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No Fail Dentistry: The Scope of Diagnostic Modeling

Popular Unexpected Failures

Painful crowns
Wrong size or shape: crowns, veneers
Bad veneers
Discolored veneers
Inflamed - swollen gums
Bleeding gums
Loss of gum tissue
Decay: Around crowns, veneer margins
New teeth requiring "adjustments"

Loose, falling off veneers
Loose crowns
Loose bridgework
Cementation failures
Sensitive or painful teeth
Ugly - uneven smile line
New restorations don't match natural teeth
Implant failure
Unable to wear new dentures

Routine Dentistry becoming Anything BUT Routine

Most patients have heard horror stories about a complex and/or costly dental treatment failing. The reasons seem to be almost infinite.

Stone Models - The First Step
We have also heard stories about how a simple treatment, perhaps the placement of a crown or a few fillings cause a cascade of new problems and treatment misery that didn't exist before the simple treatment was obtained.

Tooth sensitivity, jaw and gum pain, aching jaw joints, biting - chewing pain, intolerance for cold foods, intolerance for hot foods, clicking noises, ear congestion and even tmj headaches are some of the common complaints and events patients experience unexpectedly from certain types of dental treatments.

Complex Surgery Rarely the Cause

Dental surgery procedures including for example, bone grafting, periodontal procedures, gum tissue grafting, bone leveling and dental implant surgery, rarely cause these types of symptoms.

Bite Height Measure Long Island
Occlusion - Attention to Detail
Vertical Dimension Precision
Surgery protocols are tightly defined and leave little to chance for a "surprise symptom"

Restorative Procedures Changing the Bite

Patients frequently become mystified (even some dentists) when they discover after weeks, months and even years of pain and discomfort, that a simple adjustment to a single tooth or a simple repositioning of a jaw relationship thrown out of whack by an oversized crown can relieve symptoms within minutes.

Cosmetic Procedures causing Unwanted Cosmetics

Cosmetic Implant Dentistry Ira Koeppel
Initial Consult - Cosmetics and Function
Gum inflammation, bleeding gums, swollen gums, changing colors and cosmetic treatments (veneers, crowns, bridgework) that seem to fall off soon after leaving the dentist's office are most commonly related to unrealized technical errors related to "the bite."

Biting Forces: The Basics

The average biting force during chewing is around 68 lbs per square inch for males, less for females. Intentional teeth clenching can increase the force to about 150 lbs per square inch.

Nocturnal or night time teeth clenching however, can subject our teeth and jaws to pressures of up to 1200 lbs per square inch.

Occlusal Plane Photo
Occlusal Plane Analysis
It doesn't require much imagination to consider what can happen to our teeth, jaws and soft tissues when something like a routine crown, filling or a few veneers causes a disturbance that fails to distribute our biting forces evenly along the entire occlusal plane (alignment of upper and lower jaw when closed).

Analysis: Attention to Detail

Stone Models and Diagnostic Waxup activities are a critical component for complex reconstructive or cosmetic dentistry. Precision instruments enable the accomplished dentist to evaluate all physical properties of jaw and dental function.

Accomplished reconstructive and cosmetic dentists who rarely have a treatment failure tend to have a history of incorporating occlusal studies in all but the simplest of treatment plans.

Waxup Models Smile Design Long Island
Waxup Cosmetic Design
Articulation analysis assures the dentist of being able to maintain or correct the best upper and lower jaw relationships while providing patients the ability to design the cosmetic aspects of their treatment.

Waxup Modeling and Temporaries

Treatment plans that focus on multiple tooth replacements via crowns, implants, bridgework or denture prosthetics typically include detailed assessments of physical features and dental function dynamics that are required for recreating a bite that once existed.

Once the physical attributes of reconstructive or restorative dentistry are determined, the waxup process begins. Creating new tooth shapes, tooth positioning, color shading, harmonizing the smile line and otherwise making everything "look just right" involves the dentist AND the patient.

Waxup Design Long Island Photo
Waxup Cosmetic Design
Temporaries are created for veneers, fixed bridges or new crowns that are actually worn by the patient for a few days... to several weeks.

Critical Procedure Component Often Omitted

In complex reconstructive dentistry treatment plans the use of Temporaries is assured by most accomplished dentists.

It is within the less complex treatment plans that the common stories of cosmetic disappointments or complete failures often are due to the omission of temporaries.

Patients and even some dentists believe that with small numbers of crowns, veneers or short span bridgework (and other prosthetics) the diagnostic waxup process is an unnecessary and perhaps wasteful expense.

In some metropolitan areas, some dental practices may create attractive pricing for popular cosmetic procedures (placing or replacing crowns, veneer makeovers) by eliminating various costs that frequently include Stone Models (made from impressions) and the waxup process that is built upon these models.

