Porcelain Power

Like everything else around us...dentistry evolves.

For years, when a patient needed a full crown (cap) to restore a tooth, the state of the art, was a crown that had a metal understructure and then porcelain baked on top of the metal..and they were beautiful, strong and long lasting...

Over the last several years the standard of care has changed...and I can now offer crowns that are even more esthetic..as they are now made of porcelain only...no metal understructure.

The technology now exists where we can have porcelain strong enough to resist breaking and without the metal understructure... the translucency of the porcelain leaves it even more esthetically pleasing..

In addition..with our old style porcelain/metal crowns...no matter how well we did it, the metal could leave a slight grey tone at the gum line...not really noticeable to most people...and not objectionable...but there was a greyish tone if you really inspected.....

Now with the power of porcelain...gum line areas are no longer getting that grey tone..

These photos will tell the story...

here is the preparation of the tooth ready for 

crown try in...

Do you speak dental??

So there I was...working hard on a new crown for a patient..when suddenly I decide to talk to her...
and of course she tried to respond...but how could she...both of my hands, two instruments, saliva ejector, a multitude of cotton rolls all seemed to render her attempted answer into a new language..
I looked up and said to her..what did you say...??
that is when i realized I could not possibly understand what she was saying...

After all these years I am still expecting patients to answer my queries..that btw, had nothing to do with anything concerning the procedure I was doing!

I still don't speak dental! Even after all these years!

Decided to start a website for the office..here is the intro video.

Ok..it's time to resume posting some real life dentistry.

Let's start with this 74 year old woman...she has had dental work her entire life covering almost all her teeth...when she came to me her chief complaint was that her lower teeth looked awful
And, she was correct...as one gets older the upper teeth show less and the lower teeth show more due to muscle sagging...and now she always noticed her dark and non uniform lower front teeth...

In order to correct the crookedness and restore a full lustre look to these teeth, porcelain type crowns are the treatment of choice.. We could have opted for a laminate/crown combination plan but I felt that I would be more in control of the final look if I had full coverage of the teeth.

I would do 6 crowns in front...at today's visit we prepared 3 teeth for crowns...she could not sit through a long enough visit for me to prep all six teeth, so we decided on three preparations and temporaries today..and three next visit.

I fabricated the three temps with an alginate technique.  The patient left the office after a 90 minute visit and was very comfortable and satisfied with the fit and look of the temps.  At this point the temporaried are modeled off her original teeth but the final porcelain crowns will be straightened out as much as possible without having to do root canal or minor tooth movement.

Patient will be returning next week and I should have the next three teeth prepared and hopefully will take an impression for the permanent crowns as well.

Hope you enjoyed this real life dentistry.

Dr Stan

One tooth smile makeover...

Sometimes one tooth can disrupt the entire smile line...with this patient, a middle aged woman...she had what is called a peg lateral where the lateral incisor is in the shape of a peg. This is not an umcommon finding and there are a number of ways to treat it. In this case I decided to place an all porcelain jacket on the tooth to get the most esthetic result possible...take a look at these two images of the tooth before any treatment.


The first step is to file or prepare the tooth so that a jacket can be placed over it...in this picture you can see the finished preparation...

And one week later the patient returned and we tried in and cemented a beautiful porcelain jacket that matched the adjacent teeth and immediately changed her smile...she still has an unesthetic tooth on the other side but that tooth does not bother her and we are leaving it alone for now.


Now...if she would only let me do the tooth on the other side of the smile!!

everybody needs implants

Implants are now the first choice for restoring missing teeth.
We don't have to involve other adjacent healthy teeth to make a bridge..with implants we are only dealing with the patient's missing tooth/teeth situation.
Here is a case where a patient lost three teeth in the lower front jaw. Years gone by we would have made a bridge where we grind down the adjacent healthy teeth..but no more.
As you can see here, in the photo above, the patient had two implants placed into the area of missing teeth..these two implants will now hold three porcelain teeth.
First the lab makes a metal framework for me that I try into place...in this photo you can see the framework that was tried in..

the framework then goes back to the lab and porcelain is then baked onto the metal framework and as you can see it is made to appear as three distinct teeth.

and in the next photo you can see that this is not cemented into place but rather we are making this as an implant case which is screwed into place.

The screw holes will be filled with a tooth colored acrylic and will not be visible and the patient will not feel anything unusual in that area.
of course now the problem is that the remaining teeth that the patient has really look old compared to the new teeth..but that will be changing as the two teeth remaining are scheduled for some cosmetic work...we were not going to make the new teeth look like the old teeth!

porcelain and gold ..a winning combination.

