Another Smile Design

This case was so fun because of the long-standing relationship we had with the patient.  Our whole team had a hand in the success of this case, and it was a great way to highlight and motivate our office.  They all “knew him when,” and so they had genuine interest in following the case through completion.  This was a younger male with overall good health.  He was a faithful hygiene patient, had great home care, but this staining is intrinsic, either from excess flouride in the water as a kid, or childhood high fever.  The stain gets incorporated at the time of development and tooth formation.  No amount of whitening can correct this.  This patient was the first member of his family to attend college.  When we first met him, he was quiet, shy and not sure what he wanted to do with his life.  For several years, he kept every check up and maintained excellent dental health.  He started taking classes at a community college, then got accepted into a humble little school called Cornell!  This case got finished before he started Cornell.  This was a person who took control of his overall health, then his smile, and his entire future.  Sending him off to college with this smile gave us all a great feeling.  I couldn’t help but think that we were contributing to the future events of his life.  All the events where he’ll be smiling, accepting his diploma, advancing into his profession (engineering), standing at the altar and watching his bride to be come down the aisle.  Lots to smile about.

BEFORE

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AFTER

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I love smile designs

Here was another transformation.  She was used to covering her smile, and when we finished, she said, “I realized that I always cover up my smile.  After someone said something funny, I started to cover my smile again, and I realized that it was okay to smile again.”  This case was a real tribute to our entire team.  This type of case takes a lot of planning and patient education.  It takes excellent hygiene and home care.  Because she had had a thorough periodontal evaluation, treatment and follow up, when we went to make the final impression for the crowns, all the tissues were healthy and the impression was perfect the first time.  Not only did she become a diligent hygiene patient, her whole demeanor changed with this case.  She was happier, more confident, and she was so appreciative.  This was a huge motivator for my team, to see how they had a hand in literally changing someone’s life.  I’m not overplaying this either.  There were hugs, there was crying, it was awesome.

BEFORE

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Preopretract

AFTER

Postopsmile

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Another Smile Design

CGBefore

This patient wanted me to replace 1 crown. Can you guess which one? It’s the one that looks really bright. Old crowns are made of porcelain fused to metal. In those days, the porcelain was really flat, and bright white, since this was needed to opaque the metal that the crown is made of. These old crowns are also known for showing the metal at the margin, hence the dark gumline. Instead of replacing one crown, since it’s hard to match one exactly to the natural teeth, I offered to do 5, and here is the result.

CGAfter

These crowns are emax.  They are translucent, and made from lithium disilicate.  If the margin shows, it’s okay.  The margin is translucent and is showing the tooth underneath.  So this patient was extremely happy.

More Endo

I do a lot of root canals.  These days, patients avoid the dentist until there’s pain.  I try not to overwhelm them with guilt when they finally do make it. “Root Canal” is a word that makes nobody excited, so I have to make it fun and welcoming.  I love when it’s at least a restorable tooth and doesn’t need extraction, so that’s my starting point.  Instead of explaining treatments to patients, I try to discuss in terms of benefits, results.  I try to finish the root canal, core buildup and crown in a single visit.  The next visit is a crown delivery with no needles, that takes about 20 minutes.  This is my chance to make friends, since I am usually seeing a patient who has no more pain.

 Here are a few cases I have done:

More Endo

Look at the curved mesial root on this one:

Smile Design

I just completed a 12 credit hour course with Heartland Dental Care: Aesthetic Continuum.  This course is Heartland’s answer to the Las Vegas Institute.  It is taught by Dr. Ed Lowe, and Dr. Michael Koczarski, two great mentors.

This patient was one that I did in additionto the case I had at the continuum, and I worked on this with Dr. Neibauer himself.  This was extra credit.  I initially saw this patient because she had pain on her posterior teeth.  After I had restored her posterior teeth, it was time to address the anteriors.  She had several fillings done in the past that were starting to stain, and she simply did not smile as much.  This was the coolest lady.  As we were finishing her case, she began to smile bigger and bigger.

Preop

Final Case: Emax Crowns

LAB-FABRICATED PROVISIONALS

In this case, we have a 43 year old female patient with aggressive periodontitis. Unlike chronic periodontitis, which is an extension of gum disease and a manifestation of years of poor hygiene, this condition affects certain patients starting at a young age, and has a family predilection. Despite excellent hygiene, this patient has severe localized bone loss around the upper centrals. The tissue does not bleed, there is no infection, but the upper centrals were mobile, had a poor prognosis, and mainly, the patient did not like her appearance. After discussing her options, she preferred a bridge over bone grafting and implants, because it would be quicker and more affordable for her. (Insurances will often cover bridges, but not implants… so this can drive the decision making quite a bit.)

You can see the overall healthy tissues and that most upper teeth (besides #8 and 9) are in good alignment. Bone grafting would require a block graft, it would be highly unpredictable, costly and time consuming. There is also a tight frenum attachment contributing to the problem, so she would need a frenectomy. Yes, these things could be done in an ideal world, but bridges are covered by insurance.

On day 1, I took an impression, trimmed #8 and 9 from the stone, and ordered lab fabricated provisionals.

Never extract front teeth unless you have some new ones in your hand. I prepped #7 and 10 prior to doing the extractions to keep the sockets clean. Here is the site after placing sutures and the provisional, here is the patient on the same day of her extractions.  Yes, there are empty sockets under there:

I love this because so much of a difference was made in a single day. The provisionals will guide the tissue healing. There are 2 schools of thought on that. One is, push the pontics into the tissue to create an emergence profile resembling natural teeth and roots, the other is, let the tissue grow and thicken a little, since the maxilla has a notoriously thick layer of keratinized soft tissue covering the bone. I chose the former. The former option creates gingival papillae and a scalloped appearance, while the latter may show a flat, horizontal tissue profile. (I’ll take your comments on that.) This patient has a low smile line, so either option would suffice. This is a temporary bridge, so it is designed to be relined, trimmed, and critiqued by the patient before the final restoration is made over the mature tissue. Check it out again:

BEFORE

SAME DAY OF EXTRACTIONS: LAB-FABRICATED PROVISIONALS


And here’s the finished case, porcelain fused to zirconia, after complete tissue healing.  I was really happy with the shade match, since in most cases, people usually include the canines.  I was able to nearly match the natural canines and save the patient some money.

AFTER TISSUE HEALING: FINAL PORCELAIN/ZIRCONIA JACKET

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I was glad that the shade and incisal translucency matched her natural teeth so well.

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