Part 1 - Case Overview and Records

Instructors:

Dr. Dennis Wells, DDS 

Dr. Dennis Wells, DDS

Dennis J. Wells, DDS, founder of the Nashville Center for Aesthetic Dentistry, is a graduate of Harding University and the University of Tennessee Dental School. He received his accreditation with the American Academy of Cosmetic Dentistry (AACD) in 1994, and has since served as an examiner for the AACD accreditation process.

Dr. Wells reviews the patient case and talks about the records that need to be done in order to set up the case for success

I'm here today to talk to you for just a few brief minutes about something that I am not just a little bit but incredibly excited about and passionate about and that is prepless veneers. Now I know for some of you when you say the word prepless veneers, instantly you're going, no that's not my game, those are bulky and detectable and unhealthy and on and on and on. I've heard all of the objections believe me. But I'm here to tell you I have been doing this now for over ten years and I'm more excited about the outcomes, about the beauty and the undetectable natural light look that these veneers produce more so than ever. It truly has been a game changer for me in my practice and I know it can be a game changer for you. Now I'm a dentist too and I know if you're a normal dentist that we get in our comfort zone, we start doing procedures that we know work for us, that we know we can have predictable results with and it's really hard to change that. But I'm pleading with you please take a look at this approach to dentistry, this very conservative minimally invasive approach. One thing I want to tell you is you know, in medicine the trend toward minimally invasive has been ongoing and clearly once we learn how to take out a gallbladder for example without having to do invasive surgery and doing it arthroscopically, we don't go back and I think the same phenomenon will happen in dentistry as we continue to get better and better at doing dentistry but doing it in a very minimally invasive of a way and preserving precious enamel, then you're never going to see that trend reverse and just go back to drilling more of teeth. So it's the perfect time to jump in, to discover what's possible and to see for yourself if this is not a game changer for you. We're real proud to tell you that we've trained several hundred dentists now in how to do this procedure. I see the transformation in so many of their practices and quite frankly that's becoming more gratifying to me than the actual work that I'm doing with my hands. It's really fulfilling to see what can be done and how it can affect not only the dentist's life himself or herself but also their patient's lives.

Well I'm Ms. Tennessee USA 2014. I'm here today on how to make an appointment with Dr. Wells to kind of perfect my smile and get it ready for the Miss USA stage. We're not going to have to damage my real teeth or anything like that and we're not going to really change the teeth that much just make them better which are perfect for me because I don't want to look any different. I just want to make my smile a better version of what it is now.

Well we're super excited to have this beautiful young lady to work on here today. She's beautiful inside and out and really, I think a lot of people would look at her mouth and go why in the world are you even talking about doing any restorative work. Because she has a very beautiful frame, beautiful lips, all the things that we look for as we're talking about, as we're analyzing for smile design. But if you look real carefully, we do see a few compromises that on some level are visible and notable and Christy happen to not be just an average, ordinary, young lady. She is a beauty contestant winner on a large scale and getting ready to go to a very big contest. So she's very interested in what might be possible to take her smile, which is already very good, but make it really awesome. So in our opinion this is a perfect example of where prepless dentistry is such a great tool to have in your toolbox as a dentist because I think it would be practically criminal to go in and damage or destroy these teeth in anyway. On the other hand, if we have some opportunity to make them better, then that's something that can be appreciated you know, tremendously if we do not have to damage and do irreversible harm to the teeth. So that makes this case a very interesting one. In our examination, we noted that she had a slight class 2 occlusion on her left side the midline scooted over just a bit and we have some real obvious wear and tear on the teeth. If we look carefully, her cuspids are flattened and worn quite a bit. Her lower anterior teeth -- open there just a little bit Christy have some wear on the edges of them clearly a bit of bruxism in the picture here. Then she reports to me along with her mom that they know that she tends to grind her teeth a bit. So all of those pieces of evidence fit real nicely together to say that we've got a bit of a problem with her chewing system and that concerns us as we're getting ready to apply some [0:05:15] [Indiscernible] pour some pieces. So one of the very first things we did is that we collected all of the data and records that we need to analyze her bite as well as check for disease. We've done thorough periodontal exam and decay and so forth. So where we are at this moment is that we've gotten all of our setup as we call it completed and we're now ready to actually start the fun part of doing the icing on the cake if you will, doing the ceramic veneers. So make no mistake about it, we are not proponents of just jumping in and throwing some veneers on people's teeth without really looking broadly and deeply at their entire oral health and their entire oral presentation. So we've done that and we did find a few little laundry list of things that we needed to correct which we've done and we're now at the exciting point where we get to make the teeth look great.

