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Making Smile Design Profitable, Efficient and Predictable

Part 5 - Removal of excessive material and idealizing the shape of the teeth.

Trent Smallwood, DDS
Dr. Smallwood finishes the provisionals in this segment of the dental CE course. In the next segment of the CE video, Dr. Smallwood brings the patient back and demonstrates the removal of the provisionals and the seating of the final restorations.

Using the fine diamond mosquito burr we are going to be able to clean out the gingival embrasures and define or remove any excess material. Dr. Smallwood will continue to clean up any excess and fix any voids he sees upon closer examination. Good relief of the gingival embrasures is very critical here to be able to provide almost a breathing of the gingival tissue. Here I am just looking at contouring the facial surface of any excess that I may have had and idealizing the shape of the teeth. So I am still holding those three planes of reduction that we talked about in the prep sequence. I am just maintaining it as I go around and getting rid of any of that excess I don't want on there. This also tends to show any voids that might still be in the provisionals and I see a few right here that we have to get rid of" O.K Amanda. All right here we go, so here we are just going to go with our final polish. O.k. the final phase is just pt, Michael, how does that bite feel A little bit better. Though it is going to feel foreign to you it should feel like you are hitting on those back teeth a little bit better now. The last phase, we are really going to dry off those teeth now, go ahead and open. And we are really going to dry you out and I apologize for that but stay open and we are going to use our Perma Seal which is a nice unfilled resin which tends to really make the final restorations here pop beautifully. I usually get a 3 or 4 tooth head start from Amanda and she will start to come in behind me and cure them into place. Nice provisionals with good axial inclination with nice incisal characteristics that really will go to our final phase looking at our shape a little closer. Here we are just noticing the incisal characteristics that just bring a littlemore incisal characteristic to the realism of teeth and that way the teeth won't look so monochromatic but they will look polychromatic as you can see illustrated right here. Here you can see final axial inclination, go ahead and bite down Michael if you would. We've got nice axial inclination going right to the belly button we've got good incisal characteristic, nice realism, we've got a little bit of inflammation of the gums but that makes sense after the laser, after a day or two that will be gone. Now we are just going to get a provisional bite using, basically using a bite registration material we are going to use a blue mouse that is just a very fast set from our provisionals to our lower natural. Go ahead and open, you've got a big tip on there. All right, now go ahead and bite down and we will let that set for a second and we will basically label a Ziploc bag with bite of upper provisionals to lower natural teeth just so the laboratory does not get confused by that. This, in my opinion is one of the most difficult elements in the entire procedure because it brings everything you've put together and every thing's on the line. You are putting these teeth in that day and you are hoping that the patient likes what they've got and what you are placing. And this is where the expectations, the true test on whether your expectations and their expectations have been met. Now I will say a key part to anyone who has placed porcelain, whether it is Feldspathic or pressed will know the challenges in placement of veneers, or restorations at this point because you've got togo through several sequences here.

We are going to start off by getting you just a little bit numb ah beautiful you've done such a good job with the gums and keeping them healthy, all right to numb Michael we are going to be using the Compudent, as far as kind of an anesthetic that is very different than when we first administered the anesthetic on Michael. Now Michael was sedated last time and he is not this time he is completely with us and I want him to be because I want him to be able to choose and look at the teeth when we put them in to make sure he likes them, which I am sure he will. By the way Michael the teeth look absolutely beautiful, I sent them back twice actually because their are certain nuisances that I wanted to put in there and they just look spectacular. What I will be doing is using the Amsa technique, which is between the pre-molar we will be placing anesthetic about 10 millimeters into the palatal vault and Michael you are just going to feel a little pinch. Now once we use the Amsa technique what you will notice is that we will tend to get a numbing feeling that is almost like dead wood meaning you can feel the lip, you can feel the gum tissue, not that you feel gum tissue all the time, but you will feel any of the gum tissue on the front but you (Michael) do the teeth feel kind of strange (Yea) That is because he is numb from the standpoint of all the teeth, so this is where we can start instantaneously start to remove the provisionals. Now Michael I will tell you as soon as I start to remove these you will start to smell a little bit of bacteria, it is typically because they get trapped underneath the provisionals just abit. Not a bad thing it happens to everybody so we will justclean it off as soon as we start to remove. They will probably come off in large chunks of multiple teeth. The first thing Iwill do is use a hemostat and I just go between the teethinterproximal and squeeze and Michael you are going to feelsome pressure here and there but you should not feel anythingpainful but hear some cracking and crunching but just rememberit is not your teeth it is just the provisionals. It is aterrible sound I know but a necessary one. I and as you can seethem starting to loosen and an entire segment comes off andmaybe just a little bit of. "Are you sensitive over there' No,good. I can change all that if you would like. All right so we-got the right side in and just a tremendous job on the keeping the gingival tissue the gum tissue very clean, and Amanda I think we got that side. So in this case in came off in two large pieces and it is great when that happens. God forbid that we have to reuse those and it is very rare that we do but is very nice to have those just in case. Now Amanda is going in with Peroxide as you can see Michael has done a tremendous job of keeping the gingival tissue very clean you really don't see any what we call "black schmootz" around, that's a technicalterm, around the teeth we didn't get any leakage so as a result the gum tissue and the teeth themselves are very clean. The next thing we are going to do is before we do anything make sure we have all excess material off of the teeth so I am actually going to run a quick prophy over these and polish these teeth. And basically just pumice these teeth and this tends to remove any debris or bacteria that is trapped. And sorry about that Michael you will feel a little on the outside just because you are not numb over there. O.K, now we will be using a chlorhexidine scrub which we will just go around the margins clean off any, again, any excess we just want to make-sure nothing is on there. I will actually have Michael rinse with a peroxide material for about 30 seconds this just tends to get rid of any bacteria around there. You will notice Michael that everything will tend to bubble up just a little bit that is just a common type of thing with peroxide so we will give him just a little bit of that, I just want to get rid of any bad stuff in the mouth completely and this just ensures that it gets done that way. And O.K We're of course going to be rinsing real well here in just a few minutes but what I want to do is just go over everything and make sure we have no, none of the bisacryl left anywhere between the teeth and this will ensure that we probably have a good passive fit on all the restorations. O.k. I think we are all set so Amanda will have him rinse finally and have him do one last swish.