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 would like to explain the best techniques in doing Smile Makeover preparations so that the minimum and correct amount of tooth reduction is carried out. In this particular case, the vast majority of the prepared surfaces remained entirely within enamel, and so the preparations were done with NO LOCAL ANAESTHETIC. The patient was comfortable throughout the appointment.
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
Preparation techniques for ten porcelain veneers
Before doing a Smile Makeover, it is essential that the patient has excellent periodontal health and oral hygiene. Use of an electric type of toothbrush e.g. Philips Diamond Clean, and daily flossing is important. I also recommend my patients to use Ultradex mouthwash and toothpaste, which has chlorine dioxide for optimum gum health and fresh breath.
To do perfect preparations requires the use of the correct burs. I have created a bur kit for use in my private practice and also by dentists that attend my Hands On Courses. This specially designed bur kit (Komet burs) is available from West One (telephone 020 86656088).
The technician had provided a clear, rigid stent which correctly identified “excessive” tooth substance e.g. UR2. There were windows in the acrylic stent, which made it very easy to remove these areas of enamel.
The next step was to use the putty index made from the wax ups and some Luxatemp material syringed against the labial and buccal surfaces within the index. This was then seated in the mouth. After two and a half minutes, the index was removed. The Luxatemp material stays on the teeth. Depth cuts were then placed on the incisal edges using a parallel sided bur (1.2mm diameter), and also labial depth cuts in two to three planes using a 0.5mm depth cut bur. A sharp pencil was then used to make marks on the deepest parts of the labial surface horizontal grooves. In this way, it is easy to remove the correct amount of material in a very controlled way – I recommend the “big daddy” bur for this. The key to drilling is a very light touch, smooth precise and slow movements and lots of water spray. Once the correct amount of Luxatemp and tooth substance has been removed (i.e. the depth cuts are removed), then the remaining Luxatemp is peeled off the teeth surfaces. In Cheryl’s case it was evident that certain teeth had barely been touched e.g. all the premolars.
I re-used the soft tissue laser at one or two sites to do some very precise and minor artistic gingival contouring.
The next stage was to create precise finishing lines at the gingival margins. Contact areas were preserved, but special care was taken to ensure that the prepared finishing lines interproximally and cervically were placed correctly so that the final porcelain veneer margins were not visible. This is critical for the ideal finished smile. The preparations were smoothed and finished by using finishing burs in a speed increasing hand piece using water spray, as well as Soflex discs (the two smoothest ones). It is important to use the preparation guides to ensure there is correct amount of room for the dental technician to make the porcelain veneers. Also, the preparations need to be assessed from the side as well as the front to check there are no undercuts labially as well as the correct alignment axially of the prepared teeth.
Images left to right: Ultradex (periproducts) mouthwash, prep guide indiex in situ, areas marked where preparation needed, removal of excess enamel
Images left to right: Luxatemp temporaries, 0.5mm depth cut bur, depth cuts, removal of material till depth cuts disappear
Images left to right: removal of remaining luxatemp material, ginigival recontouring with soft tissue diode laser, interproximal polishing with red Brasseler polishing st, preparation putty index variation
Images left to right: buccal preparation putty guide, kois facial analyser record, stick bite record, stump shade guide
Images left to right: shimstock hold record, occlusion checking after new Luxatemp trial smile creation
Records required following the preparations
The following records are systematically and efficiently taken – this stage normally takes me 45 minutes:
- Master silicone upper impression
- Facebow record
- Bite registration
- Stump Shade record* (using the Natural Die Shade Guide by Ivoclar)
- Stick Bite
*The nearest ND colour to the prepared teeth is held next to the teeth and digital photographs are taken. The technician then has the ability to make coloured master dies similar in colour to the teeth. In this way, the porcelain layering technique can be made to be more accurate.
I have been mentored by some of the best clinicians in the world over the years. I would like to particularly recommend the techniques taught by Galip Gurel, which I used in this case during the porcelain veneer preparations. I also believe it is essential to have a soft tissue laser for gingival recontouring techniques, and an all tissue laser for the more experienced clinician wishing to do crown lengthening. In the next article, I will explain how to make beautiful temporaries and the important things to assess at the review appointment thereafter.
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