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? 

The comprehensive exam sets the stage for the quality of your dentistry. The information you gather is instrumental in guiding your treatment plan, getting to know your patient, and helping you effectively relieve pain or discomfort.

The temporomandibular joint is one of the 4 exam areas that comprise a comprehensive functional exam. Ascertaining where we believe the disc is relative to the condyle and whether or not we detect the presence of inflammation are the goals. We want to understand if the joint is stable, adapted or currently undergoing breakdown.

Refresh Your Joint Exam Technique

A good place to start is with lateral pole location. While the patient is lying back, place three fingers lightly in the lateral pole region. Then have them open and close. As they are opening and closing, locate the lateral poles. Observe and record palpable joint noise sounds and motion. Make sure you are documenting your findings clearly throughout the process.

You should also reference maxillary midline to mandibular midline and record opening and closing deviations from the midline. There is so much that can be learned from this basic exam protocol.

Next, move on to joint auscultation in translation and excursions. Using your stethoscope to listen, you can direct the patient to again open and close without touching, as well as move their jaw excursively. You’ll verify palpable sounds and listen to both rotation and translation…

What do you consider critical elements of a joint and muscle exam? 

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!

The best dentists I know mastered the art of examination and discovery first. They learned to understand their patients’ conditions and how they relate to one another.

Leadership Through Discovery & Complexity

In that process of discovery, highly competent dentists learn to navigate complexity by confidently using reference points. These guide their understanding of what they discover. They train their eyes to see the details of esthetics, tooth structure, function, and periodontal type and status. Their fingers learn to feel the dynamic nature of the patient’s functional system.

They use every available form of imaging and records that add meaning to their discovery. Ultimately, they intentionally, systematically, and thoroughly develop a diagnosis that can determine the treatment plan. They manage complexity by moving toward simplicity.

Absolute and relative reference points serve as guides in designing the optimal scheme for the patient. When the patient’s teeth, gingiva, bone, functional scheme, and esthetics have been lost, those reference points tell you where to start and where to end. They both establish and limit what needs to be created.

Managing Complex Cases

Dentists at this level possess a very sound understanding of the dental functional system and a very detailed understanding of dental esthetics. They specially focus on how these two systems relate to one another.

They also understand their role in coordinating, guiding, and leading their interdisciplinary team in managing the complex case. To be certain, every member has a strong voice in developing and executing the treatment plan. Leadership in knowing your work really becomes visible in this process.

Someone has to decide where the case is going and how it is going to get there. There are many voices in the process, but at the end of the day that someone has to be you the leader, who also happens to be the first and final designer of the beautiful smile that is being restored to health.

Approaching implant reconstruction as an all or nothing situation ignores the reality of future patient needs. Often it is too expensive for patients, who will not be able to proceed fully with treatment. They then receive only part of the complete treatment plan.

For example, with an edentulous arch the difference between a lower denture with two implants and locators as opposed to five implants with a fixed restoration is significant.  Alternately, it’s common for patients with two implants and a lower denture with locators to be dissatisfied with their function and esthetics. They may wish to move to a fixed restoration if they can now afford it. But does the clinical situation make this possible?

Implant Treatment Planning for the Future

It’s a good idea to create a treatment plan for a patient that doesn’t eliminate their ability to select different treatment in the future that could lead to improved esthetics, health or function. Certain planning decisions must be applied when placing implants to ensure necessary spacing and vertical room for a fixed restoration.

Ideally, the plan would include fixe fixtures between the mental foramina for a fixed restoration. If the patient currently wants a removable with two implants, the ideal placement can be planned for five. The 2 and 4 spots can then be used for placement of fixtures with locators.

This gives enough room for three potential implants later on that are spaced correctly. Though the placement choice can be based on a clinician’s preference for where locators would be, the 1 and 5 locations allow for ideal placement of five future fixtures. Still, many patients will have two fixtures between the mental foramina that negatively impact proper spacing for a fixed restoration. On top of this, the lower ridge position is another important factor to consider. It must be managed to account for vertical space.

Assessing and managing the papilla is particularly important when we are treatment planning esthetic cases. Usually, we pay attention to the papilla when planning anterior implants and are less focused on this when we are treatment planning natural teeth.

The papilla is valued in cosmetic dentistry because it is an essential element of smile esthetics. If we want patients to be truly happy with their results, we must include it in our early considerations.

Papilla Tips and Why They Matter

Many of our patients who are in their sixties and seventies will still show the tips of the papilla. This isn’t the case for other aspects such as the gingival margin. Because of this, it’s critical that we don’t ignore them when treatment planning a smile.

Two main aspects to focus on when diagnosing papilla esthetics are symmetry and papilla height compared to contact length.

Papilla Symmetry

Papilla heights should be symmetric across the midline. Papilla tips will vary for patients, with some creating a straight line when connected and others having a line that tips up toward the canines. Regardless, the left and right sides should mimic one another. For example, if the papilla tip is shorter between the canine and lateral, it should do this on both sides.

Papilla Height

Papilla height compared to contact length is also important. The papilla tip should take up 45-50% of the total length of the tooth from the gingiva to the end of the contact. Then the contact should use up the remaining 50-55% of this distance.

