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Getting it Right the First Time: What Patients Want

Cosmetic dentistry needs that focus on the upper anterior areas of the jaw can be the most challenging for even the best of the most talented restorative dentists.

Bad Crown Failure
Failed Crowns - Bad Bite
Tooth treatments that affect the most central aspects of our smile should be performed with a combination of procedures that stabilize or improves what already exists or restabilize what has been lost... in terms of Cosmetics AND Function.

The attention to detail for restorative dentistry is not as critical in other, more posterior, areas along the arch. While the selection of restorative components (premium crowns or veneers vs standard products) are an important consideration, it nonetheless requires the use of protocols that promise the highest degree possible of functional and cosmetic benefit.

Redefining the Standard of Care Protocol

Retracted Closeup Pic
Cosmetic and Function Failure
What might be acceptable dentistry (cosmetic-function) in one instance of patient need can't be assumed to be acceptable for a different patient.

As can be readily seen in the adjacent pictures of an unhappy patient, a focus was made on the need for replacing a missing anterior tooth with a basic cementable bridge product.

Text book dentistry states essentially that a three (3) unit bridge is an excellent, acceptable treatment choice for replacing a missing tooth that represents good value and can offer good function and endurance. A single dental implant is the treatment alternative.

Unfortunately.... standard protocol failed to deliver the desired outcome for this patient. Matching of color, sizing differences and what appears to be a disregard for maintenance of the occlusal plane had the synergistic effect of expensive dentistry producing substandard results requiring retreatment.

Occlusal Impressions: Diagnostic Waxup and Stone Models

Waxup Temporary Bridge
First Impression Results
Diagnostic Waxup
The waxup model shown here is created from impressions before the teeth are prepped for treatment.

An idealized set of tooth replacement measurements, as defined by the patient's interest in length, shape and sizing, are created "into" the wax model.

The dentist creates temporary restorative products in the office based on the initial waxup model.

Temporaries In Hand

With the new temporary try-ins ready for use, the patient undergoes pre-treatment procedures to prepare all tooth structures for the eventual planned treatments and placement of the temporaries. Proper planning assures the patient she leaves the office without being toothless.

Retracted Closeup Pic
Tooth Prep Begins
Removal of Failed Restorations
The adjacent photo shows how the old bridge product is being removed by creating sections in the porcelain anchor teeth that enables the dentist to easily remove the old bridge without tugging or pulling on the bridge that could potentially compromise the anchor teeth.

The second photo reflects the total amount of tooth prep required for the patient's treatment plan. In order to create the symmetry in cosmetic appearance and, more importantly, idealized occlusal bite, the six, most central tooth structure require modification.

Retracted Closeup Pic
Tooth Prep Finalized
Planned 6 Unit Bridge
The occlusion characteristics that are needed, based on occlusal analysis, rule out the use of cosmetic veneers. In cases where occlusal analysis has been insufficient, the misuse of veneer products usually result in reports of veneers continually popping off or cracking.

The horror stories associated with near total failures of full mouth veneer treatments or porcelain crown makeovers are often associated with minimum or total lack of attention to detail during this important step of analysis and use of temporary try-ins.

Stone Model Pictures
Temporaries in Place
Technical errors can and do occur from time to time ... but the use of temporaries make those errors immediately apparent so modifications can be made to assure the critical changes are made so treatment planning progresses as it should.

Treatment plans that don't incorporate the use of temporaries obviously prevent this "self-correction" event from happening that, in turn, creates the horror stories mentioned above.

Temporary Try-in Begins

Our patient is pictured here with her new temporaries... created from the Diagnostic Waxup model that was generated from the initial impression.

Patients typically wear the temporaries for about two weeks while they evaluate cosmetic value, feel, fit, changes in bite and overall comfort. Special cements are used to secure temporaries solidly but can be removed easily, without compromising the prepped tooth structures.

In situations where modifications are needed for sizing or color shading, the waxup model is modified as needed so new temporaries are created in-office, enabling the patient to continue the try-in phase of treatment.

Stone Model Impressions
Secondary Impressions for Final Fabrication

Acceptance of Temporaries

When everything is "just right" for both the patient and the dentist, the final set of temporaries (in this case just the upper arch) are removed and a second set of impressions are taken. All of the cosmetic qualities and structual characteristics of the new porcelain teeth (crown and bridge) have been evaluated.

The technical data collected during this phase accompanies the impressions that are sent to the dental lab for final fabrication of the needed components.

Occlusal Balance Midline Centering
Final Bite Registration
In the adjacent picture the patient is registering the final bite characteristics that will assure the best midline centering and proper vertical dimension that best suits the patient's facial characteristics.

During the try-in period the dentist has used the articulator to assure that any and all treatment combinations (e.g., bridge, crowns and veneers on one arch) function harmoniously and maintain a normal bite. No painful crowns, no bleeding gums from long veneers, no lateral forces caused by bad bridge design, etc.

Any and all values of malocclusion, crossbite, overbite, underbite, lateral forces, tmj function, etc., are continuously assessed by the dentist to assure that chosen restorative products and planned treatments create or maintain "optimal function."

Stone Model - Advanced Articulation Study

Stone Model Pic
Stone Model
Pictured here is the stone model generated from the secondary impressions and the technical data accumulated during the try-in phase of using the temporaries.

Precise representations of the altered tooth structures that have been prepped for mounting the crown and bridge products provide the specificity needed to assure nothing is amiss.

Stone Model Pictures
Working Representation of Reconstruction
The second picture of the stone model shows the new crown products mounted, now representing a working model of the patients bite and occlusion characteristics while displaying the LVI Rule of Golden Proportions that creates a new natural looking smile line.

Final Occlusal Analysis

With the new restorative crown products mounted, the dentist completes the final occlusal analysis to assure all elements are functioning harmoniously. No potential for hidden surprises in the way of hidden lateral forces, individual teeth hitting too high and proper jaw alignment and movement.

Final Try-In

With the final occlusal study completed, the patient is fitted with the restorative products without cementation as a last minute check that what is about to be delivered is precisely what the dentist and patient are expecting.

Miniscule modifications to porcelain products needing a slight alteration are performed at this point. While the patient typically focuses on certain cosmetic values, the dentist reviews other properties of the new restorations that assure maintenance of an optimized bite.

When the dentist and patient are in agreement that all cosmetic and functional goals have been achieved, final cementation takes place. The time honored practice of rechecking overall bite conditions, articulation paper is used to assure all biting surfaces are "hitting" appropriately and with biting forces appropriate for different sections of the jawline.



Corinne Scalzitti, DMD, MAGD
Austin Reconstructive Implant Dentistry
3900 RR 620 South
Austin, Texas TX 78738
(512) 263-3330

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