Last Chance for Perfection

The implementation of stone modeling and waxup activities guarantees the patient (and dentist) the opportunity to check and recheck all technical and aesthetic factors that make any treatment a treatment success.

Occlusion and bite, even for the smallest number of restorative products, is evaluated and reconfirmed. For the patient, the feel, fit, values of natural appearance and degree of cosmetic balance is evaluated repeatedly until the patient obtains the goal he/she wants from treatment.

Point of No Return?

When the dentist and patient are in agreement or consensus that everything is perfect as can be.... the last sets of occlusal and aesthetic data are sent to the dental lab for final fabrication. This is the step that creates the final restorative products.

Diagnostic waxup activities commonly guarantees:
- the fabrication and fitting of crowns that don't need to be "adjusted" via grinding down porcelain
- crowns that look "just right" in color, texture and match with other teeth (natural or otherwise)
- smile line changes that match text book definitions
- bridgework or prosthetics that don't look like prosthetics or fake teeth
- a veneer makeover experience that meets or exceeds a patient's original goal
- cosmetic and/or structural changes in dental function that include NO unwanted surprises
- the opportunity to create dramatic changes that change the way we think and feel about ourselves

Once fabricated, the color and shade characteristics of veneers, crowns, bridgework and other prosthetics cannot be changed. New layers of porcelain cannot be "added" to a new crown that is poorly shaped or poorly shaded. Veneers cannot be remade, lengthened or shortened be shading is wrong. Fat looking teeth cannot be re-prepped to make a veneer look more natural.

Waxup Modeling #101: Dentist - Patient Veneer Temporary Consult

waxup modeling example Long Island NY
Veneer Temporary Example
Right Maxillary Arch
The waxup example pictured here amply demonstrates the structural and cosmetic effects this female patient will experience as she designs her new smile line. In this treatment plan, strict adherence to the Rules of Golden Proportion are followed.

With only one half (1/2) of the 10 unit veneer temporary in place, the patient IMMEDIATELY becomes aware of the different properties of her teeth that will be modified to create the cosmetic result desired.

Especially noteworthy is how an unwanted color is bleeding through one particular tooth structure. Veneer fabrication and lamination "adjustments" for this particular tooth resolves this problem.

waxup veneers Long Island NY
Veneer Temporary Example
Full Maxillary Arch
The mathematically derived new smile line is perfect (as defined by the patient) that includes new tooth sizings to overcome the appearance of her natural teeth... as seen on the left side of the upper arch.

Our second photo shows the entire veneer temporary placed on the upper arch. Notice how the unwanted color shading "incident" is repeated on the left side of the arch. Idiopathic properties of these two teeth cause a discoloring event when the teeth are fully prepped for veneers.

As indicated above, attention to detail (required) will resolve this cosmetic issue.

This special need would not have been discovered without the use of temporaries.

After documenting the special fabrication and lamination needs for these teeth, the patient continues to wear the temporaries for several days, monitoring the fit, feel, changes to bite or incisal relationships with the lower jaw, speech characteristics and any changes in color shading in different types of light (incandescent, fluorescent, sunlight, etc.).

The very last step is the final fitting of the new veneers that will reproduce, minus any chance of unwanted surprise, the veneer makeover result achieved with the temporaries.

Waxup Modeling Summary

Patients undergoing nearly any dental treatment where function and/or appearance is critical (in either the patient's opinion or dentist's opinion) should always evaluate the importance of using stone models and waxup services.

Temporaries of nearly any restorative or reconstructive dental component enables precision dentistry that meets the standard of care requirements defined by the dentist and meets the aesthetic and basic dental function desires of the patient ..... without the need for retreatment caused by technical errors.

Questions - Suspicions?

Treatment failures, both cosmetic and functional are most often related to the inadequate or poor controls over the analysis and planned treatment of a particular need. In comprehensive dentistry many patients discover that poor attention to detail or the failure of following a treatment standard can cause immense dissatisfaction or unhappiness with new treatment that doesn't look right, feel right or is creating even more unplanned treatment needs.

Patients seeking details about the material discussed on this page or seeking information that is not discussed here are invited to contact Dr. Koeppel directly with our on-line Ask The Dentist form.

Or, call our office at (631)318-0000 to schedule a complimentary consult with Dr. Koeppel. For convenience, an appointment can be arranged with our Free Consult form.









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New York Reconstructive Dentist
Ira Koeppel, D.D.S.
126 Gnarled Hollow Road
East Setauket Long Island New York NY 11733
Nassau - Suffolk County Spa Dentistry
(631)318-0000