Beautiful Smiles: Still in Demand in Today’s Economy!

Today, more and more people are becoming aware of what cosmetic dentistry has to offer in their everyday lives. With this awareness, there appears to be an increase in the demand for general dentists to offer cosmetic dentistry in a fast and effective manner. More than ever before, dentists are challenged to create a beautiful smile utilizing various modalities of restorative dentistry.
Porcelain veneers are a wonderful conservative modality for creating and restoring aesthetics in the human dentition. The beauty of porcelain is unsurpassed because of the natural light transmission that occurs through the porcelain and ultimately through the tooth. It is color-stable, strong once bonded to the tooth, and has the capacity to last for years. Modern veneer cementation systems also play a key role in the optimization of these beautiful porcelain veneer cases.
This article presents a case report in which minimal-preparation porcelain veneers were utilized to enhance the smile of a young woman.

CASE STUDY

Before Image. Preoperative full-face view.

After Image. Postoperative full-face view.

A young woman in her mid 20s presented to the practice for an aesthetic consultation (Before Image). The patient was not pleased with her smile, and she did not feel comfortable in social circumstances, including at work. In particular, the patient was dissatisfied with the size, shape, spacing, and color of her anterior maxillary teeth (Figure 1). Upon clinical examination, her anterior maxillary teeth exhibited multiple diastemas (Figure 2). Although she had a Class I occlusion, her maxillary anterior teeth were small. In other words, the length of these teeth could tolerate widening and lengthening. After considering the obstacles, a diagnostic wax-up was fabricated to help visualize the solution. The patient was able to see what we were intending for the final outcome, based on looking at her diagnostic wax-up. In order to achieve the patient’s demands, the placement of porcelain veneer restorations Creation Porcelain (Jensen) (Nano-Veneers [Burbank Dental Lab]) on teeth Nos. 5 to 12 would be utilized.
Once informed consent was obtained from the patient, treatment was initiated. A clear treatment stent (Burbank Dental Laboratories) was placed over the teeth to evaluate the proposed treatment. This guide was also used to measure where gum contouring would be used to create a more ideal gingival height and contour. Utilizing the Sensimatic 600SE electrosurgical unit (Parkell), we raised the height on teeth Nos. 9, 10, and 11 (Figure 3).
Since the preparations were to be conservative, a depth cutting bur of 0.6 mm (KOMET USA) was utilized to initiate the facial reduction (Figure 4). Using a No. 4 round diamond bur (KOMET USA), a slight margin was placed at the gingival margin and wrapped around the incisal edges. Since we would be closing the spaces interproximally and we intended on changing the width of the anterior teeth, it was imperative to break contact mesially and distally to allow the laboratory adequate space to create the desired look.

Figure 1. Preoperative retracted view.

Figure 2. Preoperative closeup.

Figure 3. Gingival contouring of teeth Nos. 9 to 11.

Figure 4. The 0.5 mm reduction grooves.

Following sequential preparation of the maxillary teeth, a stick-bite registration was taken using a bite registration material (Correct Plus Bite Superfast [Pentron Clinical Technologies]). This stick-bite would aid the technician in preparing the model and mounting the case. It also communicated to the ceramist the orientation of the interpupillary line, so that the incisal edges of the final restorations would not appear canted.
Utilizing a retraction paste (Expasyl Strawberry [Kerr]), we not only controlled hemorrhaging, but also achieved gingival retraction (Figure 5). After approximately 2 minutes in the sulcus, the retraction paste was rinsed off with copious amounts of water. Impressions were taken using a fast setting polyvinylsiloxane material (Correct Plus [Pentron Clinical Technologies]). Since the proposed veneers were going to be thin, it was imperative to fabricate and bond the temporaries over the maxillary anterior teeth (Nos. 5 to 12) by spot etching the prepared surface with 37% phosphoric acid. Using a silicone putty matrix (Sil-Tech [Ivoclar Vivadent]) of the proposed wax-up, the provisional restorations were fabricated using TempSpan (Pentron Clinical Technologies), then trimmed and glazed with TempSpan glaze (Pentron Clinical Technologies).

