AMERICAN ACADEMY OF COSMETIC DENTISTRY

ACCREDITATION REVIEW

CASE REPORT 3

SIX INDIRECT VENEERS

Introduction History Clinical Data Diagnosis Treatment Plan Preparation Laboratory Instructions Finishing Summary & Conclusion References

INTRODUCTION

Bonded porcelain laminate veneers are ideal restorations for a variety of aesthetic and functional problems¹. The conservative nature of the preparations combined with desirable light reflection, absorption and transmission properties make these restorations predictably blend with existing natural dentition. This case placed exceptional demands on technique and materials as the two maxillary central incisors were left unprepared and six feldspathic porcelain veneers were created to enhance the smile and improve the occlusion.

HISTORY

The patient was a 29 year-old female in excellent health but did take ibuprofen on a fairly regular basis for headaches and was taking Paxil to reduce anxiety. Her desire was to have a fuller, lighter smile where her two front teeth were not so prominent. She worked in the area of medical sales and knew that a sophisticated natural smile would be an important asset to her career. As a teenager, she had orthodontics to correct a Class II malocclusion with a congenitally missing tooth #5. She also had her third molars removed.

Past dental treatment had been regular recall examinations and prophylaxes with several molars having been restored with amalgam restorations. She was referred by a friend to our practice for a cosmetic consultation to improve her smile.

CLINICAL DATA

Oral and radiographic examinations revealed good oral health with the exceptions of gingivitis interproximally and tenderness to palpation of some of the muscles of mastication. Excessive wear was noted on teeth # 11/22 and 12/21. The maxillary central incisors exhibited irregular incisal edges and were disproportionately large as compared with the laterals².

Because of the absence of tooth #5, teeth #s 2, 3and 4 were positioned mesial to their usual position. The space had been closed orthodontically and the teeth were in the proper vertical orientation.

The tempromandibular joints were quiet but the patient did report a history of chronic headaches and was aware of bruxing. She was especially tender to palpation on the left lateral pterygoid, medial pterygoid and masseter. She had canine guidance in right lateral excursion with no non- working interferences. In left lateral excursion, there was group function with non-working interferences on the lingual cusps of the contralateral side. Protrusively, she functioned only on the maxillary centrals and the mandibular incisors.

The shade of her dentition was generally A-3 on the Vita shade guide, with some gingival areas being A-3.5.

DIAGNOSIS

Unaesthetic smile due to disproportionate maxillary anterior dentition coupled with a shade the patient considered too dark. Myofacial pain and headaches caused by an unbalanced occlusal pattern aggravated by bruxing.

TREATMENT PLAN

After taking diagnostic models a careful analysis of the occlusion and review of the clinical data, a treatment plan was developed. It answered the patient's desire for a more aesthetic smile while at the same time improved the occlusal pattern to reduce the myofacial pain.

The patient whitened her teeth for approximately 2 weeks using Discus Dental 16% carbomide peroxide Nite White Excel whitening gel about 1 month prior to veneer preparation. A two-week period was allowed to elapse after whitening for shade stabilization at Vita shade of A-1 in the incisal 2/3 while the gingival 1/3 was a Vita A-2.

A composite cosmetic mock-up was done on teeth #s 4, 6, 7, 10, 11 and 12 to determine proper incisogingival, mesiodistal and buccal proportions and positions. During the mock-up, it was decided that leaving the maxillary central incisors unprepared except for some incisal recontouring and mesiodistal narrowing would be desirable. To simulate reduction and recontouring of the incisal edge a black Sharpie Microtip marking pen was used to block out the tooth structure to later be shaped. The results were photographed with an Olympus 600 DL digital camera and through computer manipulation were placed side by side with a before photograph of the patient. After the patient had approved of the aesthetic result, an alginate impression was taken that was later used in the fabrication of the diagnostic wax-up.

The material chosen for the veneers was Vita Omega 100 feldspathic porcelain overplayed with Ceramco Finesse low fusing porcelain. These materials provide excellent esthetics due to the ability of the ceramist to build the shade, opacifications, translucencies and characterizations from the internal of the restorations³. Low fusing porcelain on the external gave a highly polishable surface with an abrasive index similar to enamel⁴. Even though the strength of this material was slightly less than many of the cast ceramics⁵ proper preparation design, control of excessive occlusal forces and precise bonding protocols made this the material of choice for the aesthetically demanding case.

