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Meeting Patient Demands for Today's Job Market Ara Nazarian, DDS

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by Ara Nazarian, DDS
Today, more and more people are becoming aware of what cosmetic dentistry has to offer in their every day lives. With competition in the work force due to the limitation of available jobs, more and more people are trying to enhance their looks to compliment their resumes. More than ever before, dentists are challenged to create “Executive Smiles” in a fast, effective and easy method. Patients are insisting on perfect teeth and are demanding it be done as soon as possible. Occasionally, we are faced with the dilemma of using a rapid restorative solution to satisfy these patient’s needs instead of traditional methods. The introduction of adhesion dentistry has opened a realm of treatment options.

In the case presented in this article, the patient was informed of all the treatment options and it was recommended that he consult an orthodontist. The patient found the treatment time of 12-18 months unacceptable and insisted on proceeding with the option of porcelain restorations. Consequently, a mutual decision was made for minimal selective tooth reduction to achieve the result the patient was seeking.

Case Study
A young man in his early 30s presented to the practice for an aesthetic consultation. The patient was not pleased with his smile and did not feel comfortable in social circumstances and in the work force. In particular, the patient was dissatisfied with the size, shape, spacing, and color of his anterior maxillary teeth (Figure 1). Upon clinical examination, his anterior maxillary teeth exhibited multiple diastemas. Although he had a Class I bite, his maxillary anterior teeth were small. In other words, the length of these teeth could tolerate widening and lengthening. After considering the obstacles, a diagnostic wax-up was fabricated to help visualize the solution (Figure 2). By visualizing the case on the preoperative models, the patient was able to begin with the end result in mind. In order to achieve the patient demands, the placement of porcelain veneer restorations (Nano-Veneers, Burbank Dental Lab) on teeth #7-#10 would be utilized.

Once informed consent was obtained from the patient, treatment was initiated. Since the preparations were very conservative, no anesthetic was necessary for margin placement. Using a #4 round diamond bur, a slight margin was placed at the gingival margin and wrapped around the incisal edges.

Following sequential preparation of the maxillary teeth, a stickbite registration was taken using Take-1 Advance bite registration (Kerr). This stick-bite would aid the technician in preparing the model and mounting the case. It also communicated to the ceramist the orientation of the interpupillary line so that the incisal edges of the final restorations would not appear canted.

Utilizing a retraction paste called Expasyl Strawberry (Kerr) we not only controlled hemorrhaging, but also achieved gingival retraction. After approximately two minutes in the sulcus, the Expasyl was rinsed off with copious amounts of water. Impressions were taken using a fast setting polyvinyl material (Take-1 Advance, Kerr). Since the proposed veneers were going to be thin, it was imperative to fabricate and bond the temporaries over the maxillary anterior teeth (#7-#10) by spot etching the prepared surface (Figure 3). Using a siltec matrix (Ivoclar Vivadent) of the proposed wax-up, the provisional restorations were fabricated using Protemp (3M) (Figure 4) then trimmed and glazed.

Laboratory Considerations
Color photographs and diagnostic data were also obtained and forwarded to the laboratory for the fabrication of the final restorations. During the laboratory phase, the full arch polyvinyl-siloxane impressions were used to create a master model on which the restorations would be based. The master model was segmented into individual dies that were trimmed and pinned to determine the manner by which the final restorations would integrate with the soft tissue. A silicone incisal matrix of the wax-up was created to guide the placement of the incisal effects and edge position in the subsequent ceramic build-up. A shade of B-1 on the Vita Shade Guide (Vita) was selected for the porcelain veneer restorations (Figures 5 & 6).

Cementation
Before try-in of the definitive restorations to verify fit and shade, the provisional restorations were removed and any remaining cement was cleaned off the prepared dentition. After the patient was shown the retracted view for acceptance, the cementation process was initiated. The restorations were treated with 37 percent phosphoric acid for 20 seconds, rinsed, silanated (Silane Primer, Kerr), and allowed to air dry for a minute. The prepared dentition was cleaned with chlorohexidine 2% (Consepsis, Ultradent Products Inc.) for 15 seconds and rinsed to remove any contaminants during the temporary phase. The preparations were etched for 10 seconds, rinsed thoroughly and dried.

Two coats of dental adhesive (OptiBond Solo Plus, Kerr) were placed on the preparations (Figures 7 & 8) and high-speed suction was used to ensure that the material had evaporated. The adhesive was light cured for 10 seconds per tooth with the LED curing light (Demi, Kerr).

A resin luting cement (NX3, Kerr) was applied to the restorations starting from the centrals and then the laterals (Figure 9). The restorations were then placed on the preparations, and, while firmly holding the restorations in place, a rubber tip applicator removed all excess luting cement from the margins. The restorations were tacked at the gingival margin using a small diameter turbo tip in the Demi light (Kerr).

While the restorations were still firmly held in place, the restored dentition was flossed and any excess luting cement was carefully removed. When most of the excess cement was removed, the restored dentition was completely light cured from both facial and lingual sides. Any residual cement was removed with a No. 15 scalpel or finished with a fine diamond. After complete polymerization of the restorations, the occlusion was verified and adjusted. The overall health and structure of the soft tissue and restorations were very good. The patient was extremely satisfied with the definitive results (Figure 10).

Conclusion
Completion of this aesthetic dilemma with a quick restorative solution satisfied the patient’s demands of straight, white teeth in order to meet the demands of today’s job market. By using bonded porcelain restorations (Nano-Veneers, Burbank Dental), a substantial improvement was achieved quickly. It is important that dentists ensure that their patients are completely informed of all risks, benefits, and alternatives before initiating treatment. By having patients act as partners in exploring various treatments, a dentist will not merely meet their expectations, he or she will surpass them (A special thanks to Burbank Dental Lab for these beautiful restorations).

Author's Bio
Ara Nazarian, DDS, is a graduate of the University of Detroit-Mercy School of Dentistry. Upon graduation, he completed an AEGD residency in San Diego, California with the United States Navy. He is a recipient of the Excellence in Dentistry Scholarship and Award. Currently, he maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He has conducted lectures and hands-on workshops on aesthetic materials and mini dental implants throughout the Untied States. Dr. Nazarian is also the creator of the DemoDent patient education model system.
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September 2025
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