'Trial smile creation' in the Smile Makeover series by Ashish Parmar
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 article, I will explain how I created natural looking temporaries after the preparations for ten porcelain veneers, tips in occlusion and also about the important review appointment a few days later.
The series of five articles will cover the following topics in treating this case:
- Comprehensive dental assessment and treatment planning
- Laser crown lengthening, records for wax ups and mock ups
- Preparation techniques
- Trial smile creation and the review appointment
- Cementation and the celebration
Trial smile creation
It is important to take time and create exceptional temporaries to allow the patient to have a very good preview of how the final smile will be. It also gives the dentist the opportunity to verify the ideal shape and size of the teeth, ensure that the occlusion is correct, and other things such as the phonetics and general comfort are OK before proceeding to make the final porcelain restorations.
Technique of making the trial smile
The putty index made from the wax ups is tried in the mouth for accuracy of fit. A black marker pen is used to mark the putty index at a position that is coincident to the middle of the face (this will help with the correct re-insertion).
The chosen Luxatemp (DMG) shade is then used. I commonly use B1, and also BL for younger patients. In this case, ZOOM teeth whitening (home whitening) had been done for the lower teeth, and I decided to use B1 (which is fairly close to the 1M1 colour on the Vita 3D Master shade guide). There are two versions of Luxatemp – Luxatemp Fluorescence and Luxatemp Star. Both have excellent aesthetics, but the latter is stronger and should be used if the temporaries are to be in the mouth for a longer period of time, or if you are treating a wear case or bruxist patient.
The dentist needs to hold the lips upwards out of the way. Thirty seven per cent phosphoric acid is then placed i.e. small dots in the middle of each prepared tooth for 20 seconds (this is called “spot etching”). The acid etch is then washed off and the teeth lightly dried. A thin layer of Gluma (desensitising agent) is then placed on the labial surfaces of the prepared teeth and gently dried. This is followed by the application of a thin layer of Optibond FL2 (partially filled resin); this is gently dried and each tooth is light cured for about 20 seconds. The Luxatemp is placed in to the putty index keeping the tip within the material to avoid air blows. The putty index is accurately placed over the teeth and held firmly still for two and a half minutes. After removal, the temporaries will have been fixed on to the teeth in the mouth. This is called the “shrink to fit technique” of making temporaries. The excess flash is first removed from the palate area and also beyond the gingival margins labio-buccally. I normally use a Mitchell’s trimmer for this.
I then use a very fine flame shaped finishing bur in a speed increasing hand piece with water spray to carefully make adjustments at the gingival margins. Care is taken whilst drilling with a very light touch to avoid touching the gingivae and also the prepared finishing lines. The use of magnification loupes is essential for accurate work. The margins are then checked with a sharp probe to ensure there are no overhangs or excessive parts of Luxatemp. I normally finish the cervical and palatal marginal areas to ensure all junctions between the teeth and the temporary material are imperceptible.
If there are any small air blows, I use Luxaflow B1 material to carefully fill the voids and light cure. The matched composite material ensures ideal aesthetics.
Images left to right: Luxatemp, Luxaflow
I then assess the appearance from the front and decide if there are any aesthetic changes required. Teeth can be made to look wider or narrower depending on altering the line angles on the temporaries. Changes can also be made at the embrasures to create masculine or more feminine shapes. Key tips in making nice temporaries are: -
- Ensuring that there is Golden Proportion (ratio of 1.6 : 1.0 : O.6 between the central incisor, lateral incisor and canine from the anterior view, in two dimensions)
- Tapering the necks of the teeth – this creates a more attractive and feminine smile
- Tucking in the laterals – by flattening the surfaces of the lateral incisors slightly creates a more attractive look
- Hiding the distal half of the canines from the anterior view – canines have two halves with a mid vertical line angle; the mesial half “belongs” to the anterior segment, and the distal half belongs to the posterior segment
- Creation of surface characteristics for a natural look
- Symmetrical central incisors
- Vertical midline with no cant. The midline should ideally be in the middle of the face but can be up to 2mm either side of the facial midline, as long as it is vertical
- Zeniths of the centrals and canines equal in height with the highest point slightly distal to a line that is in the middle of the teeth. The zenith of the lateral incisor should be about 0.5-1.0mm shorter than the centrals and canines, with the highest point slightly distal to the middle of the tooth, or actually in the middle of the tooth
The burs with the red bands from the Academy By Ash bur kit, as well as the smoothest Soflex discs (yellow and light orange) are ideal for smoothing and finishing.
