accreditation essentials - fountaingrove dentistry · volume 17 • number 4winter 2002 • the...

36 THE JOURNAL OF COSMETIC DENTISTRY • WINTER 2002 VOLUME 17 • NUMBER 4

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INTRODUCTIONEnhancing or rehabilitating a smile using directly sculpted and polished com-

posite resin veneers can be one of the most rewarding challenges in cosmetic den-tistry. Direct resin veneers give the cosmetic dentist full control over color, con-tour, and surface texture. Occlusion must be carefully studied in advance to min-imize unfavorable forces on these restorations and ensure that they will provideyears of service. The result can be a fabulous smile that is gratifying for both thepatient and the dentist.

HISTORYThe patient is a 14-year-old female with a history of asthma. She carries a

Proventil® inhaler, but does not need it on a regular basis. A local pedodontist andorthodontist referred her. The orthodontist had been forced to remove her brack-ets early due to severe decay of the upper anterior teeth. Although she had beenwarned in advance of the consequences of her poor home care, the patient and hermother were horrified to see her smile when the upper brackets came off.

CLINICAL DATAUpon clinical examination, no soft or hard tissue pathology was noted either

externally or within the oral cavity. Her temporomandibular joint and associatedmusculature was free from pain and she had good range of motion with no para-functional habits. Her occlusion was class I molar and class I cuspids with 3 mmvertical and 3 mm horizontal overbite. Some minor rotations remained in theupper anterior segment after early removal of the orthodontic appliances. Herupper lip was thin relative to her lower, which was full and symmetrical.

The patient presented with long-standing moderate to severe gingivitis, whichwas compounded by a tendency for mouth breathing. The etiology was plaque andpoor oral hygiene. All upper anterior teeth were ravaged by caries, both faciallyand interproximally. Additionally, the weakened facial surfaces were severelystained and had been damaged by removal of her brackets.

IINN TTHISHIS SSECTIONECTION::• Clinical Case Report: Direct Veneers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .page 36• Interview with the Candidate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .page 42• Examiner’s Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .page 43

CLINICAL CASE REPORT: DIRECT VENEERS

byRobert W. Erlach, D.D.S.

Dr. Robert Erlach graduated fromthe University of California at SanFrancisco School of Dentistry in1986. He then joined the U.S.Army and completed a 1-yearGeneral Dentistry Residency beforeserving in Korea and in the 82ndAirborne Division. Dr. Erlach main-tains a private practice in SantaRosa, California, with an emphasison cosmetic dentistry. He still servesas a Lieutenant Colonel in the U.S.Army Reserves. He and his wife,Josephine, enjoy travel, hiking, andscuba diving.

VOLUME 17 • NUMBER 4 WINTER 2002 • THE JOURNAL OF COSMETIC DENTISTRY 37

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Figure 2: Correction of misalignments andenhancement of buccal corridors was desirable

(unretracted before smile 1:2 view).

Figure 1: Full-face before.

DIAGNOSIS• Facial caries ##4-13 with interprox-

imal caries #6M, #7M,D; #8M,D;#9M,D; #10M,D; and #11M.

• Recurrent decay around occlusalcomposites #12MO, #13O.

• Moderate to severe gingivitis withswollen papillae. Unesthetic gingi-val contours.

• Short clinical crown of upper bicus-pids.

TREATMENT PLANThe goal of this patient’s treatment

was to restore her smile in a mannerthat would provide a beautiful anddurable result. The treatmentsequence was as follows:

1. Diagnostic photos and studycasts. These were used for analysis oftooth and face proportions, as well asto study occlusal considerations.

2. Oral hygiene instruction and pro-phylaxis. No subgingival calculus wasevident, but poor oral hygiene andsevere inflammation of gingiva are notcompatible with excellent results. Thiswould be our biggest challenge.

