Rich or poor, most Americans have televisions. Like it or not, TV is America’s window to the world. The good, the bad, and the ugly filter down to the populace in whatever manner the networks and corporate America deem most profitable: whether selling cars, fast food, or beer. Discretionary income is on the table.
In the past, this was of no particular importance to dentistry. What a difference a year or 2 makes! Can you say Extreme Makeover or The Swan? Suddenly dentists, formerly relegated to the “do-I-have-to?” department, have been cast as cosmetic miracle workers, and looking good has moved to a high perch on the “gotta have” list. Mail carriers are now asking for the likes of da vinci veneers! Wake me up! Please!
Here comes the reality check: your average American (and potential cosmetic buyer) is likely part of a 2-paycheck family that plays it close to the bone, planning paycheck to paycheck. Do not confuse what dentists earn with what most of your patients earn. Big ticket or even semi-big ticket items need to be planned for and somehow squeezed into already overtaxed budgets. So, where does this leave dentists who do not practice in “la-la land” (myself included)?
Take notice! Even the folks at Mercedes-Benz now offer the C-Class Benz. Rather than holding out for only those wishing to purchase E-Class and S-Class vehicles, the entry-level Benz was born. Why should we as dentists hold out for only those who can comfortably afford 8-unit and 10-unit all-ceramic cases? We, too, need alternatives in our repertoire, or the result is far fewer pretty smiles than there should be and far less cosmetic treatment rendered in your office than there could be.
The rest of this article will cover methods that I employ to control the cost of smile rehabs when faced with patients whose pocketbooks don’t match up to the all-ceramic case that I have in mind. In doing so, we may re-explore some old territory for you, but sometimes we need to be reminded of what we already know.
LAB-ASSISTED DIRECT COMPOSITE VENEERS
I already know you are going to tell me that you hate direct composite veneers because they make you sweat behind the ears like nothing else. Why do you feel like that? Elective anterior dentistry has a set of expectations that accompany it, and chances are you’re afraid your composite carving skills won’t meet those expectations (or your own). This is particularly true when it comes to space management cases. Enter injection-molded direct composite veneering.
You can’t read too far in any of today’s cosmetically oriented periodicals without encountering the fabled mock-up. We are called upon to “build it before we do it.” The evolution of dentistry’s now common call for preplanned form and occlusion is a good fit for direct composite veneering. One only needs a method.
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| Figure 1. Preoperative portrait ready for Smile Vision simulation. | Figure 2. Simulated rehab of teeth Nos. 6 to 11. |
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| Figure 3. Premier Alfa Tray and Colténe Whaledent Monobody get the ball rolling. | Figure 4. Resin Replica of intended rehab outcome. |
Here’s how it works: start with a digital portrait of your patient in full smile and have a simulation done of your intended changes (Figures 1 and 2). (Yes, you need a digital camera, but if you’re doing cosmetics today, this is mandatory.) To date, I’ve found Smile Vision of Newton, Mass, to be very strong in this department. You can direct Smile Vision technicians on what you want or simply have them digitally construct the ideal smile; then, show it to your patient. If he or she likes it, take impressions for the mock-up. I favor doing this quickly and have become comfortable with Colténe Whale-dent’s Monobody PVS impression material, teamed up with Premier’s ALFA trays (Figure 3). This combination provides a well-tolerated full-arch triple-tray impression of the status quo. The Alfa trays are ana-tomic, rigid enough to provide a stable impression, come in 3 sizes, and are well-tolerated by patients owing to the trays’ streamlined form factor. The Monobody is taste-free and not runny, also providing for a comfortable impression that need not be poured in the office. Ship it to your lab for pouring and articulation. The ability of the lab to match the mock-up to your simulation will vary from lab to lab. Again, I’ve found this to be a strong suit of Smile Vision technicians. They miraculously translate the imaging to a resin mock-up that they call a Resin Replica (Figure 4). Interestingly, they don’t convert the wax-up to resin (and subsequently stone) until I’ve been allowed to preview the wax version of the mock-up online at the Web site. Once I sign off on it, the conversion takes place.
