Esthetic Excellence

Laura Kelly, CDT

Immediate Past President and Accredited laboratory technician, AACD

Featuring
A supplement to a Montage Media publication

Betsy Bakeman, DDS

Accredited Fellow and Chair, American Board of Cosmetic Dentistry

M. Johnson Hagood, DDS

Accredited dentist, AACD Accredited dentist, AACD

Kenneth F. Hovden, DDS Nelson Rego, CDT

Accredited dentist, AACD Accredited laboratory technician, AACD

John Roberts, DDS Michelle Robinson Weber

Accredited laboratory technician, AACD

The Benchmark of esTheTics

Laura Kelly, CDT*

or several decades, the American Academy of Cosmetic Dentistry (AACD) and its members have pursued higher standards in dental care. The dentists and dental technicians comprising the Academys membership strive not only to enrich their personal understanding of cosmetic dentistry and their individual skills, but also to provide a new benchmark in quality and esthetics for their patients as well. For continued professional growth, these practitioners rely on the counsel of their colleagues and additional training they receive at the yearly AACD scientific session. Many AACD members elect to further distinguish their talents by seeking accredited status from the Academy. Accredited members of the AACD have successfully completed a rigorous testing process that involves written, oral, and clinical requirementsmost specifically the completion and documentation of specific clinical cases. As shown in the Supplement that follows, these cases encompass a variety of treatment modalities and must meet quality standards and protocols as defined by the American Board of Cosmetic Dentistry. The American Board of Cosmetic Dentistry does not endorse any particular clinical technique or style, nor does it endorse particular products or materials. It is acknowledged that Accreditation success is not dependent on the technique or the materials used, but on the excellence of the final result. The applicants featured herein have utilized Ivoclar Vivadent adhesive materials and ceramics to support them throughout the Accreditation process. Ivoclar Vivadent has a longstanding history among the esthetic dental community not just for the quality of its restorative solutions, but also for its focus on educating dentists and ceramists on their optimal use during daily practice. Ivoclar Vivadents sponsorship of this Supplement is another example of the companys interest in supporting dental professionals within the Academy and those aspiring to achieve Accreditation. On behalf of the many technicians and dentists who rely on Ivoclar Vivadent for its leading role in educating dental professionals, we thank you for your support. Together we offer our congratulations to the AACDs latest group of Accredited Members, and for their continued pursuit of excellence in dentistry.

* Immediate Past President, and Accredited Member, American Academy of Cosmetic Dentistry; President, LK Dental Studio, San Ramon, California.

THE BENCHMARK OF EsTHETiCs

TABLE OF COnTEnTS

i 03 05 09 17 21 25

PREFACE: The Benchmark of Esthetics

Laura Kelly, CDT

The Road to Success: American Academy of Cosmetic Dentistry Accreditation

Betsy Bakeman, DDS

Comprehensive Restoration of Anterior Crown Length and Proportion Using a Direct Resin Veneer Technique
Kenneth F. Hovden, DDS

Esthetic Enhancement of the Maxillary Anterior Region Using a Feldspathic Porcelain System: Laboratory Protocol
Michelle Robinson Weber

Laboratory Procedures in the Esthetic Restoration of Maxillary Lateral Incisors

Nelson Rego, CDT

Esthetic Enhancement and Pathologic Occlusion Using Six All-Ceramic Crown Restorations
M. Johnson Hagood, DDS

Anterior Esthetic Restoration Using a Direct Resin Veneer Technique

John Roberts, DDS

Sponsored by an unrestricted educational grant provided by Ivoclar Vivadent

Table of ConTenTs 1

THE ROAD TO SUCCESS:

American Academy of Cosmetic Dentistry Accreditation
Betsy Bakeman, DDS*

or practitioners with an interest in advancing their education and skills in the area of esthetic or cosmetic dentistry, the American Academy of Cosmetic Dentistrys (AACD) Accreditation process provides an incomparable framework for growth, study, and learning. The AACDs Accreditation process is unique in that it requires dentists or technicians to implement what they have learned and to demonstrate a level of proficiency as dictated by the American Board of Cosmetic Dentistry. The amount of time and effort necessary to attain the required level of proficiency varies based on an individuals exposure to and participation in advanced education, as well as his or her pre-existing clinical skills. Regardless of ones starting point, successfully achieving Accredited status in the AACD requires time, dedication, and true effort. By completing this process, AACD Accredited members are able to apply a variety of esthetic skills that demonstrate their ability to deliver optimal oral healthcare using direct and indirect restorative procedures. The Accreditation testing process comprises three parts: a written examination, clinical case submissions, and an oral examination. The written examination tests foundational knowledge in cosmetic dentistry and is administered at the AACDs annual scientific session. Once the clinician or technician passes the written examination, he or she has five years to fulfill the additional requirements. The clinical case submissions and evaluations form the heart of the testing process. Individuals demonstrate, through the use of preoperative and postoperative photographic documentation, clinical and diagnostic excellence in all phases of cosmetic dentistry. The protocol dictates that the cases that are submitted offer a comprehensive mix of cosmetic treatment solutions that skilled dentists and technicians should be able to execute when providing esthetic dentistry. The five required case types for clinicians are:

Bakeman 3

EsThETIC ExCEllEnCE

ase Type 1. This presentation involves C six or more indirect restorations within the maxillary arch, treating at least the incisors and canines. The key to delivering an optimal case presentation is in ensuring that the clinicians ability to create an open, working, and successful rapport with the laboratory technician is evidenced from start to finish. ase Type 2. This case involves one or C two indirect restorations in the maxillary anterior region treating incisors, and the adjacent teeth must have no indirect restorations. The challenge with this case type is in evaluating the clinicians ability to match the natural surrounding dentition. Case Type 3. In this presentation, the clinician demonstrates an ability to deliver esthetic results via a fixed partial denture (FPD) or implant-supported restoration. The FPD should contain at least one pontic that replaces a maxillary incisor or canine. If an implant restoration is placed, it should include a root form implant into the maxillary anterior edentulous space. A radiograph must also be submitted to show the space or failing tooth prior to implant placement. ase Type 4. This case consists of an C anterior direct resin (Class IV or diastema closure) restoration, in which the dentists ability to blend composite resin with the natural dentition is evaluated. ase Type 5. This case involves six or C more direct resin veneers, with the clinician treating at least the maxillary incisors and canines. Case Type 5 tests the dentists ability to create an optimal esthetic result using direct composite resin materials. Mastery of the five required clinical case types ultimately allows clinicians to provide their patients with a broad range of treatment solutions. laboratory technicians must complete the first three case types with the addition of supplementary bench photography. The oral examination completes the process, allowing clinicians to review their cases with a team of Accreditation Examiners, defend their treatments, and provide solutions to a hypothetical clinical case.