LABORATORY CONSIDERATIONS
Color photographs and diagnostic data were also obtained and forwarded to the laboratory for the fabrication of the final restorations. A silicone incisal matrix of the wax-up was created to guide the placement of the incisal effects and edge position in the subsequent ceramic buildup. A shade of B-1 on the VITA Shade Guide (Vident) was selected for the porcelain veneer restorations (Figure 6).

CEMENTATION
A light-cured veneer cement (Mojo Cement [Pentron Clinical Technologies]) was selected to bond the final restorations into place. This veneer cement has try-in gels that match the cured cement very well, and there is no shade shifting of the final cured cement upon light-cure, or over time (according to manufacturer claims). Before try-in of the definitive restorations to verify fit and shade, the provisional restorations were removed, and any remaining cement was cleaned off the prepared dentition. The cementation process was initiated after the patient approved the color when shown the retracted view using try-in pastes that would identically match the resin cement. Upon review, the doctor and patient selected the clear shade for the cement. The restorations were treated with 37% phosphoric acid for 20 seconds, rinsed, silanated, and allowed to air dry for one minute. The prepared dentition was cleaned with chlorohexidine 2% (Consepsis [Ultradent Products]) for 15 seconds, and then rinsed to remove any contaminants during the temporary phase. The preparations were then etched for 10 seconds, rinsed thoroughly, and dried. Next, 2 coats of a fifth-generation dental adhesive (Bond-1 [Pentron Clinical Technologies]) were placed on the preparations with a small brush applicator and thinned out with a slight stream of air. The adhesive was light-cured for 10 seconds per tooth with an LED curing light (Demi [Kerr]).
The clear resin luting cement was applied to the restorations and seated starting from the centrals, the laterals, and then the canines and premolars (Figure 7). While firmly holding the restorations in place, a rubber tip applicator was used to remove all excess luting cement from the margins. Soon afterwards, the restorations were tacked at the gingival margin using a small-diameter turbo tip in the light-curing device (Figure 8). Any excess cement was carefully removed with floss while holding each restoration in place during cleanup. Once the residual cement was completely removed, the restored dentition was cured from both facial and lingual sides for 20 seconds each.

Figure 5. Gingival retraction using a proprietary retraction paste (Expasyl [Kerr]).

Figure 6. Restorations on the model.

Figure 7. The resin cement (Mojo Cement [Pentron Clinical Technologies]) was loaded into veneer.

Figure 8. Cleanup of the resin cement.

Figure 9. Postoperative close-up.

Figure 10. Postoperative retracted view.

Any residual cement was removed with a No. 15 scalpel or finished with a fine diamond FSD9F (KOMET USA). After complete polymerization of the restorations, the occlusion was verified and adjusted. The overall health and structure of the soft tissue and restorations were very good (Figures 9 and 10). The patient was extremely satisfied with the definitive results (After Image).

CONCLUSION
Completion of this aesthetic dilemma with a quick restorative solution satisfied the patient’s demands of straight and white teeth needed to help in satisfying the demands of today’s job market. The bonded porcelain restorations provided a substantial improvement that was achieved quickly. It is important that dentists ensure that their patients are completely informed of all risks, benefits, and alternatives before initiating treatment. By getting input from patients and listening to their needs, dental providers will ensure having achieved functional and cosmetic success.

Acknowledgment
The author would like to thank Mr. Tony Sedler at Burbank Dental Lab for these beautiful restorations.


Dr. Nazarian is a graduate of the University of Detroit-Mercy School of Dentistry. Upon graduation, he completed an AEGD residency in San Diego with the Navy. Currently, he maintains a private practice in Troy, Mich, with an emphasis on comprehensive and restorative care. His articles have been published in many of today’s popular dental publications. He also serves as a clinical consultant for the Dental Advisor, Dental Team Concepts, and Dental Compare, testing and reviewing new products. He has conducted lectures and hands-on workshops on aesthetic materials and techniques internationally. He is also the creator of the DemoDent patient education model system. He can be reached at (248) 457-0500 or visit his Web site at aranazariandds.com.

Disclosure: Dr. Nazarian reports no conflicts of interest.



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