Dear colleagues! Before you continue reading the article and looking at the photos, I must note that this publication is more informative-emotional rather than scientifically oriented. This by no means implies that you won’t gain practical value. On the contrary, I’ve endeavored to enrich this presentation with tips and tricks that should facilitate your professional life. However, the main message of this publication lies in introspection and the emotional subtext of the decisions we make.
Perfectionism.
I’m sure most of us have caught ourselves at least once thinking that we do our work not so much for the patient as for the satisfaction of our own ambitions. Some call this perfectionism, which on the one hand compels us to become better, but on the other hand, poisons life. Especially when things don’t go as planned.
If you resonate with the above, then I congratulate you on behalf of all desperate dentists. Psychologists say that perfectionism is a deviation. So welcome to the club. If you hold a different opinion, you’re still welcome, because by flipping through this article, you automatically fall into the category of perfectionists. After all, you want to improve or why do you need this edition?
Be that as it may, by doing work “for yourself,” we derive pleasure from what we do.
And it should be like this – you should love your job! And perfectionism plays a significant role in this regard. And for everything to function properly, constant inspiration and motivation are necessary.
Social networks.
There is good news here: with the development of information technology, sources of inspiration have appeared so much that sometimes there is an excess of it. Especially if you take social networks with thousands of professional forums and platforms.
I didn’t misspeak: inspiration can be excessive. This is the state when such a volume of content is poured on you from all sides that the brain stops noticing it. Information overload occurs, and the perception mechanism shuts down. Want an example? Remember how many cool webinars and live broadcasts there were during the quarantine. Did you keep track of all of them?
And if before the problem was access to information, now the problem is filtering this information and identifying what’s worthwhile.
I don’t want to say that social networks and other resources are bad. On the contrary, I am a big supporter of exchanging information through internet platforms. A bright confirmation of this is our professional resources for colleagues on Instagram @maximbelograd and YouTube @BELOGRAD Academy, where a lot of useful and selective material is freely available.
Emotional Dentistry.
We just need to acknowledge that often we get carried away with admiring beautiful clinical cases from social media. Inspired, but without sufficient information and sometimes lacking necessary skills, we try to replicate them in our practice. I call this emotional dentistry. It’s not about the patients and how we change their lives through smile design. It’s about us and our emotional decision-making process: “I want to do the same as in that internet case!”
There are several outcomes and scenarios in this matter.
- 1. You succeeded because you had the skills and knowledge.
- 2. You failed because you lacked the skills and knowledge.
- 3. You failed because what was demonstrated did not match reality.
The first point is clear. The second point is also solvable – you need to learn and improve. But the third point is not so simple, because it can be difficult to distinguish manipulation from reality, and there is plenty of that on social media.
What to do?
Personally, for inspiration and, most importantly, for its implementation, I prefer practical courses. Because I am convinced that actions and hands-on work are much more effective and faster than any photos and videos. Plus, you gain and refine skills through practice.
Clinical Case, 2012.
I would like to share with you one of such a cases of emotional dentistry.
The backstory is classic: I was scrolling through Facebook, and several times I came across motivational presentations where ceramic fragments were used for tooth restoration. These were not ordinary veneers covering the vestibular surface but partial laminates without preparation, replacing only the defect. Moreover, everything was beautifully presented and described, so, like any self-respecting dentist, I felt a sense of inadequacy that my personal portfolio lacked such beauty. It was very motivating.
And as it often happens in such situations: if you really want something, there will definitely be an opportunity for implementation. And it did happen – a patient with a diastema came to me for an appointment, and I seized the chance to do work “for myself.”
An ideal situation for non-prep veneers.
Now I will list a number of parameters that are suitable for cases where non-prep veneers are needed.
- 1. Diastemas and spaces larger than 4 mm. The teeth should have parallel walls or taper towards the incisal edge. Triangular teeth with a narrow cervix are not suitable due to difficulties with insertion.
- 2. Flat teeth or teeth with oral inclination. In these situations, vestibular surfaces can be added. However, caution should be exercised in the cervical area to avoid hypercontouring.
- 3. Palatal zones in case of increasing the bite height and compensating for excess space in these areas.
- 4. Cervical defects. In these situations, restorations with ceramic fragments can be made.
- 5. Correction of incisal edges with ceramic fragments.
In our case, the teeth were without pronounced relief, had parallel walls, and the diastema was more than 4 mm.
(photo 1)
What ceramic is suitable.
For making non-prep veneers or partial veneers, usually feldspathic ceramic on a refractory or platinum foil is used. These methods allow the dental technician to achieve minimal thickness of restorations. Lithium disilicate or leucite ceramics can also be used, but this requires significant effort from the laboratory, so it is used extremely rarely.
How to avoid mistakes.
Whenever closing a diastema (no matter what type of restoration is used), it is necessary to make calculations using the golden proportion rule (to prevent teeth from becoming too wide). Alternatively, visualization can be performed.
The simplest option in this case could be temporary defect restoration with composite without adhesive preparation (demonstration mock-up). This will allow evaluating the result and making a decision about the volume of reconstruction.
In our case, we performed digital modeling (using Keynote software, Apple Inc.) and made sure that we could work only with the central incisors without the need for restructuring the frontal area. (Photo 2)
The first clinical stage.
The easiest thing in aesthetic dentistry, where restorations are required, is the first clinical stage in the case of non-prep veneers. All you need to do is take an impression and provide the dental technician with information about the color.
For the latter point, a photograph using a polarization filter is ideal. This allows removing glare from the tooth surface and providing the laboratory with a lot of information for choosing ceramic shades. The polar_eyes filter from the Bio Emulation Group (Photomed, USA) was used. (Photo 3)
A photograph transmitting the relief of the teeth is also needed. I remind you that in our case we are talking about ceramic fragments and the need for integration not only by color but also by texture. A bipolar flash works very well in this regard. In my practice, I use the R1C1 flash from Nikon. (Photo 4)
A few words about the impression.