In summary, Accredited members have demonstrated a commitment to the art and science of delivering dentistry that transcends the customary boundaries of our profession. Patients can be assured that Accredited AACD dentists and technicians have demonstrated a high level of skill and expertise in providing a variety of treatment solutions as they relate to esthetic dentistry. Congratulations to the 20 newly Accredited members who were honored this past year at the AACD Annual scientific session held in new Orleans, louisiana: Duane h. Beers, DMD Jorge R. Blanco, DDs Tim M. Bradstock-smith, BDs steven h. Brooksher, DDs David s. Eshom, DDs Richard W. Featherstone, DDs Michael K. Forth, DDs Tannaz T. Goodjohn, DDs M. Johnson hagood, DDs Emil hawary, DDs Kenneth F. hovden, DDs Ted J. Murray, DDs nelson A. Rego, CDT John C. Roberts, DDs Michelle Y. Robinson Weber Troy Allen schmedding, DDs John W. simmons, IV, DMD Jenny C. sun, DDs William h. swearingen, DDs scott R. Wehrkamp, DDs In celebrating individual achievement, the Academy also celebrates the standard of excellence that Accreditation represents. The individuals honored remind us that we must all determinedly recommit to education and the pursuit of excellence. We must work together to continue to elevate the standard for optimal esthetics, the standard for serving the best interests of our patients, and the standard for maintaining ethics of the highest order. .
* AACD Accredited Fellow; Chair, American Board of Cosmetic Dentistry; Private practice, Grand Rapids, Michigan.

4 THe ROaD TO SUCCeSS

CompRehensiVe ResToRaTion of anTeRioR CRown LengTh anD pRopoRTion

Using a Direct Resin Veneer Technique
Kenneth F. Hovden, DDS*

Dental patients who request esthetic enhancement or require restorative care can often be managed through multiple treatment options, each with its ideal indications. While direct composite resins are often overlooked as viable treatment alternatives in complex cases, resin materials can allow the clinician to modify tooth color, width, length, shape, and guidance, with minimal preparation. This case depicts the use of a direct resin technique used to veneer nine teeth in the anterior maxilla, with optimal esthetics and function.

hoVDen 5

EsthEtic ExcEllEncE

Figure 1. Preoperative appearance demonstrates compromised esthetics and function in both the maxillary and mandibular regions.

Figure 2. Preoperative radiographic evaluation demonstrates interproximal bone loss and decay.

ontemporary adhesive dental techniques enable the clinician to effectively replicate the desired tooth shade, contour, and appearance. composite resin materials have also improved, allowing the successful restoration of function and esthetics with minimal wear to the opposing dentition; natural looking esthetics can also be developed using a simplified, minimally invasive technique. Unlike most prosthetic solutions, todays composite materials (eg, 4 seasons, ivoclar Vivadent, Amherst, nY) can be used with predictable results to augment the existing tooth structure with clinically reversible results.1,2

Treatment plan
the initial treatment plan consisted of root planing in all four quadrants, followed by thorough hygiene instruction and implementation of the caries prevention program. nonrestorable teeth would require extraction, and a direct resin veneer protocol was scheduled to restore teeth #5(14) through #13(25). Reparation of the buccal corridor deficiency, unesthetic tooth rotations, and malpositioned dentitionin addition to treatment of the areas of decalcification and caries-and-core were also required. Endodontic therapy was necessary for tooth #15(27), followed by a post buildup and its restoration with a full-coverage crown. Gingival crown lengthening was necessary in the anterior segment to improve the existing width-to-length ratios and raise central tissue levels to be harmonious with the existing level of the maxillary right lateral incisor. the second phase of treatment would consist of fabrication of implant ct guides to identify the position of posterior implants, for creation of a surgical guide, and for implant placement to replace teeth #18(37) and #19(36) prior to their prosthetic restoration.

Case presentation
A 26-year-old male patient presented with caries, type iii periodontal disease inclusive of multiple 5-mm and 6-mm pockets, bleeding upon probing, and heavy calculus (Figures 1 and 2). caries risk assessment was conducted and confirmed the patient was at considerable risk for caries; the patient was prescribed an athome mouth rinse (ie, cari-Free, Oral Biotech llc, Albany, OR) to reduce his caries risk. Many of the posterior teeth were nonrestorable and required extraction. Multiple teeth also required direct restorations.3-6 Once these clinical requisites were completed, it was necessary to pursue the fabrication of diagnostic models and further posterior rehabilitation with the use of implants and fixed prosthetics. Esthetically, the maxillary anterior teeth demonstrated interproximal caries, facial decalcification with caries, malpositioning, and poor crown width-to-length ratios.

Clinical procedure
Preliminary impressions were captured and models were fabricated. From these models, an ideal waxup was created based on smile design fundamentals. this was accomplished with an electric waxer and die wax. A silicone matrix was then created to guide the direct bonding technique.

6 coMPrehensiVe restorAtion oF Anterior croWn Length

Figure 3. the maxillary anterior region was scheduled for restoration using a direct composite resin veneer protocol.

Figure 4. Preoperative view demonstrates the presence of rotated lateral incisors, malpositioned canines, and decay.

Figure 5. Although the posterior mandibular dentition required extraction, unesthetic alignment was also present.

the soft tissue was first recontoured using an Er:YAG laser following the administration of local anesthesia. tissue levels were modified to be harmonious with tooth #7(12). All tissue modification was performed for the soft tissue only and never extended below the cementoenamel junction. the laser-treated tissues were allowed to heal for one week. smile design was based upon the position of the maxillary left central incisor, and teeth #6(13) through #8(11) were treated at the first restorative visit (Figure 3). One week after laser tissue contouring, the direct veneer protocol was initiated (Figures 4 through 7). With putty incisal and facial matrices from the diagnostic waxup, areas that required enameloplasty were identified to eliminate potential show through. Areas with decalcification and caries were removed, and the teeth were micro-etched to maintain a minimally invasive preparation design. Once each tooth was prepared, the silicone matrix was used to assist in the composite buildup procedure. the teeth were etched with a 35% phosphoric acid material for 30 seconds, rinsed for 30 seconds, and air dried. A desensitizing agent was applied for

30 seconds on the dentin and blotted dry with a microbrush. the bonding agent (ExcitE, ivoclar Vivadent, Amherst, nY) was then applied, air dried, and cured. With the putty matrix in place, 4 seasons Bleach Medium (ivoclar Vivadent, Amherst, nY) was used to recreate the lingual aspect and incisal edge of the tooth. An A3.5 dentin shade was then applied wherever dentin structures were missing. A thin ribbon of incisal clear (4 seasons, ivoclar Vivadent, Amherst, nY) was then placed around the dentin lobes and adjacent to the incisal edge to create some translucency in the central and lateral incisors. next, an A3 Enamel shade was placed over the gingival third and feathered into the middle and incisal thirds. the tooth was then brought to full contour with a Medium Value shade. Each layer was contoured with sable brushes dipped in modeling resin and cured for 20 seconds. Following the application of a detoxifying solution (ie, Deox, Ultradent, south Jordan, Ut), a final cure was performed on each tooth for 40 seconds prior to finishing and polishing. At the subsequent visit, the maxillary left canine, lateral incisor, and central incisor had

Figure 6. A retraction cord was used in the maxillary right quadrant, and the decalcified tooth structures were prepared.

