for today's case i'm going to take you through a veneer procedure on the anterior 6. here's our
patient Samantha. Her chief complaint was that she wasn't happy with the four veneers placed
on her centrals and laterals. I'm always curious why previous restorations were done so I asked
her for a Before photo. This is how her natural teeth were. She originally wanted veneers to
close the space between the centrals and to correct the incisal shape of the laterals.
Now, looking at the restorations she received, they DID improve on those aspects but if
we evaluate the teeth with her face and the framing of her smile they do appear rather small
and the proportions are a bit off with the centrals wider than they are long...so besides
just replacing #7 to #10 (lateral to lateral) I plan to also place veneers on the canines as it
will allow me to create more esthetic proportions on all of the anterior teeth. From my diagnostic
wax up, I use a putty matrix and seat the mock-up to evaluate the proportions once everything is
approved. The mock-up also serves as a guide for the gingivectomies with the BIOLASE® I press hard
with soft tissue laser. I begin using the laser bandage setting to superficially trace along
the areas I plan to remove gingival tissue on numbers #6(lateral), # 8(central) and #11(canine).
I then remove the mock-up and complete the gingivectomies in a higher wattage setting.
you can see I'm using my non-dominant hand to stabilize the head of the laser
as it's important to have steady control as I hover the tip above the soft tissue and also
because I had a little bit too much coffee that morning! Slow and steady movements with
the laser will allow you to flay off the tissue cleanly until the right position is achieved.
Next, I switch to a hard tissue setting that allows for removal of old restorations.
This works well with veneers as you can access more of the bonded surfaces
on this setting...Slowly guide the laser along all of the exposed aspects of the restoration
while aiming the tip toward the center of the tooth. This will allow the laser to obliterate
the bonded interface between the restoration and the cement. The mechanism is essentially micro
explosions of the water molecules along the cement interface. I must admit it's pretty satisfying to
see the restorations pop off intact once enough of the bond breaks down. Once the old veneers are off
I pack a size 000 retraction cord into the sulcus of each tooth to help drop the tissue down a bit
apically. Now we need to clean the preps. I use a fine grit round tapered diamond bur to remove the
residual cement. The original preps have adequate reduction, a nicely defined chamfered margin
and rounded internal line angles so there's not really a need to modify them much
for the canines. I place a light chamfer along the gingival margins and reduce mainly on the
distal facial so the final position of the veneers will blend with the posterior teeth. I finished
things off with a Venus super polisher to smooth and round over the incisal edges.
To ensure we get a good capture of the margins in our digital impression I pack a size one chord
to provide lateral tissue disflexion. For the impression I utilize the iTero Element®
digital scanner to capture a pre-treatment scan of the diagnostic model of the opposing arch and
the preps for the prep scan. I remove the top size one cord and dry the field really well to
facilitate an accurate impression when scanning. It's much more important to view the screen
as you sweep along the incisal lingual and facial surfaces to ensure the digital model
builds with all of the critical details of the patient's dentition. Remember to evaluate your
completed scans before sending them to the lab or your chairside design station to provisionalize.
I use a shrink wrap technique but I won't spot bond them in place since I'll actually
deliver the final veneers the next day I place a little bit of gluma desensitizer on the preps
and then fill the putty matrix with Luxatemp Bis-acryl material after the material begins
setting. I can easily peel away the excess from the scallop borders of the putty matrix. Now
in the fastdeisign.io™ software. the first step is to identify the margin positions.
You can see where I position the margins for each prep. The software is then able to establish the
designs based on the dimensions of the diagnostic wax up. Once the overall contours and aesthetics
are set I dial in the proximal and occlusal contacts and then begin milling the restorations
out of Obsidian® CAD bleach 4 blocks. Each restoration takes about 15 minutes to mill
and then requires a crystallization cycle in the final stage porcelain oven for 25 minutes.
Now at our delivery appointment the following day I use crown removal forceps to carefully
break away the temp material and then use an ultrasonic scaler to clean the preps.
I try on the Obsidian® CAD lithium silicate veneers with Kerr NX3 Clear Try and paste
to evaluate the final esthetics. Once everything checks off, we'll proceed with preparing the
restorations for bonding. Here we're using a product from Ivoclar called Monobond®
Etch and Prime which is a single component ceramic primer that etches and salinates glass ceramics in
one step. It's scrubbed in and allowed to react for 60 seconds where the ammonium polyfluoride
etches the ceramic and after rinsing the solution away a styling layer remains. Pretty cool stuff!
Now it's time to prep the teeth. I always use a total etch or etch and rinse protocol.
I apply phosphoric acid to the entire tooth surface for about 20 seconds and then rinse away.
This to me is still the best way to establish a strong bond to tooth structure. I apply gluma
desensitizer and let it sit for at least a minute and suction away any excess. I then scrub in Kerr
Opti-bond™ universal bonding agent into the preps and suction away the excess while I air thin
it. We deliver these veneers with Kerr NX3 light cure cement so I can seat all of the restorations
down at the same time I apply lingual and apical pressure using bite sticks while my assistant tack
cures each veneer down. After tack curing I remove as much excess cement with a scaler and explorer
and then floss through the contact areas before the final cure. At the end I dial in the occlusion
and also smooth out any rough areas along the lingual margins with a fine grit diamond bur.
The outcome provided a great esthetic improvement that I think fits the patient really well.
Thanks for tuning in for this episode of Chairside Live and we'll see you in the next one!