here's another clinical zirconia case that we're going to attempt you can see that the patient's
got an anterior cross-bite we've got some old composites are very large compositive on tooth
number eight we've got some discrepancies in the gingival levels we've got all kinds of stuff going
on here all kinds of esthetic issues that need to be solved and what we're gonna try to do because
the patient has had a history of recurrent decay on these teeth has used a semental material like
clinical zirconia and then we're gonna finish off his smile with some no prep veneers next to the
crowns just to kind of round it off and this has been one of the really neat things about no prep
veneers that I didn't anticipate the ability to finish off a smile with these without having to
do any additional preparation so as the first step in the reverse preparation technique you
can see we're using the round bur here this is a NATO 102 one mer form axis dental actually all
the birds you'll see in this presentation are from the reverse preparation kit also available
from axis dental and we're going in and breaking some interproximal contacts here usually I harp
on and on about not having any bleeding when I'm doing the preparation and I go to great pains to
do that but I know on this patient we're going to be using the laser to adjust some of the gingival
levels so here it's not that big of a deal if we caused some bleeding because certainly we're gonna
cause some bleeding when we go in and recontour the gingiva anyway and most of the time on these
patients as we recontour the gingiva we will not take final impressions on this day because
the gingiva I just like to see it heal a little bit and get a little healthier and if I have the
time and the patient's not in an incredible hurry I'd rather prepare it on the first appointment do
any gingival recontouring I need to do let it heal and then have the patient back and actually take
the final impression at that next appointment and that also allows me to really dial in the
temporaries on that first visit and then I know that wherever the temporaries are is where they're
going to stay now I'm trying to bio temps on right here and I'm trying this because they have fixed
if you will the gingival levels for me they've put ideal gingival levels onto these bio temps
so when I push the bio temps into place anywhere where the bio temp is covering the gingival tissue
I know that I need to reduce that to make it blunt make it the gingiva be at the right level so we're
using a little viscose stat here from ultra dent just to stop some of the bleeding so I can see a
little more easily what's going on here how do we decide we're gonna take impressions today we
would have spent a little more time making sure that the patient had some really healthy tissue
but we knew that we're gonna go in with the laser and recontour this so here we are using our diode
laser this is the laser smile from bio Lay's and we're going in and removing some tissue I'm just
free handing this we could mark it sometimes with the marker or other times we'll put little holes
with an explorer but this one's pretty easy to see what's going on and really I'm just
trying to match a couple teeth here so as I go along with the diode it's nice that we don't
have much bleeding while we're working on this on unhealthy tissue sometimes we will have a little
bleeding later but basically just recontouring the central incisor on the right to look like
the central incisor on the left and then trying to bio temps back on to see if in fact we have
reduced enough once we've brought our tissue back to where it needs to be we're gonna go ahead and
drop our margins down to that new gingival level and here I'm using a little mosquito burr to go
and it create a little more separation between the teeth I love this little mosquito burr and
once again we're using our sham Furber to create a deep chamfer or a shallow shoulder however you
want to look at it on the facial of that lateral incisor as well and because I touched that you can
see we've got a little bleeding there which isn't of a big consequence really to tell you the truth
because we're not going to impress this today so we're gonna realign the bio temps you can do this
with pissah krill you can do this with acrylic material this is with acrylic material that's
probably the preferable way to do it because we're we can manipulate the temporaries the
bio temps during that doughy stage if you do it with the bits of chrome materials such as
Lux attempt it's easier it's faster there's less heat released and it doesn't smell as bad but you
always run the risk of locking in those bio temps onto the preparations so we really try to use the
acrylic whenever we can it is of a hassle I know but it does make sure you can pump the bio temps
up and down and not lock them into place which you hate to do with the bio temps once we've done that
we're going to take it off trim around the margins and then go ahead and cement those four units into
place because the rest of the units are going to be no prep veneers we don't have to worry too much
or at all about any preparation we just need to make sure the teeth are clean and then we get a
good impression of those so remember to syringe around the gingival margins of those teeth even
though we're not going to be doing any preparation you got to make sure that the impression trail
gets down along the sulcus so since it's the next appointment we're going to go ahead and take our
impression today so here goes our double zero cord into place and you can floss that in and
approximately and then pack it the rest of the way the gingiva looks decent it's been two weeks since
we did our surgery and now our number two cords going on top of it remember the double zero cord
