Predictable Strategy to Oblique Blended-Media Beauty Dentistry

Predictable Strategy to Oblique Blended-Media Beauty Dentistry


For achievement with oblique mixed-media beauty case preplanning, every case is extraordinarily necessary to realize the perfect outcomes. Utilizing diagnostic information, akin to mounted diagnostic solid fashions, pictures, radiography, and diagnostic wax-ups, is necessary to plan out the case previous to enamel preparation. These circumstances are rather more complicated as you’re coping with various kinds of restorative supplies, methods, and aesthetic protocols. For instance, there’s a distinction in tooth preparations for veneer preps vs crown preps. This distinction can have an effect on the interior shade coloration of the tooth preps, the depth of every preparation, and the optical thickness of aesthetic restorative materials used for every tooth.    


The affected person was a 36-year-old feminine in typically good well being. Greater than 15 years in the past, her anterior enamel had been corrected with veneers and a resin-based mounted bridge. At presentation, the affected person didn’t like her smile, because it had turn into aged, worn, and visibly unaesthetic over time (Figures 1 and a pair of).

Predictable Strategy to Oblique Blended-Media Beauty Dentistry

Determine 1. For years this affected person didn’t like her smile due to the intense darkening of her present anterior restorations. This created a really aged look.

Determine 2. The retracted view reveals the intense staining of her present anterior veneers and bridge (Nos. 8 to 10).

First, a full complete examination and diagnostic work-up had been accomplished. A periodontal examination, aesthetic dental evaluation, facial evaluation, and full-mouth radiographic collection had been necessary to know the small print wanted previous to restoring the case. As well as, a complete occlusal evaluation was finished to make sure a predictable, practical, aesthetic outcome.1 Though the affected person was lacking a left central incisor, she was not concerned about having a dental implant. So it was decided that the lacking tooth could be restored with an anterior mounted bridge. Additionally, porcelain veneers would change the present, very stained veneers (Determine 3). Historically, this case might need been approached with full crowns as a substitute of porcelain veneers as a result of issue of matching veneers to completely prepped enamel for the bridge. Nevertheless, preserving pure dentition with veneer preparations was extra fascinating for minimally invasive functions regardless of the rise in issue. 

Determine 3. Previous to the beginning of therapy, you will need to arrange the case diagnostically.

It is very important be aware that the clinician should perceive the diagnostic standards, therapy planning course of, and organic parameters concerned achieve predictable outcomes when treating the aesthetic zone.2 After mounting diagnostic fashions on a semi-adjustable articulator (Denar [Whip Mix]), a diagnostic wax-up was accomplished to mirror the brand new contours and proportions within the new aesthetic association. To maximise facial aesthetic magnificence, you will need to customise the smile design to create the perfect outcomes.3-5 

Blended-Media Remedy With Porcelain Veneer Preparation and an Aesthetic Anterior Bridge

Utilizing a diamond prep depth information bur (Porcelain Veneer Package [Komet USA]), the previous porcelain restorations alongside Nos. 6, 7, and 11 and the present anterior bridge from Nos. 8 to 10 had been eliminated. For the porcelain veneer preparations, mild chamfer margins had been positioned slightly below the free gingival margin. A transparent matrix was used to confirm the clearance wanted for 0.5-mm porcelain veneers.6 The enamel preparations had been completed and marginated with tapered chamfer diamond burs (850.FG.014 [Komet USA]). Each time attainable, it’s good to go away enamel intact for optimum porcelain-to-tooth bonding, as this helps improve the long-term success of bonded porcelain veneers.

For the anterior mounted bridge, barely extra axial discount (roughly 1.5 mm) was wanted for the brand new porcelain-to-gold (PFG) mounted bridge. Compared to porcelain veneer margins, the heavy chamfer abutment margins had been positioned 1.0 mm subgingival to create a natural-appearing emergence profile7 (Determine 4). To scale back darkening alongside the facial margin of the abutments, a porcelain shoulder was included alongside the margin of the ultimate PFG bridge. This could make the ultimate outcome seem pure.  

Determine 4. Compared to crown preps, minimal preparation ought to be finished for veneer preps to retain as a lot enamel as attainable.

Alongside the pontic web site of the bridge, the gingival tissue wanted to be aesthetically refined to create a natural-appearing gingival emergence profile. State-of-the-art strategies for minimally invasive soft-tissue surgical correction had been finished alongside the pontic web site with using laser-assisted dentistry. With a radical understanding of the dento-gingival complicated, predictable correction of gingival tissue might be addressed.8,9 A excessive diploma of precision with an ovate pontic might be attained with a dental laser.10,11 Utilizing an Er,Cr:YSSG laser (Waterlase iPlus [BIOLASE]), a soft-tissue surgical process was carried out to create this new emergence profile12,13 (Determine 5). Utilizing an erbium laser leads to minimal to no bleeding, much less wound contraction, and fewer ache in comparison with a standard method.14 

Determine 5. Utilizing an Erbium (Er,Cr:YSSG) laser (WaterlaseiPlus [BIOLASE]), the ovate pontic web site was sculpted to create the proper gingival emergence profile for the bridge.

