Functional Considerations in Esthetic Dentistry



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Continuing Dental Education of Baton Rouge

October 19, 2012




Functional Considerations in Esthetic Dentistry


Thomas R. McDonald, D.M.D.


1010 Prince Avenue


Athens, Georgia 30606

706-543-8208



TMcDent@aol.com

www.DrThomasMcDonald.com



Functional Analysis



Phonetics

  1. Observe incisal edges during “E”, “F”, “Th”, and “S” sounds



Neutral Zone

  1. Observe facial musculature

  2. Analyze existing tooth position

Occlusion

  1. TMJ analysis

  2. Mounted casts in centric relation

  3. Stabilization-equilibration



Materials

Esthetic Analysis




  1. Smile Line-Lip Posture

    1. High-Low lip line

    2. Facial characteristics

    3. Gingival line



    Dento-Facial Analyzer

    1. Midline evaluation

    2. Incisal plane

    3. Golden proportion



    Face Measurement

    1. Width and length

    2. Comparison to mould guide



OCCLUSAL ANALYSIS


COMPREHENSIVE PATIENT EVALUATION
PATIENT INTERVIEW
1. What can we do for you today? ____________________________________________

2. Are you having any discomfort now? _______________________________________

3. Is there anything about the appearance of your teeth that you would like to change?

______________________________________________________________________

4. What types of dental procedures have you had done in the past 5 years? ___________

______________________________________________________________________



RADIOGRAPHIC EXAMINATION

1. General appearance on radiograph: __________________________________________

2. Missing teeth ___________________________________________________________

3. Prevalence of fillings: FEW MODERATE MANY

4. Any overhanging margins? _________________________________________________

5. Any periapical infections? _________________________________________________

6. Any cavities obvious on x-ray? _____________________________________________

7. Any bone loss? _________________________________________________________

8. Any widened periodontal ligament? __________________________________________

9. Any unerupted teeth? ____________________________________________________



CLINICAL EXAMINATION

1. Jaw relationship? _______________________________________________________

2. History of joint noise? ____________________________________________________

3. History of joint pain? ____________________________________________________

4. Headaches or neck pain? _________________________________________________

5. Appearance of soft tissue/ oral cancer exam___________________________________

6. Any premature interference or mobile teeth? __________________________________

7. Any gum pocket formation?________________________________________________



CLINICAL EXAMINATION

8. Adequate attached gingiva? _____________________________________________

9. Any malpositioned teeth? ______________________________________________

10. Any sign of tooth wear? ________________________________________________

11. Any teeth likely to fracture? ______________________________________________

12. Any generalized recession? ____________________________________________

13. Any erosion? ________________________________________________________

14. Any unmanageable bacterial traps? ______________________________________

15. Tooth by tooth analysis:


TREATMENT PLAN

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



HISTORY

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




FACIAL PAIN-T.M.J.-OCCLUSAL EXAMINATION
Patient_________________________________________ Date_________
Chief Concern_________________________________________________________
CLINICAL EXAMINATION

MUSCLE PALPATION RANGE OF MOTION

Note degree of tenderness


R

0

0mm mm

L
0=NONE 1=MILD 2=MODERATE 3=VERY


COMMENTS_____________________________

____________________________________________________________________________________________



LEFT

RIGHT

NORM=40mm

NORM=10mm

50mm


LOAD TEST OF JOINTS

SIGNS OF TENSION/TENDERNESS

MANIPULATION TO CR____________________________

LOAD TEST ROTATION____________________________

LOAD TEST TRANSLATION________________________
DOPPLER EXAMINATION

0 1 2 3 MEDIAL POLE CREPITIS 0 1 2 3

0 1 2 3 LATERAL POLE CREPITIS 0 1 2 3

____mm OPENING CLICK _______mm

____mm CLOSING CLICK _______mm

Y N LIGAMENT HYPEREMIA Y N

Y N ADHESIONS Y N

OCCLUSAL EXAMINATION 0=NONE 1=MILD 2=MODERATE 3=COARSE

COMMENTS__________________________________

DIAGNOSTIC CASTS MOUNTED IN CR FACEBOW ______________________________________________


PANORAMIC FILM

PATHOSIS _______________________________

DEVIATED SEPTUM _____________________

SINUS IRREGULARITY ___________________

_________________________________________

_________________________________________





EXCESSIVE WEAR___________________________________

TOOTH HYPERMOBILITY___________________________

FRACTURED TEETH________________________________

SENSITIVE TEETH__________________________________
OCCLUSAL-ESTHETIC ANALYSIS
MOUNTED CASTS
INITIAL CONTACT CR _____________________________________
SLIDE _____________________________________________________
ANTERIOR CONTACT IN CENTRIC RELATION Y N


INCISAL WEAR 0=NONE M=MODERATE S=SEVERE

6

7

8

9

10

11

22

23

24

25

26

27






































ANTERIOR CONTACT WITHOUT POSTERIOR TEETH___________________
_______________________________________________________________________
NEUTRAL ZONE COMMENTS__________________________________________
_______________________________________________________________________