3. Gingivectomies as needed toimprove height-to-width ratio. Thiswill also be necessary to improve gingi-val form.

4. Direct resin restorations of deepinterproximal caries #7M, #8M,D;#9M,D; and #10M.

5. Direct resin veneers to lengthenand align ##4-13.

6. Replacement of direct compos-ites on #12, #13 occlusal.

7. Reinforcement of home care.

ARMAMENTARIUM 1. Alginate (Teledyne; Elk Grove

Village, IL) and stone for diagnos-tic models

2. 35 mm camera (Yashica DentalEye III [Kyocera Corp; Tokyo,Japan])

3. Oroscoptic 4.2X loupes 4. Diamond burs #5856L-016,

#8856-018, 8392-016 (Brasseler;Savannah, GA)

5. ET9 and ET9F finishing burs(Brasseler)

6. Diamond finishing strips(Brasseler)

7. #245 Carbide bur (Midwest DentalProducts Corp.; Des Plaines, IL)

8. #6 Latch type round bur(Midwest)

9. #7408 bur (Midwest)10. Caries detector (Kuraray; Beth-

page, NY)11. Mylar strips12. Cut stainless steel matrix strips

13. ViscoStat® (Ultradent; SouthJordan, UT)

14. Optibond Solo Plus (Kerr; Orange,CA)

15. Optilux 400 curing light(Demetron; Danbury, CT)

16. Apollo 95E PAC light (DMD;Woodland Hills, CA)

17. Bard Parker (Franklin Lakes, NJ)#12 and #15 blade

18. Thompson Dental Mfg. Co.(Missoula, MT) #6 Compositeinstrument

19. IPC instrument (Cosmedent;Chicago, IL)

20. As t ropo l ( Ivoc la r /Vivadent ;Amherst, NY) polishing cups,wheels, and points

21. Point 4 microhybrid composite(Kerr)

22. Renamel microfill composite(Cosmedent)

23. Creative Color opaquers and tints(Cosmedent)

24. Enamelize and Flexibuff disks(Cosmedent)

25. FlexiDisks and FlexiStrips(Cosmedent)

26. Gingival retraction cord(Ultradent)

27. Perforated stock trays (COE;Chicago, IL)

28. 35% phosphoric acid (Ultradent)


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Figure 3: Facial and interproximal decay wouldneed to be treated concurrent with esthetic plan

(unretracted before right lateral 1:2 view).

Figure 4: Improvement in oral hygiene and healthwould be critical in this case (retracted before

facial 1:1 view).

PREPARATIONThree weeks prior to preparation,

diagnostic photos and impressionswere taken to document and study thecase (Figs 1-4). Prophylaxis was com-bined with oral hygiene instructions. Itwas made clear to the patient that thegingival inflammation had to bereduced markedly prior to restoring hercase. The mother and patient weremotivated and returned for two addi-tional visits for reinforcement of oralhygiene and rubber cup polishing usinga fluoride paste. Although not elimi-nated, the gingival inflammation wasreduced significantly. The irregulargingival architecture did not changeand gingivectomies would be necessaryto improve height-to-width ratios ofall the teeth. It was decided to proceedwith the case.

Preparation started on the fourupper anterior teeth by treating theinterproximal decay on #7M, #8D,#8M, #9M, #9D, and #10M as separateclass III restorations. A rubber damwas placed from teeth ##5-12. Decaywas removed with a 245 carbide burand #6 round bur (Midwest) on a slow-

speed handpiece. The preparationswere checked with a caries detector(Kuraray) and residual caries removed.Marginal enamel was beveled using an8392-016 medium flamed-shaped dia-mond (Brasseler). The facial enamelwas severely decalcified, but this wouldbe prepared at a later step.

The interproximal lesions wererestored two at a time. Mylar matrixstrips were placed to protect adjacentsurfaces, and then the dentin andenamel were etched for 15 secondswith 35% phosphoric acid. Afterwashing thoroughly, the preparationswere gently air-dried to rid them ofexcess moisture. Optibond Solo Plus(Kerr) was applied with agitation for20 seconds to the etched but slightlymoist preparations. Treated prepara-tions were cured for 6 seconds fromfacial and lingual using a PAC light(DMD). Tetric Flow A2 was applied tothe dentin surfaces as a liner to ensureexcellent adaptation of the restora-tions to the tooth/resin interface.Point 4 A2 microhybrid composite(Kerr) was condensed into the prepa-rations and sculpted with an IPC

instrument (Cosmedent) and themylar matrix. At this stage, a single“prep shade” composite was chosenthat later could be etched andveneered along with the facial andincisal surfaces.

Smile analysis consisted of a carefulstudy of preoperative photos to deter-mine desired incisal edge positions,gingival zeniths, and contact points inharmony with the patient’s lip line.Measurements on the study modelssuggested that an additional 1.5-2 mmof clinical crown length was desirable.Desired length-to-width ratio of 1.2would improve the proportions of thepatient’s teeth, as the central incisorswere nearly as wide as they were long.A longer, tapering ovoid or squaretapering tooth form was the goal. Withgingival recontouring, 1 mm of addi-tional length could be gained and anadditional 1 mm of length added to theincisal edge of the restorations.

