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. 

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 my daughter Kaitlyn (currently in through E2 at Pankey) finished dental school in 2020, I strongly recommended that she learn analog first, then once mastered, make the transition to digital. This lasted about four months. I learned rapidly that this generation sees things in the digital realm far better than we do. She reminded me that “she grew up with a screen in her hand.” 

We began to focus on her learning the concepts of occlusion, esthetics, biology, tooth-by-tooth structural integrity, and visualizing and planning in the virtual (digital world). We quickly learned that, although she could easily visualize things on the computer, the patient is ultimately analog. We began to utilize an analog articulator for her to learn the hand skills of what we would do on the patient. 

A great example of this is equilibration. A “trial equilibration” on a virtual articulator is a 5-minute process that lets us determine if equilibration is an appropriate treatment option. The problem is that, unlike analog, you do not learn the brush strokes that will be required to perform this skill in the mouth. I have performed hundreds if not thousands of equilibrations. I know the brush strokes. For me, once I see on the virtual articulator that I can do the equilibration without too much tooth structure removal, I am ready to go to the mouth. For Kaitlyn, who has very limited equilibration experience, once visualized on the virtual articulator, then it’s time to go back to analog. She mounts the printed models on an analog articulator to perform a traditional trial equilibration. In this way, she learns the brushstrokes of this incredibly important procedure. 

I think it is extremely important that dentists, who are learning to equilibrate intraorally, work on mounted analog models to develop their equilibration skills. 

Returning to the consideration of the financial cost of bringing new technology into your practice—input devices (scanners and CBCTs), output devices (printers and mills), and software to manipulate the data all cost money. Doctors that are going down this road usually like technology and consider the dramatic increases in efficiency to ultimately increase the productivity and profitability of the practice. This is certainly something I have seen. The bottom line is dental stone will go away. We all must make the decision when it is appropriate to make the jump. 

Dr. Lee Ann Brady has invited me to audit all the Pankey Essentials courses over the next year. I am super excited about this. She has asked me to recommend ways to appropriately implement examples of digital technologies and workflows into these core classes. While younger dentists are drawn to digital information, it is important for us to remind them that our patients are ANALOG. We are training dentists to perform complex procedures on patients, not on computers. This requires great study and a commitment to understand timeless concepts, while simultaneously developing the hand skills to accomplish these procedures accurately and use digital workflows to make things more efficient. 

In 2024, The Pankey Institute is also implementing a digital hands-on course for those doctors who would like to make the transition over to virtual articulation and digital workflows—something that I am excited to be part of. Dentistry is in a great transition. I look forward to making sure the concepts that we have all built our practices around do not get lost in the digital world. 

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.

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? 

White and brown spot lesions on the anterior teeth can be very distressing for the patient and a frustration for clinicians. Normally, they are decalcification or deposits on the teeth from fluoride or other minerals.

They do not require restoration. We are hesitant to do this and sacrifice good tooth structure, but esthetically they can really bother patients. They reduce a patient’s confidence in their smile. Recently, I have found a solution to this clinical situation that meets both the patient’s esthetic demands and my desire to be conservative.

Reversing Lesion Color on Anterior Teeth

Icon, from DMG America, is a translucent resin infiltrate that reverses the color of the lesion. It brings the tooth back to its natural color, requires no tooth preparation, and protects the tooth from further decalcification or progression into a carious lesion.

After we isolate with a rubber dam, the tooth is etched with a special etchant included in the kit. The protocol requires a longer etching time then we are accustomed to with other procedures.

After each etching procedure, we rinse and dry the tooth. Then we apply a special drying agent that allows us to evaluate the final result prior to proceeding with the resin.

If the tooth color has not yet been optimized, the etchant is applied again. This can be repeated up to five times. Once we have completed the etching process and confirmed the result with the drying agent, the resin is applied and then cured.

The entire procedure is done without any anesthesia and is very comfortable for the patient. Icon can be used on the facial and also on interproximal areas.

The resin is not visible on an x-ray, so the kit comes with a card to give the patient. This is so that if they see another dental office in the future, they are aware that the interproximal areas will still appear decalcified on an x-ray but have been fully infiltrated with resin.

I really enjoy offering this incredible, conservative esthetic service to my patients.

There are three critical components to the incisal edge anatomy of anterior teeth. Understanding the function and esthetics of the pitch and two bevels is essential to creating an ideal patient result.

How can a clinician re-create the full anatomic form of the tooth in ceramics and composite? 

In my last blog on this topic, I discussed the dimensions, characterization, esthetics, restorative approach and challenge of mimicking ‘pitch‘ esthetics. Now, I’ll delve into mastering the bevels to create superior restorative results. Combining an esthetic pitch with functional bevels will ensure a smooth composite or ceramic outcome.

Components of Incisal Edge Anatomy Function and Esthetics: Bevels

The two bevels can be found on alternately the labial and the lingual of the transition zone between the pitch and these surfaces. They are often called the leading edge and the trailing edge.

Bevels

Dimensions: The bevels on both sides have a variable width. They can be between less than a millimeter to multiple millimeters long.

Characterization: The bevels lengthen in patients who grind their teeth in an excursive pathway pattern. Patients who parafunction edge to edge might eliminate the bevel. This makes it easier to shear enamel off on the labial or lingual side of the tooth. It also could result in chipping the edge enamel.

Function: The bevel is a transition zone to create smooth functional movement passing from excursive movements onto the pitch. Intercuspal stops on lower incisors are often on or gingival to the bevel.

Whether you are finalizing an equilibration, the occlusion on composites, or ceramics, perfecting anterior guidance is all about both pitch and bevel surfaces. These critical components are a great example of marrying form and function in your technique.

What is your restorative approach for recreating incisal edge anatomy? We’d love to hear from you in the comments!