April 2, 2018
by Adamo Notarantonio, DDS, FICOI, AAACD
Communication is defined as the imparting or exchanging of information or news; means of connection between people or places, in particular. There is no doubt that communication plays a vital role in human life. It not only helps to facilitate the process of sharing information and knowledge, but also helps people to develop relationships with others. According to the book The Innovators, written by Walter Isaacson, the ability to collaborate effectively is decisive. This holds true in dentistry, even more so in cosmetic dentistry, and is of utmost importance in the matching of the dreaded single central.
A 41-year-old female presented to my office for an esthetic consultation. Before seating the patient and reviewing her dental and medical history, I noted her chief complaint: “I want veneers.” Upon meeting the patient, I discussed this chief complaint further. The patient informed me that she wanted ten veneers. When I asked why, her response led to more questions than answers. She stated, “I don’t like the old filling on my tooth” (Figs. 1-3). I continued to communicate with the patient and asked her why she wanted ten veneers if there was only one tooth that bothered her.
After an in-depth discussion, the patient informed me that she didn’t want only one veneer because they “never match.” We proceeded to take a series of intra-oral photos. I showed the patient these photos, along with some other before and after photos of single-unit cases. I also showed the patient with a quick digital smile design where we would restore #9 (Fig. 4). After further communication, we decided to restore tooth #9 alone. In my opinion, restoring ten of her teeth was overkill and against my core philosophy to practice with “responsible esthetics”. The patient was very appreciative of the time spent and the overall decision to treat only the one tooth that required attention.
The patient returned at a later appointment and treatment began. She was anesthetized with 1.8 cc 4% Septocaine via infiltration. Facial depth cuts were placed using a 0.3 mm depth cut bur, as well as incisal depth cut of one millimeter (Figs. 5 & 6). Upon reducing the incisal edge to one millimeter, it was noted that some existing resin remained. The resin was removed and the finish lines on the mesial and distal were taken lingual to the contact of the adjacent teeth. The reason for this is twofold: 1) to make the impression easier and finish line more visible, and 2) to keep the cement line on the lingual in an area that is easy to clean (Fig. 7).
At this point, communication to the laboratory regarding the shade and characteristics of the adjacent teeth, as well as the underlying preparation shade, was critical. To accomplish this, especially when dealing with a laboratory that is on the other side of the country, multiple high-quality photos are taken and sent to the lab. Being that the material selected was lithium disilicate, ie. IPS e.max from Ivoclar, a photo of the underlying preparation was taken with a shade tab from Ivoclar’s Natural Die Material shade guide so that the laboratory can make a die of the preparation with the proper underlying color (Fig. 8). Following this, shade photos will be taken. After determining the shade with the patient, in this case Vita 3D shade 0M2, the patient is seated upright and the tab is placed parallel and edge-to-edge to the adjacent tooth, so that the light reflection from the flash is consistent and gives us the most accurate shade detection possible. Maintaining this position, two photos of the shade tab are taken. The first photo shows the shade label on the tab (Fig. 9), while the second is a close-up of that tab (Fig. 10). Finally, the photo of the close-up tab is duplicated, and this duplicate is converted to black and white using software such as Photoshop or Lightroom. The reason for including the black and white photo is to make sure we communicate the correct value (Fig. 11). It has been shown that when shades do not match in the anterior region, the biggest culprit is a discrepancy in value, not hue or chroma. Including this black and white shade photo will help eliminate undesired discrepancies in value of the final restoration through effective communication with your laboratory.
In order to convey detailed characteristics of the tooth including hypocalcifications and translucency, polarized filters are placed over the flash and lenses (Fig. 12). Polar eyes is a cross-polarization filter that makes it easy to eliminate unwanted reflections on the teeth that are caused by the flash. These specular highlights can obscure details in the teeth and cause problems when communicating with the lab.
Following all data collection, a provisional was placed on the tooth. The “spot etch” technique was used and flowable resin as a cement was light-cured for twenty seconds (Fig. 13). The patient was dismissed and scheduled to return in four weeks for insert.
