Prepless Veneers

Part 2 - The diagnostics and impressions of the case for evaluation.

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 discusses the differences in the process for prepless dentistry compared to traditional prep dentistry.

You know when we are doing prepless dentistry there’s a few little nuances that we have to keep in mind because it is a little different process than traditional prep dentistry. For example, when we are making our impressions, it is so critical that we go in and literally clean the teeth prior to making our impression. We wouldn’t think of that normally but since we have in conventional dentistry prepped off all the facial surface of the teeth we never worry about plaque or other debris that might be laying there on the teeth. But since we are not prepping the teeth it is real important to go in and clean them real well prior to a master impression. Another little nuance that many probably would not consider is that it is even more important that our impressions be super clean when we do not have a preparation because we are asking the ceramist to identify where to place the margin purely based upon what he can visually see as the tooth and tissue interface. Cause we are asking in our prescriptions for our ceramist to place the margin just short of the tissue line on all the teeth. So it is very imperative that he has a clean recording of the teeth and the gums so that he knows where to place that margin.

Certainly you need perfect impressions to be able to do this, any accurate high quality dentistry starts with quality impressions. But, it’s more than that, it involves a lot of communication and a lot of doctors who are all ready doing a fair amount of cosmetic dentistry may all ready be used to the type of communication that needs to take place between the laboratory and the dental office but for those that are not familiar with that or have not been used to that it can take a significant shift in philosophy as well as some of the procedures in their practice. It just requires a lot more communication because the doctor has to translate the information or the goals of the patient to the dental technician so that they can ultimately provide the patient with what they want.
So today, we are ready to start the actual process of placing some durathin veneers but as we have mentioned earlier we have set this case up for the purposes of this video so that we are now ready to jump right in and do the actual techniques and processes for durathin. That set of processes has included, some bite equilibration and bite balancing with full diagnostic case study prior to that. In our office we will mount these cases into centric relation and do a rehearsal on the study models equilibrating and balancing the bite and determine what needs to happen to get the harmony we are looking for there and then we will go into the mouth once we have done that rehearsal on the models and execute that same thing intraorally. And that is exactly what we have done here for Sheri, we found that she was fulcoming on some back teeth specifically second molars and was grinding excessively on the front teeth, if you look at her posterior teeth as you will have a chance to later on in this video, you’ll see that there is not a lot of excessive wear, not a lot of indications of wear and tear there but she was fulcoming back there and then coming up to the front teeth and grinding and bruxxing and thus left with a deficient size in the front teeth that now we get to fix with some durathin veneers.
Once you have determined through your diagnostic efforts that this is a go and this is a great durathin case and your lab is on board, patient is on board then it is time to capture the master impressions and in our case we usually take at least two master impressions having one as a good back up. Once you have captured all of that and you are ready to begin to make prototypes, it is my personal opinion and my bias to go in and hand sculpt these prototypes in the mouth. There is so much information that you learn from doing that and there is no better way or more accurate way to really determine the final outcome of the durathin veneers than to actually do the mock up and composite in the mouth. And many people when they hear this they say well wait a minute, I don’t want to spend all that time doing mock up intraorally why can’t we just use a wax and use a matrix and do it in a more traditional way. The answer is you can do it that way but we firmly believe that doing mock ups will allow you an opportunity to go a level further in terms of really simulating what the patients really going to have, really getting the patient excited and also it is going to allow them to test drive this for several weeks if necessary to be certain that they love the outcome. You must remember that if when you do not prepare on the teeth, anything that you add over the top is going to be relatively thin and the traditional methods of transferring temporary material to the teeth will probably problematic for any length of time. So we feel real strongly to go in and spot etch each individual tooth and do hand sculpted prototypes on each tooth and separate them with a cerasaw and have them so they can floss in between them, this is invaluable in terms of the outcome, in terms of allowing everybody to really preview and test drive everything that is going on. And please remember that the time that you will spend doing that which will be admittedly be considerable will be probably at least no more time than you would normally spend in conventional dentistry preparing the teeth with drills, retracting tissue and managing all the effects that you would normally have to manage with traditional dentistry.
Ok, so after we have gotten all of our bite records, master impressions, photos, etc. all of the necessary records for the lab to do this work, we are now ready to build our custom prototypes, so we are using some chlorhexadine just to clean the teeth off real well. Then we are going to spot etch each one of the teeth here. And we use a fairly good etch area so that we don’t use the temporary’s prematurely. Of course we are careful not to get the etching around the margins. Since we are bonding only to enamel here we don’t have to be overly critical with our times with the etchant, you can leave it on there for roughly 20-30 seconds not being too concerned with overexposures as we would with dentin. Now we are placing just a little bit of prime and bond over those areas just to make sure we get a good bond in those areas. After we dry the primer real well there, we come back and take a ball of composite, roll it in our fingers to remove any voids and trapped air. I like to use the Tetric EvoCeram an Ivoclar product for this process, this particular composite is just so user friendly in my opinion, it doesn’t slump very readily, it allows me to work with it and get the contours and the shapes that I desire without running or being difficult to handle. In our hands-on courses some doctors bring up the objection that making prototypes like this is just too time intensive and it’s simply not cost effective but what we have found is that we can make these types of protypes in a ten unit case in about an hour and sometimes a little more than an hour but since we are not preparing on the teeth and spending the time that it would take to anesthetized and go through all those steps we kind of trade off that time for building a little nicer and more customized prototype. And this gives me a good chance to artistically connect with the patient and know that we are delivering a case that is exactly what they desire.