Tips and Tricks for Temporaries in Cosmetic Dentistry

You're listening to The Dr. Phil Klein Dental Podcast Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing the importance of temporaries in the smile design process, including a few tips and tricks. Our guest is Dr. Jennifer Derse, who has a restorative and cosmetic dentistry practice in Denver, Colorado, and is a mentor at the Kosi Center in Seattle. Before we get started, I'd like to mention that Dr. Derse’s webinar titled How to Structure Your Cosmetic Workflow is now available as an on-demand webinar on VivaLearning.com. Simply type in the search field Durse, D-E-R-S-E, and you'll see it. It's an excellent webinar for the entire dental team. Dr. Derse, it's a pleasure to have you on Dental Talk. Thank you so much. It is my pleasure to be here. To begin, tell us why temporaries are such an important step in the smile design process. Oh, yes, absolutely. You know, temporaries to me are the most important part of the smile design process because they play a large role in multiple factors. One of the biggest factors is that they are a way to communicate your structure, your aesthetics, your size and shape, and the way maybe a new bite might feel with your patient. So patients often can't. fully conceptualize their new smile and what it's going to look like in their face until it's actually in their face. You can do the renderings and you can do, you know, show them a mock-up, but until it's really in and they go out and they function with it in and they chew and they speak, they don't fully grasp it. And they might show you photos of their teeth. And, you know, usually when they show you a picture of what they like, the only alignment I've ever seen is that they're like, they're straight, bright teeth. The shapes are different. The translucency is different and they don't. put that together so we use temporaries to give them a better perspective of their smile yeah so you're really managing patient expectations in a lot of ways correct yes absolutely so It manages their expectations so that you can then, this leads to communication with your lab. So it's imperative that once you have your temporaries perfected to the patient's desire, that you scan or impress them or whatever methodology you use, photograph, and send this to the lab as part of the smell design process. That way, the lab can use that scan to create. almost a 3D copy of the temporaries and use it as their template for your ceramic restorations. Yeah, and you're a mentor at the Kois Center, which is really impressive. John Kois is an old friend of mine from way back, and you probably studied under him regarding occlusion. So tell us how temporization really is important to manage the occlusion and also get the patient to understand what they should be expecting in the final delivery regarding occlusion. Yes, absolutely. You know, one of the things that I have found most of the time, somebody comes in for a smile design and it's often the requirements that they have, the reasons they're anterior wear or whatever it is, has been the result of occlusal disease. So in order to address the disease so that that can be supportive of their new smile, you have to address the occlusion. Even if you may deprogram your patient or give them an opportunity before you really start the process to have an idea, the reality is they really start to feel their occlusion and understand it in their temporaries. I have videos of patients who, once you put them in a proper occlusion in their temporaries, they'll bite and they'll say, oh my gosh, they make that bite sound that sounds so perfect. And they're like, I've never had such a good bite before, which is, you know, one of the things that... Coise speaks about in his lectures. And when you get to give them that in their temporaries, that gives them that trial run, the test drive of their new bite. And it's really a gratifying feeling every time you do it. So when it comes to veneer preps, what have you found to be the most effective method for retaining temporaries on veneer preparations? You've read my mind. So the most important part of temporary retention is having proper occlusion temporaries should never hit on the front teeth when the patient bites down i've seen cases where patients might come to me in their temporaries from another doctor and if the occlusion is not addressed and they're hitting on front teeth they're breaking off their anterior temporaries remember if front teeth are worn down there's a reason for that and you have to diagnose that the other thing that is also important for retention is to just spot bond your temporaries on. And using that shrink wrap technique, if you use a good solid temporary material, the majority of the time, if you've got good occlusion and you shrink wrap the temporaries on, they don't come off. I do like to, once I've created the smile that I like with the temporaries, give the patients an Essex retainer for their post-op appointment. for them to sleep in at night. And that way, if something comes off, they can put it in over the temporaries until they come back in for repair. I have a true story. My sister-in-law texted me at 2 a.m. from Las Vegas. She was eating onion rings at 2 a.m. And so unfortunately, she couldn't get back in from Vegas. And she had that Essex to use as her backup. And at that point, you just, when they come back in, you just bond and freehand to repair it with some composite. But sometimes people do some... dumb stuff in their temporaries, even if you give them proper instructions. Yeah, onion rings are delicious, but they'll do it every time, right? So temporaries stain, right? I mean, we know that they are misacrylic materials that will certainly pick up some stain. What do you do to manage that? And what kind of post-op instructions do you give your patients regarding this? Yes. So, you know, there are some really fun spices that come from some fabulous restaurants out there that turn temps into very festive colors. So I'll remind patients anything that could stain a white t-shirt can stain your temporaries if you excessively use it. So if you are drinking, you know, eight cups of black coffee a day. rinse afterwards. Just clean that off. And if you just take care of them, they really don't stain. If you abuse them, they can darken over time. So I also remind them, cut your food. Don't bite into baby carrots on your front teeth. Keep them clean and life is great. And even when people get veneers, you still advise them, you know, they're not tools. They're not nail clippers. They're not there to tie flies. They are there to use as proper teeth. Now there's a lot of materials out there on the market that clinicians can use to make temporaries. so how does one decide which ones to purchase what are some of the considerations that are important when it comes to purchasing a system for the office oh absolutely well i've been using structure for well over a decade and i haven't found