we cut the ends of it so that when we pack it into place the ends of the retraction cord are flush I
don't want any excess retraction cord material poking up from that first cord that bottom cord
and then once we go around with our top cord r2e cord we will leave a tag as you can see there
above the gingiva and that gives us an easy place to grab on to it and remove it after it's been in
place for eight to ten minutes so we'll go ahead and pack the cord here on the rest of those four
anterior teeth dentists will often ask me do they need to pack retraction cord for no prep veneers
and you really don't want to I mean you could put a double-0 cord around a tooth that's going
to receive a no prep veneer but we really don't want the margins of that no prep Ranieri going
sub gingival because then it's gonna be bulkier underneath the gingival margin no prep veneers
by definition are little bulky at the gingival I'd rather have it right at the gingival margin which
is how we make it because that way the toothbrush will pass over it hopefully three or four times
a day and keep things nice and clean even if the patient only brushes once or twice a day it still
keeps it cleaner if we can keep that bulky no prep margin at the gingival free margin or you slightly
super gingival so after the patient bites down on these copper caps for eight to ten minutes and I
really try to be religious about that time in fact if anything all err on having them in place for 15
minutes rather than just doing it for four or five minutes we're gonna go ahead and express
our medium body impression material the syringe material from the capture system around those
teeth and my assistant hands me a full arch tray that's got the heavy bottom material in the tray
already I really like that medium body syringe material I know with the two-court technique we're
gonna get some impression material sub gingival and I want to make sure it doesn't tear and the
best way to make sure it's not going to tear is to use medium body and you can see for example on
the facial margins as you look at this impression you can see that deep chamfer shallows shoulder
that we've prepared and then you can see where the impression material goes beyond the margin
further sub gingival this show the lab technician exactly where the root structure is on that tooth
so they can nail the emergence profile and they should be able to nail the gingival third contours
as well now that we've taken that impression we're going to put the exact same temporaries
back in place we've made no adjustments on those because we know the tissues gonna be in the same
place that it was at this appointment so really you know you don't want to make any adjustments
at all to the gingival levels on your temporary when you impress it on this second visit like
that so we put the bio temps back in with some temp bond and then we gonna let that set and
clean up the temp on from around the margins of the temporary so it's been two weeks since we've
taken the master impression and we're gonna remove the bio temps and we cracked that one right there
and now we're gonna remove the temporary cement from the tooth temp on it cleans up really easily
from the teeth sometimes if you have areas where you've got a composite buildup it will stick a
little bit more and you may have to scrape it off some dentists like to put little glycerin
little Vaseline right in that area so that they don't have that as an issue that's one way to do
it or you can use the cave osanic scaler to be able to remove that as well if you do have any
irritation and again this patient does not have the healthiest gum tissues in the world in fact
he's he's diabetic and it's something he struggles with we're using a little visco stat here on the
gingiva because we do have some bleeding and this is another reason why I want to be able to use a
product like clinical zirconia is we do want the aesthetics of an all ceramic but we want to be
able to submit him obviously there's no way we could bond into that kind of area with that kind
of bleeding but we've all been able to submit and successfully P FM's and conventional restorations
into areas that aren't bleeding we're now going to try on the the no prep veneers so as we try
on these no prep veneers we always do it with a translucent cement so we can really see we'd
like the underlying color of the tooth to show through and that's really what happens in fact
if you're just going for a color change no prep veneers are not a great idea you cannot get major
color changes on teeth with no prep veneers that is not one of the indications for no prep veneers
we gave the patient ameerin he liked how they look so we're putting in the clinical zirconia crowns
now here's tooth number eight nine being put in with relaxed luting cement plus my favorite cement
for these routine crown and bridge applications and then I use these orange wood sticks just to
hold them in place on posterior teeth patients can bite them down on anterior teeth I like to
use these sticks to help hold them in place and get a nice firm seating on the tooth with the
orange wood sticks if I do it with my fingers the incisal edges of the crowns dig into my finger and
I can't hold that same kind of steady pressure so we're gonna go ahead and clean up the excess
cement around these clinical zirconia crowns on teeth number eight and nine we always start with
eight and nine because if we don't get these two teeth in the correct position we basically blown
the whole case so could we cement seven eight nine and ten at the same time yes we could we
absolutely could but there are times where you have contact issues sometimes and you don't want
to have to deal with those I don't want to by putting in four units so a lot of times I put