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| Figure 5. Reduction template is used to confirm adequate tooth preparation. | Figure 6. Soft template modified for composite injection and placement of mylar strips. |
From there they return to me the resin and stone mockup models along with suck-down templates and a reduction guide to assist me in doing the case (Figure 5). As long as I inform Smile Vision technicians that I will be doing an injection-molded direct composite veneer case, they will alter the template accordingly. This involves separating the individual teeth that are to be bonded as well as creating small facial portholes into which a composite compule will be inserted and composite in-jected (Figure 6). It is important that you include an empty compule with your impressions so that the porthole can be properly sized for a snug fit.
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| Figure 7. Finished case. |
Typically, I will schedule a full morning to complete such cases, knowing full well that at least half of it will be spent trimming, refining, and polishing the easily placed resin veneers. The good news is this: the base anatomy of the new smile has been preformatted, if you will. So the pressure associated with how it will look is, for the most part, alleviated. The supplied reduction template allows me to gauge my preps for adequate reduction. If I can stay within the lines of the reduction template, my case will look just fine (Figure 7).
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| Figure 8. Preoperative view of lower anterior lab-assisted direct veneer case. | Figure 9. Case completed with J. Morita’s Palfique Estelite Sigma. |
In a nutshell, once the teeth have been prepared in accordance with the guide, they are etched and bonded as an entire group. The specially prepared injection template is then seated over the preps, after which each tooth is injected with resin through the lab-created portholes. The resin flow is controlled with everyday mylar strips leapfrogged in such a way that both interproximal surfaces are closed with strips on the tooth that is being injected (Figure 6). Each contact is cured independent of the other while the respective mylar strip is cinched together, much like a class III resin formation. This dictates that your composite resin flows easily. My current resin for this approach is J. Morita’s Palfique Estelite Sig-ma. It possesses the exact flow characteristics needed for injection-molded bonding, and trims and polishes beautifully (Figures 8 and 9). In the past, I’ve also used Ivoclar Vivadent’s 4 Seasons, but heated it first with AdDent’s Calset heater. This clever heating device will make any stiff resin flow easily in a matter of minutes. (Still not clear on the approach? A technique video is offered at drgoldsteinspeaks.com that squeezes a 4-hour morning into 32 minutes.)
THE ECONOMICS OF THE CASE
Yes, you do have to allow for your lab expenses when establishing a fee for this type of case and predetermine what you would like to net hourly. In my office a single veneer fee of $450 to $500 for an 8-tooth case will command a fee in the $3,600 to $4,000 range for the entire case. As mentioned, I typically devote a 4-hour morning to complete such a case. Allow $50 to $60 per tooth for lab fees, and you’ll be able to calculate what your hourly return will be on the case. Contrast this fee with the $8,000 to $10,000 fee that might accompany an all-ceramic case, and you can understand the advantages of having an alternative approach up your sleeve, one that is attractive, predictable, and can be expected to last 6 to 10 years based on this author’s own experience with direct composite veneer cases. Of course, patients are told this from the get-go when presenting both methods and are provided with a protective, soft night splint as part of the case. They are also told that nothing will kill the look of their composite veneers more than smoking, and that if they ever wanted a good reason to quit, now is a good time. Also included in the cost is a 30-minute follow-up visit 2 to 3 weeks later, during which I check for flash, occlusal discrepancies, and tissue health. This is the best time to take final photos of the case.
If and when a veneer chips down the line, it is typical to repair it using the same fees that would accompany a conventional restoration of the surface involved. The good news is that with today’s resins, the chips are infrequent. They are also easy and fast to repair with the advent of specialized composite repair bonding agents such as Parkell’s Add and Bond. Such agents reactivate the chemically inert resin surface, allowing for a much more dependable as well as invisible repair.
INTEGRATED CASES: MIXING PORCELAIN AND RESIN
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| Figure 10. Teeth Nos. 4 and 5 ready to join the rest as part of a 10-tooth maxillary rehab. | Figure 11. Etching of teeth Nos. 4 and 5. |
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| Figure 12. Colténe Whaledent Alpen fine diamond used to rough out preliminary contours on tooth No. 5. | Figure 13. Finished Palfique Estelite Sigma composite veneers Nos. 4 and 5. |
For those instances in which you really wish to do porcelain on what should be an 8- or 10-unit case, consider placing porcelain veneers on teeth Nos. 6 to 11 and hand-building direct composite veneers on the remaining bicuspids. This approach can shave thousands off the fee. Bicuspids can be done quickly, are less demanding anatomically with respect to freehand work, and usually require very little preparation, as one is typically “expanding” the smile into the buccal corridor. Shade matching is also less critical so long as you are in the ballpark, so to speak. Patients are told that they can be converted to porcelain at any time, at a later date. They are grateful for the enhanced affordability, and I am grateful for case acceptance, having found the patient’s comfort zone with respect to my fee (Figures 10 to 13).