Figure 7. A conservative preparation design was applied in the maxillary left quadrant

Figure 8. Facial view of the completed direct veneers. the mandibular teeth were scheduled for subsequent care.

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EsthEtic ExcEllEncE

Figure 9. Postoperative occlusal appearance following direct composite resin restoration of the maxillary anterior dentition.

Figure 10. the posterior dentition were extracted prior to implant placement and prosthetic rehabilitation.

Figure 11. Postoperative view of the anterior region following predictable restoration with a direct resin veneer protocol.

direct veneers placed using the aforementioned techniques. Both first premolars had buccal decalcification but were positioned well in the arch, so facial resins were placed to conceal the decalcifications. the maxillary right second premolar also had a direct resin veneer placed to overcome its buccal corridor deficiency. the patient returned for additional visits to fine-tune line angles, complete final polishing, and obtain definitive photographs and radiographs (Figures 8 through 11). throughout the procedure, the importance of proper oral hygiene was reinforced.

was very pleased with his new smile and anticipated completion of the posterior protocol in order to return the patient to normal function.

References
1. Peyton J. Direct restoration of anterior teeth: Review of the clinical technique and case presentation. Pract Proced Aesthet Dent 2002;14(3):203-210. 2. Erlach R. Accreditation clinical case report: Direct veneers. J cosmet Dent 2002;17(4):36-41. 3. Blank J. creating beauty with your own two hands: A simplified approach for direct veneers. J cosmet Dent 2002;17(4):49-56. 4. Rufenacht c. Fundamentals of Esthetics. chicago, il: Quintessence Publishing; 1990. 5. Goldstein R. Esthetics in Dentistry. 2nd ed. hamilton, london: B.c. Decker inc; 1998. 6. Dawson P. Evaluation, Diagnosis, and treatment of Occlusal Problems. 2nd ed. st louis, MO: cV Mosby company; 1989. * Adjunct Assistant Professor of Endodontics, University of the Pacific School of Dentistry, San Francisco, California; Clinical Instructor, Hornbrook Group; Faculty, IDEA; Director, Bay Area Aesthetic Masters Hornbrook Group Study Club; private practice, Daly City, California. Accredited member of the AACD.

Conclusion
this case demonstrates smile improvement using direct resin veneers and conservative tooth modification. As the procedure progressed, the patient underwent not only an esthetic transformation but also an oral health awakening. his home hygiene improved dramatically, as did his perception of overall facial esthetics. the patient

CLiniCaL Tip
I use a feathering technique when applying the A3 4 Seasons Enamel shade over the incisal layer around the dental lobes. This allows me to create a more natural shade transition in the middle and incisal thirds.
Kenneth F. Hovden, DDS

8 coMPrehensiVe restorAtion oF Anterior croWn Length

esTheTiC enhanCemenT of The maxiLLaRy anTeRioR Region

Using a feldspathic porcelain system: Laboratory protocol
Michelle Robinson Weber*

Patient confidence is often dictated by the esthetics of his or her smile. Dental professionals thus have a responsibility to ensure that any restorative treatment given is of the highest possible quality. The dental technicians role in the restorative process is to provide esthetic restorations that blend in well with the natural dentition. This presentation describes the use of a systematic laboratory fabrication process as means of delivering full-coverage crowns for seamless integration with the patients natural dentition.

robinson Weber 9

EsthEtic ExcEllEncE

patients smile can have a significant impact on his or her quality of life. Both professional and personal relationships can be either enhanced or diminished by the condition of ones teeth. the clinician and dental technician have the ability to improve a patients confidence and, therefore, overall well-being by providing a means to correct the length, shade, function, and shape of not only the individual teeth, but as they relate to each other in the entire smile. in the anterior maxilla, these goals are directly influenced by the ability of the restorative team to achieve a harmonious transition between the natural dentition and esthetic dental restorations. As shown in the presentation that follows, when a single tooth or teeth is required, this challenge is magnified, as a proper shade match will be critical to postoperative success.

three-quarter veneers. lastly the lateral incisors were prepared for full-coverage crowns to close the diastemata and replace the existing composite restorations. All contacts were broken to ensure the ceramist had control over porcelain layering interproximally and at the embrasures; postoperatively this would deliver a more balanced smile. An impression of the prepared teeth was made, and the teeth were provisionalized. the impressionand all related diagnostic informationwas subsequently conveyed to the dental laboratory for use throughout the restorations fabrication.

Laboratory protocol

Case presentation
A middle-aged female patient presented with the desire to revitalize her smile. the anterior dentition had been worn over the years and several diastemata were present (Figure 1). Additional tooth length was desired by the patient in the anterior region, combined with diastema closure, straightening, and whitening. the patient also expressed a preference that her smile maintain a natural appearance. the tissue height on both central incisors was raised approximately 1 mm using an 810-nm soft tissue diode laser (eg, Odyssey, ivoclar Vivadent, Amherst, nY). Due to the presence of existing restorations, the premolar teeth were prepared for full-coverage restorations. the canines and central incisors were reduced using more conservative techniques to accommodate

A feldspathic porcelain (ie, iPs inline, ivoclar Vivadent, Amherst, nY) was selected for use in a refractory technique. the photographs and model of the provisional restorations were to be closely followed for shape, length, and function (Figures 2 and 3). the clinician had also requested a contact lens effect, since the shade of the prepared dentition was uniform and light in color. Additional information received from the clinician included a final tooth shade with a slight color variation for the canines. Approximately 1 mm of incisal translucency and medium surface texture were also required.

the fabrication of models for this case began with the pouring of all impressions using die stone (ie, Yellow Prima Rock Die stone, Whip Mix, louisville, KY). the models, with the exception of the working model, were all allowed to harden. next, they were trimmed,

Refractory models

LaBoRaToRy Tip
Once the restorations are refined and ready to glaze, I like to steam the porcelain to remove any debris, and then thin the Universal Glaze Paste with a Glaze Medium using a small stain brush to provide the best possible luster.
Michelle Robinson Weber

10 esthetic enhAnceMent oF the MAXiLLArY Anterior region

Figure 1. Preoperative view demonstrates the presence of esthetic spacing, tooth wear, discoloration, and short clinical crown length.

