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Restorative TC-christmas 6/19/08 11:26 AM Page 34 restorative townie clinical All I Want For Christmas... Front Teeth This may be Christmas in July as this case documents a challenging set of composite veneers. Log on to the message boards of Dentaltown.com today to participate in this discussion and thousands more. ka Posted: 12/20/2007 Post: 1 of 29 Total Posts: 153 I have been seeing this patient for a few months and have been working him up with a view towards a comprehensive restorative plan once his etiology and risk factors are controlled. Patient is a bruxer, has gastritis with reflux, smokes 30 cigarettes per day, consumes one to two bottles of white wine per day and is dental phobic. We are doing well thus far and a month ago, I took records to initiate treatment. He wanted to have a semblance of a smile for Christmas. I initiated treatment to establish the incisal edge position so he could have his wish and will follow this with, cores, clinical crown lengthening and pending compliance and stability the final restorative phase. All this with a conformative approach. Pre-op Pre-op Direct composite resin Same build-ups. Tetric Evo Ceram A2 / Tetric colour White Finish for now Conclusion: Hope he sticks to the game plan. ■ jasonsmithson Posted: 12/20/2007 Post: 3 of 29 Total Posts: 1416 Nice resin... most likely nicest I have seen on the boards. For me, I would have preferred to angle distal line angles of laterals more mesially (i.e. to midline). This is a “personal taste” thing and in no way detracts from the case. I bet the directs got you “buy in.” continued on page 36 34 July 2008 ■ dentaltown.com Restorative TC-christmas 6/19/08 1:11 PM Page 36 restorative townie clinical continued from page 34 Why are you going comformative? Is it so you can stage without total commitment to FMR [fullmouth restoration]? ■ Jason dboudro Posted: 12/20/2007 Post: 4 of 29 Total Posts: 673 You did a very nice job for this patient, better than I can do. I’m sure he’ll have a much better Christmas. I also like the way you are handling the case, it shows compassion for the patient yet conservative until stability/compliance is at least demonstrated in the short term. ■ sea_bass Posted: 12/20/2007 Post: 7 of 29 Total Posts: 465 What do you use to contour and finish? Really well done. ■ Jason, I decided conformative approach as soft tissue profiles are reasonable, clinical crown heights can be managed with crown lengthening. FWS, closest speaking space OK. Julio, these anterior restorations form part of the diagnostic process for his treatment, if he smashes them or not, either way it will give me further information. His dentition as you can see has much tooth surface loss and these anterior build ups aside from locating the incisal edge position, restored light anterior lingual contact between the anterior mandibular and maxillary teeth with some freedom. I have put him into a splint as well. Don’t know how things will pan out, will just have to wait and see. Polished these with the HfO [Hafnium Dioxide] protocol diamonds, rubbers, and pastes with goat’s hairbrush and then felt wheels. ■ ka Posted: 12/20/2007 Post: 8 of 29 Total Posts: 153 sea_bass Posted: 12/20/2007 Post: 9 of 29 Total Posts: 465 How do you create the surface detail, lobes, etc? I either get too flat or a gouged look when I try to create lobes I can’t continued on page 38 36 July 2008 ■ dentaltown.com Restorative TC-christmas 6/24/08 1:07 PM Page 38 restorative townie clinical continued from page 36 get that subtle irregularity. All I want for Christmas is your anterior skills and Jason’s posterior skills. I also wish like I could golf like Tiger. Keep posting. ■ bugalga Posted: 12/20/2007 Post: 10 of 29 Total Posts: 32 I was thinking the exact same thing. I’d like Jason’s posterior skills and your anterior skills as well. You’re not located in the U.S. are you, ka? My guess is that you’re actually Vanini or Dietschi using the pseudonym “ka.” Most guys who use HfO are abroad in the U.K. or Europe. Those are some sweet directs. Did you use a lingual shell or is that all freehand? How long did that take you, six hours? ■ ka Posted: 12/20/2007 Post: 12 of 29 Total Posts: 153 Thanks for your comments. Mounted models and diagnostic wax-up and worked of a lingual matrix. Freehanded the rest. I only used one shade, Tetric Evo Ceram A2 and White Tetric Colour. Used diamonds to develop some macroanatomy and then pumice impregnated rubbers to blend and modify, fine diamond polishing pastes with goat’s hair brush and selectively superfine paste with a felt wheel. In the pre-op, the 23 has almost no residual structure. I placed one teardropshaped Whaledent pin distally on the 23. Took a two and a half hour appointment to place and two days later one hour to finalize. ■ bugalga Posted: 12/20/2007 ■ Post: 14 of 29 Total Posts: 32 Did you use the infamous pull-thru technique to get the contacts? ■ ka Posted: 12/21/2007 Post: 15 of 29 Total Posts: 153 Pull thru technique? Not sure of that one. Can you describe it for me? ■ ■ bugalga Posted: 12/21/2007 Post: 16 of 29 Total Posts: 32 It’s when you place composite against a mylar strip from the facial interproximally then pull the mylar strip through while torquing slightly to the lingual to “hug the tooth.” This will pull the composite towards the lingual. Afterwards you go back and brush the composite towards the contact area on the facial and make any minor adaptations prior to curing. Newton Fahl came up with it and there is a small video clip by Mike Melkers in one of his threads. I don’t remember which one though but it was a step-by-step direct composite veneer on a peg lateral. It works really well for tight contacts. ■ ka I haven’t heard Newton lecturing. He was here in Australia recently but I was busy with some studies. I just used the wax-up to make a lingual/incisal matrix with a raised surface on the distal occlusal like a kind of bite block for the patient to rest his mandibular teeth on. I cut up a thin toffelmeier band into about one Posted: 12/21/2007 Post: 17 of 29 Total Posts: 153 38 July 2008 ■ dentaltown.com Restorative TC-christmas 6/19/08 11:26 AM Page 39 restorative townie clinical centimeter sections. After building the lingual surface to just short of the interproximal contact points, I inserted the little strips through the contact area and into the putty matrix which made the strip stable, followed with a custom wedge and then built the interproximal areas and contacts. I developed all in this way and then came back and finished all the labial surfaces. ■ d_utas Nice job ka! I use a similar Posted: 12/29/2007 technique but with teflon Post: 19 of 29 plumber’s tape to produce tight Total Posts: 4 contacts between the anteriors. After the first one is built-up the tape is wrapped across the inter-prox surface. The next tooth can be built-up against the tape without the problem of bonding to the other composite. I learned the technique from Dr. Bruce Kleeberger. Cheers. ■ ka It will be interesting to see Posted: 1/4/2008 how this one plays out. I saw Post: 25 & 26 of 29 him yesterday; restorations are Total Posts: 153 still there, in one piece, took a hard line regarding the etiology and management. [Posted: 2/18/2008] Review today, See photo. Poor compliance, does anyone have any ideas on how to proceed. There is only so much advice one can give, I guess I will have to wait until he values his teeth. Hope there’s something left to work with. Three months later... What now? ■ Find it online at Read the rest of the dentaltown.com conversation and add your comments on www.townie central.com. Type in “All I Want for Christmas” in the search text box and click, “Search.” ■ FREE FACTS, circle 13 on card dentaltown.com ■ July 2008 39