Direct mock-up digital workflow for ceramic veneers

The need for a digital workflow has become quite trendy in the dental world to take records and spend time on an electronic device for treatment planning. It all seems so simple and we feel we are doing a job which is contemporary.

It is a known fact that bonding is best achieved when done to enamel, so the goal of indirect veneers should be additive as much as possible. This, as stated in previous articles, can be achieved by pre-prosthetic orthodontics, bleaching, preparation through a mock up and with the vertical preparation technique.

Time is also of the essence and it works in a clinician’s favour when the result of the treatment suggested and executed has the least promise gap.

Quite often there is a sense of “what if it will not look good in the mouth although it seems alright on the computer” and “Will it alter my speach?” or  “Will I be able to bite normally?” are common concerns that affect the patient we receive in our daily practice.

Also, with the popularity of social media and with smart phones being used a common entity, easy and quick communication helps suggest treatment. Quick and effective communication also reduces steps and time for both the clinician and the client.

A very valuable tool in the initial consulting of the patient who wants to have indirect veneers as a treatment choice is a Direct Mock Up. A case is shown and dos & don’ts are explained for an effective direct mock up.

A very simple device used for MDP (Mobile Dental Photography) is also being used more and more and a case of quick communication is being shown with the device with a direct mock up.

The author would like to thanks DT, Lamberto Villani, Oral Design, Dubai for this valuable support in fabricating the veneers.

Fig.1

A 35 year old female patient came in seeking a better esthetic outcome with her smile. She presented with some diastemas and also with some wear of her teeth. Inability to perceive the final result had her defer having any treatment done.

Fig.2

Pre operative Frontal View.

Fig.3

Right side Pre Operative View.

Fig.4

Left side Pre Operative View.

Fig.5

A Direct Mock up done in the 1st appointment can be a very effective tool for patient communication as well as for diagnosis and treatment planning.
TIP 1
Do not etch the tooth tissue and, keeping this in mind, do not use a self-etching adhesive system for the mock-up.
TIP 2
Use a medium opacity shade of restorative resin as the very translucent ones give a greyish appearance which, sometimes, is not appealing to patients.

Fig.6

Sculpt the composite on one side first and keep in mind the final desired outcome and the primary anatomy of the teeth.

Fig.7

Another view of the Direct Mock up on the right side.

Fig.8

Sculpt the composite on the other side, again keeping in mind the final desired outcome and the primary anatomy of the teeth.

Fig.9

Evaluate the mock up and check for incisal edge position, esthetics, smile line, phonetics and function. Adjustments to this can be made using polishing discs (Sof-lex ; 3M Espe).

Fig.10

It is imperative to sit facing the patient with the patients face parallel to the horizon when adjusting the mock up. In case one tends to ignore this and do it in a reclined position, he is more likely to make a mistake with the smile line which often turns out canted to one side or the other.
[This image is for illustrative purposes and is not of the case being presented]

Fig.11

The adjusted mock up as shown should be a close representation of the desired final outcome.

Fig.12

Intra Oral View of the adjusted Mock up. An alginate impression can be made of the same to convey what has been achieved to the laboratory technician. In case one wants to follow a digital work flow a scanner can be used to scan the mock up and create a 3D wax up model.

Fig.13

Once the mock up has been done, photos can be taken with a smart phone and using Smile Lite MDP (by Prof. Louis Hardan) to have quick and effective communication with the patient and also with the laboratory technician. This has 2 distinct advantages:
1) Very quick transfer of images not needing attachment to change size, then attach to an email. On receiving the images the patient has to open an email and download them.
2) Due to built-in compression algorithms in the messaging applications images are relatively of small size there by enabling them to be shared with whoever the patient might want to include in the decision making process. This results in easier acceptance of treatment suggested.

Fig.14

Once a wax up has been received it is then duplicated in the mouth using temporary crown and bridge material in silicone key/index.
TIP 3
Always mark the midline of the index. This enables quick orientation while seating it in the mouth and, hence, a more accurate mock-up at the preparation stage.

Fig.15

Prepare through the mock up and the goal should always be tooth tissue preservation.

Fig.16

A light chamfer is suggested for the best long term out come and the tooth surface should be smoothened with no sharp edges.

Fig.17

Finish lines inter-proximally are placed according to the clinical situation. In case a diastema is being closed they are extended far more palatally.

Fig.18

A stump shade is taken and sent to the laboratory technician.
TIP 4
Take the stump shade before taking an impression as the materials cause dehydration of teeth and thereby a wrong shade might be chosen.

Fig.19

8 Feldspathic veneers were cemented and adjusted.

Fig.20

Intra Oral Occlusal View shows the final result which is very close to the initial mock up design

Fig.21

Incisal edge position in relation to the lips.

Fig.22

Right side post operative view.

Fig.23

Left side post operative view.