Figure 2. A diagnostic model with the desired crown length and tissue contours evidenced following laser treatment.

Figure 3. Once the teeth were prepared and impressions transferred to the laboratory, a working model was created to ensure development of optimal function.

pinned as needed, and based. the working model was then poured using the same die stone and a pre-drilled base plate (Zeiser base plate, servo Dental, northbrook, il) with pins placed into the prepared impression. Once the material hardened, the model was removed from the impression. All excess stone was removed with a lathe. the dies were separated using a diamond disc (#911h, Brasseler UsA, savannah, GA) and trimmed with a #8 carbide bur. the models were duplicated and the dies were degassed prior to articulation (stratos, ivoclar Vivadent, Amherst, nY) to the facebow and bite.

porcelain fabrication

Prior to building any part of the restorations, an incisal matrix was fabricated from the provisional model in order to avoid overbuilding. Once the refractory dies had cooled from burnout, they were ready for a wash/foundation firing using an equal mix of B1 and A1 body porcelains on the facial, incisal, and occlusal surfaces of the dies. An Opal Effect 2 porcelain was applied around the marginal area to create the contact lens

effect (Figure 4). thin layers of porcelain were placed on the water-soaked dies, then lightly tapped to ensure smooth, even coverage to the prepared areas. the porcelain was then touched with tissue paper to remove any moisture and placed into the porcelain furnace (ie, Programat P100, ivoclar Vivadent, Amherst, nY) for firing. the dies were fired to 925c. Once firing was complete, the dies were again soaked in water, then placed back into the duplicating tray. Referring to the incisal edge matrix, the first buildup was performed using a mix of the same B1 and A1 porcelains. this mix was built up onto the incisal areas to form the internal lobes. the premolar dentin structure was built up and Occlusal Orange porcelain was applied to the central fossa area. Porcelain was blotted with a tissue to remove excess moisture. no condensing was performed. A porcelain knife was used to cut through the contact area to separate each tooth, and the dies were fired again to a maturation temperature of 915c. Once cool, the dies were placed back onto the duplication tray and onto the articulator, then closed into the incisal matrix to verify that the lobes

Figure 4. Porcelain buildup was commenced, using the silicone template to enable precise reproduction of the desired contours, length, and width.

Figure 5. A combination of B1 and A1 porcelains (iPs inline, ivoclar Vivadent, Amherst, nY) was used to form the internal lobes prior to firing.

Figure 6. Evaluation of the incisal buildup and lobe appearance following initial porcelain firing.

robinson Weber 11

EsthEtic ExcEllEncE

Figure 7. the lingual-incisal aspects of teeth #7 through #10 were built up to allow esthetic internal effects.

Figure 8. contours and incisal edges were corrected, and a light Mammelon porcelain was used to create flickers of internal characterization.

Figure 9. light translucency and color effects were carefully evaluated prior to final contouring.

had not been over-built and were in the correct position (Figures 5 and 6). the dies were again soaked in water to accept the next porcelain application. the body porcelain mix was applied as it was previously to compensate for shrinkage. the lingual aspects of teeth #7 through #10 were built up to create a canvas on which to apply the internal effects (Figure 7). the dentin structure was built up on the canines as well as the premolars using the body porcelain mix. stain was used in the central fossa areas of the premolars to create more depth. All units were separated with a porcelain knife, the interproximal areas were touched up, and the porcelain was fired again to 915c. the fired buildup was placed onto the duplication tray and onto the articulator, then placed against the incisal matrix to ensure that the incisal edges and lobes were correct. the contours and incisal edges of teeth #7 through #10 were corrected with Opal Effect 1 and Opal Effect 2 porcelains (iPs inline, ivoclar Vivadent, Amherst, nY). the light Mammelon porcelain was used to enhance the lobe detail and create light flickers of internal charac-

terization. A small amount of Amber was used for additional characterization (Figure 8). the porcelain was then fired again at 915c. the cooled dies were placed into the tray and the contours were evaluated using the incisal matrix. A micro diamond disc was used to remove a small amount of excess porcelain from the mesial and distal edges prior to continuing. Following an evaluation of color and effects (Figure 9), the final contour was created, alternating Enamel 1 and Effects 1 and 2 (iPs inline, ivoclar Vivadent, Amherst, nY) over the entire surface of the teeth. the lingual aspects were completed in the same wayagain, keeping within the form of the matrix with the exception of compensation for shrinkage. A small amount of neutral Enamel was beaded across the incisal edges with a brush to create halos within the finished porcelain (Figure 10). this brush technique enabled the fabrication of refined restorations that required minimal contouring with a bur. the teeth were separated with a porcelain blade, and a small amount of porcelain was added to the contact areas. the porcelain was then fired once more.

Figure 10. Enamel effects were added to the lingual and facial surfaces, and care was taken to refine the restoration using a brush technique.

Figure 11. Postoperative view of the final, glazed restorations. note the contact lens effect and natural translucency achieved using the refractory technique.

Figure 12. Postoperative appearance demonstrates harmonious integration and a natural, lifelike appearance.

12 esthetic enhAnceMent oF the MAXiLLArY Anterior region

Contouring

the cooled restorations were each tried in on the model individually, beginning with teeth #8 and #9 in order to maintain the correct midline. the porcelain was marked with marking tape and any heavy contact areas were relieved with a diamond bur. Each restoration was placed in the tray one at a time, and the contacts were adjusted accordingly. in addition to using articulating tape, each restoration was tried in with mylar strips as well. the adjacent teeth were removed and placed into the tray to verify all contacts again. Finally, all pieces were tried in together. the complete model was placed on the articulator, and any necessary adjustments were made for centric relation. Protrusive and canine movements were also checked, and final contouring was achieved by using a combination of a #850 diamond bur and microdisc (Brasseler UsA, savannah, GA). Final morphology was refined using a flame-shaped diamond bur and perikymata were created by lightly sweeping the bur horizontally across the surface.

Once the restorations were seated to the master dies, the margins were checked under magnification. the master dies were then placed back into the duplicator tray and all restorations were carefully placed; small adjustments were made to the contacts as necessary. lastly, the restorations were fit to the solid model, at which time the margins, contacts, and occlusion were verified once more. All restorations were re-polished with a bristle brush and polishing paste to shine any areas that had been adjusted (Figure 11). Prior to delivery of the case, the intaglio surfaces of the restorations were lightly sandblasted with 50 m aluminum oxide, then etched for one minute using a ceramic hydrofluoric porcelain etch. they were rinsed with water, placed in a neutralizing solution for 30 seconds, soaked in a cup of alcohol in an ultrasonic cleaner for an additional 5 minutes, and air dried. the entire case was then evaluated, packed for delivery, and cemented by the clinician prior to occlusal adjustments as needed (Figure 12).

final glaze

Conclusion
By diligently following each step of the treatment plan, the restorative team was able to significantly improve the patients quality of life. During fabrication, careful attention must be paid to details of color, contour, and shape. taking care to accommodate for porcelain shrinkage and continually verify fit, the laboratory technician may provide esthetic restorations that blend in seamlessly with the natural surrounding dentition.
* Dental technician, CMR Dental Laboratory, Idaho Falls, Idaho. Accredited member of the AACD.

the restorations were fired to 830c and then left to cool. A diamond-impregnated wheel was used to lightly refine the glazed surface and areas of the restorations that would contact the patients lips and create natural wear. Finally, a Robinson bristle brush and a medium porcelain polishing paste were used to bring the porcelain to a medium luster. the restorations were steam cleaned and divested using glass beads at 80 psi. Any remaining porcelain around the marginal areas were removed with the impregnated rubber wheel prior to fitting to master dies.

