Replacing old composite bonding with porcelain veneers (Lumineers) Minimal Prep Veneers

By: Russell McFarlane

In 2011, we completed composite bonding on the patient’s peg laterals. A peg lateral is a tooth that naturally is smaller due to a genetic variation. Peg laterals or even missing laterals (Tooth #7 and #10) are very common. So, patients with peg laterals or missing laterals are often looking for a solution. Minimal Prep or No Prep Veneers can work very well on a case like this, so, for this case we used Lumineers with a guided minimal prep.

Photo from 2/7/2019 showing composite bonding (completed 2011) on the laterals.
Photo from 2/7/2019 showing the peg laterals with the composite bonding removed.
Photo from 3/7/2019 case follow-up, after seating the porcelain veneers on 2/26/2019, then, letting the gums heal before the final photos were made.

This case shows how attention to detail and communication with patients is very important. My patient expressed her growing dislike for the composite bonding and we have been discussing the idea of bumping up to porcelain veneers for the past 8 years. While we were discussing fixing the laterals, the patient expressed that the central teeth were rotated and the patient wanted to know if we could fix that.

We fixed the rotations and improved the overall look of the peg laterals. This case shows a major upgrade for a well-deserving patient, whom has been thinking about doing this for a long time. In this case we used Lumineers ‘030’ with ‘B1’ shading to add warmth in the neck.

We used the A.R.T. technique, which is promoted through DenMat Laboratory, which allows a patient to see a “Trial Smile” version of their teeth before we prep and allows prepping the teeth to be done with the minimum reduction necessary using a reduction guide.

Bicycle Accident – Dental Implant Replacement Case

X-ray: Patient presents after bicycle accident with fractured teeth. (2/19/18) One tooth was completely avulsed and the others adjacent were fractured in half.
X-ray: Patient presents after bicycle accident with fractured teeth. (2/19/18) One tooth was completely avulsed and the others adjacent were fractured in half.

The patient was in a bad bicycle accident, which left her severely injured. Her most notable injuries were the fracture of her front teeth. One tooth (a central) came out completely, while the other three anterior teeth were fractured off. It was determined that the other central (think: front middle tooth) would also have to be extracted as the tooth was fractured in the root. The other teeth, the laterals would need crowns to restore them, but, could be saved. So, we proceded to extract and bone socket preservation graft the sites for #8 and #9.

NOTE: If you are looking for the blurred out picture from the Instagram video, it can be found below in the gallery of images.

X-ray: showing the bone graft in the site replacing the missing central teeth.
X-ray: showing the bone graft in the site replacing the missing central teeth.

The bone graft was placed into the site of the missing teeth. In this case we used cortical bovine bone, covered with a collagen plug and sutured with 3-0 Chromic Gut, resorbable suture. These grafts typically take 4-months to turn into “your bone.” After your body discovers the graft bone, it determines that it should replace it with its own bone. This starts a two-tiered process of osteoclasts, which break down the grafted bone, followed immediately by osteoblasts, which replace the old bone with your own brand new bone.

Feel free to flip through the other images of the case in her gallery. Note: the bone graft photos that show the area immediately after extraction and grafting show a little blood, and the laterals were not yet restored with crowns. So, feel free to skip the fractured image if you have a delicate stomach for even a minimal amount of blood. The patient waited longer than the normal 4-months before implant placement. We elected to wait 7 months to let the bone solidify, since the facial plate was destroyed during the accident. After implant placement, we allowed the implants, plenty of time to heal, as they required careful and adequate healing. Today we finished the case and delivered the two computer designed custom-
titanium abutments with Zirconia crowns.

Smiling Patient: thrilled to have her smile back, and she now has something fixed that does not have to come in and out.
Smiling Patient: thrilled to have her smile back, and she now has something fixed that does not have to come in and out.

This was a challenging case due to bite and spacing considerations. But, we were able to give her back a fixed solution that allows her to floss these teeth separately. You will be pleased to know she is still an avid cyclist. Thanks,

Dr. Russell McFarlane

(below you will see the original censored Instagram version, then, the uncensored YouTube version of the photos immediately following)

Unedited Version

If you need to book an appointment, you can call us at 512-454-2744 (or) book online.

Composite Veneers vs Porcelain Veneers (Before and After)

Composite Veneers vs Porcelain, which one would you choose?

By: Dr. Megan Mobley

BEFORE

This is one of our beloved employees. She had composite veneers placed about 5 years prior by a previous boss on her upper canines. She is congenitally missing her upper laterals ( #7 and #10) so she had orthodontic treatment to close the space and her upper canines ( #6 and #11) were reshaped as laterals. The struggle with composite veneers is they absorb stain over time and this is a perfect example of that. Porcelain restorations are color stable, meaning they do not absorb stain, they will remain the same color for the life of the restoration in your mouth. Our assistant was very sensitive to her appearance and would even cover her smile to try to hide her discolored composites. One day she asked me to fix her smile and I was happy too.

AFTER

She had recurrent decay under the old composite veneers so we had to place full coverage crowns. The porcelain I chose was Obsidian (lithium silicate ceramic) which is a glass ceramic. I removed the old composites cleaned out the decay and placed new buildups. I used our 3M scanner for our digital images. Once we had our digital scans we sent the images wirelessly to our design software where I designed the crowns. Our mill was able to mill out each crown in about 15 minutes and then we placed the crowns for glazing and sintering in our furnace. Within a few hours we had a beautiful result that my assistant and myself are very happy with.


Treating Special Needs and Intellectually Disabled Patients

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Intellectually and developmentally disabled patients (commonly referred to as: “Special Needs”) are a very broad and diverse group of individuals. When I started practicing dentistry 10-and-a-half-years-ago, in 2008, I was still developing my skill set and clinical parameters (determining what could be accomplished in our office.)

