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Making Smile Design Profitable, Efficient and Predictable

Part 1 - The key elements in smile design efficiency.

Instructors:
Trent Smallwood, DDS
In this dental continuing education course, Dr. Trent Smallwood discusses the importance of having a strict protocol when creating dental restorations. Dr. Smallwood starts by demonstrating a frenectomy using a C02 laser.

Hello, I'm Trent Smallwood and today our segment will be dealing with working on efficiency with smile design. From the start to the finish, we want to make smile design profitable, efficient and productive all at the same time.

As there is an art to aesthetic dentistry there is also an art to making the business of dentistry successful, profitable,memorable and unique. Hi everyone, I'm Marlene Hilton for HDiQDental. With the detriment of maintaining a aesthetic based practice on the rise, one must have their marketing, team and philosophy poised to handle the overhead strain that faces the modern day dental practice today. From contemporary marketing skills to creating beautiful dentistry through out the mouth learn from a dentist and an entrepreneur who has accomplished it and so much more. As Dr. Trent Smallwood shows us, your goals can be obtained if you strive to succeed.

Today with the sequence you will noticing that we are going to to bring be looking at key elements of smile design that are going to bring a certain level of success all the way through the procedure for you, going from the records appointment, to the wax up to the provisional, after the preparation sequence and then leading into the seating sequence. We want to bring all of these elements home for successful smile design every time.

To begin the sequence, go ahead and open Michael, we are going to first place some topical anesthesia, and this really helps to make the entire procedure pain free. We are going to dry off the tissue with a 2x2 and then we have placed a topical anesthetic called Emla onto a 2x2 unrolled and put right up into the vestibule. Now Michael this is important for you that you not talk and just stay steady for a few moments and we are going to let that set for a time and you should be ready to go. O.K, once we have let this in for a good 4 to 5 minutes, we will remove it and use just infiltration articaine 4% to get the area numb. Because of the conservativeness of the preparations for Michael here I do not need to get him very numb at all. Now when we look at the sequencing with regard to preparation we will notice that there is a very strict guideline that I follow, now my sequencing with regard to the preparation is only about 20 or so minutes so for some people they will say there is no reason that you can create a quality restoration or preparation in that time to which I would offer you that there is. It is just the matter of not picking up the same burr twice for example it is keeping a protocol and a sequence all the way through the preparation to be able to provide a quality product, a quality preparation for you laboratory at the same time maintaining some nice speed. It can all be done together it just needs to be sequenced. If a strict protocol is adhered to you will have success.

Now that the patient is numb the nest aspect that we are going to achieve is the removal of any superfluous tissue or any tissue that we don't want in the smile. Now what I have done is created composted pictures to create a smile line to tell me exactly where we want to remove tissue and where we want to keep the tissue intact.

So now we are going to begin the laser sequence. Watch where I am going to remove more tissue in the pre-molar area after I sound the tissue to bone so that I can make sure that we can remove the tissue adequately.

When sounding we are getting to about four millimeters which allows about 1 mm of gingival reduction. Anything more than that can lead to biological width issues. O.k. so we will be able to reduce about 1 mm of tissue.

As one can see we've got the position of the right side the patients right side stabilized so now we are going to do the same to the left side. Now based on the left side we will be mirror imaging the gingival height and zenith "and creating an ideal gingival height. Last is just the pre-molar on the left side, go ahead and open real big for me Michael you're doing great, I am going to switch this over to the right side.

Now as we had talked about in the wax up sequence we will see that we are doing 10 teeth we are going to be idealizing we've got a frenulum to detach here in just a moment which I am going to do here in just a moment but what we've got is a diastema to close as well so we have to change the proportion of tooth number 8 and 9 and distribute it amongst the rest of the teeth to get ideal proportion again. Now with a frenectomy, we want to be able to remove all of the tissue all the way down to the periostium and this will ensure that the tissue does not grow back. And with frenectomies it is always important to let the patient know kinda what to expect because sometimes, though not painful really it can really look a little worse than they really are. Here we are right about down to peristium. Everything is looking great and we're just relieving the tissue as we go. This is always Amanda's favorite part. Now it use to be widely believed that the periostium would extend almost to the K9's and we have found now with experience that that is just not needed we are not having to pull the tissue nearly as much, usually to the mid tooth of the central to the mid tooth of the distal of 8 and 9 is sufficient to be able to achieve the goal. Now we've got the preparation sequence we are going to begin, we've got the bite block in place and we are going to very conservatively begin to remove some hard tissue here and we are going to first start off using a depth cutting burr which is approximately .5 millimeters in width to be able to make the initial reductions within the enamel. Now to improve efficiency we are going to do all ten teeth at one time. As referenced and discussed in the diagnostic phase we have our reduction areas within and in this case because of the conservativeness of what we are having to do for Michael we are going to be able to do very little in the way of reduction for these teeth which is always nice and it is kinda the trend these days to be able to have more of prep-less type of veneers this is by no means prep-less but it will be very conservative. There is no reason, at least in my opinion, that we need to spend 4 hours on preparation of 10 teeth. It is one of those things that I have found over the years that I just get in and I do it and let me explain that a little bit. There are some key elements in regard to preparation sequence. One is, don't use the same burr twice. It may seem simple but if any of us and think back to dental school and probably many people still do this is you do what I call the dink factor you just tend to get a burr and do something in regard to the tooth, you put it down, you bring up the next burr and before you know it you've gone through all the burrs six or seven times and picked them up and changed them within the chuck probably 30 or 40 times on some cases. Well I say start with one burr and go till it is completed then go to your second case. In my case I tend to do gross reduction, if I need to break contacts I will and would say I do at some point in probably 30% of the time I break contacts, but I will break contacts, I will then go in with large barrel burr and start to reduce incisal create a lingual bevel facial reduction then I move into a long tapered course burr and this is really important where we have the three planes of reduction we have to remove. We have the gingival plane, the straight plane and the incisal plane, and the incisal plane is usually missed by many doctors because of the fact that they feel based on the angulations that I suppose just based on the feel of the angulations of the burr that they've done proper reduction but what ends up happening is they have not done that incisal reduction and the ceramist ends up having to build the ceramics or the porcelain out quite a bit and you don't get that nice axial inclination down to the belly button. All preparations should also decline or converge towards the belly button. If your preps don't do that then there is something then there is something that is still missing and those are key elements to be able to look at and create successful and predictable smile design with regard to the preparation sequence. Lastly, we smooth all the preparations I personally use a Shofu burr for that and what I am able to do with or a Shofu rubber point and I am able to polish everything down so that when they are all poured up all the sharp areas have been eliminated. Because if you have sharp, knife edge through out any of your preparation it often will not transfer to stone and you will have some problems with the veneers or the restorations seating fully. So this is a great type of rubber, it can be done with wheels or a rubber-point to be able to smooth down this process. This leads us right into the provisional phase.