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EsthEtic ExcEllEncE

bALAncing siMPLicitY anD VeRsaTiLiTy

Case 1
Dr. Nick Addario, Chula Vista, CA. Mr. Andre Michel, Dana Point, CA.

Before

After successful tooth replacement with an IPS e.max bridge.

Case 2
Dr. Michael R. Sesemann, Omaha, NE. Mr. Lee Culp, Bradenton, FL.

Implant components

After placement of an implant-supported IPS e.max crown restoration.

14 bALAncing siMPLicitY AnD VersAtiLitY

With IPS e.max, dental professionals have a system for fabricating either lithium disilicate, high-strength glass-ceramic or zirconium oxide restorations. Its clinical performance combines esthetics and strength for any region of the mouth, enabling clinicians to provide their patients with beautiful, natural smiles. The ability of dental technicians to achieve a predictable shade match in even challenging combination cases makes IPS e.max a valuable treatment option for numerous AACD members and alumni.

Case 3
Dr. Tom Trinkner, Columbia, SC. Mr. Matt Roberts, Idaho Falls, ID.

Before

After placement of IPS e.max lithium disilicate and zirconia restorations.

Case 4
Edward Lowe, Vancouver, BC. Mr. Nelson Rego, Santa Fe Springs, CA.

Before

After esthetic replacement of gold intracoronal restorations with IPS e.max inlay/onlay.

IPS E.max 15

EsthEtic ExcEllEncE

16 Anterior Aesthetic restorAtion Using A Direct resin Veneer techniqUe

LaBoRaToRy pRoCeDURes
in the esthetic Restoration of maxillary Lateral incisors
Nelson Rego, CDT*

While creating esthetic full-mouth rehabilitations can be an exhilarating experience, it is singletooth replacement that presents a greater technical challengeand ultimately, rewardto the ceramist. Successfully blending a single restoration with the adjacent tooth structures requires not only ones ability to identify the innate qualities of the natural tooth, but then to imperceptibly mimic them in dental ceramics. This situation presentation details a case where a severely discolored lateral incisor was replaced with a laminate veneer in order to provide a harmonious, esthetic result.

rego 17

EsthEtic ExcEllEncE

Figure 1. Preoperative view demonstrates discoloration in tooth #7 and, therefore, an unesthetic shade match in the anterior region.

Figure 2. the patient was instructed to cease athome whitening in order to secure accurate shade data for fabrication of the porcelain veneer.

aboratory technicians are challenged to replicate natural esthetics on a daily basis. Further complicating the charge to recreate the multiple shades and nuances of natural teeth via a porcelain medium is the need to precisely match the existing dentition when treating only one or two teeth within the esthetic region. todays dental materials have given clinicians and technicians a large array of options for restoring the anterior teeth; these include ceramic materials that mimic enamel in both wear resistance and appearance. this case presentation demonstrates the laboratory protocol used for the restoration of anterior lateral incisors with unrestored teeth surrounding the restorations.

Case presentation
A 38-year-old female patient presented with an existing porcelain veneer on tooth #7(12) (Figure 1). the patient had whitened her teeth using an at-home system and, while she was

Clinical examination

satisfied with the existing bleached result, a shade discrepancy was evident within the anterior dentition. Although orthodontic treatment was presented as an option to correct the patients tooth alignment, the patient was satisfied with the minor misalignment present. her primary concern was about the shade of the single lateral, and a porcelain laminate veneer was selected to repair the existing esthetics. Once the at-home whitening protocol was discontinued, shade information was captured and transferred to the laboratory (Figures 2 through 4). the abutment tooth was then prepared with a chamfer margin, and the preparation was polished to ensure elimination of any sharp line angles. the provisional restoration was fabricated and seated, and impressions were forwarded to the laboratory to facilitate fabrication of the definitive prosthesis.

Laboratory protocol

A class iV die stone was poured and allowed to harden for 24 hours. careful attention was

Figure 3. the ceramist was challenged to recreate translucency and luster of the natural dentition using a predictable technique and material protocol.

Figure 4. closer evaluation of the discolored lateral incisor demonstrated the extreme shade variation evident in that single tooth.

18 LAborAtorY ProceDUres in the esthetic restorAtion oF MAXiLLArY LAterAL incisors

Figure 5. the desired tooth contour was waxed up on the working model to ensure proper width-tolength ratios prior to porcelain layering.

Figure 6. the preparation was evaluated and blocked out as needed.

paid to the water-powder ratio in order to ensure proper expansion. the working models were fabricated and mounted on an articulator; the approved provisional restorations were also mounted on the opposing model. A matrix was created and used to evaluate the facial and proximal reduction. the dies were carefully trimmed, and all undercuts were blocked out with an undercut wax material. A full-contour waxup was then created (Figure 5). At this time, the contacts were waxed into place, and the margins were sealed with a minimal shrinkage margin wax (Figure 6). the waxed laminate was sprued and invested using the speed press technique, and pressed in iPs Empress Esthetic (ivoclar Vivadent, Amherst, nY), using an EOc-1 ingot (Figures 7 and 8). this ingot was selected because of its optical properties and high opacity, which would conceal the underlying shade of the prepared tooth structures. Once the laminate was cooled and divested, it was evaluated for fit and layering commenced.

porcelain Layering procedures

Following careful evaluation of the digital shade map and preoperative photographs, the porcelain buildup was cut back to allow the author to create the many-faceted nuances that would be required to ensure a naturallooking integration. A foundation bake was readied with a small amount of stain and glaze paste, and fired at 770c. the laminate was layered with incisal White and Bamboo powders (iPs Empress, ivoclar Vivadent, Amherst, nY) to create the esthetic dispersion of colors that were present in the natural dentition, and fired at 840c. the laminate was checked with the matrix to ensure that the effects were in the proper positions, and a final layer of Mt incisal was added to create the translucency that was so clearly demonstrated by the natural dentition.

evaluation, Contouring, and seating

the laminate veneer was temporarily cemented to the stone die using systemp.link (ivoclar Vivadent, Amherst, nY) to facilitate

Figure 7. the incisal cutback procedure was initiated to ensure development of esthetic incisal translucency.