Communication to the laboratory is critical when attempting to match a single central. The rate of success is increased even further when the laboratory communicates with the doctor in return. Following completion of the wax-up and prior to pressing the lithium disilicate, the laboratory technician, Mr. Juan Rego from Smile Designs by Rego, emailed the author a picture of the shape of the tooth (Fig. 14). Following approval, the technician then sent photos of the veneer from every angle to make sure the author liked the shape, size and position. This technique saves a lot of try-in time and can almost guarantee success of shape, size and position (Figs. 15-22). With the ease of digital photography and communication via the internet, this is a great service both to the doctor and to the patient when completed.
The patient returned one month later for insertion. When the veneer was received, it was etched with 9% hydrofluoric acid, rinsed, dried and silanated with Bis-Silane from Bisco. The patient was again anesthetized and the provisional removed. The preparation was sand blasted with 50-micron aluminum oxide to remove any residual cement or debris (Fig. 23). Following sand blasting, size 0 cord was placed in the sulcus to help with hemostasis and to prevent crevicular fluid contamination during the bonding process (Fig. 24). The veneer was tried in with translucent cement. The value appeared low so shade B1 try-in paste was utilized, resulting in an ideal color match. Following approval by the patient, the bonding process was completed.
The tooth was etched with 35% Phosphoric Acid Etchant with Benzalkonium Chloride for 15 seconds (Fig. 25). The etch was rinsed with water only (Fig. 26) and the preparation was blot dried with a cotton roll to avoid desiccation (Fig. 27). Parts A and B of All Bond 3, in a 1:1 ratio, were mixed and applied in 1-2 consecutive coats to the preparation (Fig. 28). The preparation was gently but thoroughly air dried to evaporate solvent with a hot air tooth drier (Fig. 29). The surface was then light cured for 10 seconds (Fig. 30). A very thin layer of HEMA-free resin, PORCELAIN BONDING RESIN* from Bisco, was applied to the internal surface of the veneer. Finally, a generous amount of the selected shade of CHOICE 2 Veneer Cement, in this case B1, was applied to the internal surface of the veneer. The veneer was gently guided into place and tack cured for three to five seconds (Fig. 31). The excess was removed and the veneer was light cured for 40 seconds from each side as per the manufacturers instructions. The cord was removed after curing was complete, occlusion was adjusted and the margins were polished to ensure complete removal of cement and finishing of the restoration. The patient returned three weeks later for post-operative photographs (Figs. 32 & 33). The patient was ecstatic with the final result.
Choice 2 is a light-cured luting cement designed specifically for cementation of porcelain and composite veneers. Choice 2 exhibits color stability which is a critical factor in esthetic veneer cementation. A range of VITA®* shades as well as chromatic shades are available allowing for flexibility to achieve high esthetics. Corresponding try-in pastes (sold separately) are available for shade confirmation prior to final cementation.
Communication is a process of sending and receiving information among people. Humans communicate with others not only by face-to-face communication, but also by giving information via the Internet. This process, as seen above, is critical in esthetic dentistry. Between communication with the patient regarding restoring one tooth versus ten, and impeccable communication between the doctor and laboratory in both directions, an ideal esthetic result was achieved in one of the most difficult situations we face in dentistry today. OH
Oral Health welcomes this original article.
The author would like to give a very special thanks to Mr. Juan Rego, CDT, FAAACD, Smile Designs by Rego Laboratory, for his outstanding ceramic work in this case.
About the Author
Dr. Adamo Notarantonio is a graduate of the State University of New York at Stony Brook School of Dental Medicine (2002) and is currently a partner at Huntington Bay Dental in Huntington, NY. He is one of approximately 400 dental professionals internationally to achieve Accreditation status in the American Academy of Cosmetic Dentistry. Achieving Accredited status from the AACD requires dedication to continuing education, careful adherence to the protocols, and a resolve to produce exceptional dentistry. He was further honored by the Academy when asked to serve as a consultant and examiner for the Accreditation process. Dr. Adamo has completed The Dawson Academy Core Curriculum Series, and is a recent graduate from the Kois Center. Dr. Adamo recently received the AACD’s “Rising Star” Award. He has multiple published articles and lectures nationally and internationally on multiple topics in dentistry.
Fantastic case report, and communication with us… the readers! Bravo Dr. Adamo, one of the best around!
Great article and glad to see you talked her out of 10 veneers. True professional.
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