Composite Veneers for a Budget minded Patient By: Martin Goldstein, DMD

I hounded this patient for about two years to do something about his deteriorating anteriors. Finally he popped a facial restoration on #9 and made a move, agreeing to composite veneers on five teeth. The case took me four hours to complete and included considerable playing with incisal effects and tints.

An alternative method for veneer characterization to the method presented here (as described with photo 14 caption), is to build up to full contour in body shade, cut back .5 to 1 mm of material, tint with Miris’ effects paste where desired, cure, and then apply the thin translucent enamel shade paste over it to reestablish contour. The advantages are of course, that the obtained look will be permanent. The disadvantage is not being able to preview the effect prior to curing. Applying the effect tint on a roughened surface (diamond or microetch), after the build up allows for immediate viewing and assessment. To be sure, however, the effect will be lost sooner via normal wear than when using the alternative approach described above, as recommended by the manufacturer.

		Photo 1 Excessive wear, multiple restorations...you name it. A veneer want-to-be for sure. Composite veneers are wonderful for the budget minded consumer/patient.
		Photo 2 Lingual view of anteriors prior to tooth preparation.
		Photo 3 A sneak preview of the completed case accomplished with Coltène/Whaledent’s Miris. It was important to keep the shades in line with the rest of the dentition in this 72-year-old male.
		Photo 4 Dentin and enamel Miris shades chosen: S2 dentin and NT enamel.
		Photo 5 Shade tabs nested for final base shade. A drop of glycerin between the tabs ensures a homogeneous shade.
		Photo 6 Prepped teeth...chamfer preps to the level of the gingiva but not subgingival in this case. Contacts were broken where large, older discolored composites remained. Approximately 1 to 1.5mm in reduction in buccal and incisal dimension as well as lingual incisal preps that traveled 2mm down the lingual aspect of the teeth. High-speed instrumentation was carried out with my old faithful NSK Ti-Max EL-400 electric high-speed (very sweet) and Brasseler diamond cutting instruments...a formidable combination!!
		Photo 7 Initial application of Miris is used to approximate length and thickness of finished veneer. Preps are “washed” for ten seconds with 33% phosphoric acid, rinsed, dried and coated with Parkell’s Touch&Bond as the primary bonding agent, and then further coated with unfilled resin to make them “stickier” for the Miris paste to follow. As an aside, since I began using Touch&Bond a year ago, sensitivity following restorative and cosmetic work has all but disappeared. The change has been dramatic.
		Photo 8 Interproximal contacts can be formed nicely without having to cinch the mylar strip. The shape retaining aspects of Miris allows one’s contact forms to remain intact and excess can easily be removed prior to curing. This is a time saving measure. Additionally, it allows for buttering and forming the contact perfectly before curing. This is SO important! Shown here is one of Hu-Friedy’s XTS composite placement instruments. I rely heavily upon this series of instruments as they’re extremely thin, non-sticky black surfaces perfect for placing and sculpting composite.
		Photo 9 Curing of the interproximal contact with Caulk’s Spectrum 800 curing light.
		Photo 10 Horizontal check of #8 to assure that incisal edge is horizontal to the inter-pupillary line and or the horizon.
		Photo 11 Checking that the midline will be perpendicular to the horizon. This is key! A canted midline will kill the case the same as with porcelain veneers or crowns. After completing #8, I match #9 to it. They must be symmetrical and complement one another if the case is to succeed. The centrals will often consume half of the time spent sculpting while the remaining teeth can be done relatively quickly. Kind of like filling in the pieces on the tail end of a jigsaw puzzle.
		Photo 12 Monochromatic veneers have been completed. They were sculpted with Brasseler ET burs, notably the #9 8 fluted carbide (red stripe). Incisal shaping is aided and abetted by using their OS1 and OS2 ET carbides. Although intended for occlusal surfaces, they lend themselves to creating subtle curves in the incisal edges as can be noted particularly in #8 and #9. Polishing is furthered with Caulk’s Enhance polishing cups and enamel gloss polish. Seen here is a dry view of Miris veneers prior to characterization.
		Photo 13 Shown here are the lingual incisal edges hollowed out to various depths without breaking through the labial walls. Varying the depths will create a more natural effect. They are subsequently restored with the enamel shade chosen. Often, I will also layer the enamel shade on the labial surface of the entire veneer that is cut back minimally, as was the case here.
		Photo 14 Although not shown, the veneers are painted with Miris’ effects shades, orange at the gingival and cream white streaked throughout the entire labial surface, over the orange as well. These “paint ons” are heavier than the usual glaze, but flow nicely and enable a textured look to the surface as is shown in this image. When lost from brushing and function, such effects can be replaced in a matter of minutes. Retention of the effects layer is increased if the labial surfaces of the composite veneers are dried and microetched prior to placement of the tint. These maxillary anteriors were off-set by using a PhotoMed contraster to mask the lower dentition and tongue.