The gingival contouring was doneon ##7–10 using a #15 Bard-Parkerscalpel, followed by ViscoStat®

(Ultradent) for hemostasis (Fig 5).Because the patient’s tissues were still


accraccr edi tat ioneditat ion essentialssomewhat edematous, a #1 gingivalretraction cord (Ultradent) saturatedwith aluminum chloride was packed inthe sulcus to retract the tissue and pre-vent seepage of crevicular fluids ontothe preparations. I have found thatusing a new scalpel blade for eachtooth, followed by application ofViscoStat® prior to preparation, yieldsa predictable result with virtually nopostoperative discomfort. In combina-tion with an impregnated cord, tissuewas managed yielding good visibilityand complete moisture control.

Because the midline was deter-

mined to be acceptable and toothwidth would not be changed, it wasdecided to prep one tooth at a time.Preparations were accomplished usingBrassler course round end diamonds,creating a light chamfer at the gingivalmargin, interproximally and overlap-ping the incisal edge. In this case, achamfer margin was chosen over along bevel to ensure that all superficialdecalcification was removed near themargin. A gingival chamfer also wouldaid in precise margin placement,which was needed in this case toenhance moisture control. The incisal

edge was prepped in such a way as tomimic a basic mamelon pattern andbreak up any straight line (Fig 6). Dueto the extensive facial decay, someareas were prepped into dentin and thepreparations appeared much like thosefor indirect porcelain veneers.Interproximal margin placementextended to a point where the marginwould not be obvious if a color demar-cation was present between tooth andresin. The preps were polished with afine chamfer diamond.

Figure 6: The incisal edges were prepped to avoidthe appearance of a horizontal line.

Figure 8: Layers were placed to mimic the naturaltooth structure.

Figure 7: Mamalon development was sculpted intoeach direct veneer and cured.

Figure 5: Gingivectomies to improve gingivalcontours and height-to-width ratios.

A2 Point 4T1 Point 4A2 Renamel MFA1 Renamel MF


accraccr edi tat ioneditat ion essentialsaccraccr edi tat ioneditat ion essentialsBONDING ANDSCULPTING

Adjacent teeth were protected witha section of stainless steel matrix whilethe tooth being bonded was etchedwith 35% phosphoric acid for 15 sec-onds. The prepped tooth was washedwith copious irrigation for 5 secondsand excess moisture blown away. Dueto exposure of significant dentin,Optibond Solo Plus (Kerr) was used tobond the restorations. The adhesivewas applied to the slightly moist toothstructure with a micro brush and agi-tated for 20 seconds. Excess adhesiveand solvent were removed with astream of dry air, leaving a shiny sur-face. All areas of the preparation werecured for 6 seconds with a PAC light(DMD).

The first layer of composite resinapplied was Point 4 A2 (Kerr), toextend the incisal edge to approxi-mately 1 mm short of its final position.This would be my dentin replacementmaterial. It was chosen for its combi-nation of strength and polishability.Point 4 could have been used for theentire restoration, but I prefer using amicrofill for the final facial surface.The dentin layer was sculpted with awashed, gloved finger (my favoritesculpting instrument), IPC(Cosmedent), and Thompson #6 tomimic mamalon development andleave room for translucent compositeat the incisal edge, between themamelons and at the incisal-inter-proximal transition (Fig 7). This layerwas fully cured with a PAC light(DMD). Next, a judicious amount ofCreative Color A2 opaquer (Cosme-dent) was applied with a fine sable

brush to highlight the mamelon devel-opment and mask the transition fromtooth to microhybrid resin. The opa-quer layer was cured for 60 secondswith a standard halogen light.

To accentuate the incisal character,Point 4 T2 microhybrid (Kerr) wasused to build the incisal edge to fulllength. The translucent composite wasblended to the facial, interproximal,and lingual using a finger and IPC.Care was taken to leave 0.5 mm ofroom on the facial for the final layer ofmicrofill resin. This layer was curedwith a PAC light for 6 seconds fromfacial and lingual.

