Smile-on News Logo

Smile-on News

Healthcare Learning Logo

Smile Makeover: Article five

4 October 2013

Smile Makeover: Article five

Cementation and the celebration: last in the series by Ashish Parmar

Introduction

This series of articles will review in detail a clinical case that required a Smile Makeover (laser gum lift with hard and soft tissue lasers, followed by the provision of ten porcelain veneers).

In this final article, I will explain how the ten veneers can be fitted in a predictable and stress free manner using the best materials. I have used this technique for the last ten years very successfully. I allow 2 ¼ -2 ½ hours for the cementation appointment.

This series of five articles has covered the following topics in treating this case:

  1. Comprehensive dental assessment and treatment planning
  2. Laser crown lengthening, records for wax ups and mock ups
  3. Preparation techniques
  4. Trial smile creation and the review appointment
  5. Cementation and the celebration

Cementation stage: step-by-step

The following is a comprehensive summary of the steps in cementing the porcelain veneers:

  1. Assess the porcelain veneers individually and on the master model
  2. Take an alginate of the trial smile (this is just as a back up in case the veneers are not fitted and a new trial smile has to be made)
  3. Give the patient local anaesthetic – I normally give four cartridges of lignocaine, although in Cheryl’s case no local anaesthetic was actually needed
  4. Remove the temporaries
    • Bur cuts in the middle of each temporary, and also going over the incisal edge. Care has to be taken NOT to touch the teeth at all
    • Mitchells Trimmer and a Brasseler instrument called EB134 (available from West One) is used to help remove the Luxatemp pieces
  5. Inspect the prepared teeth for cement or material
  6. Floss all contact areas till clean with no interproximal debris
  7. Clean and polish the teeth with a small polishing brush and a mixture of Hibiscrub and pumice
  8. Let the patient have a rinse at this point
  9. Try in the porcelain veneers (dipped in water first) – I normally start at the UL5 and work my way around to the patient’s right 
  10. Once you are happy with the fit and aesthetics, let the patient have a look for the approval of the new smile
  11. Shade selection – I normally use Vitique base and low viscosity catalyst (dual cure cement) and transparent or B1 as the colour of choice. NOTE the try in pastes of Vitique are matched very well to the actual cements, and are water-soluble. In case they are needed, the cleaning of the cement off the teeth and fitting surfaces of the veneers is very easy.
  12. Remove the porcelain veneers and place them on the worktop in the correct sequence (verify this with the dental nurse). Confirm sequence of cementation i.e. left to right
  13. Treat the porcelain veneers (a trained dental nurse to do this):
    • Ensure the veneers are dry
    • Hydrofluoric acid (Optident) - etch the fitting surfaces for 20-30 seconds only
    • Wash and dry really well
    • Silane coupling agent (thin layer, leave for two minutes, then gently blow dry); Use the two bottle system by DMG – ensures a fresh mix every time
    • Excite (bonding agent)…apply a thin layer to the fitting surfaces, gently air dry and then cover the veneers up (they are now ready for cementation)
  14. Isolate the teeth
    • Rubber dam (I prefer non latex rubber dam by Roeko), wingless clamps on the molars, and use of guaze and O Bite to seal the palate completely
    • Optragate (Ivoclar) is an alternative (but NOT as good as rubber dam)
  15. If there are any red areas of gingivae (e.g. interproximally as the patient could not floss), apply Expasyl (Kerr) for a few minutes, then wash and dry to ensure clean tissues with no bleeding
  16. Etch the teeth for 20 seconds (dentine areas) and 45 seconds (enamel areas), keeping the etchant gel off the gums - consider doing 4-5 teeth at a time
  17. Wash and gently dry
  18. Apply Gluma desensitiser for 20-30 seconds, then gently dry
  19. Apply the bonding resin (Excite (Ivoclar)), leave for about 30 seconds, gently air dry and light cure each tooth for about 20 seconds
  20. Load the first porcelain veneer with the Vitique cement, and place on to the tooth. Clean the excess with a Benda Brush and a cotton roll
  21. Load and seat remaining restorations in a similar way
  22. Use Benda Brushes dipped in a small amount of bonding resin to remove excess cement. Also use cotton rolls to gently take away excess amounts of cement on the palatal surfaces
  23. At the mid cervical margin tack the UL1 porcelain veneer for five seconds with a 4mm Turbo tip
    • Ensure 100 per cent seating via incisal pressure with a finger and labially across with a periodontal probe
    • Dentist to command when the nurse is to turn the light on and off. This is repeated for the other veneers
  24. A Brasseler saw is placed interproximally between two veneers and a second tack is done incisally (with a normal wider light curing tip) between two teeth for 10 seconds at a time
  25. A fine sickle scaler is used to remove the slight excesses of cement at the margins (labially and palatally). A sharp scalpel blade is also useful at this stage
  26. Verify the contact areas are flossable (a Brasseler saw can be used if there is some cement stuck between teeth)
  27. Ensure 95 per cent clean-up is complete by now, including interproximally!
  28. Full light cure i.e. 40 seconds labially and 40 seconds palatally by the dental nurse
  29. Finishing
    • Margins (minimum or no finishing is required cervically. If any is to be done, I use a yellow banded very fine finishing bur with a very light and gentle drilling technique)
    • Artistic contouring (e.g. embrasures – only if required)
    • Interproximal polishing with a yellow polishing strip (perforated wider strip (Brasseler))
  30. Check occlusion very carefully:
    • Centric stops
    • Lateral excursions
    • Protrusive excursion
    • Fremitus – finger pressure on a tooth to sense the pressure applied when the patient bites
    • Re-verify pre-operative Shimstock holds
  31. Polish any areas adjusted (porcelain polishing points in a fast hand piece with a lot of water spray, followed by Luminescence diamond polishing paste on a buff and mandrel (slow hand piece))
  32. Apply a little vaseline on the lips to moisten them

