Cosmetic TRIBUNE The World’s Cosmetic Dentistry Newspaper · U.S. Edition

September 2009 www.dental-tribune.com Vol. 2, No. 7 New approaches for patient acceptance and appreciation

By Lorin Berland and Sarah Kong

This 51-year-old executive has lived with the effects of tetracycline- stained teeth since she was a little girl (Fig. 1a). All her life she wanted to have a great smile, but she never knew what her dental options were. The general dentist she had seen for many years told her there wasn’t anything he could do to help her, so he referred her to our office. When the patient came for her first visit, she had a number of dental concerns she wanted to address. In addition to the severe tetracycline staining, she felt her teeth were worn from years of grinding. She also had old resin bonding on her lower front teeth that was not only discolored, it was mismatched from years of patch- ing and re-patching every time some- thing would break off. After listening to her chief com- Fig. 1a: Pre-op full face. Fig. 1b: Post-op full face. plaints and performing a thorough exam and cleaning, we recommend- Smile right on the patient’s teeth. 6–12 were prepared for Microveneers pared teeth for an impression. Then ed she try deep bleaching and, after We loaded the matrices with an to preserve as much natural, healthy the alginate-filled tray was seated in evaluating the results of whitening, A-1 bisacryl temporary material — tooth structure as possible. the mouth, directly onto the hydrocol- a minimum of four minimal prep such as Temphase (Kerr), Integrity Tooth No. 5 had an existing crown loid. After a mere minute and a half, Microveneers™ for her lower front (DENTSPLY Caulk) or PERFECtemp that the patient wanted to replace the impression was removed with a teeth and her upper seven teeth, II (Discus Dental) — and seated them to match No. 12, so it was prepared snap and handed off to an assistant and a zirconium porcelain crown for in the mouth. After the material was for a zirconium crown at the same to pour. tooth No. 5 to achieve the smile she set, the matrix was removed and time. Digital photographs of the prep In the lab, the impression was was seeking. what remained on her teeth was a shades were taken for our ceramic disinfected and dried. Next, Mach-2 Because her maxillary six ante- new smile. artist (Fig. 8). PVS (Parkell) was dispensed into the riors had worn, flat incisal edges, it We took a series of photographs Once the preps were finished and impression to pour up the model on was essential that we knew what the with the Slip-On Smiles in place and refined, it was time to provisionalize a vibrator. A fast-setting bite regis- patient hoped for in terms of shape the patient was ecstatic. She was able the teeth. While an assistant loaded a tration material (SuperDent, Darby and length. We went over the Smile to see and feel what her teeth could tray with alginate, hydrocolloid (Dux Style Guide (www.digident.com) to look like before committing to any Dental) was expressed over the pre- g CT page 2D select a smile design (Fig. 2). With the dental work (Fig. 7). The patient was patient’s input, we determined that truly amazed by this and wanted to AD P3 — pointed canines with square wear the smile home to show her centrals and round laterals — would husband. look the best for her (Fig. 3). Though the patient had loved the The length combination she liked selected smile design and cosmetic the most was L-2, laterals slightly image, she was not quite sure about shorter than the centrals and canines pursuing this treatment. This is why (Fig. 4). We submitted her pre-op the Slip-On Smile was such an impor- photo to SmilePix for a cosmetic tant part of her treatment presenta- image (Fig. 5) and concluded with tion. She accepted the treatment as PVS impressions (Splash, Discus Den- soon as she could experience her tal) and a bite registration (Vanilla new smile firsthand. Bite, Discus Dental). We began her treatment with a At her second consultation appoint- combination of in-office and take- ment, we confirmed the smile design home whitening. The incisals of the and length combination she had pre- canines and bicuspids, the part that viously selected by showing her a shows, had acceptable results. diagnostic wax-up of her upper and We used this as a base shade, lower teeth (Fig. 6). Matrices were planning to make the lower veneers fabricated from the wax-ups before even lighter toward the front and the this appointment and were used to upper veneers slightly lighter than make an upper and lower Slip-On the lowers. As planned, teeth Nos. 2D News Cosmetic Tribune | September 2009

COSMETIC TRIBUNE AACD unveils plans The World’s Dental Newspaper · US Edition Publisher & Chairman Torsten Oemus [email protected] for its 2010 meeting Vice President Global Sales Peter Witteczek [email protected]

Chief Operating Officer Eric Seid [email protected]

Group Editor & Designer Robin Goodman [email protected]

