Journal IDA Special Section - Annual Session
Journal of the Indiana Dental Association | Volume 97 · 2018 · Issue 1
Smile design was also taken into consideration. The midline,
axial inclination, lip line, incisal edges and phonetics, inter-
proximal contacts, gradation, gingival symmetry, gingival
contour, and zenith were all taken into consideration when
designing the case from preoperative models, wax-up, tem-
poraries, and final restorations.
Although it was a given
before we started this case that we would not be able to
achieve the perfect smile design, the intent was to design a
natural symmetry by improving tissue contour.
On tooth preparation day, the wax-up, color choices, and
any concerns the patient had were reviewed and discussed.
All instruments, materials, and supplies were out and ready
to use to help facilitate the efficiency and speed of the pro-
cedure. A simple checklist was used to keep the clinician
on track, eliminate mistakes, and improve the information
provided to the lab.
To manage the bite and maintain centric stops during the
course of the preparation, a preoperative hard-bite (Lux-
aBite, Zenith/DMG) was taken before anesthetic was given.
The patient was anesthetized, an OptraGate (lvoclar Viva-
dent) was placed to aid in lip retraction, and a diode laser
(HoyaConBio) was used to improve tissue symmetry and
contour. An incisal guide stem was then tried in to aide the
clinician in visualizing and preparing the wax-up.
One mistake commonly encountered by the author and ob-
served by dental laboratories is the over- or underpreparing
of teeth in the wrong dimension facially, lingually, incisally,
mesially, and distally. This can ultimately affect the arch form
by allowing for too thick of a restoration facially or lingually
and affect the laboratory’s ability to create a natural golden
proportion. With an incisal guide stent, the clinician can pre-
pare the case to the wax-up to give the laboratory the ideal
arch form, base, and golden proportions to build the case
from. In this case, the preparation of the teeth began with
slice prepping the anterior to allow the laboratory the room
to create a natural esthetic symmetry.
The incisal guide stent made from the wax-up was tried
in to evaluate if the clinician had made the proper facial,
incisal, and interproximal reduction. Adjustments were made
and the initial bite was relined to maintain centric stops
in six dimensions. The final preparations were evaluated,
smoothed, and contoured, and a final check compared the
incisal length of the wax-up and the prepared centrals to en-
sure proper incisal reduction. Note that the lingual cusps of
all four pre-molars were kept intact to allow for the preser-
vation of tooth structure (Figure 5).
Full-coverage crowns aren’t always necessary as long as
there is adequate healthy tooth structure to bond to and the
occlusion is stable.
An impression was taken with Take
1 (Kerr Corporation) fast-set medium body and wash and
inspected for marginal integrity, distortion, and voids near
margins. It is important to use like materials with the same
setting time to eliminate delamination of the wash and me-
dium body materials.
Before the preparations were to be temporized, stump
shades and pictures were taken and sent with the case to
the laboratory. Stump shades allow the laboratory to build
the veneers/crowns on the same color of the underlying
tooth structure. This allows for a more natural and predict-
able final restoration and a better cervical blend at the
marginal area. A symmetry bite was taken with a John Kois
Facial Plane analyzer (Panadent Corp) to correct/con-firm
any midline or cant issues.
The temporary stent made from the wax-up was tried into
place to get a feel for the fit and removal. A midline/frenum
mark was inscribed on the stent with an instrument to give
the clinician a reference point when the stent was filled with
temporary material. A desensitizer with fluoride (Aquasil,
Dentsply Caulk) was coated copiously on the prepared
teeth and lightly desiccated.
The stem was then filled with the temporary material B1
shade (LuxaTemp, Zenith/DMG), being careful not to lift the
tip of the dispenser out of the material to avoid air bubbles.
As soon as the stent was filled, it was tapped two to three
times on a hard surface to bring any air bubbles to the
surface before placement into the patient’s mouth. The
temporary material was allowed to set for 2.5 minutes and
was then removed by pulling one side out and around while
holding the other side firmly in place. The intent was to al-
low the material to stay on the prepared teeth and polymer-
ize (shrink wrap) to allow for proper retention. The temporar-
ies were trimmed for excess, contoured, a flowable B1 resin
(LuxaFlow, Zenith/DMG) was added where air bubbles and
voids were present, and light-cured.
After adjusting the occlusion and polishing the temporaries,
a light-cured varnish (LuxaGlaze, Zenith/DMG) was applied
with a brush and light-cured. The patient was pleased with
q Figure 5 - ﬁnal preparations