WALTZ OF THE PONTICS: REPLACING NOS. 7 AND 10
Who hasn’t been faced with a parent seeking to replace a child’s missing lateral incisors postorthodontically who is tapped-out with respect to funds available for tooth replacement. Or simply, a lateral was lost due to pathology or trauma, and the expense of an implant or conventional fixed bridge just wasn’t in the cards.
History has taught us that Maryland bridges can work but will likely result in a gray cast to the abutments owing to casting show-through. Another solution is fiber/resin bonded-on frames with attached porcelain veneers, but they have a weak point: namely, the veneer as it’s bonded to the resin/fiber frame. This approach is best employed with only the most ideal occlusal schemes.
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| Figure 14. The Block inlay bridge. | Figure 15. Preoperative portrait of postorthodontic space management issue. |
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| Figure 16. Preoperative close-up of postorthodontic case. | Figure 17. Tooth No. 11 prepped, and Parkell Brush and Bond bonding agent applied. |
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| Figure 18. Lingual view of inlay bridge in place. | Figure 19. Retracted anterior view of case combining composite bonding and Block inlay bridge. |
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| Figure 20. Portrait of finished case. |
Enter the Block inlay bridge. As seen in Figure 14, it consists of a fully cast frame with 2 wing/inlay retainers and a porcelain-fused-to-metal pontic. The wing/inlays are also coated with porcelain, with the bonding side pre-etched in preparation for bonding to 2 definitive but shallow preparations made on the lingual surfaces of the abutments (Figures 15 to 20). This appliance is named for its developer, David Block, of Aesthetic Porcelain Studios, who has enjoyed great success with this approach.
The advantages include an absence of the gray cast inherent to classic metallic bond-on bridges, as well as an integrated pontic that will not separate from its frame, as can happen with fiber/resin-bonded appliances. As might be expected, careful occlusal adjustment is dictated, making sure to protect the pontic in lateral excursions. Meticulous bonding approaches with self-curing resin luting agents are required, such as J. Morita’s Bistite II DC or Kerr’s MaxCem.
Temporization of such cases consists of simply sealing the prepared rest seats with a suitable protectant while the bridge is being fabricated. This author has employed Parkell’s Brush and Bond coupled with its TR2 temporization cement for this purpose between visits. At the time of bridge delivery, the temporary TR2 seal can usually be popped off with an explorer and the bonding surface freshened via diamond instrumentation and/or microetching. Typically, whatever replaced the tooth prior to preparation, such as a retainer or flipper, may continue to do so without modification. The exception to this would include an instance in which it is desirable to create an ovate pontic site via laser or electrosurge. This would dictate that the removable appliance be added to in some manner so as to maintain the depth of the created ovate site.
As can be imagined, provision of a Block bridge requires little chair time and modest lab costs, allowing one to offer a more affordable alternative to titanium. In the case shown here, the Block bridge was combined with additional direct composite bonding to teeth Nos. 7, 8, and 9 to provide a serviceable anterior rehab at an affordable price. Again, the door has not been closed to a more permanent solution down the road, particularly since very little tooth structure has been sacrificed to secure the bridge.
OPTIONS, OPTIONS, OPTIONS….
I’m sure the 3 scenarios covered haven’t been lost on you. It’s simply a matter of expanding your imagination when seeking affordable solutions to your patients’ cosmetic desires. Finding a neutral zone that provides both patient and doctor satisfaction will create happier patients (who doesn’t want to look better?!) as well as practitioners able to say they practice cosmetic dentistry on a frequent basis.
Dr. Goldstein practices general dentistry in a group setting in Wolcott, Conn. He serves on the staff of Contributing Editors at Dentistry Today and contributes regularly to multiple dental periodicals. He can be contacted at martyg924@cox.net. He lectures on digital dental photography and its use to further the cosmetic and restorative practice. Information on his lecture schedule can be found at drgoldsteinspeaks.com, while info on the Comfort Zone Cosmetics seminar series that teaches the veneer technique discussed in this article can be found at smilevision.net.