One of the things we did not have time to include in this two-hour segment today is the management of the patient's bite. That was done previous to today's appointment and super critical. Our patient today is very common in her presentation of showing some abnormal wear and tear and certainly a chewing system that's now working efficiently. So people ask me all the time can we do these prepless veneers if we have a bruxer or a we have a grinder and the answer is absolutely yes but I would argue that as with your traditional preparation dentistry, it's always critical that we manage bit forces and that we have a great understanding of how that system is working and how to protect the work that we're about to place. In this instance, we chose to equilibrate her using the Jimmy U Bank style of equilibration, one of mentors. Of course, we've talked also about post treatment having nighttime protection. We do feel that this young lady will have a tendency to brux her teeth even though we've equilibrated and removed the balancing forces and have her in a very nice home position. So those are things that are very critical.
I would argue to you that if we didn't manage the bite forces, our bet will probably be hedged in these prepless veneers as opposed to the traditional for two big reasons, number one we're bonding to 100% enamel and we know from the literature very clearly that that's our strongest, most rugged restoration and bond is to be in enamel bonds. Then number two we're bonding these restorations outside of the existing envelop of functions which gives us a little bit more clearance perhaps than a traditional veneer where we removed the incisal edge and then replacing that with the ceramic. So those two factors are very important in our opinion in looking at the longevity and managing people who have tendency to brux and grind their teeth.

One other piece in the setup was to do what we call a mockup where we take some composite materials and as you can see on the screen over here, we'll flip over to that, this is our mockup that we did several weeks ago just to verify that additive only process would in fact be appropriate here. We knew that the teeth already had plenty of facial presence. This is a bit of a class 2 situation and we knew we were going to be out on the limb just a bit to make this work. But once we put the composite on very thinly, we're able to verify with several people looking in and weighing in on this, family members and so forth that this was going to be an enhancement, an improvement that was going to have value and something that definitely worthy to consider.
So that leads us back to where we are here today of actually starting this process and the way we do that is we are going to collect some master impressions and of course a normal bite registration. We've already equilibrated her occlusion, have her hitting in a very strong home position and so this will be nothing more than asking her just to bite together. There'll be no jaw manipulation needed or any special technique to capture that bite because we feel comfortable that we have her in a very nice centric relation home position.

We're going to also take shade tabs and record the color of her teeth as they are right now. That's very important for our ceramists to know where we start as well as where we want as well as where we want to finish. We're going to prophy our teeth so that we make sure there's no plaque on there before we can get our impressions. You will see there are several things that are involved in this early process so that we set ourselves up for success. So without further comment, we're going to go ahead and prophy the teeth. Some people have asked me now why do you prophy the teeth before you make the impression and the answer to that is that we have actually had people with enough plaque, natural plaque on their posterior teeth especially that it was a problem in reading the impression. When you prepare the teeth conventionally then obviously there's not going to be any debris on the teeth at all but in this instance where we're not preparing that's a concern. So you want to remember every time before you master impress to clean the teeth. It's a good idea to go ahead and complete the cleaning with some floss as well. We obviously want to have a very clean substrate that we're going to be impressing and then a very important step that you don't want to overlook is to drive the teeth real well and look for any areas where we might have a small or a large or a black triangle. Any degree of opening near the gingival part of the tooth that could potentially trap the impression material and tear when you pull the tray out.

It's very important that we record accurately the tooth's surfaces as we get down and around the gum tissue for several reasons. For one the gum tissue becomes the landmark by which the ceramist will place the margin. Our standard prescription to our ceramist is place the margin and stop it just short of the tissue. So if that tissue is moving around so for example we never would use the traction cord before we make our master impression because we do not want to alter the tissue height, and then of course if we have this black triangle here between our front two teeth if you look carefully, there's a tiny bit of space that maybe would in fact catch the material and tear it.

So we're going to flow a little bit of flowable composite just on the lingual area. We're going to be certain not to put too much where it hinders our bite and keeps her from closing. But we simply want to block that material from flowing back and locking teeth. Okay let's cure that. This is a very important step to get a super clean impression, which is very, very essential in the no prep process. It's a bit counterintuitive. Some people in fact have felt that well the master impression is just not that critical if we don't have a margin. I can even maybe just let my auxiliary team members take this. But to the contrary, the impression is so vital that it's very accurate because the veneers you're working with are going to be so thin that if there's inaccuracy and they don't see right down to the model and to the tooth then you could fracture one very easily. So we want to be certain to capture very accurate impressions.

For an old an prep you've got to have a really good impression, clearing the gingiva, clearing the inner proximal areas, clearing the occlusal because it's such an intricate system that you need to make sure that everything is correct. So I'm a dentist and if I was a dentist and I don't mean to be you know, if I was a dentist, I wish I was but if I was definitely I would have my best assistant on myself doing the impression for those particular cases because any type of polar drag right along the gum line is disastrous whether you use platinum foil or whether you use the refractory material, that veneer is not going to work.
Now the last thing we're going to do here, as a matter of routine is to smooth with a sandpaper disk the incisal labial line angle and we're talking about just smoothing. We're not trying to alter this in any visible way. But for example we have a little jaggedness here and this can create some real sharp internal line angles that might be detrimental to the strength of the porcelain. So we're simply going to take our sandpaper disk and just very light-handedly but smooth those areas where we don't have any sharp internal line angles. This is again something that you shouldn't be able to observe with your naked eye any change in the tooth but we do want to minimize these sharp areas. So now that we have our teeth clean no plaque anywhere, now that we have the black triangles closed up and now that we have the edges of the teeth smooth so that we don't create any sharp internal stresses we are ready to master impress.