Armamentarium (significant):

1. Vivadent Helioprogress microfill composite shade A-1
2. Daler-Rowney Cryla #4 C30 flat end sable brush
3. Olympus 600 DL digital camera
4. Dentsply Jeltrate fast set alginate
5. Discus Dental Nite White Excel 16% carbomide peroxide whitening gel
6. Milestone Scientific The Wand anesthesia delivery apparatus
7. Cook-Waite Marcaine 0.5% with epinephrine 1:200,000 anesthetic solution
8. Hygienic extra heavy rubber dam
9. Vic Pollard diamond rotary burs (66R, 86R, 102, 103)
10. Pulpdent etching gel (38%)
11. Parkell bowed cheek retractors
12. Kerr Extrude polyvinyl siloxane impression materials (tray and syringable)
13. Zimmerman Tray Tree (telephone 425 823-5097)
14. 0.12% chlorhexidine solution
15. Dentsply Caulk Regisil bite registration material
16. Espe Protemp temporary material (A-1)
17. Cosmodent Creative Color composite tints
18. NTI finishing diamonds (889-009F, 859-014F, 379-018F)
19. Midwest finishing burs (7902, 7404)
20. Dentsply Caulk Enhance finishing cups
21. Centrix Benda -brush
22. Washington Scientific 35mm clinical camera
23. Sonicare ultrasonic toothbrush
24. Butler floss threaders
25. Glide floss and tape
26. 3M Ceramic primer
27. Heraeus Kulzer Gluma
28. Vivadent Excite resin adhesive
29. Vivadent Dual Cement
30. Glycerin
31. #12 Bard-Parker scalpel blade
32. Horico interproximal separating strips
33. Brassler interproximal diamond finishing strips
34. Epitex interproximal finishing strips
35. Axis porcelain polishing cups (P0355, P0365, P30035)
36. Brassler extra thin perforated diamond disc (806-104)
37. Vident porcelain polishing paste
38. Danville Engineering Microetcher with 50 micron aluminum oxide
39. Optilux 401 curing light with turbo tip
40. Demetron 2mm curing tip
41. Kreative Kuring light
42. Design for Vision 4.3x surgical telescopes
43. Oroscoptic Zeon Illuminator
44. Vita shade guide
45. Buffalo clear temporary stent thermoplastic material (.020")

PREPARATION

A diagnostic wax -up was done prior to the preparation appointment using the model of the cosmetic mock-up as a guide. A polyvinyl siloxane matrix was constructed for intra-oral temporary fabrication following the preparation of the teeth. A sulcular groove cut into the diagnostic model allowed for the excess temporary material to be easily and rapidly removed following temporary fabrication. A reduction guide was made with .020 clear thermoplastic stent material on a vacuum-forming machine and was used to optimize the preparations.

A Vita shade of A-1 for the incisal 2/3rds and A-2 for the gingival 1/3rd was selected. The AACD photographic series was taken with additional views of full centric occlusion, protrusive, right and left lateral excursions and shade tabs in place.

Anesthesia was delivered with The Wand using 2% Marcaine and a rubber dam was placed.

The maxillary centrals were recontoured and refined first with careful attention given to the plane of the incisal edge and it's perpendicularity to the long axis of the face. The mesiodistal width was narrowed slightly to allow for a more aesthetic proportion.

Teeth #s 4, 6, 7, 10,11 and 12 were prepared using the reduction guide to verify ideal contours. The preparations were all supragingival and no retraction cord was needed. Finishing was done with an Axis porcelain polishing cup (PO355) to remove any sharp areas that potentially could place excessive isolated stress on the restoration and cause a fracture.

The teeth were impressed with Kerr Extrude polyvinyl siloxane impression material and the impression was carefully examined for accuracy under magnification. An opposing model was taken with alginate and immediately poured and placed in a humidified box that was designed to hold the tray by the tray handle (Zimmerman Z-Tray Tree). This technique greatly reduces the incidence of distortion. A bite registration was recorded with Regisil and a Benda-brush was placed to parallel the aesthetic plane and a full facial photograph was taken before the registration was removed. This plane was transferred to the working models and gave the ceramist a clearly defined reference while the incisal edges were being established. The photograph was used as an additional reference in the laboratory by providing facial landmarks.

The preparations were scrubbed with 0.12% chlorhexidine, rinsed, spot etched with phosphoric acid for 15 seconds, rinsed and lightly dried then coated with Excite adhesive resin. A matrix made from the diagnostic model was filled with A-1 Protemp, placed on the preparations and carefully trimmed in place. The temporaries were then stained with Cosmodent Creative Color tints to create lifelike characterizations. This allowed the patient to see and verbalize her specific likes and dislikes about the temporaries which was then communicated to the ceramist.

An alginate impression was taken and poured in Whipmix Snapstone. A vacuum formed stent was made from .020" thermoplastic clear temporary material, trimmed and given to the patient to wear at night to protect the temporaries. This was especially important in this case because the temporaries did not cross the midline and hence were much more prone to breakage. However, because of the spot etching and the temporary stent, the temporaries stayed attached and did not break.

LABORATORY INSTRUCTIONS

A prescription was written to the laboratory instructing them to make six feldspathic porcelain veneers for teeth #s 4, 6, 7, 10, 11 and 12. Included were photographs, a diagnostic wax-up, study models, temporary models, shade and texture information.

Using the study models, the ceramist was instructed to duplicate the facial surface texture and anatomy of the existing dentition. Specific directions were given to establish a well-defined canine guidance and to move the buccal surfaces of the bicuspids buccally. Due to the relatively short clinical crown length of the lateral incisors, addition of slight vertical depressions in the facial surface were used to give the illusion of a longer tooth.