Gold..still the best metal that dental scientists have to offer us..but you would be hard pressed to find a patient willing to accept any gold showing when you make them teeth, no one wants any gold showing.

So here is a case where i used gold for the posts underneath and then porcelain crowns on top.
The implant surgeon placed 5 implants and I made 5 gold abutments/posts...on top of those posts we place a 10 unite porcelain splint..done in two sections...
in the photo above you can count 5 posts and one natural tooth upon which the porcelain bridgework will be made.

I decided to make this case in two sections...lower left and then lower front...



First I cemented the lower left for the patient and then lower front...
the patient feels great and loves the fact that by giving a slightly different size and angle to the teeth they look like they are his teeth and not just another set of straight caps with an artificial look.

Combo Case

Implants are everywhere in people's mouths today...
here is a case where there are two implants in the back section of the mouth and I connect those two implants with a natural tooth that had a root canal and a post.
The natural tooth is somewhat questionable as to its longevity so i am hoping that by stabilizing it with the impants I will get extra years from it...
If in the future the natural tooth needs extraction then I will have a single tooth implant placed there...we shall see

4 little teeth/caps

Well when you are in dental school they sort of scare you away from doing crowns/caps on the lower front teeth..why...well they are very small and hard to prepare properly..the angle to work on them is tough even though they are right up front...and the teeth are small and any mis-prep and you hit the nerve...
but sometimes we have no choice..this gentleman had radiation and chemotherapy about two years ago and since that time his lower front teeth were continuously getting new areas of decay...
finally we decided to cap them all and hopefully prevent future decay...I had to make sure to get the crown margins below the gum level to prevent gum level decay and that made it even harder..but here he is and here are the crowns at the cementing visit..
the gums are a little puffy from irritation from the temp but i am optimistic that they will tighten up around these little caps!!
It helps when they come out looking this good..the patient loved them!

sometimes you get lucky...

A long time patient came in about two months ago...reported that she took a fall and may have injured her front teeth...clinical and xray exam showed nothing unusual.
About a week later the tooth took a turn for the worse..it was still asymptomatice but it had turned a dark grey...I explained this was due to the traumatic injury and would need to be treated ASAP with a root canal treatment to remove the damaged puly tissues.

Root canal treatment was successful but she still had a greyish tooth..and being that this is right up front and center it was no good!!!

A crown or laminate was ruled out as the whole tooth was basically intact and I felt that due to the unusual prominence of the tooth any artificial restoration, no matter how good, would be obvious...

So we decided to do an internal bleaching, often called a walking bleach...although this can sometimes have some unintended side effects...we decided to go ahead with it.

It basically involves placing a bleaching material in the tooth and letting the bleach penetrate the internal discolored aspect of the tooth...well the patient came in ten days after the first treatment and we had a huge success.

The patient and doctor were thrilled!
Please click on the photo to get a larger version!

Ouch..that's got to hurt...

Unfortunately when you have a practice with a lot of elderly patients you occassionally get the phone call telling you that one of your patient's took a fall and stopped that fall with their face...
In any case this wonderful woman was just in last week for a routine procedure and yesterday she called to say she took a fall yesterday and needed to see me right away...
I told her to come on down and here she is..fresh out of the emergency room...

Clinical exam shows that although none of the teeth are unusually loose there are some chips evident on the two central incisors...take a look...


Now we have a machine to tell us the vitality of the nerves that are in the teeth and the test revealed that all of the teeth except for these two respond normally..
these two teeth show no response to an electrical stimulus...
so stay tuned...she is returning next week and we will re-examine her and see if
she will need to have work done on these teeth....

Did you say white???? Yes Dr. - I said WHITE!

As dental students one of the first things you learn about cosmetic dentistry is that you don't want to give someone really white white teeth...it just looks too fake.
Well in today's world it seems that patients will occasionally want that overly too white to be true look and here is one of those cases.
This gentleman has seen his share of dentists over the years and he wants to have a certain look at all costs...
He had his upper teeth capped with really white porcelain and now he is in my office to have his lower teeth "fixed"....He says he wants them to be whiter, and bolder, and stronger ...and bigger and so on and so on.
So take a look at these two pictures and you can see how the lower front six teeth are looking pretty poor next to what was done on the upper...
As usual for this blog..click on any picture to get a larger version then hit the back button to return to the blog!

