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July 2, 2009

Question: I'm a dentist in the southeast region of Georgia. I was reading your article on diagnostic wax-ups, which was an awesome article. I have done a few veneer cases but would like to do more. I'm gun shy with the temps, so this was great. One question I have is: you said you use luxaglaze and cure temps into place. (Fig. 28) What do you use to cement in your temp veneers? I've had trouble with this stage on a few of my cases. Thank you for your time. I'm on my way to your Web site and am looking forward to seeing your reverse prep technique.

Answer: Thanks for your kind words. My temp technique is a cementless one. The temps are mechanically locked into place. I would prefer to cement them into place, but that's nearly impossible to do, as every time I try to remove the veneer temps to polish and cement, they break. In a case where you are only prepping Nos. 7, 8, 9, and 10, you can usually get them off to cement (with TempBond Clear), but any more units than that and they break.

So I mechanically lock them into place and keep them on for the shortest time possible. I find myself prepping into dentin less often as time goes on, so I worry about it less. I consider a "minimal-prep" veneer any veneer that is prepped entirely in enamel, and it has become my goal to use this technique as much as possible. More and more, when the prep ends up in dentin for esthetic reasons, I find myself doing an all-ceramic crown, such as Ivoclar's e-max CAD, so that I don't have to worry so much about exposed dentin and possible post-op sensitivity.

Question: Please tell me what you use to adjust and polish porcelain crowns and bridges, both intra and extraorally. From rough polishing to final polish. A lab I don't use anymore sent me some wheels for my lab mandrels and I cannot find them now so I am looking for a good practical system even if the pieces are from different manufacturers.

Answer: To polish porcelain well you MUST have an electric handpiece. I have a benchtop electric handpiece from Kavo for out of the mouth polishing, and I use a Kavo electrotorque handpiece for intraoral polishing (and all prepping).

I like the Axis Cerglaze wheels, cups and points for polishing, with the straight mandrels for out of the mouth and the latch mandrels for intraoral polishing.

Question: I really enjoy your articles and videos for better dentistry! I just read an article in Vol. 2, Issue 2 of "Chairside" and I have a few questions regarding your article on diagnostic wax-ups:

1) What is the cost of the Glidewell Lab for doing an esthetic wax-up for a specific case?

2) I'm having trouble with temps for prepped veneer cases. I like your technique using the putty material with Luxatemp. I notice you just leave it in place after forming the temps in the mouth. With no cement, do you have trouble with sensitivity or stain leaking under the margins? Also, how strong are these temps?

3.) Finally, are there other materials as good as Luxatemp, or is that the best one?

Answer: A diagnostic wax-up is $20 per tooth. Many times I feel like if patients aren't willing to pay for that to see what the veneers could look like, they aren't really ready to do the veneers anyway. So it is kind of like a screening to see who's serious.

With regard to mechanically locking on the veneer temps, I don't have much problem with sensitivity, although most of my veneer preps stay within the enamel. I know people who put a desensitizer like Tublicid Red down and then dry it prior to placing the temps, but I don't do that.

I have about the same amount of staining that I did with cemented temps, and we warn people to stay away from dark colored foods and drinks. If they must have dark drinks, it's better to drink them through a straw, for example. The worst staining I've ever seen was a guy who went to a bachelor party and smoked three cigars. His teeth were black underneath, but not sensitive. Hydrogen peroxide removed the stains quickly and easily. Temp veneers are a necessary evil and we simply try to get people through those two weeks knowing they have thin little plastic facings hanging onto their teeth. No temps is definitely an advantage of no-prep and minimal prep veneers!

I use Luxatemp out of habit, but I have used other bis-acryl materials also and they all seem to work the same. Any one should work fine.

Question: How many ounces and for how long do you have the patient swish with Cyclone?

Answer: Thanks for the question. My hygienists fill up one of those Dixie cups up about 2/3rds of the way and have the patient swish for about 60 seconds before having them spit into the hand-held cuspidor. If they swallow part of it, it is harmless but it feels a little weird having your throat be a little numb, but it's really not an issue.

Question: I have read several of your articles which mention using profound. I would like more detailed info on your technique of anesthetizing molars with a furca injection using a 30 gauge extra short needle. I have copies of your chairside publication already so I am really looking for a detailed step by step technique (e.g., how much solution to inject, how much pressure for how long, etc.)

Answer: I have been using the STA anesthesia system (www.stais4u.com) for the past year for this technique, but prior to that I did it with a typical hand syringe.

I place the Profound (stevensrx.com/dentistry.html) in the buccal furcation for 60 seconds. I bend the 30 gauge needle at a 45 degree angle and place it in the furcation with the bevel facing the occlusal surface of the tooth.

I am going to give 2/3rds of a carpule of Septocaine slowly. There should be a lot of pressure as you get into the injection, although at the beginning of the injection go slow to keep the patient from feeling pain. If you don't feel a lot of pressure in the middle of the injection remove the needle and reposition the needle in the furcation.

If I look at an xray of the tooth and see that the mesial and distal roots do not have an obvious furcation or the roots are fused, I give half of a carpule of Septocaine (www.septodont.com) on the buccal in the area of the furcation and the other half on the lingual in the area of the furcation.

One of the reasons I like the STA anesthesia system is that it takes a lot of the thinking out of the process by constantly showing you how much pressure you are encountering and the rate of anesthesia administration.

Question: Could you please tell me the name of the high speed handpiece you recommend to be good and inexpensive?

Answer: Good and inexpensive? I am not sure if that handpiece exists or not!

I know CRA has always recommended the Lares Research high speed handpieces as a good value, and the Kavo handpieces if you are willing to spend a little more for some more durability.

At this point I won't use anything but electric handpieces, and my favorite is the Kavo Electrotorque system. Electric handpieces allow me to prep crowns better than ever, especially because I can turn the speed way down and finish the margins without the water on. I can also now polish porcelain intraorally as well as I can outside the mouth due to the high torque of the electric handpiece. This means any time I have to adjust occlusion after cementation I know I can get the same smooth polish on the crown as if I sent it back to the lab and had them polish it.

Question: In your recent issue there is an article about making veneer temps with Luxatemp. Nothing is said about what keeps this in place. Can you let me know if cement is used and if so what?

Answer: There is no cement used in this technique, the temporary veneers are mechanically locked into place. This is a potential shortcoming of this technique and I have tried many times to remove the temporaries to finish them out of the mouth and recement them, but they break literally every time I try to remove them.

The only exception is when there are only four veneers, such as 7, 8, 9, and 10. In those cases my cement of choice is TempBond Clear from Kerr since there is no cement show through which can be a big problem with thin veneer temps.

With minimal prep veneers, the tooth structure under the temps is enamel, so you don't have to worry about bacterial invasion of dentin. WIth normally prepped veneers and this technique some dentists place and cure bonding agent on the tooth prior to mechanically locking the temps into place to provide some protection to the dentin. At the seat appointment the dentist can is etched and bonded as usual, although I use a fine diamond in an ultrasonic handpiece to freshen the dentin surface prior to bonding.

Dr. Michael DiTolla is the Director of Clinical Research and Education at Glidewell Laboratories in Newport Beach, Calif. He lectures nationwide on both restorative and cosmetic dentistry. Dr. DiTolla has several free clinical programs available online or on DVD at www.glidewelldental.com. For more information on this article or his seminars, visit www.drditolla.com.

If you have a question you would like to submit to Dr. Michael DiTolla, click here

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