In-Office Smile Rehabs

INTRODUCTION
Those of us with a hankering for resurrecting smiles have at one time or another tried our luck placing direct composite resin veneers; often referred to by our patients as “bonding.” And while many have dabbled in this dental art form, far fewer of us have embraced this process as a cosmetic mainstay, let alone an income producer in our practices. The reasons for this are many, but in the end, 2 primary issues surface that are “deal breakers,” if you will. First and foremost is the requirement of the dentist to recreate accurate and symmetrical anatomic form from “scratch.” Simply put, one needs a bit of Michelangelo in him or her to be good at it. Runner-up to this objection might be the time and care required to produce an optimal finished composite surface. Combined with comparisons that would have composite resin the crowned subordinate to porcelain, these factors have relegated direct composite veneers to the back of the dental bus. That said, I have interesting news for you; but first, let’s regress a bit in time.

Dental History
Some of you may be old enough to remember what might be thought of as “dental dinosaurs.” They roamed the land in the very early ’80s (that’s 1980s) and were called “Mastique” (DENTSPLY Caulk). Mastiques were thin, single-shade acrylic “veneers” that came in a variety of sizes and shapes. After slight shape modifications, they could be bonded to deserving teeth with composite and composite priming agents, producing accurate anatomic form and a shiny surface in a single visit. Much like the dinosaur, however, Mastiques inexplicably disappeared from the dental landscape after a relatively brief existence of approximately 5 years. It might have been the lackluster bonds between composite and acrylic that contributed to their demise, but the advent of the lab-fabricated porcelain veneers and the recognized superior properties of porcelain most certainly shifted the focus away from using “acrylic solutions” to improve smiles. With the extinction of Mastique went the option of a same-day cosmetic solution for those dentists not inclined to take on the role of “sculptor,” a requirement for aesthetic direct composite resin bonding. For the legions of dentists not wishing to participate in direct bonding efforts, conservative smile rehabilitation options have been restricted to lab-fabricated porcelain solutions that are often too costly for our patients to afford. So, what is the end result? Nobody wins.

Moving Into the Here and Now
Let’s fast forward to the interesting news to which I alluded to above. The single sitting prefabricated smile solution has resurfaced as the brainchild of Switzerland’s Dr. Mario Besek and has been named Componeers. Brought to us by Coltène/Whaledent, this next generation solution is a prefabricated composite veneer that comes in but one shape and 3 sizes (small, medium, and large) grouped in sets of 6 for restoring canine to canine, maxillary, and mandibular (Figure 1). In an effort to keep it simple, the Componeer is the “factory” version of Coltène/Whaledent’s own acclaimed Synergy D6 nanohybrid composite. Available in 2 enamel shades (Universal and White Opalescent), the Componeer must be custom shaped by the dentist to conform to the tooth shape being veneered (don’t wince just yet). To assist the dentist in placing these restorations, the available “first purchase kits,” (one with 14 sets, and one with 4 sets) contain all of the instruments and finishing materials that are essential for placing them successfully; essentially a “turn-key” package. While they won’t fit every tooth shape and size that you might encounter, they manage to fall within the basic morphology of most dentitions (surprisingly!).

Figure 1. Complete set of Coltène/Whaledent Componeers.	Figure 2. Close-up view of what looks like a porcelain veneer but is a Componeer.

What is a Componeer?
The Componeer needs to be thought about differently than you might think about a porcelain veneer, though when held in your hand, they look quite similar (Figure 2). While the porcelain veneer is in and of itself, the final restoration, the Componeer serves as a “scaffolding” for a direct composite resin veneer. It can also be thought of as the “outer layer” of a dual-layered technique where the dentin colored composite placed in direct contact with the tooth is united with its pre-formed enamel shaded “sibling.”

Because the luting agent (Synergy D6 with One Coat Bond) and the Componeer are one in the same material, the union can become seamless when finished and polished with the abrasives provided within the kit. As one might imagine, your smile creations could indeed take on a cookie cutter appearance if you choose to adhere mostly to the preformed shape of the Componeer. But because you don’t have to worry about the perils of reworking the shape and finish of glazed porcelain once placed, you are free to customize the shape of a Componeer any way you see fit. Needless to say, the more of the original Componeer is left intact, the less finish time you’ll need to spend to complete the case. It’s also worth mentioning that unlike thin porcelain veneers, the Componeer (at 0.3 mm in some areas) is quite robust and can be handled freely without fear of accidental breakage.

Neither should you think the Componeer necessarily represents a “minimal- to no-prep” solution. While that might be the case with a tooth that is in lingual version that is being “moved” forward, the majority of the time you will need to remove or modify tooth structure to some degree to accommodate the thickness of the materials that you’ll be placing; including the Componeer. But, since finish lines, incisal shortening, or removal of undercuts aren’t mandated by the technique, Componeer placement may still be thought of as a conservative approach to restoring the appearance of one’s dentition, as has been conventional direct composite bonding. We must also remember and take comfort in the fact that because it’s composite, when the need arises, we can repair it. Fortunately, a lot of water has flowed under the dam since the advent of Mastique. Today’s nanohybrid composites and enamel/dentin bonding agents have narrowed the gap between ceramic and composite solutions. Improved physical properties and the consequent longevity offered by composite elevates this approach to a worthy option that we can offer to our patients so long as we’re willing to endure a brief learning curve. The good news? It’s not rocket science.

