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 the first article, I explained about the importance of doing a comprehensive dental assessment and treatment planning.
In this article, I would like to explain about the records that are required to submit to the dental technician to get accurate wax ups. I will also explain about the excellent dental materials I use to ensure a high standard of dental care. Finally, I will share how mock-ups are done and the importance of these in showing the patient a preview of the final smile, as well as being an invaluable tool for the technician to create more accurate wax ups.
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
In this case, there were some non-working interferences on the molars. I decided that it was important to remove these before doing the veneer preparations. I used T Scan and articulating papers to mark these contacts and made small, precise adjustments. The lateral excursions were also in group function, and it was important to create wax ups that had good canine guidance, so that there would be no contacts on the premolar veneers in lateral excursions.
Images left to right: T Scan handle with sensor, 100 micron blue articulating paper used first, micron red articulating foil used second
Crown lengthening with lasers
Before the records were taken for the wax ups, lasers were used to do gingival contouring to reduce the gumminess of the smile, as well as create better width/height ratios of the incisor teeth.
From some basic additive wax ups done previously, a putty index was made. This was used to create a basic trial smile using Luxatemp B1 (DMG) material. The appearance was verified for accuracy. A soft tissue laser (Pico Elixxion laser) was then used to mark the new zenith positions. Following some local anaesthetic, the soft tissue laser was used to remove the gingivae artistically up to the new zenith positions. At this point, there would be much reduced probing depths and the loss of the biological widths. A hard tissue laser (Versawave by Hoya ConBio) was used to carefully remove bone up to 2mm to recreate the biologic width. In this way, crown lengthening can be done non-surgically. The advantage is that the treatment is faster, the healing is excellent and also quicker, and the post operative feedback from patients is very good compared to conventional surgical crown lengthening by a periodontist for correcting a gummy smile. The pictures show the stages of the laser treatment and the appearance of the gingivae two weeks after the laser work.
Images left to right: trial smile (laser planning), marking of new zenith positions, premolars (new zenith positions), gingival contouring with soft tissue laser
Images left to right: premolars (gingival contouring with soft tissue laser), bone removal with hard tissue laser, two weeks after lasering (healed tissues), two weeks after lasering (anterior view)
Following healing time of three weeks, an appointment for about one hour was made to take the definitive records for the wax ups.
Wax up records appointment
On this appointment, the following records are required in Smile Makeover techniques:
A new upper silicone impression
I use Honigum rigid fast set putty (DMG) and Honigum light body material in a two-stage putty/wash impression technique. I prefer the Ash rigid Polytrays (often I use the yellow larger upper tray). The nurse mixes a scoop each of the base and catalyst putties and loads the tray (which has already been coated with the silicone adhesive at least 5 minutes beforehand). A thin layer of cling film is placed on top of the putty and this is seated in the mouth firmly. Once set (after about two minutes), the tray is removed and the cling film is taken off. The teeth are dried and wash material is syringed over all the upper teeth and the nurse places a small amount of the yellow wash material also in to the putty index in the tray. The tray is re-seated fully and held firmly upwards for about five minutes until fully set. On removal, you can predictably expect very accurate impressions every time!
Image: Honigum impression material
A new lower alginate impression
The patient had some subtle cosmetic contouring done at the edges of the teeth to make them smoother and aesthetically better looking. Therefore, a new alginate was required.
Bite registration in centric occlusion
Two bite records were taken – one with a material called O Bite (DMG) and one with a material called Luxabite (DMG). O Bite (orange in colour) is an excellent bite registration silicone type paste. It is fast setting and accurate. It is rigid yet slightly flexible. Luxabite (blue in colour) on the other had is very rigid and inflexible. It is the most accurate bite registration paste I have used and actually needs to be adjusted carefully by the dental technician before articulating the models to ensure total accuracy. I normally syringe the paste on the dried occlusal surfaces of the lower posterior teeth and then ask the patient to bite firmly together for a few minutes until the material is fully set.
Images left to right: Luxabite, trimming of luxabite records in the laboratory
A Shimstock recording is also taken. Shimstock foil is placed between molars (i.e. teeth that are not to be treated). The patient is asked to bite together. Where the paper locks is a “Shimstock hold” – this is recorded for the technician.
I use two systems in practice – the Denar facebow and also the Kois Facial Analyser. If I use the Denar facebow, then I use brown composition (Kerr) as a recording material to capture the occlusal surfaces of the upper teeth. In this case, I used the Kois Facial Analyser and O Bite material to take the record.
Stick bite record
This is also an important record. I take it by standing the patient upright. I syringe some O Bite on to the incisal edges of the lower anterior teeth and then ask the patient to bite together. I then place a straight Benda Brush in to the material ensuring it is horizontal and parallel to the interpupillary line (or the floor if the eyes are not level). More O Bite paste is placed on top to secure the Benda Brush and a full-face photograph is taken. The Stick Bite record and photograph are useful for the technician to ensure the mounting of the models using the facebow record is accurate, as well as ensuring that there is no cant in the smile line in the finished wax ups.
Image: Stick bite record
I use B1 shade composite (e.g. Ecusphere (DMG) or Kalore (GC)), and a special composite instrument made by Hu Friedy to mock up the new smile. The important things to establish in the mock-ups are:
- The incisal edge position
- The accurate centre line (must be vertical)
- The correct buccal fullness (Cheryl had a narrow smile)
These mock-ups are done free hand without wax ups and can be done fairly fast with experience and skill. Once the smile looks good, the patient is shown for approval. After this, accurate measurements are taken of all the teeth from the gingival margin till the edge using a digital caliper to 0.01mm accuracy. Digital photographs of the mock-ups are taken, as well as an accurate alginate impression. The set mock-up facings are carefully removed and also sent to the technician for thickness measurement and review.
Images left to right: Mock ups (face), mock ups (at rest), mock ups (smile), mock ups (retracted)
Photocopy of clinical assessment notes and photographs
A photocopy of the comprehensive assessment documents is sent to the technician. This explains the pre-operative situation recorded during the Smile Analysis, as well as desired changes required in the new smile both aesthetically and with respect to the occlusion.
The pre-operative digital photographs and also the photographs of the mock-ups are saved on a CD ROM and sent to the technician.
The laboratory prescription document is filled out as appropriate so that the technician has all the information required. In this case, wax ups were required for the top anterior ten teeth. Another useful piece of information for the technician is to indicate the style of smile required (there are couple of great books showing different shapes and styles at the incisal edges). This can be reviewed with the patient before hand.
The other things requested from the technician in this case were:
- A putty index of the wax ups to make the Trial Smile
- A clear plastic stent with windows where there is excessive tooth substance (this will be used in the initial stage of the preparations of the veneers using the technique taught by Galip Gurel)
- Preparation guides (to help check the space required for the porcelain veneers
This article explains the “gold standard” of records that are required to help a dental technician create perfect wax ups suited for the individual. By having excellent laboratory made wax ups and supporting indices, saves a lot of time at the preparation appointment and allows amazing temporaries to be made!
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.