Maximum Results With Minimal Preps

This article will focus on a minimally invasive restorative technique utilizing thin porcelain veneers. It will also demonstrate the importance of having and offering the right financial plan to your patients because this often plays a significant role in achieving case acceptance. In addition, we will describe a technique to fabricate beautiful and predictable indirect provisionals.

BACKGROUND

For the past 10 years, our practice has collected payments in full. This was done at the time of the hygiene visit or prior to scheduling any treatment. At first, we were reluctant to introduce financing to our practice because we did not think we needed it. However, we were wrong. After listening to our patients, we discovered that we did have great long-term patients who were interested in interest-free payment plans.
We went on to investigate several financing programs. We looked for one that offered several interest-free plans that range from 3 to 18 months in duration. Having financing options would allow our financial specialists to select the best plan for each patient.

CASE REPORT

Figure 1. Preoperative full-face view.	Figure 2. Preoperative close-up view.
Figure 3. Smile Style Guide.	Figure 4. P-4: pointed canines with square, rounded centrals and laterals.

Figure 5. Length codes.

This successful sales executive (Figure 1) was originally referred to our practice by another dentist when she moved to Dallas 7 years ago. Just prior to moving to Dallas, she whitened her mandibular teeth and masked multiple anterior fillings as well as diastemas with direct resin veneers (Figure 2). Porcelain veneers were always in the previous doctorís long-term plan.
Over the last several years, her resin veneers began to chip on different teeth at different times. These emergency repairs al-ways required emergency treatment at inconvenient times and with additional costs. We discussed porcelain veneers at each visit. Despite repeated and costly visits to repair the resin veneers, she was not convinced that she needed porcelain restorations. For whatever reasons, she simply did not want to part with such a large sum of money at one time.
If we were going to be able to proceed with her care, then it would require the ability to offer her payment alternatives. After researching various options, we had chosen CareCreditís financing program primarily because it offers a variety of payment options for our patients. A card (resembling a credit card) is issued that can be used at the patientís convenience. The money is deposited into our business account at the enrollment time, usually in less than 24 hours.
When we introduced CareCredit as an option for this patient, she was reluctant to fill out the application. We told her that it was interest free for 12 months, but she still wanted to think about it and get back to us. The next day, she called our office to say that she had been approved and that she was ready to schedule an appointment for her new smile: 5 porcelain veneers and two 3-unit bridges. It was the flexible monthly payment options that made her decision to proceed easy, and, more importantly, immediate.
Because she already had many crowns and bridges, she was reluctant to have her front teeth ìground down.î But once the patient had committed to porcelain veneers as a more definitive restoration for these teeth, we decided that minimal-preparation porcelain veneers I call ìMicroveneersî would be appropriate. These conservative restorations would allow her to retain as much healthy, natural tooth structure as possible while achieving the beautiful smile that she was seeking.1
The first and perhaps the most critical aspect in planning a cosmetic case is excellent communication. We began with color. First we wanted to whiten her lower teeth. The upper teeth should be at least one shade lighter, the maxillary centrals the brightest.2
The next step, smile design, can often be a confusing and overwhelming task for the patient. The Smile Style Guide (digident.com) can help provide excellent communication among all parties involved in the treatment process: the patient, the dentist, and the laboratory (Figure 3). First, the desired shape of the canine was selected from 3 choices: pointed, flat, or round. Then, the shapes of the central and lateral incisors were chosen. This can be based on either patientsí natural teeth or simply their personal preferences. Finally, the preferred length variation between the incisors and canines were selected. In this patientís case, we selected P-4 (Figure 4). We enhanced the shape and length of her natural teeth; pointed canines with square-round centrals and laterals. As for length, she chose L-1: her centrals about the same length as the cuspids and the laterals 0.5 mm shorter. Ensuring that the dentist, patient, and dental technician all are on the same page is pricelessóand essential. This preliminary information helped us to create the perfect smile design for our patient and provided the blueprint for her planned treatment.3 There are four length choices featured in The Smile Style Guide, including L-1 and L-2 (Figure 5).

RESTORATIVE TREATMENT BEGINS

We began by taking out the existing resin veneers and restorations, but removing very little natural tooth structure for teeth Nos. 6 to 10 (Figure 6). Once the old interproximal, facial, and incisal composites were removed, as well as any recurrent decay and unsupported enamel, we built up the teeth. A sixth-generation bonding agent (eg, OptiBond Solo Plus [Kerr], Excite [Ivoclar Vivadent], or Adper Single Bond Plus [3M ESPE]) was used. Then, the anterior teeth were built up using a microhybrid composite (eg, Premise [Kerr] or Filtek Supreme Plus [3M ESPE]). Because of the extent of the reconstruction, we deemed it prudent to close these contacts in porcelain.4 The old bridges, teeth Nos. 3 to 5 and teeth Nos. 11 to 13, were removed at this time with the goal of creating a harmonious full-arch smile in the final restorations (Figure 7).5

Figure 7. Resin veneers have been removed.	Figure 8. Finished provisionals on instant model (facial view).

