’s case and did a stellar job. She can now go forth confidently into her career and help others embrace treatment that can change their lives.

What case put a smile on your face recently? We’d love to hear what you think in the comments! 

When Dr. Richard Green read Dr. Lee Ann Brady’s blogs on pitch and bevels, he decided to jump in with a thoughtful response. Read on for more discussion of this fascinating topic.

Crossover and Movement: Consider the Edges

I loved Dr. Brady’s article concerning edges (pitch and both bevels) and the conversation about natural teeth, composition, and porcelain. I was reminded of some of my learning with and from Henry Tanner while refining my occlusion in the mid-70s. It worked for me no matter what material and bite splints were used.

Henry was the first to introduce me to ‘crossover.’ At the time, one of the anterior teeth you did not talk about were the cuspids. They too have important facets (pitch and two bevels) that need to match cusp tip to cusp tip, regardless of the material.

When moving into crossover and the cuspid tips touch, if the pitch facet does not match or is pointed, sloped, or rounded, you often see the masseter or temporalysis muscle twitch. This occurs as the patient hesitates in their movement. That smooth transition back to the incisal edges of the centrals and laterals is important.

I also realized during my career that certain patients (teens, golfers, baseball players) would often stabilize their head while their teeth were cuspid tip to tip or in a crossover position at the point of their impact with the ball.

Improvements can be accomplished by simply taking the flat portion of a ½ J (wheel fine diamond) and creating matching facets on upper and lower cuspids. Polish them and both the leading and trailing bevels so that the movement becomes smooth. If the patient wants to stop cusp tip to cusp tip on the upper and lower cuspid, there is a stable stop and the muscles are comfortable.

To be continued…

Dive into this case for a look at Dr. Owen’s thought process and treatment protocol leading to porcelain restorations. 

Angela was 27 when she came to us asking about options to improve her smile. She was getting married within a year. She hated the appearance of the bridge #3-6 that had been placed in high school. It was repaired at the buccal margin of #6 the day of delivery. She also said she wanted to avoid implants because of time issues and she didn’t want more crowns.

Patient Background

Angela was congenitally missing #4, 7, 10, 12, 13, 20, and 29. In the past, she had implants to replace the lower bicuspids and said the process took too long. Her previous dentist had placed two upper bridges – #3-7 with pontics on #4 and #7 and #14-10 with pontics on #13 and #10. The space for #12 did not exist.

Treatment Plan

I noticed her narrow central incisors compared to her laterals and the general contour and color of the bridges. I knew we could improve her smile with all porcelain restorations. Implants to replace missing teeth and veneers on the centrals would make a difference. We did a wax up that she took home to study, comparing it to the model of her existing restorations. She visited the periodontist who would do the implants and I showed her lots of photos of other cases similar to hers.

Creating Porcelain Restorations

Ultimately Angela agreed with our plan. She had implants replacing #7, 10, and 13. We used Zirconia abutments and e.max crowns, as well as an e.max crown for #14. She opted for a Zirconia bridge #3-5. While she was healing, we made provisional bridges, including the cantilevers for the laterals. She was hesitant about the veneers on #8 and #9, but before we began I removed the bridges and created a trial restoration with the wider veneers and proper bridge contours. I took photos and let her think about it before she agreed. She got married with a beautiful new smile.   

What interesting cases are you currently working on? 

Do you feel reticent about having someone other than you use the facebow? 

A Spatial Reference Point Story

Recently over the holidays as I was “channel surfing” I came across the movie Apollo 13. This is one of those movies that no matter how many times I have watched it, I just have to stop and watch it one more time. Every time I do, I can’t help but get misty-eyed when it gets to the part when the crew make it back to Earth safely (SPOILER ALERT … But you probably read this in the history books anyway).

For me, there is one super exciting moment in the film when Astronaut James Lovell (aka Tom Hanks) has to find a reference point to correct their descent back to Earth from space or burn up on re-entry. Since he cannot use his on-board computers, he lines up his spaceship with the Earth in his window.

“Keep the Earth in the window!” A spatial reference point! Too much correction and their spaceship burns up on re-entry. Too little and they skip off the Earth’s atmosphere.

Make Your Facebow Process Simpler

In our dental offices, the facebow is used to give us a spatial reference point for mounting diagnostic or working models of our patient’s dentition. This is done onto an articulator that approximates the realities of our patient. Sure, you might be able to mount casts arbitrarily, but is your accuracy reproducible? The facebow is a simple tool in our armamentarium to make our life easier.

The question remains, “Is this a task that the dentist must perform?” In my office when we create exquisite dental mountings, I delegate this task to my awesome dental assistants.  With a little training they can do this immediately and the procedure only takes a few minutes.

This involvement is a great way for them to demonstrate their knowledge. It paves the way for more opportunities to open conversations about the Dentist’s Care, Skill, and Judgement. They become your chairside cheerleader and highlight your expertise. They will also express how a critical bite registration record or protrusive record performed by the dentist will only enhance the outcome of treatment.  

Information gathered through the use of a facebow makes our dentistry more predictable. It distinguishes you and your team as a highly trained dental practice.

Don’t burn up on re-entry or skip off into space. Glide effortlessly into beautiful predictable dentistry by using your facebow. Keep your Earth in the window!

This is part 2 in a series where Dr. Mike Crete describes an conservative esthetic case where he combined Invisalign and veneers.  Part one looks at helping the patient become aware of the possibilities. Read on for the conclusion.

A Smile Dialogue

… All of this conversation took place in about 5 minutes at the end of the patient’s initial hygiene examination. I then invited him to return for a ‘complimentary smile analysis’ appointment where I would take a series of digital photos and then sit down with him and talk about what we could do to improve his smile.   

I find I can build trust and credibility with a new patient by offering to see them for this complimentary appointment. It only takes about 20 minutes and I typically ‘convert’ the patient to a records appointment (comprehensive exam, X-rays, and mounted study models).

The records appointment was scheduled. More co-discovery revealed how significant Drew’s self-esteem was impacted by his smile and his ‘baby face and baby teeth.’ The records appointment was followed by a diagnostic wax up (or a “3D Design” as I like to call it when talking to patients).

Then a consultation was done to review treatment options. This was a formal case presentation using Powerpoint, photos, and mounted models. Drew’s mother sat in on the consultation appointment.

By having accurately mounted study models on a semi-adjustable articulator, I was able to determine I could give Drew an ideal occlusion AND a pleasing smile. This would involve some minor tooth movement using Invisalign for 6 months and then restoring his upper and lower anterior teeth with conservative porcelain veneers. His posterior teeth were equilibrated during the restorative process. Also, an upper bite guard was fabricated for nighttime wear and added protection of the restorations.  

Drew graduated from college approximately 18 months after I first met him. He completed an internship during his final semester and then was hired by the Fortune 500 company immediately following graduation. He recently got married and said to me, “After I had my teeth done everything in my life started to fall into place. I graduated, got a great job, and met the love of my life. Thanks, doc.”  

Changing a smile and changing a life. It’s being able to impact the lives of others in this way that makes it so rewarding to practice dentistry!