ESTHETIC ANALYSIS

LEVEL LINE


INCISAL PLANE R L

GINGIVAL PLANE R L
MIDLINE
FACE MEASUREMENT HEIGHT _____ WIDTH ______
INCISOR MEASUREMENT HEIGHT _____ WIDTH ______

EQUILIBRATION

1




7




2




8




3




9




4




10




5




11




6




12




TMJ-RESTORATIVE PROTOCOL





Splint Therapy Considerations
Muscle Symptoms

Joint Symptoms

Load Test

Splint Therapy

Yes

Yes

Positive

Yes

Yes

Yes

Negative

Yes

Yes

No

Positive

Yes

Yes

No

Negative

Maybe

No

No

Positive

Maybe

No

No

Negative

No



Restorative Protocol


Muscle Symptoms

Joint Symptoms

Load Test

Restorative

Yes

Yes

Positive

No

Yes

Yes

Negative

Yes

Yes

No

Positive

No

Yes

No

Negative

Yes

No

No

Positive

No

No

No

Negative

Yes




Restorative Position


Posterior Stop After Prep

Anterior guidance in IP

TMJ Symptoms

Restore in IP

Yes

Yes

No

Yes

Yes

Yes

Yes

Maybe

Yes

No

No

Maybe

Yes

No

Yes

No

No

No

No

No

No

No

Yes

No


Phonetic Evaluation



Sound View Clinical Relevance



“E” Frontal Observe an imaginary line from commissure

to commissure. If incisors fall below this

line, they generally cannot be lengthened. If

shorter, can generally be lengthened.

“F” Profile Observe interaction between incisal edges

and lower lip. Evaluate length and position.

“S” Profile Observe interaction between upper and

lower incisal edges. Evaluate length and

position.

“Th” Profile Observe clarity and crispness of sound.

Evaluates lingual contour.



Laboratory Esthetic Evaluation and Diagnostic Wax-up

Armamentarium: Dividers, red and blue pencil, Bunsen burner, presentation wax,

PKT waxing instruments #1 and #2, Hollenback and cleoid-discoid carvers,

Bard Parker lab knife, Boley gauge, Denar ruler, and Panadent platform with golden proportion guides


  1. Remove upper cast from articulator.

  2. Analyze and correct lower occlusal plane.

  3. Replace upper cast and correct posterior occlusion (equilibrate).

  4. Establish parallel incisal plane with Dento-Facial Analyzer.

  5. Attempt to correct midline if possible.

  6. Scribe gingival margins with blue pencil.

  7. Measure and establish absolute symmetry at the central incisors.

  8. Use golden proportion guides for placement of laterals.

  9. Use canines and first premolars to add and subtract space needed elsewhere.

  10. Evaluate gingival levels. Central incisors must be at least 10mm.

  11. Rationalize with desired occlusal scheme and refine anterior guidance.

NOTE: When closing spaces;

  1. Close entire space

  2. Measure, establish, and scribe the proximal line.

  3. Remove wax from gingival/facial embrasure and incisal/facial embrasure alternately until tooth size is pleasing.

  4. To narrow teeth, move facial line angles away from the contact area.

  5. Straighter line angles = longer looking teeth.

Instruments and Materials

Digital X-Ray

Dexis

DEXIS, LLC


1910 North Penn Road
Hatfield, PA 19440 USA

www.dexray.com



Facial Measurement

Trubyte Tooth Indicator

Densply-Trubyte

York, PA


800-877-0020

www.trubyte.densply.com



Occlusal Measurement

Range of Motion Scale

Great Lakes Prosthodontics

Tonawanda, N.Y.

800-828-7626

800-324-4434(NY)

www.greatlakesortho.com


Impression Material

Jeltrate-Plus

Dentsply-Caulk

Milford, DE

800-534-2855

www.caulk.densply.com



Alginate Mixer

Alginator II

Great Lakes Prosthodontics

Facebow

Kois Dento-facial Analyzer

Panadent Corporation

Grand Terrace, California

909-783-1841

www.panadent.com



Facebow Registration

Bite-Tab

Panadent Corporation

Occlusal Registration

Delar Wax (D-Style)

Delar Corp.

Cast Stone

Silky-Rock White

Whip Mix Corporation

Louisville, Ky.

www.whipmix.com


Mounting Stone

Kerr Sno-White #2

Kerr Manufacturing Co.

Orange, California

1-800-KERR-123

www.kerrlab.com



Articulator

Panadent PCH

Panadent Corporation

Diagnostic Wax

Presentation Wax

Great Lakes Prosthodontics

Waxing Instruments

PKT 1,2,4

Cd 3/6,#7 wax spatula, Bard-Parker lab knife



Hu-Friedy Mfg. Co., Inc.

Chicago, IL

800-HU-FRIEDY

www.hufriedy.com



Articulating Paper-Lab

Surgident Full Arch

Heraeus Kulzer

South Bend, IN

www.kulzer.com


Articulating Paper-Oral

Bausch 40μ

Bausch Articulating Papers

Nashua, NH

www.bauschdental.com


Retraction Cord

Raycord #9 and #10

Pascal Co.

C+B Impression

Impregum Penta

3M-ESPE

Matrix Material Single

Matrix Buttons

Advantage Dental Products

Matrix Material Multiple

Genie Putty

Sultan Chemists

Provisional Resin

Protemp Plus

3M-ESPE

Provisional Burs

Thomas R McDonald DMD Provisional System Kit

Komet USA




Thomas R. McDonald, D.M.D. Copyright 2012

Functional Considerations in Esthetic Dentistry




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