Part 3 - Central and lateral prototypes

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.

In this section of the video, Dr. Wells will demonstrate the build-up of the central and lateral prototypes

It may have seem like a long time on the video perhaps but you know, relatively speaking, we're now ready to put our prototypes in place after just a relatively short amount of time. So we get to exchange the time commitment that we would have normally spent numbing and preparing and drilling and all of that, retracting the tissue and so forth. Now we get to have more of that block of time that we would normally allow to be able to go in and build these prototypes. This is where for me it's really fun and it's where we get to demonstrate some artistry and hopefully be able to create something that's going to be special and unique.
So the way we do this is we start out by using a retractor that's rubbery and very kind and forgiving. Your normal photographic retractors for example would be very uncomfortable after just a few short minutes but this is called [0:22:10] [Indiscernible] it's by Ivaclor and it works very, very nice to keep the patient's lips out of the way and not burden them too bad. Now we wet and moistened it here a little bit so it will slide in the lips a little better. It's still sometimes a little cranky in there but for your patient you can get this right where you need it.

All right. I think we've got that pretty well where we need it. Christy okay there with that? Doing all right? Okay. So this is chlorhexidine. We're going to go ahead and scrub the teeth. As we've shared with other dentists through the years what we're doing and how we approach it there's usually a good bit of pushback about this process of building prototype. So a lot of dentists feel strongly that this is just not their game or they comment that it would take them forever to hand sculpt 8 or 10 feet. What we've found through the years is that as we've timed this over and over it takes us about an hour to an hour and 15 minutes to do 8 or 10 upper teeth. I would challenge all of the dentists out there that are watching this to consider developing the skillset if you don't already have it because you can use it in so many other ways and it's very enjoyable I think once you've passed that learning curve to have that build and not have to rely totally on your laboratory for all of the artistic endeavors you're doing.
So what we're doing now is we're spot etching these teeth. We're making a pretty good size etch area right in the center. As we've mentioned already we're doing ten teeth in this smile. It's better if you use a gel that has a pretty high viscosity. It's not real runny and difficult to manage.

Okay. So we really want to draw the teeth excessively here and then we're going to come back with our warm air dryer. This is a product by ADeck that I really like a lot, that just screws on your dental unit. We got to be sure we have no moisture here. I happened to be using OptiBond here. You can use any fill resin you prefer. We usually just try to keep it pretty much confined to the etched area but it won't be problem obviously if you cover more than that. We're going to air dry that.

What we're doing here is we're rolling up the composite between our fingers to compress all the air bubbles out of that. This particular composite is carbon material. It's herculite and it's a bleached enamel color. It's a great one. Also Ivoclar's tetric ceram. Bleach L is another great product. I like them both a whole lot.

So I get a lot of questions about how do you do these prototypes in an hour, hour and 15 minutes and many times people are so concerned about how to move through that in a normal day in their schedule. But what you'll find is that the first two teeth, the two front teeth are going to take you more time. They're more time intensive because that does set the cornerstone as I like to say of the smile. You will find that once you get those like you want them you will begin to progressively speed up and do the laterals a little quicker, the cuspids a little faster perhaps and then the bicuspids really quick. So yes, it does take a little while but you will get quicker and quicker and particularly you'll learn that you spend your time wisely on the front two teeth and then the rest of it you can be a little faster.

You do want to use a very viscous material to do the prototype process because you do not want this material running and slumping and losing control of the morphology. Be sure and keep your mirror there always in your left hand or in other your other hand to check the incisal wrap. Because this material is so viscous it's not going to just naturally flow over the incisal edge. You're going to have to more or less drag it there and place it as you want. Okay.
So once I have number eight here looking pretty close to what I want it to look like then we're not going to polymerize that yet. We're going to go ahead and do number nine and well polymerize both centrals at the same time trying to keep the option there creating perfect symmetry, keeping the incisal edges level with the horizon. All of the important aspects of design here are much simpler to accomplish if we do that before we cure one side. If you cure one side, one, two first then you're going to have the burden of matching that one, two perfectly and that's difficult.

So the spaces strategically determine how we want to deal with those. You will find some patients occasionally not often but occasionally that would prefer to keep a little diastema. Most of the time they will like them closed but the beautiful thing about doing these composite prototypes is that you both get to determine where we're going with the case and what changes we want to make and whether or not for example we want to leave a diastema there or whether we want to close it.

The two centrals normally take me the longest. We just tend to pick up a little speed as we move past them so the rule here is to be patient as you kind of set the main actors in place here with these two central incisors.

So it's super important that we keep referring to the incisal view as well as the facial view so that we can honor the natural contour that should be there in terms of reflective and deflective zones.

Now usually at this point somewhere around this point in time I'm going to get up and stand over the patient and look from that viewpoint because it certainly has a different perspective than looking over the face. Okay. So ladies and gentlemen, I think we're about at a good spot to polymerize these two.

So the time we've spent getting those two pretty well anchored where we want them I think is time well spent. They are clearly the cornerstone of our smile and important that we get that locked in there and the midline set perfectly and all of the important parameters are in place for the centrals. Now we're going to start with the lateral incisors and do the exact same thing. I think you'll see us picking up a little speed as we move into these teeth. One of the desires of that the patient expressed to us before we started the day was that she wanted to keep some of the appearance of the front teeth being a bit longer. She liked that flavor if you will of the smile, a very youthful look. So we're definitely going to honor that request today and before we polymerize this, we'll be certain that we've got that relationship of the centrals to the laterals that give the youthful look with the centrals noticeably longer.

So where we have the diastema here between 9 and 10, we get a lot of questions about this and how we manage that. Clearly it's pretty easy for me just to wrap some composite around this and it's not easy for the ceramist to duplicate that because they have to have a line to draw in their ceramic. So what we do here is we plan on our ceramist wrapping this as far as he can and then we will accept the fact that we may have some degree of composite resin cement that fills in the lingual area so that we don't end up with spacing that we don't want so we don't have to go in and create lots of damage to the tooth for proper line of draw.
All of the facial area will be covered with ceramic and thus we won't have a visible glitch with that. You know, if it is necessary to have composite it will be to the lingual and we're now cementing our prepless veneers with a restorative composite cement or composite restorative material such as this very material I'm using for example. We also use the Ivaclor tetric ceram as a cementation product as well. So we have no problem with the composite being part of our lingual structure.

For the purposes of the mockup however, we'll want to tease this material all the way on around to the lingual, be certain that we don't have drop-offs and voids there that will irritate the patient's tongue or simply not look appropriate. This is probably a good time to get up and look at a different perspective over the patient and we'll see how our laterals are looking, see if we got some symmetry going on there. Now with the laterals, going back to some basic smile design principles we're not necessarily striving to make perfect symmetry between 7 and 10. In fact, I would argue if we really want to make the case creative and customized and emulate nature we need to not necessarily have these perfectly symmetrical.

Let's get up and look over here from this perspective. Okay. So we've just finished up the laterals. By design we have a left a little bit of asymmetry from right to left and we have also by design tried to leave the two centrals notably longer to give a more youthful appearance. Okay. So we've got our centrals and laterals done. We're going to move on to the cuspids.