Today, I am proud to tell you that our office has been serving intellectually-disabled (IDD) patients for the better part of the past 10-years. We now have extensive experience delivering a full range of services to these patients. There have been 3 things that have made this possible. 1. Training in Sedation 2. Strategic Partnerships, and 3. Staff Willingness.

Immediately after graduation (2008) from UT School of Dentistry in Houston, TX, a friend and I went to Dallas, TX to take the 2-day Enteral Sedation Course, which was co-taught by two teachers Dr. Clark Whitmire and Dr. David Canfield. I took this course before I even had a job, because I knew it was a tool that I needed to have in my toolbox. Since then I have taken renewal CE in 2011, 2014, 2016, and 2018. Some of the most valuable training you gain in sedation is your clinical practice of sedating patients. Our office has safely completed hundreds of Level I Enteral Conscious Sedation procedures on the full spectrum of normal healthy patients to medically-complex special needs patients.

Strategic parternership started with ATCIC, (Austin Travis County Integral Care.) When we got on board with ATCIC, that really opened our doors to seeing increased special needs patients. It has proved to be a very rewarding connection, on a personal and professional level. We try to treat the care takers of these patients with a great deal of respect and kindness. As time has marched on, the state has splintered it’s dispensation of the dental healthcare dollars from the centralized control of ATCIC to now include many of the group homes and facilities that house these IDD patients. [So, now we are partnered with additional entities (e.g. Draco, Bluebonnet, et. al.)]

When we decided we were going to increase our connection to this underserved* patient population (IDD patients,) I knew I needed to build consensus from the McFarlane Dental staff, because decisions do not exist in a bubble. At the time, I knew I needed to make sure I had a hygienist who could roll with the punches of treating the needs of these patients. So, she and I sat down and discussed what we thought would be realistic possibilities. We talked about measuring success and understanding that these cases would probably present new challenges. We specifically discussed how her ideas about delivering a perfect cleaning might have to come second to treating these patients with gentleness and doing our best to help them maintain their autonomy, whenever possible.

The rewards of treating this patient population has been on many levels. We have felt the encouragement from being engratiated into the family of caretakers. We’ve become part of the families of the individuals who are brought in by their aging parents or siblings. And of course, we are able to make a living, doing the work we love, caring for these individuals. It’s also very common for us to become the dental office for the whole family of these patients.

If you have a special needs person in your life, check and make sure they are getting the dental care they need. If you need a dental office with experience treating special needs IDD patients, we might be a good fit for you.

If you are a dentist who would like to get more involved treating IDD patients, call me and I would be happy to help you draw up a road map to help you make that a part of your practice.

Before and After Same Day Resin composites to close diastema

before-and-after-same-day-resin-veneers Click the picture to see it enlarged

Before and After Photos are favorites for people discovering what is possible. This patient presented with a history of her friends making fun of her and telling her that “she looks British.” This jabbing hurt her feelings and she asked if there was anything we could do about it.

Patients who have an open diastema, which is the technical name for the space between the teeth, have 2 primary options when closing the space.

  1. A minimal (or) no prep veneer, such as a Lumineer.
  2. Same day in-office treatment with a white resin composite.

A porcelain veneer has a very beautiful finish and a very high shine. Porcelain veneers tend to last 10 to 15 to even 20 years. They stay very shiny. Usually they have esthetic failures at the gumline, due to recession and/or staining at the margin. It is realistic to assume that you will replace a set of veneers every 10 to 20 years.

Same day resin composites to close diastema can be applied in the office using a bright composite applied directly to the teeth after etching and bonding. This procedure is sometimes called composite veneers, bonding, or resin veneers. The advantage of this procedure is that it is less expensive because there is no lab fee. Also, it can be applied right away with no waiting for porcelain to be made ready.

This patient left with same day resin composites and was thrilled because she hopes to longer hear the jabs from her friends about her teeth.

Before and After In-Office Whitening (photo with no flash)

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This is a before and after in-office whitening. This took 5 (15-minute) sessions all completed in one sitting. The teeth moved up the shade guide considerably. This was taken using ‘No Flash.’ Because it is hard for a camera to capture the real effect your eyes can see with an in-office whitening. This is because when a camera flashes it resets the white balance. So, these images with no flash are a better representation of what your eyes actually see when it comes to color change. It is harder to get a perfect focus without a flash. 🙂

Immediate Bridge Using Natural Tooth And Ribbond

The patient has had a lower anterior tooth that had gradually lost all the attachment around it as a result of localized periodontal disease. This left the tooth mobile and hopeless and it was starting to become uncomfortable chewing with it.

Before and Afters Of Immediate Bridge using Natural Tooth
Before and Afters Of Immediate Bridge using Natural Tooth

Once we determined that the tooth was hopeless, we set out to make the mouth healthier by removing the tooth. Then, we used the removed tooth to make a bridge between the teeth that will act as an immediate bridge. To make this possible, we anesthetized the area and extracted the tooth. Because it was already mobile and had very little attachment remaining, there was not very significant bleeding. We then, sectioned the tooth to get it out of the unhealthy pocket so that the periodontal tissues below it can heal. Then, we backfilled the root canal space internally in the tooth with bonding agent and flowable composite. We made a channel in the two adjacent teeth and the extracted tooth, then, using unfilled bonding agent on the Ribbond, and normal (etch, Scotchbond Universal) bonding agent on the teeth, placed a thin layer of composite and bonded 2 strips of ribbond into the channel to reinforce the teeth being intracoronally splinted together. We then, placed additional composite over the top, and I added a small amount of flowable composite from the facial interproximally to finish. Then, I touched up the occlusion with an ortho disc and smoothed off the edges of the composite in the channel with a flame diamond.