Looking at the existing papilla symmetry and height enables you to decide if the esthetics are acceptable. Your goal will be to maintain them optimally. If they are where you want them to be esthetically already, then you have a reference to determine the positive or negative effect treatments like crown lengthening, ortho, and restorative procedures could have. If papilla esthetics are not where you want them to be, you can use these parameters to evaluate treatment options and improve them.

What is your favorite part of treatment planning a case? We’d love to hear your thoughts in the comments! 

Helping patients move past denial over their dental health is no easy feat. In your dental practice, you have likely encountered this situation many times.

The truth is, patients who won’t or can’t accept the treatment they need for improved oral health can be put on a more positive path. The hard part is that they often require a significant amount of patience.

In a previous blog, I discussed the mechanism of denial and how it functions to constrain our patients despite our best intentions. There is no ‘forcing it’ because the psychological weight is too heavy. Facing a loss of a measure of health is extremely difficult, despite whether we ourselves believe the issue isn’t significant.

Characteristics That Support Change For Patients in Denial

One way to help our patients in these situations is to avoid frustration. Acceptance of other people’s emotional struggles can come from checking in with our own personal response to stress.

How do you create lasting change? Exploration of this question can give you a clearer perspective about similar answers for others. It can also reinforce the sense that our reactions to stimuli or upset can be quite different.

Once you (or a patient) have accepted change, you will still need to rely on your own resilience to parry the unexpected difficulties or days where your resolve is less strong. Some of the qualities that help in this situation include courage, commitment, awareness, curiosity, confidence, support, and skill.

The foundation of change is the first of these qualities: courage. Making changes in spite of fear is reliant on our willingness to see the potential risks and move ahead anyways. A big piece of this is recognition. If you can recognize what is holding you back from change, you can externalize the fear, make it more manageable, and talk about it rationally with others.

How do you help patients accept and appreciate change? 

Successful restorative dentistry now hinges on an understanding that physiological changes occur over a lifetime. It’s detrimental to treat the dynamic relationship between dental occlusion and adjacent craniofacial structures as static.

We are all generally familiar with the fact that there is a significant change in facial profile (convex to straight) between adolescence and adulthood. Jaw growth usually ends between 17 and 20-ish years old, but 3-dimensional craniofacial skeletal growth and remodeling does not cease after adolescence.

It’s lifelong growth even though it’s slow. As a result, we can’t consider adult patients morphologically stable. This is actually a relatively new concept that we’ve become aware of because of implant dentistry.

So what does this mean for restorations? First, we need more information.

Physiological Changes and Restorative Dentistry: A Quick Overview

These adult growth changes can be seen in both a decrease and increase in the dimensions of the craniofacial skeleton. There is an increase in maxillary and mandibular anterior dentoalveolar heights.

We should also pay attention to vertical growth of the maxilla, which continues after transverse and sagittal growth end. It has been suggested that reductions seen in arch width, depth, and perimeter may be due to interstitial wear and mesial drift. The latter occurs because of an occlusal force stemming from root angulation, mesial eruption force and the direction of occlusal contact during chewing. It’s integral to consider tooth movement because it compensates for wear while maintaining interproximal contacts.

There are different patterns of growth in short-faced and long-faced people. Short-faced individuals have greater transverse maxillary growth. As they mature, their anterior teeth tip forward and enable mesial drift. This process occurs more vertically in long-faced people. Short-faced individuals experience upward buccal movement of the teeth, while long-faced individuals experience lingual movement and continual tooth eruption that supports a normal interarch relationship.

What we now know from recent research is that eruption after the tooth has reached occlusal contact is a compensatory response to occlusal wear. Eruption creates vertical growth if there is no occlusal wear.

A comprehensive understanding of the complex interplay between all of these changes in the dental arch is essential to restorative dentistry.

How do you keep up to date on the latest dental research? We’d love to hear your tips in the comments! 

Why Focusing on the Lower Anterior Teeth in Restorations is Important for Esthetics and Function

If you ignore the lower anterior teeth in a restoration, you may be sacrificing a significant amount of potential case benefits.

The process of improving dental techniques is one of constant refinement throughout our careers. We build upon techniques and begin to see our blind spots with each new case.

This blog is about specificity and detail-oriented technique. Excellent clinical dentistry balances the patient’s desire to improve their smile esthetics with effectively conveying the overall importance of planned changes to their health.

Incorporate the approach I discuss below into your restorative work and you’ll see the benefits extend widely to both final case esthetics and patient satisfaction. After all, those twin goals entwine throughout everything we do in the dental practice.

Restore Lower Anterior Teeth for Esthetics and Function

Have you ever noticed cases in various dental publications where nice restorative work has been completed on the upper anterior teeth, but the lower incisors were completely ignored? Oftentimes the lower anterior teeth (the little guys) are crowded, uneven, worn, and/or damaged.

This discordant aspect is visually jarring and detracts from the perceived beauty of the final result. The pristine nature of the upper anterior teeth throws the correspondingly less appealing look of the lower anterior teeth into greater relief.

The little guys are important for esthetics and function. They show considerably more on speech as we age, something very few patients realize. They are also critical for distribution of forces as we move into protrusive and excursions. The Pankey Institute recognizes the importance of lower anterior teeth as a vital aspect of complete dental care.

This is a periodontal case where a simple equilibration substantially improved esthetics and force distribution. Patients really appreciate an enhanced smile. They immediately feel better function and stability.

What commonly overlooked areas or techniques do you use to improve restoration esthetics and function? We’d love to hear from you in the comments!