I'm using the head of a 850 014 Burr to create three depth Cuts along the incisal edges of each
tooth once the depth Cuts have been marked I switched to a larger 850 018 Burr to expedite
the finishing of the preparations when all of the veneers are in place I use orange with
sticks on the facial and incisal to ensure that they're fully seated against the preparations
with the proper planning with the diagnostic wax up transitioning from patient acceptance
preparation to final Restorations can be done quite seamlessly we have a 41 year old female
that presents with some worn maxillary anterior teeth some on the mandibular as well and she's
really just unhappy with the aesthetic appearance of her maxillary teeth when she smiles you can see
they are a bit worn 7 through 10 actually 6 through 11 all of these are relatively
worn at the incisal edges and she also wants to correct the diastomata between five and six we
we want to get an idea of what we can achieve with this and where our possible limitations are
in order to do that we create a diagnostic wax up and just want to let you see the wax up here
this wax set was created with the patient's ideal smile in mind so the patient actually
submitted a picture of what she thought was the ideal smile and if we kind of compare the wax up
that we created for her it looks pretty similar it's certainly longer at the centrals and what we
consider aesthetically pleasing slightly shorter laterals canines that have some prominence to them
from the wax up it's important for us to be able to transition this or at least have the patient
preview what this model is going to look like so in order to do that we create a putty Matrix
that is shaped to the wax up so this putty Matrix is created once that ideal diagnostic wax up has
been made and the putty Matrix we will then apply some bissacrum material into here and seated on
the patient which you'll see and at least have the patient trial fit this they can wear it for a day
and I recommend actually having them wear it for a week this way they can see if they're comfortable
with the plan and sizable Edge positions the added bulk if there is any and if just to see if there's
speech patterns are the same there's several several things that we want to look into and
certainly having their family's approval friends approval but usually this is a great way to have
the patient get comfortable with the planned treatment so whenever we seat the biscro the
excess material that flows out along the facial once the entire Matrix has been set it's really
easy to remove the excess material once it's scalloped so that's just my preference so after
the patient's approval with the mock-up and we know what our limitations or where we're actually
going with this case from there I will apply the acrylic mock-up on the patient and actually prep
directly through the mock-up for me prepping through the mocha is one of the best ways to
guide yourself on where tree structure needs to be removed where you may not need to remove as much
material so I recommend highly recommend having a diagnostic wax up for all of your aesthetic cases
so I wanted to review the prep sequence that I went through for this case based off the
diagnostic wax up that we have and from the putty Matrix we create a mock-up that goes right over
the patient's existing dentition and since the mock-up is going to guide us on the preparation we
prepare right through the mock-up on the patient so I first create three depth Cuts using an 850
014 Burr we make three depth cuts on all of the incisal edges and I use more of the body of the
Burr which is about 1.4 millimeters in diameter and create the depth Cuts along the incisal and
then the tip of this Burr is approximately 0.8 millimeters in diameter so I create the depth cuts
on the facial aspect first along the gingival margins ensuring that I get down to where the
tip of the Burr is buried and then I transition and round this over since this surface is flat
I create ensure that the marginal depth cuts are created first and then I will roll this over to
the incisal edges on each of the teeth and I create three along the facial and then one on
each of the line angles to make sure that enough reduction is created in those aspects so for the
actual preparation this is what the finals look like you can see here that with just a single
cord you'll see on the clinical video a single cord was used to create enough retraction all the
margins were brought right to the gingival margins the free gingival margins on each of the teeth
and with one single size one cord used to help displace the tissues apically and you can see it
also push the tissues out laterally allowing the light body PVS material to flow into the sulcus
and have that separation I begin the preparation directly through the mock-up by preparing through
the mock-up I'm able to ensure the final Restorations have the appropriate material
thickness while reducing tooth structure only in the areas that require it I'm using the head of
a 850 014 Burr to create three depth Cuts along the incisal edges of each tooth for the facial
depth Cuts I first ensure that the tip which is 0.8 millimeters in diameter Begins the depth
cuts at the margins and then gradually connects to the incisal I place five depth cuts on the
facial three near the center and one along each line angle the depth cuts are then marked with a
lead pencil so I have an easier time identifying when I've Blended the unprepped areas down to the