Figure 8. the laminate veneer was built to contour on the working model.

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Figure 9. Postoperative lateral view of the definitive restoration following cement cleanup.

Figure 10. note the harmonious integration and natural-looking shade match achieved.

final contouring. Various diamonds and rubber wheels were used to provide an esthetic surface luster, with care taken to the reflective and deflective areas. the matrix of the approved provisional restoration was used to ensure that the final contours of the definitive restoration closely matched those communicated by the temporary. the laminate was lightly stained and baked once. the final polish was accomplished using a soft bristle brush and paste to achieve the prescribed gloss. the restoration was returned to the clinician, where it was inspected for fit and shade on the model. the provisional was then removed and the preparation was cleaned with chlorhexidine and rinsed. A resin cement material (Variolink Veneer, ivoclar Vivadent, Amherst, nY) was applied to the internal surface of the laminate. the value shading of this cement was a benefit in matching the single-tooth restoration to the adjacent dentition. the veneer was positioned, excess cement was removed,

and the restoration was spot polymerized with a 2-mm tacking tip. Occlusion was verified, adjustments made as necessary, and a porcelain polishing kit was used to render the final appearance of the restoration following definitive polymerization (Figures 9 and 10).

Conclusion
Matching a single laminate veneer to a patients existing dentition can lead to a high level of satisfaction, since in this instance the laboratory technician is challenged to create a restoration that blends imperceptibly with the natural dentition. A pressed ceramic was selected accordingly, based on the ingots ability to deliver optimal opacity to mask the underlying substructures, with a natural luster and incisal translucency.
* Laboratory Technician, Santa Fe Springs, California. Accredited member of the AACD.

laBORaTORY Tip
Using a Sil-Tech matrix, I can inject wax into the preparation models and verify if sufficient reduction is present prior to beginning the fabrication process, reducing the need for remakes and eliminating potential error.
Nelson Rego, CDT

20 LABORATORY PROCEDURES IN THE ESTHETIC RESTORATION OF MAXILLARY LATERAL INCISORS

esTheTiC enhanCemenT anD paThoLogiC oCCLUsion

Using six all-Ceramic Crown Restorations
M. Johnson Hagood, DDS*

All-ceramic restorations such as IPS Empress (Ivoclar Vivadent, Amherst, NY) enable clinicians to predictably and successfully address their patients increasing esthetic expectations. The following presentation demonstrates a clinical protocol used to place IPS Empress restorations in a patient with compromised anterior esthetics and wear. The provisional restorations served as a trial therapy that enabled the clinician to resolve the esthetic expectations of the patient as well as the occlusal concerns present.

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ince the time of their introduction to the dental industry and its professionals, iPs Empress (ivoclar Vivadent, Amherst, nY) all-ceramic restorations have offered a new dimension in anterior restorative dentistry. While providing esthetics with optical characteristics similar to tooth enamel, iPs Empress crowns are composed of a homogeneous leucite-based ceramic, which scatters light like a natural tooth and ensures that these restorations blend in with the adjacent dentition. Restorations fabricated in iPs Empress material exhibit life-like translucency as well. in the case that follows, iPs Empress full-coverage crowns will be used to improve the appearance of the patients smile while restoring her to pathologic occlusion.

Case presentation
A 30-year-old female patient presented for esthetic enhancement of her maxillary and mandibular dentition (Figures 1 and 2). clinical examination revealed the presence of a PFM crown on tooth #9(21), diastemata in the maxillary arch, and slight to moderate wear of the incisal surfaces of the mandibular incisors (Figures 3 and 4). the patient was in excellent periodontal health. the patients skeletal relationship had a class iii tendency and the mandibular incisors were retroclined. there were no stable holding contacts between the lower incisal edges and lingual surfaces of the maxillary incisors. the location of the wearpredominantly on the facial surfaces of the mandibular incisors was indicative of tooth loss occurring during functional movement of the mandible. trial therapy and evaluation would thus be necessary to determine if occlusal correction would resolve the pattern of wear on these teeth.

the class iii skeletal tendency combined with the tooth-arch discrepancy of the maxillary arch created a path of closure that generated excessive frictional force between the lingual surfaces of the maxillary incisors and the incisofacial surfaces of the mandibular incisors. A conservative approach to treatment would utilize orthodontic therapy to facilitate an efficient closure path to maximum intercuspation that did not create premature loading of the teeth. however, the patient, duly informed, declined orthodontic treatment. A restorative option that would serve to address both the functional and esthetic concerns involved porcelain restorations on the six maxillary anterior teeth. An efficient path of closure to maximum intercupsaton would be facilitated by hollowing the lingual surfaces of the anterior teeth to accommodate the patients mandibular incisors during function. A secondary functional goal of treatment would be to create stable centric stops on all teeth.

Treatment sequence
A diagnostic workup was fabricated; it was confirmed that both the esthetic deficiencies and occlusal problems could be resolved through the placement of full-coverage restorations on teeth #6(13) through #11(23), and occlusal equilibration. iPs Empress was selected as the restorative material of choice, not only for its esthetic qualities but for its low wear potential. the provisional restorations would be used as a template for directing treatment outcomes esthetically, phonetically, and functionally. A vacuum-formed template was constructed on the diagnostic cast for use as a reduction guide during preparation and for fabrication of the provisional restorations. An occlusal index was also fabricated to aid in positive seating of

Figure 1. Preoperative view of diastemata and incisal edge positions of the maxillary anterior teeth, which created disharmony.

Figure 2. While the gingival architecture was symmetric, the patients smile was not esthetically pleasing.

Figure 3. Occlusal view of the maxillary arch preoperatively revealed the PFM crown on the maxillary left central incisor.

22 esthetic enhAnceMent AnD PAthoLogic occLUsion

Figure 4. the PFM crown on tooth #9(21) restricted natural light transmission around the gingival margins.