The refractory models were returned for review and modification before divesting and finishing of the veneers.

FINISHING

The fit and form of the veneers was checked on the models and a detailed inspection was done with transillumination under magnification to verify no stress fractures had developed. The internal aspect of each restoration was inspected for a frosty looking appearance indicative of adequate etching. Translucencies, opacities and characterizations were also carefully reviewed.

Anesthesia was delivered using 2% Mepivicaine with 1:20,000 levonordefrin and the temporaries were removed. The teeth were cleaned and scrubbed with .12% chlorhexidine and the restorations were tried dry to verify fits then with water to transmit color from the underlying tooth structure. The shape, shade and fit as all deemed acceptable and the veneers were removed and prepared for cementation.

A split rubber dam was placed and the teeth were rinsed and again scrubbed with chlorhexidine. Another rinse was followed by etching with 38% phosphoric acid for 15 seconds. Teeth were etched three at a time, then lightly dried and coated with Tublicid Red. After evaporating the Tublicid, Excite resin adhesive was applied continuously for 15 seconds, air thinned and light cured.

Simultaneously, the restorations were prepared by first being rinsed, dried and acidified using liquid 35% phosphoric acid. Again after drying, Ceramic primer (silane) was applied and left in place for a minimum of 1 minute. The internal surface was then dried a final time and a thin coating of Excite adhesive was air thinned on the restorations and they were placed into a light protected box.

Vivadent Dual Cement was mixed and placed inside the restorations and three were placed at a time on each side. A dual cure was chosen to insure complete polymerization of the resin cement and since the gingival shade was slightly yellow the concern of the yellowing of the cement over time was not an issue. After initially seating the restorations they were spot tacked at the gingival with a 2mm light tip and Glide tape was passed through the proximal areas to remove excess cement. A Benda-brush and rubber tips were used to remove excess facial and lingual cement and a layer of glycerin applied prior to curing with Optilux 401 and 501 curing lights.

Excess cured cement was then removed with a #12 Bard-Parker and NTI finishing diamonds. Interproximal areas were cleaned and finished using a Horico interproximal separating strip, Brassler diamond and Epitex finishing strips. NTI finishing diamonds were used to finalize the occlusion and place incisal characteristics. A Brassler ultra-thin perforated diamond disc was used to refine the incisal embrasures before polishing with Axis porcelain polishing cups and Vident porcelain polishing paste.

Impressions were taken for a maxillary acrylic night guard that was delivered and adjusted at a subsequent appointment along with a check for any excessive cement. Final intra-oral photos and a portrait session were completed.

SUMMARY AND CONCLUSION

All ceramic restorations provided an exceptional result for this challenging functional and aesthetic case. By recontouring the two maxillary central incisors, whitening and judicious placement of six porcelain veneers this was state of the art conservative adhesive dentistry.

Establishment of canine and protrusive guidance with simultaneous elimination of non-working interferences has led to fewer headaches for this patient through a probable decrease in neuromuscular activity that has been translated into less bruxing^6,7,8,9,10.

Aesthetically, the patient was extremely pleased with the natural and full appearance of her new lighter smile. The beautiful translucencies and surface texture of the final result make these restorations truly invisible.

ACKNOWLEDGMENT

The author would like to thank Mr. Lennart Hoerler and Mr. Alan Wollman of PR Dental Laboratory of Kirkland, Washington for their attention to detail and the excellent aesthetics of this case.

REFERENCES

1. Miller, M., The Techniques: Section 3, Porcelain and Indirect Resin Veneers; Reality 1999: 3-333
2. Spear, F., The maxillary central incisal edge: a key to esthetic and functional treatment planning. Aurum Cer Den Lab News, 1998; 2(4):1-5.
3. Cornell, D. and Winter, R., Manipulating light with the refractive index of an all-ceramic material; Pract Perio and Aesthet Dent; October 1999, pp.913-917.
4. Lehner, C.R., All ceramic crowns; Current Opin Dent; 1992; 1:45-52.
5. van Dijken, J., All ceramic restorations: classification and clinical evaluations; Comp of Cont Ed Dent; December 1999; pp.1115-1134.
6. Manns, A., et al., The immediate effect of the variation of the anteroposterior laterotrusive contacts on the elevator EMG activity. J Craniomand Pract 1993; 11: 184-191.
7. Hunt, K. and Haupt, J., Bioesthetics: An interdisciplinary approach to improve function and appearance. AACD Journal, Spring 1998; pp.36-44.
8. Williamson, E.H., Anterior guidance: it's effect on electromyographic activity of the temporal and masseter muscles. J Prosthet Dent 1983; 49: 816-823.
9. Shupe, R.J., et al., Effects of occlusal guidance on muscle activity. J Prosthet Dent 1984; 51: 811-818.
10. Kerstein, R.B., and Wright, N., Electromyographic and computer analyses of patients suffering from chronic myofascial pain dysfunction syndrome before and after treatment with immediate anterior guidance development. J Prosthet Dent 1991; 66: 677-686.

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© copyright 2001, Rhys Spoor DDS