An impression was then taken with hydrocolloid (Dux Dental) and alginate so we could easily create beautiful, indirect provisionals. This method of fabricating indirect provisional restorations (the technique is outlined below) is especially useful when doing large cosmetic cases. First, the prepped teeth were sprayed with a wetting agent, PrepWet (Dux Dental). The hydrocolloid was expressed through a syringe and placed on the prepared teeth. In the meantime, our assistant mixed the alginate and loaded the tray. The tray was then seated in the mouth on top of the hydrocolloid. After 1.5 minutes, the impression was ready to remove with a snap. The beauty of this impression technique is that it can be poured up immediately with no waiting. Our assistant then poured the impression immediately with Mach-2 VPS material (Parkell) on a vibrator. A base was poured with Blu-Mousse (Parkell) expressed from an impression gun right onto the Mach-2. In less than a minute, the model was set and ready to fabricate the provisional. A small amount of block-out resin was placed interproximally and in any undercuts. A little water-based lubricant was applied to the prepared teeth on the model as well as to the adjacent teeth for easy removal. The putty matrix previously made from the wax-up was used as a template for the chosen shade (B-1) of bisacryl material. The matrix was filled with bisacryl and placed on the silicone model. After 1.5 minutes, the provisional was trimmed (Figure 8). This indirect technique makes it simple to create faster, better-fitting, and more predictable provisionalsóall outside of the patientís mouth (Figure 9). The provisional was polished and tried in the patientís mouth. With this technique, the provisional fit great and the patient loved the shape, since she had already selected it from the Smile Style Guide and previously approved it on the wax-up.

Figure 9. Provisionals on instant model (occlusal view).	Figure 10. Provisionals in the mouth.

Expasyl (Kerr) was placed around the margins of the prepared teeth. Then, 2 impressions were taken with a polyvinyl siloxane material (eg, Extrude [Kerr] or Virtual [Ivoclar Vivadent]) in custom trays as well as a bite registration Super-Dent, Darby).
The provisionals were then seated with flowable composite. The excess was removed with a microbrush and explorer before light-curing. However, because the provisionals were finished outside the mouth, final finishing in the mouth was much easier.
When the patient returned for the pressed porcelain restorations, she was hopeful that they would be as nice as her provisionals (Figure 10). Our patient was reassured when the porcelain veneers and bridges were tried in. To achieve the most natural-looking smile possible, it is always a good idea to try in the restorations with various shades of try-in pastes such as Prevue (Cosmedent). This way, the patient can see and approve her smile before final seating. A variety of shades of veneer cements (eg, da vinci Veneer Cementation System [Cosmedent]) or Insure [Cosmedent], were used to give her smile a more natural appearance.

Figure 11. Postoperative closeup (occlusal view).	Figure 12. Postoperative closeup (facial view).

For the actual bonding procedure, it is important to use a fresh bonding agent (eg, OptiBond Solo Plus, Excite, or Adper Single Bond Plus). This ensures that the maximum bond strength is achieved compared to that of a used bottle that has become less effective with multiple uses. We used a da Vinci Brighter shade for tooth No. 6, Brightest for teeth Nos. 7 and 10, and an opaque white for teeth Nos. 8 and 9. I call this ìmix to matchî and use this technique for most of my cases to achieve the most natural-looking appearance possible (Figures 11 and 12). The bridges were cemented with a self-etching resin cement (eg, Multilink [Ivoclar Vivadent] or Maxcem [Kerr]).

CONCLUSION

Figure 13. Postoperative full-face.

For a long time, our patient knew that she needed porcelain veneers. However, she was not ready for them, despite the repeated emergency visits she had to endure to repair her resin veneers. When we offered flexible monthly payment options that gave our patient the peace of mind, she decided to proceed with her desired treatment. She is currently in great dental health and visits us for 3 routine cleanings per year. Now, she even has plans to have her mandibular anterior teeth orthodontically aligned, followed by an implant to replace a lower left molar.
A combination of patience, persistence, good communication, and a flexible, interest-free payment plan (CareCredit) made for maximum results with minimal prepsóand a very happy patient (Figure 13).

References

Acknowledgment

The authors thank their ceramic artist, Cornelia Ferenschuetz.

Dr. Berland is accredited by and a Fellow of the American Academy of Cosmetic Dentistry. He is a sought-after speaker and published author on cosmetic dentistry in America, and has been featured in national and regional magazines, major dental journals, and recently NBC News, Fox News, and ABCís 20/20. He can be reached at (214) 999-0110 or drberland@dallasdental-spa.com. For more information on The Lorin Library Smile Style Guide and/or the 8-AGD credit DVD A Full Mouth Rehab in Two Appointments, call (214) 999-0110 or visit dallasdentalspa.com and denturewearers.com.

Disclosure: Dr. Berland is the developer of the Lorin Library.

Dr. Kong graduated from Baylor College of Dentistry with the highest honors, where she currently serves as a professor in prosthodontics. She focuses on preventive and restorative dentistry, transitionals, anesthesia, and periodontal care. Prior to entering dental school, Dr. Kong worked with a master ceramist in one of the worldís finest dental laboratories. She is an active member of several professional organizations, including the ADA, AGD, American Academy of Cosmetic Dentistry, Texas Dental Association, and Dallas County Dental Society. She can be reached at drkong@dallasdentalspa.com.