Editor in Chief Cosmetic Tribune The AACD Dr. Lorin Berland will meet [email protected] April 27 through Managing Editor/Designer May 1 next Implant & Endo Tribune year at the Sierra Rendon Gaylord [email protected] Texan in Managing Editor/Designer Grapevine, Ortho Tribune & Show Dailies Texas. Kristine Colker [email protected] By Fred Michmershuizen, Online Editor lectures and hands-on workshops, combines art and science to opti- Online Editor the debut of AACD Digital World, a mally improve dental health, esthet- Fred Michmershuizen The 26th Annual American Acad- bigger team program, the explora- ics and function. [email protected] emy of Cosmetic Dentistry (AACD) tion of international laboratory mod- Composed of more than 7,000 Scientific Session will take place in els and more. cosmetic dental professionals in 70 Product & Account Manager Mark Eisen Grapevine, Texas, April 27 through More than 80 educators will pres- countries around the globe, the [email protected] May 1, 2010. According to the AACD, ent at the 26th Annual AACD Sci- AACD, based in Madison, Wis., ful- the 2010 educational program offers entific Session. (A complete list of fills its mission by offering superior Marketing Manager more learning platforms than ever those scheduled to speak is avail- educational opportunities, promot- Anna Wlodarczyk before, in-depth lectures and hands- able at www.dental-tribune.com/ ing and supporting a respected [email protected] on workshops, a mix of innovative articles/content/scope/news/region/ accreditation credential, serving as Sales & Marketing Assistant presenters and topics, and social usa/id/730 and at www.aacd.org.) a user-friendly and inviting forum Lorrie Young functions that foster legendary The AACD is the world’s largest for the creative exchange of knowl- [email protected] AACD camaraderie. non-profit membership organization edge and ideas, and providing accu- Other highlights of the meeting dedicated to advancing excellence rate and useful information to the C.E. Manager will include deeper learning during in comprehensive oral care that public and the profession. CT Julia E. Wehkamp E-mail: [email protected]

f CT page 1D material was used to record her bite registration (SuperDent). Dental Tribune America, LLC 213 West 35th Street, Suite 801 To cement the provisionals, the New York, NY 10001 same bisacryl was placed in the tem- Tel.: (212) 244-7181 Fax: (212) 244-7185 poraries and seated in the mouth. The excess was removed with a micro- brush before the material set up. The Published by Dental Tribune America patient loved the way her provisionals © 2009 Dental Tribune America, LLC looked and fit (Fig. 11). There were All rights reserved. no surprises as she had chosen the smile design she liked best before any Cosmetic Tribune strives to maintain utmost work was ever even started. accuracy in its news and clinical reports. Fig. 3: P-3, pointed canines with When she returned for the final If you find a factual error or content that requires clarification, please contact Group square centrals and round laterals. porcelain restorations, the patient was Editor Robin Goodman, at r.goodman@ Fig. 2: Smile Style Guide. concerned that they might not look as dtamerica.com. Cosmetic Tribune cannot good as her provisionals. Because the assume responsibility for the validity of prod- uct claims or for typographical errors. The provisional was set up and ready to minimal preparation was all in enam- publisher also does not assume responsibility Dental) was then placed directly onto be trimmed. el, we could try the restorations with for product names or statements made by the Mach-2 for a model base. Because this method of temporiza- no anesthetic and no discomfort. This advertisers. Opinions expressed by authors are their own and may not reflect those of In less than two minutes, an accu- tion involves a quick way to make a is important to the patient to really get Dental Tribune America. rate, instant silicone model was ready model of the prepped teeth, the pro- a “feel” for the teeth, especially when on which to fabricate a provisional visional can be trimmed and polished we are increasing length. — all of which was completed by an in the lab. Finishing provisionals in We assured her that we would try assistant and outside the patient’s this manner is much more accurate, them in and get her approval before mouth. kinder and easier for the patient, and they were seated permanently. Thus, Tell us what Using the matrices made from the especially for the gingiva and the we invited her whole family to the you think! diagnostic wax-up and approved by prepped and impressed teeth (Figs. seat appointment to offer their opin- the patient in her Slip-On Smile, the 9a, b, 10a–c). ions. As is often the case, it was espe- Do you have general comments or criti- provisionals were fabricated. To prepare the gingiva for the cially important to please one family cism you would like to share? Is there First, the instant silicone model final impressions, Expasyl (Kerr) was member in particular, and this time it a particular topic you would like to see was lubicated with a water-based placed around the gumline. Final was her daughter. articles about in Cosmetic Tribune? lubricant such as KY Jelly. Next, the impressions with a PVS material, For the try-in, we used different Let us know by e-mailing feedback@ putty matrix was filled with bisacryl such as Take 1 Advanced (Kerr), or shade combinations of try-in pastes dtamerica.com. We look forward to and then placed onto the silicone Virtual (Ivoclar Vivadent), were then hearing from you! model. After a minute and a half, the taken in custom trays. A slow-setting g continued Cosmetic Tribune | September 2009 Clinical 3D