Now the upper six teeth, were like I said, done elsewhere....and I made the 2 back teeth that you see on each side on his lower jaw...

And to tell you the truth in this particular case I see his need to have his lower teeth whitened, since they are so off shade from the uppers...so here goes...
I determined that in order to make them a bit taller and stronger I would have to
open his bite slightly...which he was able to easily tolerate with the temporary caps I made for him...
After about three try in visits in which our patient had numerous requests for changes we finally settled on this result....
He loves it and is very happy...and he is especially pleased with the slight overlapping of the teeth to give them a more natural appearance instead of the straight line across look.
Would I do it from the outset...probably not..but he claims he is in show business and he needs it...
so there you go....white as white can be...maybe he should say he is in snow business with this level of white! Here are a few different views.


Of course, now the upper teeth don't look as white as he would like them to look..
I would not be surprised if he wanted his upper teeth redone to look this white...
and by the way these crowns are pressed porcelain and are very easy for the labs to work with and modify!

And now for something completely different...

Had to leave the office early yesterday...was one of the semi-official photogs at a wedding for a family member..second wedding for both so now real official photogs there but nonetheless lots of pressure to get the shots!

Front tooth face...

so far pretty busy today but not much to really blog for you..
so how about a small little one..
really nice gentleman comes in and has a chipped front tooth...right in the middle..

And he tells me that this tooth has been bonded several times and it keeps chipping off...and he wants to know if I can help him out..
Well my bonding is not going to much different than the next dentist's bonding..we all really use the same materials..but i decide to give it a shot even though he may need a full veneer to really give this tooth a long term fix..so I bond the tooth with tooth colored acrylic and we hope for the best!!

now of course the teeth around this need some cosmetic work but that will wait for another visit...

I can chew... continued...

About a year ago we told the tale of a woman who had to lose all her lower teeth..
we replaced them with implants and here is how the implants looked about a year ago, right after they were placed and before the tissue had healed...

Now fast forward to the present and here is a picture of those implants with the gum tissues healed up nicely and the final teeth in place...in this first photo, you are looking at the gold custom posts upon which the porcelain teeth will be cemented...


Still to come..we are doing the same to the upper teeth!!

It helps to have connections...

This patient has braces as an adult and to prevent the lower teeth from drifting back to the original crooked positions we try to connect the teeth by bonding them together.
This patient had it done about a year ago and now the plastic that was used was starting to loosen...

The treatment is to drill out the old plastic and create a fresh channel to place a new connection..here is the new channel prepped...

A twisted steel wire is fitted to the space and will be bonded into place to help hold the plastic and teeth together..here i am fitting the wire to get the right size...

Once the wire is sized I then take the soft plastic and embed the wire as you see here...I then continue to fully cover the wire and polish it so that the patient has no feeling whatsoever that anything is even there...


Unfortunately the mouth is a tough place to survive and this procedure will have to be repeated every so often..but the patient does not mind..her teeth are straight!

Cracked!

Most of the time, no matter what you do to your tooth/teeth we can figure out someway to save them...whether a filling or crown or root canal or something else.
But occasionally a patient presents with a situation where no way no how can I fix the the problem...and here is one of those situations. A cracked tooth, where the crack runs the entire width of the tooth and the two pieces are now separated.
Usually this can be a rather tricky diagnosis...because the tooth pieces that are cracked are not separated..but in this case it is rather obvious...
In this photo..rather gruesome, you can see an up close picture of a molar where the crack has developed and the tooth is now in two pieces! Amazingly the patient has no pain whatsoever and was not even aware of the seriousness of this situation.
The patient has been referred to a surgeon for removal of the tooth and hopefully we will be able to place an implant to restore him back to full function.

Which camera do you use...

That is probably the question I get asked most..
Most of the dental pics that you see are taken with a simple point and shoot camera..
in the old days before digital we had fancy set ups with single lens reflex cameras and ring lites and macro lenses..Wow..things have changed..now I use a simple little camera with a built in flash on the macro setting..and I am very pleased with my results..


For pictures that require me to get deep into the mouth I will use an intra oral camera...it is a small camera placed on the end of a wand which has a lens and two lights to to illuminate the dark workspace.
The intra oral camera has been especially useful in educating my patients as to dental situations in the mouth that they would normally not see!
This is a good example of new technology which I use daily.


and this is what it looks like with the lights turned on...