 Since we will predict the place the gingival tissue will heal previous to the precise therapeutic course of, ultimate impressions (Impregum [3M]) had been finished on the identical day because the laser surgical procedure and enamel preparation.8 As well as, a inflexible chew registration (Blu-Mousse [Parkell]), a face-bow measurement (Denar Slidematic Facebow [Whip Mix]), and inside shades of the prepped enamel had been taken. The interior shades are significantly necessary because the ceramist must see the precise coloration worth and chromacity of all of the underlying enamel preparations with a view to neutralize the various inside shades of the totally different prep depths and have the ultimate exterior coloration seem uniform15 (Determine 6).

Determine 6. As totally different depths of a tooth preparation will exhibit totally different chromacities of inside shade, you will need to convey the interior shades to the ceramic artist.

Aesthetic non permanent prototype veneers (TurboTemp 3 [Zest Dental Solutions]) and a bridge had been hand sculpted. The non permanent prototypes had been designed to help the therapeutic gingival tissue, meet the aesthetic expectations of the affected person, and dial within the correct occlusal steerage (Determine 7).

Determine 7. The non permanent prototypes had been designed to help the therapeutic gingival tissue, meet the aesthetic expectations of the affected person, and maximize facial aesthetic outcomes.

Assembly the affected person’s aesthetic expectations is especially necessary because the success of the case all the time wants to fulfill the aesthetic imaginative and prescient of the affected person. Compared to utilizing a pc software program for aesthetic improvement of the case, inventive time was spent with the affected person mixing the proper contours, proportions, and coloration shading to maximise her facial stability and facial aesthetics.16,17 Creative hand sculpting was used to intensify the contours of her non permanent prototypes to match her character, lip curvature, and distinctive facial options (Determine 8). This invaluable time spent with the affected person results in no guesswork within the aesthetic facets of the ultimate restorations.18,19

Determine 8a. Creative hand sculpting of the non permanent prototypes is necessary to match the brand new smile to the affected person’s character and distinctive facial options and meet the aesthetic imaginative and prescient. Determine 8b. An exterior coloration shade was taken to convey to the ceramist the shades wanted to mix to the present dentition.

Together with the lab prescription, a custom-made coloration map and texture map was despatched, so the ceramic artist was in a position to artistically create the ultimate porcelain veneers and aesthetic anterior PFG bridge utilizing the non permanent prototypes as a information (Figures 9 and 10). After receiving the aesthetic restorations from the ceramic lab, they had been evaluated to make sure the brand new porcelain restorations would meet the affected person’s aesthetic expectations.20,21 

Determine 9. The ultimate porcelain veneers and anterior bridge had been fabricated utilizing an in depth lab prescription, coloration map, texture map, and artistry by the ceramic artist to mix the mixed-media case.

Determine 10. Correct anterior steerage and canine-protected perform had been instilled into the ultimate restorations.

Attempt-in and Closing Bonding of the Closing Restorations

On the seat appointment, the non permanent prototypes had been eliminated and the surfaces had been cleaned with a plain flour of pumice slurry utilizing an ICB rotary brush (ICB Brush [Ultradent Products]). Optimum gingival tissue therapeutic was seen on account of high-quality marginated temporaries and correct hygiene upkeep throughout this provisional interval (Figures 11 and 12). 

Determine 11. Upon elimination of temporaries, there was optimum gingival tissue therapeutic alongside the enamel preparations and the ovate pontic web site. This was a results of high-quality marginated temporaries and correct hygiene upkeep.

Determine 12. Wonderful therapeutic was seen alongside the pontic web site to develop correct emergence profile of the brand new bridge pontic.

The brand new porcelain veneers and bridge had been tried in to judge total match, aesthetic contours, interproximal contacts, and gingival embrasures. Moreover, an intimate match of the pontic of the bridge to the ovate pontic web site was verified (Determine 13). Subsequent, the exterior coloration of the veneers to the PFG bridge was significantly scrutinized to make sure the ultimate aesthetic look would have uniform exterior coloration mixing. Porcelain veneer try-in pastes (Selection 2 Attempt-In Pastes [BISCO]) had been used to evaluate this uniformity. 

Determine 13. The brand new porcelain veneers and bridge had been tried in to judge total match. Discover the slight blanching of the gingival tissue over the pontic of the bridge. This verifies an intimate match for a naturally showing emergence profile of the pontic web site.

After acceptance of the try-in section by the affected person, the porcelain veneers had been cleaned and ready with a ceramic etch after which silanated with a silane coupling agent (BIS-SILANE [BISCO]). After air-drying, a skinny layer of porcelain-bonding resin (Porcelain Bonding Resin [BISCO]) was positioned alongside the intaglio floor of the veneers to additional optimize adhesive power.22  

In making ready the PFG bridge restoration, the intaglio floor was micro-etched (MicroEtcher II [Zest Dental Solutions]), then 2 coats of primer (Z-Prime Plus [BISCO]) had been positioned for five minutes and dried completely. Utilizing a primer helps facilitate the chemical bonding of the restoration to the luting resin cement23 (Determine 14).

