Show Your Work by Dr Christopher Leech

Chris presents a case detailing the importance of a comprehensive pre-operative assessment and careful execution of a previously failing cosmetic case.

Introduction
This pleasant patient came to see me following a friend’s recommendation as she had previously had two sets of veneers elsewhere that were not getting her the result she wanted.

The first thing we had to ascertain was why the restorations were failing and why this had happened more than once.

On examination, the ceramic seemed to be breaking away in sections from the teeth leading to concerns over the bonding process and perhaps, the fabrication of the veneers themselves. Also, in the absence of any habits putting undue stress on the restorations, the occlusion needed to be assessed.

The BACD offers its members a fantastic assessment document that I often utilise and would thoroughly recommend to ensure a comprehensive assessment of patients.

The occlusal clinical photographs highlight the signs of incisal edge wear on both the upper and lower arches. These seem to have an erosive nature as well due to the cupping of the wear lesions and there were interferences in excursions also.

The initial point of contact was recorded and mounted models made for a full assessment. After assessment some minor tweaks demonstrated that with some composite addition and slight adjustment, the interferences could be removed.

We also discussed the crowded lower arch and the slight imbalance to the gingival margin caused by the slightly misaligned upper centrals however the patient did not want to align these teeth.

This was disappointing as it is known that the narrowing of the lower arch will likely get worse with time. This was highlighted to the patient before commencing treatment and would have corrected the slight gingival discrepancy but again this did not concern the patient.

After discussion with the patient it was decided that with the occlusal adjustments, some new veneers (all materials discussed including composite and Emax veneers were opted for) following a good protocol would give the result the patient was looking for.

Stage 1
A diagnostic wax up (via facially generated treatment planning) was made allowing for a ‘trial smile’ in the mouth to ensure the patient was happy with the proposed cosmetics.

Once this was correct a simple alginate was taken (although today I would likely take a Trios scan or similar). This allows the laboratory to know the final aesthetic result desired for the final veneers.

This is an important stage to ensure that the dentist, the lab and the patient know the proposed shape of the final restorations before you have begun. Much conversation was had with the patient about the finish to her veneers since her natural teeth have multiple white patches and individual characterisation.

The patient however specifically requested not to mimic these aesthetics in her new veneers. This was another benefit of the trial smile as it allowed her to have a better idea of what the proposed finish would look like.

Good photographs are essential in communicating with your lab with regards to shade and appearance as well as communicating with the patient.

Stage 2
Once the smile was confirmed the famous “Gurel” technique was followed by ‘prepping’ through the temporaries to ensure that the most minimal approach could be taken to protect the natural tooth structure.

Since the teeth had already been prepped, minimal modifications were made mainly around polishing and removing old

cement and some caries. Immediate dentine sealing was performed again as per “Gurel” (his book “The Science and Art of Porcelain Veneers” really is a must read and an essential text in my opinion).

A double layer cord technique was then used and a 2 stage silicone impression taken to ensure crisp margins. Again a scanner could also be used if the dentist wished.

The planned occlusal adjustments were also made at this stage.

Stage 3
Rubber dam was placed (a split dam with bite registration paste in the palate works really well for cases like this). This ensured a dry field and the ‘temporaries’ were removed and the teeth air abraded to ensure the best possible bonding surface.

Try in pastes from the Variolink Veneer bonding system from Ivoclar were utilised to check fit and contacts.

Once the cement shade had been decided on, the veneers were cemented and cured according to the manufacturer’s instructions. I choose to spot cure just the centre of the veneer initially to hold them steady and then floss can easily be passed interpoximal and a 12c scalpel run over the margins gently to easily remove any excess cement.

An air barrier (glycerine gel or similar) is then placed and a full cure performed.

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Christopher Leech is a partner at the award winning Clear Dentistry and on the board of directors for the British Academy of Cosmetic Dentistry. If you are interested in developing your skills then please see the full BACD Academic Calendar.