a better bang for the buck yet so um one of the main reasons i love it is it's really predictable it's got a one-to-one ratio of the acrylic composite so some of the other products when you mix them might have a four to one or ten ten to one ratio of materials so you've got to bleed it more and then sometimes if you bleed it before they put on the tip it'll come out goopy and doesn't mix correctly and then you go to take off your um you know your your temporary matrix and you've got a gooey mess it didn't it didn't set up so it's just difficult to incorrectly mix that one-to-one ratio the other thing recently i went down a rabbit hole in pubmed and if you think about this acrylic ratio is that many of the other brands have more acrylic in them and when i was doing this pubmed research there's a lot of articles about acrylic allergies we can thank the nail salons actually for this reason for research because in dermatology when some people have allergic reactions to acrylic nails so if you think about that we're going to put that in somebody's mouth and on their tissue we want to have the least amount of acrylic possible there's also less shrinkage when you're using less acrylic if the temporary is removable like a more of a posterior crown type temporary the fit's more predictable and it doesn't have to sit on the tooth as long to set up and it doesn't get as hot so that's more pulp friendly there's also a few different options when you use structure Structure is the name of the product. To clarify for our audience that that's the name of the actual product, and that's made by Voco? Yes, Structure is made by Voco. Structure has a couple of options. The Structure I use is designed more for the longer span applications that happen the majority of the time in my practice. I go with Structure 2. most of the time um you want when you're doing a smile makeover where all those units are connected to have that strength and be able to you know address the patient's demand for that aesthetic outcome i've also found that the nano field structure gives you that balance of strength with great polish ability i like to polish my temporaries and i go through the the four phases of flexi discs but if you want to do something maybe quicker and you're short on time and you're not going to go through all of the adjustments, that structure premium, you wipe off that oxygen inhibition layer and they already look like they're polished. So you've also got a really, really stunning option with the structure premium. So it gives you, you have choices of what you can work with within the structure family. But to be honest, I often default to the structure too. My patients aren't in their temporaries that long and it works great and the cost is incredibly reasonable. So when you compare the chair time savings with the premium, does it take you longer to manage the polishing of the Structure 2 where it would make a difference? It does, actually. So if I'm going to use Structure 2, I'm going to spend a little bit more time polishing it, which I'll use with those 3M FlexiDiscs. but when it comes to using the structure premium oftentimes you don't have to polish anything so if i want to make sure that my patient has that surface texture and lobing in their temporaries and i don't want to i don't want to polish that away right so i'm going to use a structure premium for those kind of patients where i want to make sure they see what it means to have these beautiful bright white teeth but i'm trying to convince them to keep some surface texture in their temporaries does that make sense Yes, absolutely. So for the routine procedure where you're fabricating these temporaries and they're long-span temporaries or they're even single crowns or even veneers, for the routine cases, you can use structure two for those considerations that you just explained you would use the premium. Yep, absolutely. So let's talk about duration for a minute. For some patients, it's required that they wear their temporary for an extended period of time. So when it comes to structure two, how long could you have the patient in a temporary, if made correctly, where you feel confident that it continues to do its job. Can you get 24 months out of it? I haven't gone two years with structure. Probably the longest term temporary I've done with structure is nine months on an aesthetic case because of some of the tissue surgeries that the patient was going through. And it looked great. It lasted. The patient took care of them. And, you know, the color stayed beautiful. But I've also done milled temporaries for some of the longer term patients where you're going closer to five years. But the structure is solid. So just because of the margins and my trimming of the margins, I like a milled temporary if I'm going to go longer than a year. Yeah, that would make sense. No, I think you've given us great insight, Dr. Derse, into the importance, first of all, of temporization in the smile design process. You talked about occlusion. You talked about patient expectations. Just to close, we didn't talk much about shade. Does this system have a shade system where you could aesthetically match what the patient is expecting? Yes. So structure has multiple shades available. I like to keep three shades on hand in my practice. Shade A3. the B1, and the BL shade. And the reason behind all three of those, most patients, when they're doing a smile makeover, want to be in that brighter, lighter shade. So they're going to want to go for the BL shade. And I give them that opportunity so that they get to see what their teeth are going to look like that much brighter. So I also think it's really important to use your temporary design. as your reduction guide so that you make sure you have the proper thickness in your preparation design so in my role as as a clinical director over 45 doctors i get to interact with the labs and see you know what what kind of feedback they give for me to be able to mentor some of the younger doctors in our in our company and most commonly missed will be an under reduction on oftentimes a distal line angle on a veneer we want to create this prep less environment for veneers but at the same time you still have to make sure you are either adding enough or reducing those couple areas that might stick out and need a little bit more reduction so i will use the a3 structure because it's darker than the natural two structure usually and i'll put that on prep that back peel it off And then I can see if there's anywhere that I need to make a little bit of an adjustment. It just creates an increased accuracy to your preparation design. Dr. Derse, thank you so much for your insight. And we encourage everyone to take a look at that webinar that Dr. Derse did, again, titled Structure Your Cosmetic Workflow. That's something you can look up on VivaLearning.com. Again, just look up Derse, D-E-R-S-E, and you'll find it. Thank you very much, Dr. Derse. Thank you so much for having me.