ideal depth once the depth Cuts have been marked I switched to a larger 850 018 Burr to expedite
the finishing of the preparations now it's just a matter of ensuring the finger projections at
the incisive wedges and the facial surfaces have Blended together through the depth Cuts resulting
in a smooth and continuous surface throughout the preparation anytime we lengthen teeth with veneers
a flat incisal Edge preparation is preferred for ease of fabrication smooth path of insertion and
a great adaptability of the Restorations to the preparations the incisal edges have a
slight angulation from lingle to facial for the teeth adjacent to the diastomada the preps must
be extended farther inapproximally to allow room for the final Restorations to create the desired
emergence profiles and contacts when we prepare teeth the axial occlusal or axial facial line
angles typically result in a sharp angle since the Burrs we use create flat planes it's good practice
to round these over to minimize the amount of internal stress placed on the final Restorations
to ensure the labial and size of transitional line angle is smooth and rounded I use a coarse
venous super polisher along these aspects at 5000 RPM all of the finished margins terminate
at the free gingival margins of each tooth I typically use a dual core technique but wanted
to try something a little bit different since all the prep margins are at the free gingival
margin right Echo gingival I'm going to place only a size 1 retraction cord along all of the
teeth to help displace the gingiva slightly for our final impression once the retraction cord
has been allowed to sit for five minutes we'll remove the cord and then begin flowing capture
light body PVS material along the margins and into the sulcus you can see with just one cord how the
tissue has been displaced enough to visualize the margins once the light body has been applied
I'll now slowly adapt the anterior triple tray filled with heavy body material to the preps once
the impression has been taken we'll then get the patient ready for their provisional Restorations
for the provisionals I'll use a shrimp rack technique using the same putty Matrix that
we use for the initial mock-up I first spot etch each tooth with curves 37 phosphoric
acid followed by a thin coat of 3M Scotch pie Universal which will light cure for 10 seconds
now I'll fill the putty Matrix with tough temp bicicrow material and then slowly seat
that over the teeth to minimize the inclusion of any air bubbles
now we're on to the final delivery and we need to ensure that the temporary material is completely
removed the temps can be somewhat tricky to remove since they were bonded in here I use
a slow speed carbide round bur to facilitate the removal of the bonded acrylic and ensure we reach
the preparations beneath very gentle pressure at a speed of 2000 RPM will do the trick I finished
cleaning the preparations with a profi cup and pumice paste at a very slow speed of about two
or three thousand RPM now it's time we try in the final bruxer aesthetic veneers in place once the
margins and contacts are verified we can now begin the bonding sequence I use a total etch technique
first etching the preps with 37 phosphoric acid etching numbers 11 through 13 followed by 7
through 10 and then four through six breaking them apart to ensure we aren't over etching any teeth
once the teeth have been etched a thin layer of gluma is used as a desensitizing and antimicrobial
agent I allow the glumens to sit on the teeth for at least a minute allow it to soak into the teeth
and then remove any excess with a dry micro brush with gluma it's important to avoid allowing the
material to come into contact with a soft tissue as it can be an irritant to those soft tissues
after gluma I then scrub a layer of 3M Scotch Bond Universal for at least 20 seconds per tooth to
ensure the resin monomers effectively infiltrate any exposed Dental tubules and into the enamel
Matrix these veneers have already been air braided with aluminum oxide at the lab after we try them
in we need to now prepare these zirconia veneers for bonding to ensure we have a pristine and
taglial surface for bonding we scrub ivaclean for 20 seconds in each veneer to remove any salivary
phosphates that may have adhered during the tri-in phosphate groups have a very high affinity for
zirconia and can compromise bonding ivaclean is a special formulation that effectively removes
these unwanted layers once the Restorations have been washed and dried we then use monobon plus
which is an mdp containing primer that is the special coupling agent needed to bonds or cornea
Restorations to resin now I see each restoration with curves nx3 Universal resin cement I'll light
using the cement for its handling properties and the fact that it's light cured to set since it's
a light cured cement it offers unlimited working time allowing me to seat all of the Restorations
at the same time when all of the veneers are in place I use orange with sticks on the facial
and incisal to ensure that they're fully seated against the preparations once they're fully seated
I tack here along the margins to hold the veneers in place and to allow for easy removal of the
gelled cement the final bruxer aesthetic veneer successfully created a fuller more youthful smile
that the patient was extremely thrilled about with the proper planning with the diagnostic wax up
transitioning from patient acceptance preparation to final Restorations can be done quite seamlessly