an eight and nine first almost all the time like we did here put in eight and nine first and then
once we've cleaned up the excess cement we try seven and ten in again to see if we do have any
contact problems if we do then we'll adjust 7 and 10 with 8 and 9 in the proper position whereas if
I had tried to put in 7 8 9 and 10 at the same time it did have some contact issues you could
see I would be just as likely to get teeth 7 and 10 in the correct position as I would to be to get
teeth number 8 and 9 in the right position and that would blow the whole case aesthetically so
over the years I've learned to slow down a little bit I get 8 9 in first and then recheck contacts
and make sure everything's ok because during the trying you can have contact problems and it looks
like they're down but until you go to cementum you never really know now that 7 8 9 and 10 are
cemented in place where you're starting to work on our note prep veneers so we're edging tooth
number 11 and tooth number 12 as you can see here that etches on enamel so it's gonna stay in place
for 15 seconds there is no dentin exposed which is nice we don't have to worry about post-operative
sensitivity and we know we're gonna get the strongest bond available in dentistry today
and that is to enamel where you don't have any dentin exposed once we've rinsed and dried that
off it's fun to be able to dry enamel again once you've etched it and get that frosty look which
we've been told not to do to dentin we're placing our bonding agent into place well thin it out with
a little bit of air will cure it first although you can wait to cure it if you would rather do
it that way and then we're putting these veneers in with the translucent shade of ivic lars veneer
cement this is very Oleg veneer and then holding it down with the orange wood stick so that they
don't move as my assistant comes in and does a little tack at the incisal edge for about 2
seconds with the curing light and she'll do that at the gingival - and as you can see it's in the
gel stage and I'm able to clean that up very easily with just an explorer because there are
no prep veneers and they don't have the same kind of positive seat as you would see with a regular
veneer that's why I hold it in place with the orange wood stick is she tacks those into place
then we're just using a little handheld cutter a little separator here a strip that's built into
a handle from axis dental and this is a really nice way to go and make sure there's no cured
composite that's stuck or left between those two teeth once we've done that we go over to
the other side and here we're going to go ahead and at teeth number five and six and then place
the bonding agent just as we did on the other side the patient had bicuspids removed earlier
in life and so we only have the cuspid and the one bicuspid here if there was another bicuspid
we would probably place a veneer on that as well again it just fills out the buccal corridor and
makes the smile really look uniform and it's these no prep veneers as we're using them here
are a great way to finish off a smile and turn it into a whole smile case without having to do more
than prep those for anterior teeth and you can see as I press down on that cuspid no-prep veneer with
the orange wood stick how it seats all the way and you want to make sure it's all the way down
this thin press material from Glidewell that we use for these no prep veneers is very strong it's
stronger than other press ceramics that we've used before and I've never actually had one break you
know holding it down into place like that with the orange wood stick as my assistant tax that
gingival area for me so I can clean that off and then she taxed the lingual for me for about two
seconds so I can begin to clean off that excess cement in the gel State as you can see it peeling
off right there now if I took that orange wood stick and held it down on the facial of an errand
banged it in a place with a mallet it probably would break so you know I'm not leaning on it
with all my weight but you know I'm not being you know super gentle and using a cotton roll either
I just don't have a problem with that orange wood stick putting a reasonable amount of pressure and
I apologize for being vague but I don't know how else to put it you know I'm not being extremely
gentle but I'm not like leaning into it trying to break it as well for excess cured cement on
the facial surfaces of these veneers this brownie wheel that you can see that I'm using here it's
just a great way to make sure that all that cement is cleaned off you're right mmmm bird
the brownies and greenies and super greenies from shofu as part of the cast gold technique
that you were taught in dental school as I was and it was almost by mistake that I found out it
works really good for these veneer cases as well to remove submit on the front for restorations
with the cz obviously there's no need for that because we used a conventional cement and on the
before-and-after as you can see even though it's a patient with compromised gingival health and
compromised medical history we were able to go from a look that wasn't real nice to something
that are pretty nice for him and is this ever gonna win awards and a ACD Journal no no it won't
but it doesn't need to you know for this patient who raided his smile on a scale from one to ten
as a three in the beginning he actually gave it a ten now and all dentists may not feel that way
looking at it but for this patient we were able to accomplish the goals he set out to accomplish
and that has give him a nice-looking smile and we were able to do it in a somewhat conservative
fashion utilizing the clinical zirconia restorations and the thin press no prep veneers