Let’s take a quick look at the technique for placing Componeers.

CLINICAL PROTOCOL
Shade Selection
A typical case would begin with shade selection. This is accomplished with a dual-layered shade guide that features a dentin substructure tab and an enamel-shaded outer layer that corresponds to one of the 2 colors that the Componeers come in. The enamel shell snaps over the dentin tab to “suggest” the final color (Figures 3 and 4). I use the word “suggest” since the final shade will be influenced by the tooth’s actual color and the thickness of the composite placed. So as is often said: “actual results may vary” with respect to final shade. I have found that for cases in which doctor and patient have agreed to a “natural” shade that blends in better with the surrounding teeth, the universal enamel shade Componeer when combined with the A1 or A2 Synergy composite yields results that will work toward that end. Those desiring the “bleached look” are best served using the White Opalescent Componeer atop Synergy’s BL/O (Bleach Opaque) shade or perhaps the A1 shade Synergy D6.

Figure 3. Dentin and enamel shade tabs prior to nesting.	Figure 4. Nested shade tabs of Componeer and Synergy D6 (Coltène/Whaledent) providing approximate final shade.

Size Selection
The next step involves size selection via the included sizing shells that directly correspond to 3 sizes that the Componeers come in (small, medium, and large) (Figure 5). To reduce my shape modification responsibilities, I have found it helpful to choose the size that is slightly narrower than the actual tooth, if possible. This will accelerate your placement efforts and make it easier to finish the “seams” as you’ll actually be able to see them. Shape modification is easily accomplished with the discs included in the Componeer kit (Figure 6). I then find it helpful to make sure the 6 can lay side by side, in place, before beginning the bonding procedure (Figure 7).

Figure 5. Sizing guide to assist in selecting the best fit for the case at hand.	Figure 6. Typical Componeer shaping procedure via kit provided forceps and abrasive discs.
Figure 7. Try-in of set of 6 Componeers before final luting.	Figure 8. Use of Garrison Dental Solutions small (yellow) wedges to assist in securing mylar strip, which contains excess composite during luting procedure.

Placing Mylar Strips, Wedges, Luting and Finishing Procedures
From this point on, you are in familiar territory with perhaps one exception. In order to contain your luting composite (Synergy D6), you’ll have placed a series of short mylar separating strips, perhaps securing them with your smallest wedges. I like Garrison Dental Solutions’ small yellow wedges for this purpose (Figure 8).

Luting process in bullet form:

• Etch tooth, rinse
• Coat tooth with One Coat bonding agent that comes with kit, thin it with air and cure
• Coat inside of Componeer with One Coat (don’t cure)
• Place Synergy D6 on tooth to fill in recessed areas (ie, approaching the line angles)
• Place Synergy D6 on undersurface of Componeer; avoid over-bulking
• Sandwich the Componeer onto the tooth and press into place using the special placement tool included in the kit. It evenly distributes placement pressure (Figure 9).
• Remove gross excess with the kit included specialized plastic instrument
• Smooth the margin with the plastic instrument seeking to blend the edges of the Componeer with the Synergy D6. (Voids discovered later can be filled in with the flowable Synergy D6 included in the placement kit.)
• Cure it! Move on to the next.

See? I told you it wasn’t rocket science. There might be virtue in placing the central incisors first and both at the same time to assure an accurate midline, but I’ve placed them singly as well with equally good results (Figure 10). (One other side note: You can mix and match sizes so long as you are okay with breaking up a complete set.)

Figure 9. Special rubber tipped positioning tool used to float the Componeer to place.	Figure 10. Central incisor Componeers placed together to assure an accurate midline appearance.
Figure 11. Before Componeer placement.	Figure 12. After Componeer placement.

The rest of your time is consumed by removing flash, flattening margins, reshaping where needed, and polishing those areas of the Componeer that have been roughened during modification. It is important to realize that after Componeer placement, you have a unified veneer of composite atop the tooth being restored. You can create surface irregularities, alter lengths, in essence customize the veneer in any way you see fit. The polishing process will allow you to return the “Componeer-guided” veneer back to its original luster. And, of course, you’ll dial in the bite and possibly protect your creation with a night guard if the original destruction took place as a result of bruxism. What you will find striking is that despite the fact that you might not have an ounce of Michelangelo in you, you’ll be looking at an anatomically convincing, symmetrical set of composite veneers. In the end, your true responsibilities are case selection and being methodical and thorough in your finish work. The “heavy lifting” has already been done by the manufacturer (Figures 11 and 12).

