Prepless Veneers

Part 4 - Prototype removal and prepping the case.

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 will remove the prototypes, try-in the veneers and finally seat the veneers.

So we are getting ready to remove these prototypes and we’ve spot etched each one of them and most of them have stayed on pretty well. Occasionally, we will have a patient lose one or two of these because they are designed so that we can get them off. Generally, what we will do to get them off is just try to catch a large spoon up under the edges of them and gently torque them off of there and hopefully we can do that without hurting Ms. Sheri very much here. She is not anesthetized so we have to pretty gentle and careful.

As you can see, removal of the temporaries is relatively quick and easy. Perhaps best of all notice there is no damage to the underlying tooth structure.

Again, she has been able to floss regularly between these teeth so her tissue is real nice and healthy. And that is certainly a big benefit as we’re doing our bonding procedures for the permanent. We don’t want any hemorrhaging or weeping of the tissue. So now we are just flossing and cleaning between the teeth real well. We are going to use so chlorhexadine to scrub them and clean them and we’re just about ready to begin the try in for our permanent veneers. We’re going to try them in dry first to be certain that we have a great fit and that the margins are there. And of course, some of these are very thin so we have to be very light handed and conscious of the fact that they are going to be a little more delicate until they are bonded in as compared to conventional veneers. But this is a great example of how Durathins are not always real, real thin. In Sheri’s case we felt like we had more room to come labial and create a little more presence with her teeth. So these are not super thin particularly in eight and nine. Our ceramist, Mark Willis, has done a super job at getting the contacts just right. You can see here that these contacts are not bouncing around, there definitely fitting farely snug with a definite seat position as we place these over the natural teeth.

So now we are using a clear try in gel. With these veneers it is important to, with a few exceptions, to use clear leuding cements and try in gels. Since they are so thin, colored cements are just going to begin to shine through and not have the undetectableness that we are shooting for. Try in gels give us a real good glimpse of what the final cemented product will look like. We are starting to see real nice natural blend of colors, a little bit of influence of the under lying teeth that makes it look even more real and even more believable. Again, I’m being very, very gentle and careful. As I place these and press these into place, I’m not putting much pressure at all. Just basically always thinking a light touch here. So notice how we can go around and gently go around and gently press on each tooth with an explorer and we are getting little to no movement or settling. Maybe a tiny bit on number 7 but we’ll check the contact on. But it’s pretty much verifying that every veneer is going right to place, right where it was intended to seat. And when we seat with our composite resins, we will not have to put any kind of excessive force or undue pressure, which is very important. We do not want to put any stress or cracks in it while we are seating it. But as always our ceramist Mark Willis has done a beautiful job here of fitting this case and basically making a set of veneers that fit like we had prepared on the teeth and had created margins and had reduced enamel and yet we have not at all. So we’ve got the green light here to move forward and to do the final bonding and cementation process.

Well Michelle has treated our veneers for us in the very traditional way, cleaned them and etched and salinated. We’ve got our cement loaded and so now we are going to treat the teeth themselves. We are going to start by isolating with a rubber dam and this is a neat little trick here, we use plastic little rubber dam clamps that really aid in not hurting the patient too much since we do not have anesthesia here. So we are going to try to place these clamps here in a way that hopefully our patient will not be too uncomfortable. Sheri are you OK with that? How about that? Can you stand that, I know it presses on your gums just a little bit? Are you sure? If it gets too uncomfortable, you let me know. So we’ve got our split rubber dam in place here and we are going to use some vanilla mousse by Diskus Dental to seal up the palate area. This is a little trick we came up with years ago and it has proved very helpful for a lot of clinicians to really seal up the palatal area and get a moisture free environment to do our bonding. So now we have our teeth isolated and we are going to use some superoxal to manage the little bit of tissue weeping that might occur here. Again, Sheri has done a good job of keeping her tissue healthy during the prototypes. When patients are not anesthetized this is a little uncomfortable and we are aware of this and yet most patients can handle it well enough that we do not have to anesthetize. So we just use some chlorhexadine after using the superoxal to help us clean the teeth one last time before we etch the teeth.

Next Dr. Wells will place a separator to keep the etchant off the other teeth. Ok , so now we have some separators in place and we are now ready to aggressively etch all the teeth. The beautiful thing here is that we are etching enamel and enamel only so again we can not be quite as concerned at the exposure time with the etchant. So we’re back to kind of the old school day here of having real nice etched enamel. Frosted enamel is something that us old timers remember well and we know the bond strength that comes from this well etched enamel. Now we are going to go straight to our dentin bonding agent, in this case we are going to use Prime and Bond by Dentsply. We will put 2 or 3 good coats of that on the teeth. Now we are going to dry out all the acetone in this dentin bonding agent using the Adeck warm air dryer to make sure that we have absolutely no moisture. A quick light cure and the teeth are now ready.

So again we are using very gentle pressure.

The leuding cement that we have chosen here to use with all of our Durathin veneers is very alinked to which has a very low viscocity and very thin cement and in our opinion works very well for these prepless veneers where we just don’t need a lot of resistance as we are seating the veneer into place. This is a time where you do not want to be very heavy handed, just gently tease them into place.

Dr. Wells will replace the remaining Durations, making sure to remove as much cement as possible.
Ok, so we have done just a rough cleaning here of the cement and now we are going to take our 2 mm tapping tip and make certain that every tooth is where it’s supposed to be and tap it into place. Again, we want to be careful not to put excessive pressure on this tip because that could certainly create a crack in the veneer until it’s all bonded in. Good, Good.