To check the occlusion, I have two excellent tips:
- Use of 100-micron Bausch blue articulating paper (with transculase bonding agent), followed by thin red articulating foil (8 microns). There will be blue marks with small red dots in the middle of the larger blue marks. It is these red dots that require adjustment. This is the called the “two phase articulation system” of occlusion checking
- Making precise adjustments until the pre-recorded Shimstock hold is verified. You can then be sure that the temporaries are NOT “high”
The other goals of occlusion checking are to have canine guidance, multiple contacts anteriorly in protrusive guidance and no non-working contacts – all these were present in this case.
A thin layer of Luxaglaze (DMG) is then applied over all the Luxatemp surfaces and left for about 45 seconds after which each tooth is light cured for about 30 seconds. A second coat of Luxaglaze can be applied for an ideal glazed finish that will look great and resist stains. Finally, the patient is handed the mirror for them to admire the new trial smile. This is often an emotional time for the patient particularly if they were really embarrassed with their smile before – there are often tears of joy at this stage!
Images left to right: trial smile (face), trial smile (at rest)
Images left to right: trial smile (anterior smile), trial smile (at rest)
Postoperative instructions are given with a particular emphasis on excellent oral hygiene (the patient cannot floss as the temporaries are linked together). I always give my patient a large bottle of Ultradex mouthwash (Periproducts). This will ensure excellent gingival health and no bleeding upon removal of the temporaries.
The review appointment
I normally see the patient two-three days later for a 45-minute review appointment. The main objectives of this important appointment are:
- Get the patient’s feedback on the shape of the teeth, the colour, the bite, the speech and the general comfort
- Make any small changes required to enhance the temporaries. These include making changes to the incisal edges of the teeth, increasing the buccal fullness with Luxaflow, etc
- Getting a score out of 10 for the trial smile – the nearer you are to 9/10 or 10/10, the happier your patient will be with the final result
- Choosing the shade – this should be done in the treatment room as well as in natural daylight. The commonest colours I use are 1M1, or a mix of 1M1 and OM3. The amount of surface texture and gloss is also recorded (most often I go for “polished gloss”). Sometimes it is necessary for the patient to go to the dental laboratory for shade selection. Books can also be used to select the amounts of translucencies and specify other features such as the shape of the incisor teeth
- Accurate measurements of each tooth are taken with a digital caliper (to an accuracy of 0.01mm)
- A full series of digital photographs of the approved temporaries is taken
- An alginate of the approved temporaries is recorded
- A bite is recorded using O Bite – the material is placed between the first premolars anteriorly, also covering the incisal edges of the upper temporaries when the patient has bitten together. This is called the “temps to opposing” bite, and will help the technician in getting the correct positions of the incisal edges in the final restorations
- A signed consent is obtained from the patient for the approval of the final shape changes and the shade selected
- A copy of the notes at the review appointment is sent to the technician as well as the records taken and a CD ROM with the new photographs of the approved temporaries
Sometimes it is not necessary to get perfect temporaries. It is adequate to make notes about small changes to be made in the final porcelain restorations by the technician e.g.
- Make the centre line vertical
- Patient prefers the right side
- Make UR1 and UL1 0.5mm longer
These can be written down and sent to the technician with the other review records.
Making the trial smile is my favourite stage in the Smile Makeover process. It allows the dentist to become an artist and truly create a smile to suit the person’s face. The more precise you are with the assessment, diagnosis and prescription of the wax ups, the more accurate they will be; which means there will be minimal or no changes required in altering the temporaries.
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 firstname.lastname@example.org.
Alternatively, you may phone Ash personally on his mobile number 07971 291180.