To close the diastema, space of the gingival sulcus is necessary. This will allow the technician to perform restoration with a smooth contour and create support for the gingival papillae.
For this, double-cord retraction method is most often used. The sizes of the retraction cords are chosen according to the biotype and depth of the sulcus.
It is important to remember: retraction should be done passively and should not cause pain to the patient.
In our case, I used a size 000 cord without impregnation, which was placed first in the sulcus. Then a size 0 cord was placed on top. The first cord mainly provides vertical retraction, and the second one – horizontal.
Usually, the second cord is left for 5-6 minutes and removed just before taking the impression. The first one remains in the sulcus.
(Photo 5) First retraction cord is placed into the sulcus
(Photo 6) Second retraction cord for lateral retraction
(Photo 7) First and cords to compare
(Photo 8-9) Before taking out the second cord.
Practical Tips.
- 1. Before removing the second cord, it should be well moistened (thoroughly irrigate the entire retraction area with a puffer). A dry cord can “stick” to the gingiva and cause bleeding when removed.
- 2. After removing the cord, you have only a minute before the sulcus “snaps shut,” so the impression material (corrective) should be ready.The sequence of actions: rinse, remove the cord, dry, and quickly place the light body material into the sulcus, inflate. By this time, receive the impression tray with the mixed putty and light body from the assistant, smoothly insert it into the oral cavity, and take the impression.
(Photo 10) Impression with sulcus details.
(Photo 11-14) Some photos from the lab.
Second Clinical Stage.
If the first visit was super easy, then receiving the veneers from the laboratory makes you realise that everything in life has a balance. Adventures begin from this moment.
Fitting.
Somehow, you have to manage to deliver small and extremely thin ceramic fragments to the oral cavity and place them in position. The last point is especially dramatic because the concept of “its place” in this case is very relative. We are talking about micron shifts, but this is enough in the esthetic zone for the veneers to “shift” along with the midline tilt.
And one more thing. Under no circumstances, no matter what happens, do not press on these veneers during fitting! Otherwise, you’ll end up with a mosaic under your finger that you’re unlikely to be able to put back together as intended by the technician.
(Photo 15) Try-in. And, yes, the picture is beautiful.
Isolation.
Yet another challenge. Remember how carefully we took the impression, passing the sulcus space? Well, now there’s a rubber dam in there, and it interferes with the veneer settling into that same place! Here should be an emoji with clenched teeth, or just your photo at the moment when you’re trying to adapt the fragment after isolation. Your teeth will be clenched, trust me.
Advice: You can use Teflon for retracting the rubber dam. Carefully tuck it where you need to move the dam apically.
(Photo 16) Isolation. Teflon helped to open extra space on the tooth 1.1.
Bonding.
Everything before this stage can be considered a warm-up. We’re dealing with positioning again, and this time with cement that gets everywhere. If you ask how it’s better to bond such veneers – one by one or both at once, I’ll tell you this – it doesn’t matter. At this point, it’s much more important not to end up with a mosaic, a heart attack, and a nervous tic.
I fixed them one by one. It was easier to control the position of the veneer, excess cement, and solve one problem at a time.
Advice: Use a filled restorative flowable composite for such works. You won’t be able to integrate the ceramic fragment perfectly with enamel, and the composite will provide a smooth transition. Again, we’re talking about not the standard cement for luting but about a flowable composite shown as the final direct restoration. For example, G-aenial universal flow, GC, or similar products from other companies.
Polishing.
The luting turned out to be a warm-up. I spent a lot of time ensuring that the transition between the veneer and the tooth was seamless. It took me several visits, and still, the result was below expectations for a perfectionist. And those cases from Facebook were perfect (again, an emoji with clenched teeth).
As it turns out, I was struggling with two things: physics/optics and, perhaps, Photoshop from those beautiful cases on social media.
The thing is, the refractive index of ceramic and enamel is different. And we will ALWAYS see the optical boundary if the veneer fits flush rather than covering the entire surface. But who knew about this index of refraction, desperately continuing to polish those small but tricky restorations by all possible means?
(Photo 17-18)
On macro photographs of dry teeth, boundaries are visible. At a social distance, this is not noticeable.
Then I learned one more thing: if you don’t know Photoshop but want to present a similar case in a more favorable light, you can take a photo from such an angle where everything looks perfect. It’s also playing with refraction. But who are you fooling…
(Photo 19-20).Results after 5 years were pleasing.
In fact, despite all the irony expressed in this publication, everything is not so bad. Such restorations have a place, they demonstrate good survival rates, and add points to the professional karma. You just need to approach them more easily, know all the pitfalls, and find a dental technician champion who can implement such projects at the highest level. I was lucky with the laboratory. By the way, you can also collaborate with them – you can find them on Instagram @bgdentallab.
And also remember that such cases can be easily solved using direct composite techniques. In one visit. With less time and financial investment. But not every prosthodontist will accept this, thinking that composite is only for temporary restorations.
Conclusions:
Motivation and inspiration should always be present everywhere.
Sometimes you need to try it yourself to understand what works and what doesn’t. Or what skill and knowledge are needed to make it work.
Not everything demonstrated in the information field actually looks the way it is presented.
Critical thinking and mastery of alternative techniques will allow you to work successfully and cope with stress.
And finally. If something doesn’t work for you, remember that teeth are not eyes – nothing terrible will happen.
Hello to perfectionists!
P.S. If something doesn’t work for you, then you need to learn and give yourself time to develop skills. The fastest way is through practical courses. And we have the best ones at BELOGRAD Academy (en.belograd.com)