Determine 14. The intaglio floor of the bridge was handled with Z-Prime Plus (BISCO) to extend the chemical bonding to the bridge abutments.

To scale back gingival crevicular fluid contamination, a skinny gingival wire (4-0 suture wire [Patterson Dental]) was gently tissue-packed for all enamel. Within the ultimate bonding of the veneers, plain flour of pumice was used for ultimate cleaning of the prepped surfaces. Subsequent, chlorhexidine gluconate (Cavity Cleanser [BISCO]) was used as an preliminary disinfectant. A 32% phosphoric acid (Choose HV Etch w/BAC [BISCO]) was positioned on the enamel utilizing a selective-etch method for 20 to 30 seconds, then rinsed off completely. A desensitizer (MicroPrime G [Zest Dental Solutions]) was swabbed for 20 seconds previous to inserting the dental adhesive (ALL-BOND UNIVERSAL [BISCO]). A number of layers of this adhesive had been thinly positioned, blown skinny, and light-cured alongside all surfaces (Determine 15). 

Determine 15. A number of layers of ALL-BOND UNIVERSAL (BISCO) adhesive had been thinly positioned, blown skinny, and light-cured alongside all surfaces of enamel Nos. 6, 7, and 11.

For all 3 porcelain veneers (Nos. 6, 7, and 11), a light-cured luting resin cement (Selection 2 translucent luting resin cement [BISCO]) was positioned, positioned, and tack-cured for two seconds alongside the incisal edge. After light flossing by way of all of the proximal contacts, a lot of the extra luting resin cement was eliminated. Then all veneers had been light-cured concurrently alongside all surfaces. After ultimate light-curing, the margins of the veneers had been cleaned utilizing a curved scalpel blade (#12 Bard-Parker [Aspen Surgical]). Then the margins had been completed with ending burs (H50A.FG.010 and 8379.FG.012) (Determine 16). Lastly, a Ceramic Sprucing Package (4533C.RA [Komet USA]) was used to create a ultimate stunning luster on the case.

Determine 16. After bonding the porcelain veneers, new restorations had been completed and polished previous to seating the anterior bridge.

Determine 17. The bridge was positioned with TheraCem luting cement (BISCO). The distinctive chemistry allowed straightforward cement elimination through peeling off the surplus after the preliminary setting.

Determine 18. Oblique mixed-media beauty procedures might be profitable when incorporating all the mandatory particulars.

Within the ultimate placement of the PFG bridge, a self-adhesive luting cement (TheraCem [BISCO]) was used. With constructive stress, the bridge was positioned on the abutment enamel, and extra cement was allowed to extrude (Determine 17). The margins had been tack cured for a number of seconds. This allowed the surplus cement to semi-set so it could possibly be simply peeled off. Due to the distinctive properties of TheraCem, easy elimination of extra cement was carried out alongside the interproximal surfaces and below the pontic web site with floss. Extra flossing and margin cleanup had been finished to finish the process (Determine 18). The ultimate results of oblique mixed-media beauty circumstances might be very profitable aesthetically with long-term success (Figures 19 to 21).

Determine 19. Shade mixing of the porcelain veneers and PFG bridge might be profitable by following therapy protocols.

Figures 20 and 21. By incorporating a methodical diagnostic method, aesthetic protocols, and correct execution of the oblique mixed-media beauty case, profitable outcomes might be predictable.


In training beauty dentistry, there are lots of totally different procedures carried out. The clinician wants to know the totally different particulars to carry out oblique, mixed-media beauty dental therapy effectively. Though these circumstances are rather more complicated, by incorporating this methodology into beauty dental therapy, the clinician can cut back pointless tooth preparation, turn into minimally invasive, and obtain long-term outcomes.


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Dr. Okuda is a previous nationwide president (2002 to 2003) and an accredited member of the American Academy of Beauty Dentistry (AACD). He’s additionally a fellow of the Worldwide Faculty of Dentists and the Worldwide Congress of Oral Implantologists. In 2014, Dr. Okuda achieved his Accredited Fellowship with the AACD. He’s presently the aesthetic dentistry skilled to the Nationwide Dental Professional Advisory Board of the AGD. He has additionally been the aesthetic columnist of the AGD’s Normal Dentistry publication for the final 9 years. Over the past 28 years, Dr. Okuda has been a keynote and featured speaker on beauty and restorative dentistry at quite a few conferences and universities. For the final 16 years, Dr. Okuda was one in all Dentistry At this time’s Leaders in Persevering with Schooling. He’s the co-founder of the Give Again a Smile Nationwide Charitable Basis. He could also be reached at, on Fb @drwynnokuda, or on Instagram @drokuda.

Disclosure: Dr. Okuda experiences no disclosures.