All images were captured via a PhotoMed rigged Canon G2 as well as a Nikon 880 without add-ons.

Conclusion
In a battle for truth, justice and prettier teeth, composite veneers can go a long way. Case completed with Coltène/Whaledent’s Miris composite and Parkell’s Touch&Bond bonding agent. Free-hand placement technique.

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Dr. Goldstein is a 1977 graduate of the University of Connecticut School of Dental Medicine and practices general dentistry in a group setting in Walcott, Conn. He can be reached at martyg924@cox.net or at his office at (203) 879-4649.

For more information on PhotoMed camera equipment please visit their website at http://www.photomed.net or call 800-998-7765.

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Townie Comments on Dr. Martin Goldstein’s Clinical Presentation

When Dr. Goldstein presented this case online at www.dentaltown.com, questions and comments were immediately raised. If you would like to see all of the comments on this case, or perhaps add some of your own, go to DentalTown.com’s homepage, click on the Today’s Active Cases button. (If you are not logged in, or a member, you will have to log in, or become a member to view and/or comment on the case. Membership is free.) Once at the Case Presentations page in the Username box type in: martingoldstein. This will bring up all cases posted by Dr. Goldstein. Look for the one entitled: Miris direct composite veneers and click on martingoldstein with your mouse.

skip 1/9/2003 7:26:01 AM		Looks very nice! How much do you charge per tooth in a case like that?
mmelkers 1/9/2003 9:04:30 AM		Free hand?! You are working WAY too hard! I saw Dietschi at the Mid-Winter do his Miris presentation. This stuff is pretty cool.
martingoldstein 1/9/2003 12:17:32 PM		Charge for case: $400/tooth....$2000 out the door. (very reasonable...). Thickness of veneers generally 1 to 1.5mm with 1.5 to 2mm incisal length build up. All wrap around lingually...about 2mm down the tooth.
jmaya 1/9/2003 7:42:41 PM		Good to see this kind of stuff from a wet-fingered dentist. And I thought I was good at freehand. I bow to thee. Doesn’t get any better than this.
doctored 1/10/2003 6:34:48 PM		The result is very impressive. Your fee is so “fair”. Bet BOTH of you went home that day with very big smiles on your faces. Did you use retraction? Did you place a gingival chamfer? Would love to watch over your shoulder.
martingoldstein 1/10/2003 8:21:49 PM		In answer to your questions, yes, a gingival chamfer was used but preps remained at the gingival margin so retraction wasn’t needed in this case.
walrusx 1/13/2003 7:53:55 PM		I like to see doctors that have the confidence to push the limits using bonding, as most would automatically choose porcelain in a case like this. I just have a few questions: 1) Please explain your tech. for incisal effects. Especially when you dug a trough in the incisal edge. 2) Do you ever get any problem adding new composite to composite that was cut back and has no oxygen inhibited layer anymore?
martingoldstein 1/13/2003 8:25:52 PM		Regarding my technique with the incisal effects, as you hollow out the edges, and hold something dark behind the teeth, (I use the PhotoMed contrasters) you begin to see the translucency effect as the labial wall thins out. I use a round diamond to do this and bury it to varying depths. You keep checking to assess the effect. Once you like the look, you simply fill in the cavities with your chosen incisal composite. The show through will continue, but will be more subdued as the composite will refract the light to some extent. I’ve not experienced any problem with adding on. I do, however, etch to clean things up and apply an unfilled resin coating to enhance the bond. I hope that answers your questions and again, thanks for taking the time to comment.
walrusx 1/16/2003 7:16:01 PM		That’s an interesting variation in technique for incisal effects, I have not seen it done that way before. In your opinion what’s the advantage of making a trough in the incisal edge as compared to shaping lobes on the facial and applying a layer of enamel over it? To me getting the incisal effects is a very difficult thing to do!
martingoldstein 1/16/2003 8:07:55 PM		Yep, incisal effects are tricky. The lobe technique is certainly viable. I suppose I feel more secure building the veneer up to full contour and having what could pass as a finished veneer, minus the characterization. I start to relax at this point. In fact, on occasion, I’ll dismiss the patient if the morning has run long, and then bring them back for the “finish work”. One advantage of the trough technique is that it allows you to go gradually and continue to preview what the effect will be, but make no mistake, to really see the effect, you’ll almost penetrate the labial wall of the veneer. The good news is, the lingual shape and the contour of the veneer, when left undisturbed (i.e. assuming you haven’t taken away the incisal edge anatomy) are very quickly restored when you add the enamel composite....a matter of minutes. Try it...you’ll like it.