f continued

Fig. 4: Length code L-2, laterals Fig. 9b: Indirect provisionals on Fig. 10a slightly shorter than centrals and instant silicone models. cuspids. Figs. 10a–c Fig. 7: Slip-On Smile full face. (above, left and below): Upper and lower indirect provisionals on instant silicone models. Fig. 10b

Fig. 5: Cosmetic image. Fig. 8: Upper preps and prep shade.

Fig. 10c

Fig. 6: Diagnostic wax-up and putty Fig. 9a: Indirect provisionals on matrices. instant silicone models. to see what looked the most natural. Once the restorations were seat- I call this the “Mix to Match Method.” ed, the patient was ecstatic with the This method is especially impor- results. She simply could not believe tant when doing large cases with how natural her teeth looked. multiple types of restorations and They were exactly the way she porcelains. had anticipated in shape and shade, In this case, feldspathic porcelain only better (Fig. 12). The once tet- was used to fabricate the veneers racycline-stained smile was the only while the crown was made with a smile she had ever known. zirconium core. Now, for the first time in her life, When it comes to mixing cements, she could look in the mirror and we generally like to use the light- smile with confidence knowing she Fig. 11: Provisional full face. Fig. 12: Final full face. est shade for centrals and warmer had a beautiful, natural smile. shades as we go distally. This Mix In this case, a cosmetic image was About the authors to Match method helps to achieve a helpful in showing the patient a 2-D natural-looking smile. photo of how her smile could look. We ultimately decided, with the Yet, it was not until she saw her Dr. Lorin Berland, a fellow of the AACD, pioneered the patient’s input, to use a dual-cure personalized smile design in real life Dental Spa concept in his multi-doctor practice in the resin cement such as Maxcem (Kerr), with the Slip-On Smile that she could Dallas Arts District. His unique approach to dentistry Multilink (Ivoclar Vivadent) or Per- really feel and sense what that new has been featured on television (“20/20”) and in national maCem Automix Dual (Foremost) smile would truly be like. publications and major dental journals, including Time for the zirconium crown on No. 5; She was pleased with every step magazine. In 2008, he was honored by the AACD for his Cosmedent Ludicrous for Nos. 8, 9, of her smile transformation, with contributions to the art and science of cosmetic dentistry. 24, 25; Bright for Nos. 6, 7, 10, 11, 12; her provisionals and ultimately with For more information on The Lorin Library Smile Style and Yellow-Red Universal for Nos. 23 her final results. Though the Mix to Guide, www.denturewearers.com and Biomimetic Same and 26. Match Method is an extra step that Day Inlay/Onlay 8 AGD Credits CD/ROM, call (214) 999- A fresh bottle of bonding agent, requires more chair-time, the end 0110 or visit www.berlanddentalarts.com. such as Optibond Solo Plus (Kerr), results justify the means. Excite (Ivoclar Vivadent) or Adper And for this patient, that meant Dr. Sarah Kong graduated from Baylor College of Den- Single Bond Plus (3M ESPE), was a beautiful new smile with minimal tistry, where she served as a professor in restorative den- selected. Using a fresh bottle ensured tooth reduction to achieve the most tistry. She focuses on preventive and restorative dentistry, that the bond would be at its strongest natural esthetics. transitionals, anaesthesia and periodontal care. She is an potential. Each step of this process gained active member of numerous professional organizations, The teeth were cured from all more of the patient’s acceptance of including the American Dental Association, the Academy angles with the FLASHlite Magna the proposed treatment, but it was the of General Dentistry, the American Academy of Cosmetic (Discus Dental). Because it is a LED, extra steps that ultimately gained the Dentistry, the Texas Dental Association and the Dallas there is little danger of over-heating patient’s appreciation of the final County Dental Society. the teeth. results. CT