One of the key positions to design when creating an occlusal scheme is edge to edge, or end to end as some people prefer to call it. The position of the maxillary incisal edge is always dictated by the face to create a pleasing esthetic result. With this in mind adjustments to the occlusion are made by altering the incisal edge position and shape of the lower anterior teeth. All incisal edges have three pieces. The pitch is that flat surface at the top of the incisal edge. Each incisor tooth has two bevels, a leading edge and a trailing edge.
As I complete the series on soft tissue esthetics around anterior implants we have worked our way back to assessing the existing architecture and planning for success. John Kois has simplified the risk assessment process when a natural tooth will be extracted prior to implant placement using five diagnostic keys, and I find the thought process invaluable when I plan.
- Tooth Position/Existing Free Gingival Margin: Low risk patients have am existing free gingival margin that is more coronal than the final position, and lingually placed teeth. High risk patients have an existing free gingival margin that is apical to where we are proposing for
One of the most challenging pieces of anterior implant esthetics is anticipating and controlling the tissue response. In the early days of implant dentistry we were cautious of loading implants due to osseous healing and response. Our plan was to place the fixture with a healing cap and wait for 3 or more months for healing prior to placing a temporary or final abutment and restoration. As our understanding of the process improved over time we began to feel more and more comfortable placing an abutment and temporary restoration the same day the fixture was placed. The decision to immediately load is most often based on bone quantity and quality, present condition around existing teeth ( or not), and our desire to give the patient an immediate esthetic outcome they are pleased with.
Another piece of learning for me out of this week’s symposium was about the design of implant abutments in the esthetic zone. A common challenge with implant restorations is that the interface between the abutment and the crown is placed further apically then it should be. Our thinking behind this is to utilize the emergence profile of the crown to help develop and hold tissue form. The final pink esthetics are founded on the surgical outcome and developed and maintained by the abutment design. The tooth esthetics is controlled by the crown.
In the last two days I have heard some really wonderful presentations on implant dentistry. From treatment planning to cementation I have lots of new ideas to take back to my patients that I will share in the next few blog posts. One such idea was addressed cementation of the final crown over an implant abutment. One of the reasons we see changes in the soft tissue and bony topography after placing an implant restoration is cement remaining below the restoration margin. This cement situated between the abutment and the junctional epithelium acts as an irritant. The results can range from gingival irritation to osseous recontouring around the fixture.
Preparation designs for porcelain veneers have varied dramatically over the years. We began utilizing them as a conservative alternative to full coverage and strove to do a minimal prep. Then the pendulum swung back the other way and we were doing much more reductive veneer designs. Now we are moving back to thinner and smaller pieces of porcelain, replacing just corners, and even no prep restorations.
The last few weeks have been full of restless nights, intense conversations, much reflection and tireless analysis as I work through the process of purchasing the dental practice I have been part of for the last 9 months. I have created countless excel spreadsheets to look at all the possible financial scenarios that may happen after I’m the owner to make sure the numbers work. I asked my friend Gary Takacs if he would be my coach through this process, and he graciously agreed. Together we have reviewed year after year of tax returns, profit and loss statements and appraised the practice.
One of the most challenging restorative situations is matching a single central incisor. There are many factors that affect our ability to fool the eye and have a restored central appear to be an identical match to it’s neighbor. One of the factors that is often missed and easy to control is facial embrasure form. Part of the reason we miss this aspect of tooth shape is you can only see it from a different perspective, incisal edge down. When I am shaping provisionals, direct composite or completing a wax-up with intention I shape the facial embrasure form.
As we have talked about in past blogs, Facebook is a place to share information. You have heard the quote, “A picture is worth 1,000 words”. Today we are taking that principle and applying it to Facebook. We will cover four album ideas for your dental practice. Albums are groups of photos on Facebook. You can create different albums for different events. Otherwise, if you just have one picture you can post it directly to your wall. Here are four ideas for albums:
I have been doing a lot of research and analysis on recall systems recently as we attempt to revamp ours in the office. As with many of the systems in a dental office when things are working and the hygiene schedule is full we tend to relax the system. When there are openings in hygiene we focus on the system. The problem with this approach is that the attention we pay to the system today reaps positive rewards 3-6 months from now not next week where the openings are. Having a consistently productive hygiene department depends on a consistent system. With all systems the first thing to do is decide what we want it to accomplish. With this in place we can then look at the process or pieces of the system, and decide who is accountable for the overall success, and the independent pieces.