Figure 5. the provisional restorations enabled the patient to provide feedback on esthetics, fit, function, and phonetics.

the template on a working model during indirect fabrication of the provisional restorations. teeth #6 through #11 were prepared conventionally, except that minimal tooth structure was reduced in the cingulum areas and slightly more reduction was performed on the incisal two-thirds of the lingual surfaces in order to hollow them and thus better accommodate the envelope of function. the crown on tooth #9 was first removed, and then gross reduction of the other preparations was performed with diamond burs. Retraction cord was placed in each sulcus, leaving 0.2 mm to 0.5 mm of tooth structure visible between the margin and the cord. the preparations were then refined with fine diamond burs used in a mid-speed handpiece. Following polishing of the preparations to eliminate any surface irregularities, alginate impressions were made of the maxillary arch and immediately poured with fastsetting dental plaster. indirect provisional restorations were processed in acrylic, trimmed, and tried in to permit adjustment of occlusion. Equilibration was finalized and included the establishment of appropriate anterior guidance. the provisional restoration was then separated into individual units and polished with a Robinson bristle brush.

the provisional restorations were cemented and the final impressions were taken the following week (Figure 5). At the final impression appointment, the patient provided feedback with regard to the shade, contour, phonetics, comfort, and esthetics of the provisional restorations. this information was conveyed to the dental laboratory to aid in the fabrication of the definitive restorations. An alginate impression of the maxillary arch with the seated provisional restorations was then taken; it would be poured in stone and mounted against the working model on an articulator: 1) to guide the optimal occlusion of the provisional restorations and 2) to aid the laboratory technician in predictably reproducing the desired occlusion, contour, and incisal edge position in the definitive restorations. Following the completion of all impression making, the provisional restorations were recemented and the patient was excused.

Laboratory instructions
A work order accompanied by an esthetic checklist, color mapping, preoperative and provisional images, casts of the diagnostic

Figure 6. View of the iPs Empress all-ceramic crowns seated on the model prior to try in and cementation.

Figure 7. Polishing cups and points were used for initial polishing, and the restorations final luster was created.

Figure 8. Occlusal view of the iPs Empress crowns postoperatively. Minimal occlusal adjustment was necessary.

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Figure 9. Postoperative view of the enhanced esthetics achieved through the iPs Empress crowns and their integration.

Figure 10. View of the patients smile following treatment demonstrates improved proportion and harmony with her lips.

workup, and provisional restorations were sent to the dental laboratory. these data would be essential in ensuring the desired results with the iPs Empress crowns.

finishing
the crowns were inspected upon their return from the dental laboratory and were well-adapted to the model (Figure 6). the facial index fabricated in the laboratory against a mounted model of the provisional restorations fit precisely against the facial contour of the definitive all-ceramic restorations. the internal surfaces of the iPs Empress crowns had a uniform frosted appearance indicative of well-etched surfaces. At the delivery appointment, the patient was anesthetized, the provisional restorations were removed, and the teeth were cleaned. the crowns were tried in with Variolink ii tryin paste (ivoclar Vivadent, Amherst, nY). the patient was given the opportunity to assess the restorations and the appropriate cement shade (ie, transparent) was determined. the crowns were then cleaned and etched with 37.5% phosphoric acid gel left on for one minute and then rinsed. this process removed any surface contamination and acidified the porcelain surface, which increased the efficacy of a silane coupling agent. A freshly mixed silane coupling agent was applied following drying in order to increase the bond strength between porcelain and resin cement and to decrease microleakage. All teeth to be bonded were cleaned and rinsed, and a retraction cord was placed in each sulcus to ensure a dry, uncontaminated field. the teeth were etched with 37.5% phosphoric

acid gel for 15 seconds, rinsed, and left wet. A wetting agent (eg, tubulicid Red, Global Dental, Bellmore, nY) was applied to wet and disinfect the etched surfaces. Dentin primers were mixed, and five to seven coats were applied to each preparation. Once fully dried, the preparations were light cured for 30 seconds per surface. Pre-Bond resin (Bisco, schaumburg, il) was applied to the preparations. transparent-shaded dual-cure cement (eg, Variolink ii, ivoclar Vivadent, Amherst, nY) was mixed and placed in each crown. the crowns were seated and each was spot-cured in the center facial surface with a 3-mm curing tip. Excess cement was brushed and flossed away, and final curing was accomplished with 60 seconds per surface for each tooth. Further cement removal was accomplished using an h6/h7 scaler and Bard Parker #12 blade. the cervical and interproximal surfaces were finished using diamond finishing burs and carbide finishing burs with an air-water mist. All margins and tooth surfaces were carefully inspected for overhangs and roughness and were then polished (Figures 7 through 10). Additional treatment would consist of minor restorative care, routine examinations and prophylaxis, and monitoring of tooth wear.

Conclusion
the esthetic results were very satisfying. By simultaneously addressing the patients esthetic and functional concerns, a successful long-term prognosis could be ensured.
* Private practice, Vero Beach, Florida. Accredited member of the AACD.

24 esthetic enhAnceMent AnD PAthoLogic occLUsion

anTeRioR esTheTiC ResToRaTion

Using a Direct Resin Veneer Technique
John Roberts, DDS*

By challenging clinicians to deliver esthetic restorations using a variety of restorative materials, forwardthinking dental professionals are exposed to an expanded armamentarium. Of the case types required for accreditation, the delivery of naturallooking direct resin veneers in the anterior region represents a level of mastery different from any other type of skill demonstrated in the operatory. This presentation demonstrates the use of composite resins to create natural, lifelike results using a direct chairside technique.

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sthetic dentistry demands a certain level of mastery when using a variety of restorative materials in order to obtain the desired final result. skill in preparation design and cementation of porcelain veneers alone are not the only qualifications of a good cosmetic dentist. in addition to the mastery of indirect porcelain restorations, composite expertise remains a necessary skill in the armamentarium. Very few dentists develop the skill and the art of the direct composite technique for the purpose of veneering six or more anterior teeth. For a majority of dentists, more predictable, esthetic results can be obtained easier and faster with porcelain restorations (eg, iPs Empress or iPs e.max, ivoclar Vivadent, Amherst, nY). While esthetic treatment solutions often call for the use of indirect restorations, there are certainly indications for direct protocols. these may include (but are not limited to) addressing esthetic concerns in young patients, treatment of patients who wish to avoid aggressive tooth preparation, or patients in need of transitional materials during multidisciplinary protocols. Understanding composite resins and the associated layering techniques well enough to block out and develop consistent shade, translucency, and characterization will certainly provide an opportunity to create naturally undetectable restorations as an alternative to porcelain veneers.

Case presentation
A 32-year-old female patient presented for smile enhancement (Figure 1). A clinical examination

with necessary radiographs and a professional cleaning indicated that no soft or hard tissue pathology were evident. Although the patient had previously undergone orthodontic treatment (ie, invisalign, Align technologies, santa clara, cA) in addition to esthetic crown placement, fillings, and routine care, class i occlusion and class iii skeletal tendencies remained evident (Figure 2). Minimal, if any, wear patterns existed in the enamel. Functionally, satisfactory guidance was evident during right, left, and protrusive excursions. no balancing or working interferences were noted in the posterior region.1,2 no history or complaint of temporomandibular disorder, pain, popping or crepitis upon maximum opening, or lateral or protrusive excursions were noted (Figure 3). Facial symmetry was evident, with no midline shift. A mild cant was present on the left side, with low tissue in the gingival architecture. short central and lateral incisors resulted in a reversed smile line and poor esthetic proportions (Figure 4). the buccal corridor appeared satisfactory (Figure 5). the patient did not feel comfortable with the white and brown spots visible on the anterior dentition, and desired greater incisal length, improved phonetics, and enhanced esthetics. the patients periodontal health was excellent. tooth #13(25) was restored with a provisional crown and required replacement with a definitive porcelain restoration. Adequate composite restorations were present on teeth #2(17) through #5(14), and #9(21), #12(24), #15(27), #18(37) through #23(32), and #26(42) through #31(47). teeth #1(18), #16(28), #17(38), and #32(48) were missing.