DISCUSSION
Observations
I’ve found that while the Componeer created smile can thankfully relieve one of the dentist’s artistic requirements, at first, the time required to complete a case might be similar to that required to do a freehand case. On average I will spend the better part of a morning on a case (2.5 to 3 hours for 6 teeth). This will likely change as I become more proficient at placing them. The fact that I am a compulsive polisher and sometimes employ retraction cord to better visualize the cementoenamel junction might slow me down some (Figure 13). But an average fee for such a service, at $500 to $650 per tooth, will generate nice production for the time spent, even factoring in the cost of the Componeer (they approximate $50 per unit). You may also find yourself free-hand bonding the first bicuspids to complete the case, which can further enhance the bottom line. While bicuspids are not currently part of the Componeer family, Coltène/Whaledent suggests that modifying the shape of the canine Componeer can easily generate a shape suitable for bicuspid coverage if you would prefer that route.

Patients will ask you how long they can expect out of a Componeer smile. Since the Componeer restoration is made from composite, I will tell them that a 5- to 10-year life expectancy is within reason, depending upon wear and tear. They are also told that composite can break from time to time, but fortunately, we can usually effect a nice repair, quickly! That seems to satisfy them, as does reassurance that they don’t just wake up and find them on the pillow after their predicted life span is up. Need for replacement is dictated by how shop-worn the veneers look down the road and to a great extent, that need is subjective.

Figure 13. Use of DUX Dental “0” Gingibraid with epi to better expose location of cementoenamel junction.	Figure 14. Screen shot of SNAP Instant Dental Imaging (SNAP Imaging Systems).

Creating Desire
As one of the themes here is “in-house” rehabs, I’d like to change the subject completely and complement this discussion with one of the ways I manage to get people interested in pursuing such things as Componeer restored smiles. Those who have read my articles in the past may be aware of my fondness for smile simulations both for case marketing as well as for case design. My go-to simulation lab has been, and still is, Smile Vision (smilevision.net); most notably when doing a laboratory based restoration that requires an anatomically accurate rendition of the smile being reconstructed. But, for those cases that are to be done “in-house,” as might be a Componeer smile, simply exposing the perspective recipient to the appearance benefits of a smile rehab can ignite patient desire or at the very least, curiosity. To that end I’ve found imaging software (SNAP Imaging Systems) to be a valuable tool. While SNAP can do all sorts of smile manipulation with aplomb, I use it most simply to swap a new smile in its entirety on top of an old smile. I can tweak it with sliders to make it look remarkably natural and print out the before and after images in a matter of minutes. Of course patients are told that “actual results may vary,” but that doesn’t seem to dampen their interest. In keeping with the “not rocket science” cotheme, using SNAP does not require a manual. The user is dutifully lead by on-screen prompts and built-in safe-guards that make it near impossible to mess up. Accompanying instructional videos make SNAP even more user friendly, rendering a package that is immediately usable (Figure 14).
The one key ingredient to round out your “in-house” smile rehab factory is the ability to take a serviceable portrait. As a convenience to you I’ve listed below several pointers on taking a serviceable portrait that lends itself to a smile simulation.

Summary of Portrait Technique

• Distance: 6 to 8 feet from patient (Figure 15)
• Camera is in autofocus mode if camera and lens combination allow this (it’s okay to use your 100 macro lens for portraits)
• F 5.6 to 6.7 or portrait mode
• Camera turned vertically
• Lens perpendicular to the nose
• Focus on the teeth (lock focus by pressing shutter release halfway down), then frame the face by lifting camera
• Have patient say “hiiiieeeeeee” sustained
• Take 6 shots and pick the best one.

Figure 15. Note the distance from photographer to subject; this is critical for taking a serviceable portrait.

If you don’t have a good digital camera, by all means visit the Web sites of dental photo vendors such as PhotoMed International, Dine Corporation, Dental Learning Centers, or CliniPix, to name a few. You might also consider PhotoMed’s Quick and Easy Portrait Kit that will take your portraits to a more professional level with a minimum of effort and cost.

CLOSING COMMENTS
Not to beat a dead horse (okay, I will anyway), but there is daily talk amidst our profession that due to the faltering economy, patients can no longer afford high-end elective dental services such as smile rehabs. Ceramic rehabs, while wonderful when affordable, aren’t for everyone. Presented herein has been a proposed “work-around” and reentry into the world of aesthetic dentistry that does not require a continuing education continuum to master nor a long-term lease to afford.

This has been fun! Over and out!

Dr. Goldstein, a Fellow of the International Academy of Dento-Facial Esthetics as well as the AGD. He practices general dentistry in Wolcott, Conn. Recognized as a Leader in Continuing Education by Dentistry Today, he has expertise in the field of dental digital photography and lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. Dr. Goldstein has authored numerous articles for multiple dental periodicals internationally. He can be reached at martyg924@cox.net or at drgoldsteinspeaks.com.

Disclosure: Dr. Goldstein is a consultant to Coltène/Whaledent and SNAP Imaging Systems.