Renamel Microfill Resin A2(Cosmedent) was used to form the gin-gival third of each tooth. Mylar matri-ces were placed interproximally andused to pull the microfill into the con-tact area flush with the margins of thepreparations prior to curing. The A2microfill was beveled to disappear atthe junction of the gingival and mid-dle thirds of the tooth. Once shaped,this layer was cured with a halogenlight for 60 seconds. The entire facialsurface was then veneered withRenamel Microfill A1, again using themylar matrices to pull the excess intothe contact area to seal the interproxi-mal margins. Due to the prior contour-ing of deeper layers, the A1 final layerhad minimal thickness at the gingivalto yield a warmer A2 shade. Also, onlya thin layer was beveled to the incisalso as not to mask the carefully placedincisal characteristics. This final layerwas cured using a halogen light for 60seconds. The resin layer placement issummarized in Fgure 8. The four upperanteriors were sculpted and rough fin-ished during this appointment in an

identical fashion. The canines andpremolars were done at a subsequentvisit and included gingivectomies toimprove the appearance of the buccalcorridors.

FINISHINGThe restorations were shaped with

an 8-fluted ET9 finishing bur(Brasseler) and Flexidisks (Cosme-dent). A 12 fluted 7408 football-shaped bur (Midwest) was used toshape the lingual slopes. When thefinal gross contours were achieved,Astropol points were used to definefacial developmental lobes and lingualconcavities. Gingival areas were fin-ished with Astropol cups. FineFlexidisks combined with Brasselerdiamond interproximal finishing stripswere used interproximally, althoughmost of this finishing had been donepreviously. Careful attention was givento reproducing developmental lobesand avoiding overuse of disks, whichtend to flatten the facial surface. Atthis point, we finished with the fourthappointment, took a series of photo-graphs, and made another appoint-ment to complete the case.

After evaluation of the mid-treat-ment photos, some minor changes incontour were made and restorationstaken to a polish with Astropol finepoints and cups. Unfortunately, thepatient’s oral hygiene had slipped andfinal polish and evaluation had to bedelayed. Oral hygiene was reinforcedusing an Oral B 3D (Gillette;Kronberg, Germany) electric tooth-brush and dental floss. After severalother visits to monitor the progress ofher home care, the final polish was


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achieved using the finest Flexidisks,Astopol points and cups followed byEnamelize (Cosmedent). Anotherappointment was made for postopera-tive photos 1 week later (Figs 9-12).

CONCLUSIONRemarkable esthetic and functional

results can be achieved with directresin veneer restorations. This proce-dure gave this young lady a secondchance after poor oral hygiene duringthe course of orthodontic treatmentended in horror. Patient satisfaction isincredible for this procedure when

taken to a high level of excellence.Additionally, direct resin veneersallow the cosmetic dentist to betterunderstand the process of smile designfrom start to finish.

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REFERENCES1. Miller MB, ed. Direct resin veneers. Reality 15

Section 3, The Techniques, 2000.

2. Willhite C. Complex bonding. AACD JournalWinter 1997, 16-23.

3. Willhite C. Dramatic smile makeovers usingdirect resin veneers. Compend Cont Ed Dent18(7):646-656, 1997.

4. Ubassy G. Shape and Color—The Key to SuccessfulCeramic Restorations (pp. 197-210). Berlin,Germany; Quintessence Publishing, 1993.

5. Terry DA. Enhanced resilience and esthetics in aclass IV restoration. Compend Cont Ed Dent Supp26:19-25), 2000.

6. Fahl. N, Jr. Achieving ultimate anterior aesthet-ics with a new microhybrid composite. CompendCont Ed Dent Supp 26:4-13, 2000.

7. Moppe, KW, O’Malley M. The RenamelRestorative System Illustrated Technique Guide (pp.29-35). Chicago, IL; Cosmedent, rev. 1994.

8. Lee KK, Tam LE, McComb D. The fractureresistance of dentin composite interfaces. AACDJournal, Winter 1999, 17-22.

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Figure 12: Natural contours, finish, and internalcolor combine to create beautiful restorations

(retracted after 1:1 view).

Figure 11: Improved home care and ideal gingivalcontours promote periodontal health (unretracted right lateral 1:2 after).

Figure 10: A beautiful smile is a great social asset(unretracted after smile 1:2 view).

Figure 9: Patient, mother, and dentist were allthrilled with the results of treatment (full-face).

accreditation essentials - fountaingrove dentistry · volume 17 • number 4winter 2002 • the...

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