Diastema Closure Steps to Success

Patients present for Diastema Closures all the time in our practice. This is one of the most challenging cases to be done correctly in dentist office. Lumineers is hot due to their direct marketing. The case below would have been a disaster if a dentist wuld have allowed the patient to dictate the treatment. Although patients have demands we are the professionals and must guide them to what is possible or not. Here are the steps we go through.

1) Discuss patient's expectations
2) Discuss Shade Change
3) Discuss Monetary Restrictions
4) Discuss Orthodontics
Step 1: Intraoral Photos
Not only are they important for you and your lab technician to see the case, but more importantly for the patient. This allows them to now OWN their problem and see where they are. This usually leads to more case closing.

Smile and Profile

Notice the deviation of her chin that is masked by her diastema

Intraoral Photos

Now that we have our case we see the challenges.

1)Diastema is large so doing two veneers is out of the question

Options 4-8-10. We never do 6 . That is a whole other discussion

2)Lack of papilla so long contact will be present. Papilla is not present because no bone peak is present. 

Tissue is the Issue but Bone sets the TONE

3)Flared Incisors and and edge to edge. This shows is that NO prep is not possible. Minimal Prep Maybe

We then go ahead take good diagnostic impressions, Bite registration and Kois facial Analyzer Registration to make sure that final waxup is straight.

Here are the models and Waxup.

Duplicate of Waxup

Recommended preparation to make teeth proportional. Moving everything MeDially

Diagnostic Waxup

Preparation Guide. In this technique a Clear Stent is placed. Teeth are prepped through the Windows. The Waxup is then transferred to the mouth and a 0.3mm reduction bur is used. This prevent haphazard preparation and allows Minimally Invasive Dentistry to be performed

Day of Prepartion. All the Work is transfered to the patients mouth.

Adequate preparation done. Prep polished and Polyether Impression taken.

Trial Smile done.

We don't like to make the temporaries So SPECTACULAR as patients then get too comfortable and do NOT return

Temporaries after Diode Laser Recontouring of gingiva

Notice Change in shade

Now is when we hit a speed bump. this is what the case came back looking like. In Diastema Cases make sure that your lab understands that no papilla is presents and to close the gingival embrasue completely.

After ditching the dies they lost sight of the embrasure so finished it to normal size. We resent to reaply porcelain.

Day Of insertion

2 week post op

2 week post op

 

All in all with 4 veneers we were able to get away with closing the diastema and not making her teeth look bulky. 

Enjoy! As always comments are welcomed.

What to do when Immediate loading is not a possibility?

Immediate load / Teeth in a day/hour/minute/flavor of the month, is the hottest thing in Implant Dentistry. Patients are asking for more and more from us as clinicians. Marketing hype is nice but those of us who understand the principles of Implant dentistry know that it is not always possible.
Here is a case that I just started yesterday.

Patient 84 y.o
Retired, Loves to play golf, Loves life.
Heathy All WNL
Dent Hist: Has history of wear and wear facets on his teeth.
Edge to edge bite (may or may not be condusive for immediate load)
Fell and cut his lip open and fractured #9.
Here is the Xray

Patient has Vertical/Horizontal Root Fracture.

Treatment Options:
1) Do Nothing
2) Rct, Crown Lengthening (causing more black triangles), Post and crown
3) Extract and Fpd
4) Extract Implant, Crown
5) Forced Eruption, Rct and post core Crown

Patient chose #9. I do understand That this tooth could have been saved but patient did not want to bother with other options and chose implant.
The root was measured at 18mm, so the longest implant we had was a 16mm plus 2-3 mm subcrestal would be fine.
Here is what we did.

Tooth Extracted Atraumatically

After tooth Extraction, Implant was placed and bone graft was performed. Mixture of Cerasorb M dental and DFDBA

At this point you have realized that I did not immediately  load this case. Implant placed was MIS 4.2X16mm. Stability was at about 25Ncm. Because of the patients wear I didnt feal comfortable loading the implant right away. So now what?

Many clinicians rever to a flipper. I dont like mucosal supported restorations when implants are healing. So How will I Maintain My gingival architecture and still develop the tissue. 

Essix Retainer is one way. Only problem with an essix is they get grimy after a while. 

In comes Ribbond. Ribbons allows us to fabricate a fixed pontic that will be adjusted as the tissue heals.

We used collatape and 5-0 Chromic Suture to hold it in. Papilla not sutured but rather supported by temporary.

Here is the remainder of the case. Enjoy!

Comments are welcome

5-0 Chromic suture.Notice papilla not sutured.

Papilla SPace created will adjust gingival embrasure after swelling goes down. Leaving a black triangle will allow papilla to develop

Final Xray

3 Appointment Cost Effective Implant Denture

Every dental office has patients that are in desperate need of implant restorations, but a lot of patients find the conventional type of restorations beyond their financial means.

We have created a new way of providing Implant Dentures in as little as 3 appointments at a very affordable price to patients.

Enter the Laser Bar Denture.




It is a denture processed onto a laser assembled new generation, high retention bar profile.

Starting Point :
Bite Registration using Kois Dento-Facial Analyzer
Copy Denture and CR bite

Transferred onto articulator using the Kois Transfer Stand. You can easily make your own jig so the Stand can be used in most high end articulators

One way to mark anatomical landmarks without painting on the patient's face

This is the amount of reduction that was needed.

This is where we ended up.

Patient is getting married in a month.

That will be a very happy person walking down the aisle.

Intra-oral detail

Denture teeth: Tribos 501

Denture Modification: Shofu Lite Art and GC Gradia

That tiny little dark mark on the canine is the screw access hole that came out bucally.

We covered that up by very minimally moving the lower incisors mesially and rotating the canine out mesially so we could have the metal cylinder on the distal aspect. Jonathan did his magic chairside. Who is ever going to notice there is a screw covered?

Now, there is a before and after shot that will generate more cases like this once the patient finds out they can actually afford it.

Hydraulic Sinus Lift/Extraction/Implant PLacement/Bone graft/Cytoplast

Molars are one of the most common teeth to receive fillings, crowns, rct , perio surgery etc etc. They are the teeth that we use most hence break down the fastest. When the molar is not able to be saved (rct failures, non restorable etc etc.) implant therapy shines.

Implants in molar sockets have historically been a long process. From extraction to bone grafting to sinus lift to implant placement the process can take over 1 year in time. With today's implant systems, bone graft materials and Piezo Surgery this process can be cut down to 3-4months. Here is a case I just did today.
#3 had failing endo that was unable to be retreated. Tooth had recurrent decay

a)#3 was atraumatically extracted by sectioning the roots and preserving the bone
b) Hydro-Dynamic Sinus Lift: Piezo surgery tip is used to lift the sinus with water pressure only, through the existing interseptal bone
c) no bone graft is placed in sinus cavity but rather a collatape to stabilize the clot and maintain the space
d) 5.8mmX12mm Biohorizon Implant is placed
e) socket is grafted with Dynablast
f) The biggest challenge with a molar is closure. So instead of raising a flap we guide the healing by gaining attached tissue. We place a cytoplast membrane that is removed at 4 weeks.

Also to consider is with molars no matter what you do you get lots of resorption after the extraction. So in immediate molars we like to place the head of the implant 2-3mm subcrestally. this allows for soft tissue development and  beautiful emergence profile.
Here is the case, any questions please place in comments box.
Regards
Jonathan