   

Images left to right: Veneer try in (face), veneer try in (smile right side)

Why I prefer Vitique

Vitique is the best cementation system for all porcelain restorations I have ever used. The shades are very good, with matched try in pastes that are water-soluble (i.e. can be easily removed from the fitting surfaces of the porcelain veneers if used). I almost always use the dual cure version of the cement i.e. the base and low viscosity catalyst tubes are joined together. The small tip extrudes the mixed material very nicely when required.

If the ceramic work has been done so that the technician has made the final restorations half a shade brighter than the desired shade (this is the ideal for me), then I normally use the transparent colour of base material. If I wish to brighten up the colour slightly, then I choose B1 as the base. Remember that veneers tend to drop down in colour by half a shade or so especially if dual cure cements are used – this is important to know!

The other major advantage of Vitique is the long working time during the cementation (even if the dual cure version is used). This makes the whole process a lot less stressful.

I have successfully fitted hundreds of cases using this technique. There are alternative ways of fitting multiple porcelain restorations – some clinicians prefer to cement one at a time.

   

Images left to right: Vitique cementation system kit, Vitique try in paste, base only and base - catalyst set up

The final review appointment

On a separate visit about a week later, I arrange another 45-minute appointment. I check the margins, the occlusion including all the excursions and the final aesthetics. I often use T Scan at this stage to ensure I have done the best job possible in verifying the occlusion is accurate. If the patient is to be provided with a mouth guard, then new impressions/records are taken. I also use this appointment to take a full series of postoperative photographs.

   

Images left to right: Post-op (face), post-op (smile)

   

Images left to right: Post-op (retracted), post-op (anterior)

The celebration

A great way to celebrate the patient’s new smile is to have a celebration. In our relaxation lounge, we surprise our patient. We will have a bouquet of flowers ready, relaxing music playing, some candles lit, and also non-alcoholic champagne in crystal glasses ready to be enjoyed by all. We also have a personalised card written out for the patient signed by all the Team, and the before and after photos in there. We have a goody bag with various offers, business cards and items in it.

Our patients are genuinely touched by the effort we take to share this special moment in their life when they celebrate their new smile, and the increased confidence this will bring them.

We also send our patient to a professional photographer for a photo shoot. They have their hair done up as well as make up, and it is the photographer’s job to capture some special photographs which the dental practice can then use for various marketing reasons. Cheryl looks fabulous in her makeover photographs and the confidence she now has in her smile and the way she looks is definitely different to the fist photograph of her face in Article one before her Smile Makeover.

Image: Makeover

Summary

Cosmetic dentistry can make an unbelievable change to someone’s life. I was one of the leading dentists on Extreme Makeover UK, and I created the concept of Dream Makeover Essex. Time and time again I have seen tears of joy and appreciation from patients I have treated on TV and in my Practice. The scores of testimonials from our satisfied clients are very gratifying. Changing peoples’ lives by creating beautiful, healthy and natural looking smiles gives me the passion for dentistry. Any dentist can learn the skills I have shared in these five articles. You just need to have the confidence, desire, focus and the right practical and theoretical training.

I would like to take this opportunity to also thank the two laboratory technicians that helped me with this case – Ian Taylor of Castle Ceramics (www.castle-ceramics.com) and Rob Storrar of Amdecc Dental Laboratory (www.amdecc.com).

 

Ashish B Parmar (Ash) is a private dentist and has a unique state-of-the-art practice in Chigwell, Essex called Smile Design By Ash (www.smiledesignbyash.co.uk). Ash is a national and international lecturer and was one of the main dentists on the three series of Extreme Makeover UK. He offers an outstanding 8-day Course which includes training on leadership, vision creation, goal setting, step by step techniques in doing Smile Makeovers, treating advanced cases (e.g. wear cases), lasers, fibre-reinforced composite dentistry, photography, communication, case presentation skills, team development, occlusion, etc. Ash has written numerous clinical articles in dental journals and is well recognised for his passion in cosmetic dentistry – using both composite and porcelain techniques.

For lots of FREE information, clinical videos and articles and to find out more about the unique training Course run by The Academy By Ash, visit www.theacademybyash.co.uk, or send an email to training@theacademybyash.co.uk.

Alternatively, you may phone Ash personally on his mobile number 07971 291180.

comments powered by Disqus

Features

This month's special feature is:

Restorative


Newsletter

Sign up to our newsletter


Twitter