Figure 1. Preoperative appearance demonstrates the presence of gingival decay and short clinical crown length.

Figure 2. Preoperative appearance of the patients smile revealed anterior staining and unesthetic incisal characterization.

26 Anterior esthetic restorAtion Using A Direct resin Veneer techniqUe

CLiniCaL Tip
When patients present with dark underlying structures, a specialty dentin shade (eg, B1 Dentin, 4 Seasons, Ivoclar Vivadent, Amherst, NY) should be placed on the cervical aspect and tapered towards the incisal edge to create the desired body shade, while adding strength to the underlying incisal length. Enamel Effects shades (White and Blue) can then be used to develop internal characterizations.
John Roberts, DDS

Minor gingival tissue correction would also be required to improve the cant.3

Treatment plan
After multiple treatment options were discussed with the patient, direct veneers were selected to restore teeth #5 through #12 to alter the smile line and the shade. tooth #13 was also scheduled for crown replacement. the following steps would be followed in the treatment plan: 1) Continued periodontal maintenance and good home care was expected, as it was already habit for this patient.

2) Teeth #5 through #12 would be prepared for veneers or veneer onlays. 3) A hybrid composite would be placed as a base for the dentin shade and strength in the final result. 4) Because the dentin structures were more opaque and contained a more saturated chroma, the use of a layered restorative technique with calibrated translucencies was selected to promote exceptional esthetics and an accurate shade match. 5) An enamel-shaded microfill would be placed over the dentin layer to be polished to a natural luster. 6) Maintenance of functional occlusion would ensure that the new composite veneers would last in the new length and shape.

Figure 3. Following orthodontic treatment, improved lateral and protrusive guidance protected against occlusal interferences.

Figure 4. the position of the cusp tips on the premolars was longer than the canine position during preoperative evaluation.

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Figure 5. Maxillary occlusal view of full, rounded, well-defined incisal edges.

Figure 6. Postoperative view. note the improved clinical crown length, tooth shape, and contour.

Restorative sequence
Discussion regarding tooth length and the removal of the brown spots were of primary importance because these were, essentially, the patients primary concerns. Each tooth was prepared and rebuilt individually so that tooth form and position would not be lost (Figure 6). the tooth preparation design was maintained in a simple manner, with margins maintained supragingivally, and the incisal third of each tooth prepared more aggressively to allow space for the development of incisal shade and translucency. care was taken to extend the preparations into the interproximal area far enough to eliminate interproximal shadowing.4 Following rubber dam isolation, a clear plastic strip was placed between each preparation to maintain optimal interproximal contacts. Using the total-etch technique, the teeth were etched with a 35% phosphoric acid material for 15 seconds and rinsed thoroughly. A microbrush was used to absorb the

excess water on the bonding surface, and an adhesive material (ie, ExcitE, ivoclar Vivadent, Amherst, nY) was generously agitated on the preparations for 20 seconds, then air dried to evaporate any alcohol carrier in the bonding agent.5 this layer was light cured for 20 seconds per tooth. shade B1 Dentin (ie, 4 seasons, ivoclar Vivadent, Amherst, nY) was placed on the cervical aspect and tapered towards the incisal edge to establish the body color and to provide strength to the addition in incisal length.6 this also helped eliminate a transition in color between the dentin body of the prepared tooth and the desired length. this layer became the functional surface on the lingual aspect. Developmental lobes were subsequently formed in this layer and then stained. internal characterizations were then added to give warmth and help decrease the natural tendency of teeth to become too gray when increased in brightness. translucency was instilled along the incisal edge to encourage

28 Anterior esthetic restorAtion Using A Direct resin Veneer techniqUe

Figure 7. incisal guidance and excursive movements were also improved postoperatively.

Figure 8. Postoperative view shows increased clinical crown length and enhanced esthetics.

recognition of the underlining characteristic colors. the halo effect was formed by beveling back the incisal edge at the proper angle to create a refracted line of light. several layers of the final resin layer were removed and replaced in an attempt to create proper tooth contour (Figure 7). canine guidance was then developed on the lingual aspect.7 the Bennet shift was induced with mild pressure on the balancing side of the mandible to ensure all balancing and working interferences were cleared.8 Protrusive occlusion was verified prior to definitive finishing and polishing. interproximal resin was removed with finishing strips and fine-fluted carbide burs under copious water irrigation. Although the facial surfaces were polished using disks with varying grits, care was taken not to remove all surface texture created during placement of the enamel layer of composite resin.9

when the clinician is masking dark, underlying tooth structures or attempting to create uniformity in color of the preparations for a porcelain veneer case.

References
1. Okeson JP. Management of temporomandibular Disorders and Occlusion. Fourth Edition. st. louis, MO: Mosby; 1998. 2. Dawson PE. Evaluation, Diagnosis, and treatment of Occlusal Problems. second Edition. st. louis, MO: Mosby; 1989. 3. chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. carol stream, il: Quintessence Publishing; 1994. 4. Beagle JR. surgical reconstruction of the interdental papilla: case report. int J Periodont Rest Dent 1992;12(2):145-151. 5. heymann hO, Bayne sc. current concepts in dentin bonding: Focusing on dentinal adhesion factors. J Am Dent Assoc 1993;124(5):26-36. 6. Albers hF. tooth colored Restoratives. 7th ed. hamilton, Ontario: Bc Decker, inc, Alto Books Divison; 1985. 7. Manns A, chan c, Miralles R. influence of group function and canine guidance on electromyographic activity of elevator muscles. J Prosthet Dent 1987;57(4): 494-500. 8. Rufenacht cR. Fundamentals of Esthetics. carol stream, il: Quintessence Publishing; 1990. 9. Miller MB, castellanos iR. Reality. houston, tx: Reality Publishing; 2001. * Private practice, Idaho Falls, Idaho. Accredited member of the AACD.

Conclusion
Often, the rebuilding of an entire anterior tooth in composite is necessary in the field of dentistry for improved communication with the ceramist. the clinicians ability to rough out the desired final results for a porcelain veneer case in composite prior to preparation is a vital skill for any practitioner that expects to excel in esthetics. Understanding the optical properties of composite resin also becomes mandatory

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