Written by Andrew Sedler / April 1, 2021
Successful dental treatments rely on communication between the dental lab and the dentist. The ability to communicate effectively in the dentist-lab relationship is what sets excellent case outcomes and mediocre outcomes apart.
While communication has advanced over the years, it remains one of the most critical aspects of overall patient satisfaction. Modern dental practices and labs have excellent resources to model the desired result and put a plan together to meet patient expectations.
Burbank Dental Lab has been fortunate to work with some of the top clinicians in the country. Dr. Craig Goldin sent in the following case to help the patient remedy some of the areas of her smile that she felt needed improvement. Her biggest concerns were her dislike for the spaces between her teeth and her desire to have whiter teeth.
Dr. Goldin began treatment planning the case by diagnosing the patient's current situation and how to best meet the patients’ expectations.
The evaluation determined that the patient’s incisal edges did not follow the contour of the lower lip, indicating a reverse smile line. Her anterior teeth flared out labially; the bicuspids tipped lingually, revealing negative space in the posterior. There were diastemas between the anterior teeth at numbers 6/7/8 and 9/10. Her teeth appeared short and square with attrition indicative of a bruxism habit. A darker shade and discoloration were also present.
A treatment plan was developed to remedy the patient's chief concerns and address the current diagnosis.
Orthodontics was considered as a possible part of the overall treatment in this case, but since the patient appeared to have an upper arch tooth to jaw size discrepancy, this issue would have led to residual spacing post ortho treatment.
Orthodontics can be a viable pre-prosthetic treatment option before starting many veneer case scenarios and can often allow for more conservative treatment and advanced esthetic results.
For this particular case, part of the treatment plan consisted of overall teeth whitening to meet the patient's desire for a whiter, brighter smile.
While making preliminary planning steps of the case, shade selection should be discussed. The shade selection in these types of cases is one of the most significant decisions the patient will make.
This particular patient wanted the whitest shade available (BL1). According to Dr. Goldin, it is crucial to provide guidance when discussing color, but it is imperative that the patient ultimately make the final choice.
In addition, to address the need to close the existing spaces, add length, and decrease the labial flare, it was decided to place ten E.max layered veneers on teeth 4-13. E.max was chosen as it is one of the most widely used materials for anterior veneers.
According to the Ivoclar website, there have been over 150 million e.max restorations placed over the last 15 years, with an overall 96% survival rate.
E.max is a lithium disilicate glass-ceramic with ingots available to match the full spectrum of shades. The ingots come in five translucency levels to achieve almost any desired result.
Restorations can be monolithic utilizing the staining technique or layered to incorporate built-in characterization. Some of the benefits of e.max restorations include:
Considering the long history of clinical success with e.max, along with its many benefits, it was an easy material choice for this case.
As with any large case, a diagnostic wax-up was done to provide a mock-up of all of the key information provided by Dr. Goldin. In the wax-up stage, Burbank Dental Lab created a template that incorporated the length, shape, and position of the new smile. Crown lengthening is evaluated at this stage and incorporated if it is necessary to achieve the desired results. This diagnostic wax-up was presented to the patient, but more importantly, it was used to create the patient's provisionals.
Provisionals are a test run for the patient before final restorations are fabricated. The patient can wear these for a time and report any corrections they may want before the fabrication of their final restorations. In addition to length and shape, the shade can be tried out in this stage as well.
Whenever possible, use the corresponding temporary material shade as the patient's final shade selection. If there is no exact match, simply mention that the color will either be lighter or darker.
After Dr. Goldin's patient accepted the proposed plan to address her gummy smile, a minor gingivectomy was performed using a diode laser. This procedure helped add length to the teeth and create more ideal symmetry to the gingival contours.
Dr. Goldin suggests that it is crucial for the final restorative margin to be 3 mm from the bony crest to prevent invading the biological width. Many cases require osseous crown lengthening procedures to avoid this issue. Failure to respect the biological width parameters can result in chronic inflammation.
The final prescription, along with impressions, bites, and face-bows, were provided to the dental lab.
The wax-up was used as the template in fabricating the final restorations. This, along with the notes and feedback gathered from the patient's trial run with the provisionals, was used to create this patient's ideal smile.
Finally, because this patient was noted to be a bruxer, an occlusal guard was fabricated to protect her teeth and the new e.max restorations. An occlusal guard was used to ensure her teeth and restorations would be protected throughout the night.
Burbank Dental Lab offers either soft, hard, or a combination of hard and soft guards depending on indication and preference. No matter the material, they are custom designed to protect teeth and dental restorations.
Planning and communication between the dentist and the lab are essential in achieving optimal results. Listening to the patient's desires and the proper diagnosis, treatment, diagnostic tools, and an understanding of the best materials to achieve the desired results all come together to ensure patient satisfaction.
We want to thank Dr. Craig Goldin of Cosmetic Dentistry Institute for providing photos and specific information about this case.
Contact Burbank Dental Lab to let us fabricate your next e.max layered veneer case.
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