Building the Bridge from Dentist to Ceramist: Why Communication Matters Part I

Part 4 - The build up of the upper arch utilizing Lava material.

Instructors:

Tom Trinkner, DDS

Tom Trinkner, DDS

Thomas F. Trinkner, DDS, teaches as an associate at the L.D. Pankey Institute and is a clinical instructor for the General Residency Program at Palmetto Richland Memorial Hospital in Columbia. He lectures both nationally and internationally in the field of Aesthetics and Complex Restorative Dentistry.

Matt Roberts, CDT

Matt Roberts, CDT

Matt Roberts is one of the most recognized Dental Ceramists in the United States. His goals are to elevate the quality of restorative treatment received by patients by creating an interactive working relationship between dentists, ceramists, and specialists.

Ceramist Matt Roberts evaluates the information that was sent by Dr. Tom Trinkner and then demonstrates the build up of the upper arch utilizing Lava material in the next section of this dental program.

We now join ceramist Matt Roberts as he prepares Dr Trinkner's case utilizing not only the stick bite and other material Dr Trinkner has sent but also the good old fashion telephone. Matt will utilize the Lava System from 3M to build this case. O.K. let's look at Judy's photo here and Tom talk to me just a little bit about what her goals with the case are. I see an old PFM bridge it looks like running back from like 4 to 6 or some where in that zone. Yes, and the same thing exist on the left side too Matt not quite as much into the esthetic zone. Certainly as you can see, she's got some thin lips. Her lower lip has a little different angulation to it, a couple flat central areas. She has a multitude of different axial inclinations and tooth shape and certainly also she's got some different tissue heights that are very visible and those are all things that from a study perspective as we talk and as we educate her, I think she sees that there is huge potential for improvement here. We've looked at our patient, looked at photographs of the provisional restorations that were made from the diagnostic wax-up that we originally did. We know we want to follow this very, very closely so as long as she's happy with everything, we'll try to duplicate this in porcelain as closely as we can. What I would like to start by is looking at the impression of the provisional restorations. And Tom was kind enough to not only photograph our provisional restoration but give me a stone model of that,and from that we want to produce an exact replica or at least as close as we can to the incisal edge position to tooth shape and then just refine the surface morphology a tiny bit and translucency pattern a little bit with the porcelain. In order to do that what I want to do is make an incisal edge matrix of these provisional restorations so that I know where I'm building my porcelain. It's real easy to get lost in space as your doing a build up on a full arch so what I'll do is mix a little bit silicon putty here and we'll make a matrix that will give us preference point of exactly where we want to go with our refractory dies. I'm also where we have zirconium restorations in the posterior in refractory restorations in the anterior to maintain reference; we're going to be doing both of those slightly different times. We'll probably do a wax injection of the provisional restoration so that we have the posterior teeth represented in wax on the model and then we can slice out the anterior section and put our refractory dies in there and we'll have a good reference to work from, where we'll look like we're just working on the front five teeth. We'll have the tooth positions of all the rest of the teeth there so we can keep track of the buckle corridor and everything else. It's just a way of taking a large complex case and breaking it up into pieces and making it a little more simple to work from. Looks like our putty set up for incisal edge matrix here. What we want to record is exactly the incisal edge position so I'll just take a shape knife or Bard Parker and I'll trim to the facial incisal edge of the interior teeth here because I don't want a little flange of silicon coming up the facial surface and hiding length on my restoration. I want to know exactly what the final length should be. I'll just trim this to clean it up; hopefully we won't cut a fingertip off in the process here. That's right they always taught us in Boy's Scout always cut away from ourselves not towards me like I was doing on the other side. There we go and then I'll take this off and trim some of this back side off so that we don't get any interference from the model there. So I should be able to peel this off now and clean that up as well and then with our refractory restorations, we're going to be working on the front five teeth if I'm not mistaken so in a moment we'll go ahead and slice this so we'll have just the teeth that we want. We can have the posterior section out of our way because sometimes cusp tips in the posterior will make it hard to close easily. Since we're doing a powdered build up with Lava porcelain here we want to be able to close very easily, without disturbing our build up. So that gives me a transfer of exactly where the provisional is relative tothe lower teeth, I'll go ahead and put my refractory dies back on my model now and we'll close into those. We'll be able to see where we need to build or reproduce that tooth shape. The other thing I'm doing with my model with refractory dies is that I'm doing a wax injection onto that model so I'll have my posterior teeth set up in wax and then I can build up the anterior segment by itself but I'll have a reference as to where the posterior teeth are going to be so I got continuity of form and buckle corridor or in cusp tip position, so we'll do that next. But we're going ahead and taking an impression of the provisional restorations and I cut a little hole in theincisal edge of that impression and fit it over my prepped model and injected wax so I have a duplicate of the provisional restorations in wax here. The first thing I'm going to start on are my refractory based restorations so what I want to do is take the wax out of that refractory area and I'm going to do that by simply heating this up. So what I'm going to do is take an electric waxing unit and just melt the connector between 6 and 7 because 6 is zirconium restoration and 7 is going to be refractory based restoration. And then I'll slice that with a very thin blade and I'll do the same thing over here between 11 and 12 which is the other demarkation line between zirconium and refractory. What we want to do is take the provisionals that the patient likes and try to figure out how to transfer all that information over to my model that I'm going to be doing the refractory dies and the refractory based veneers on and the crowns on. So we have really nice stone models of the provisional restorations so what I'm going to do is have an incisal silicon excuse me afull silicon matrix made of that and then I'm going to drill a little hole in the incisal edge with a #8 round Burr that hooks up from the incisal to the central. From there we've gone ahead and transferred this over to our other model and we've injected wax into this matrix so this was seated on our stone die model that I also can put refractory dies in and the wax was injected through this little hole so we should have a real good accurate transfer here. One thing I always want to check with a wax injection is to make sure it's valid, to make sure thematrix hasn't moved. So I'm going to do that by checking into the incisal edge matrix that I made previously. And as you can see we're closing very, very close to the same position, so we got a pretty good injection there. What I would like to do now is I'll take the anterior pin out of this articulator just for filming purposes so we can actually see what we are doing. So yeah we are really close there, so what we will do is we'll leave the posterior teeth in place here and we'll pull the anterior segment out and we'll replace these stone dies with refractory dies and we'll be ready to build porcelain. I think everything we talked about so far you noticed we've done quite a few things here and yet we haven't picked up a porcelain brush yet. But we looked at a lot of photographs, we've looked at a lot of stone models, we made matrices of successful provisionals, we've checked with stick bites to see how those relate to the provisionals restorations, we've looked at photos of stick-bites. All of these things are preliminary checks and steps that have to be done before you start building porcelain. When I was young in this field, I use to be quick to pick up a brush and grab the porcelain, pick up the model and start building thinking I knew where I was going and I very rarely ended up with a case that was successful. If you want to be successful doing large comprehensive cases you have to lay the infrastructure for success, orient your case in a way the provisionals are oriented or at least correct from a known position. So that what's everything has been about so far, now we can actually build some porcelain. Now we have our five anterior refractory dies ready to go, we can start building porcelain on these and then we have wax for the buckle corridor in the posterior so we have a reference to build against here.