A Step-by-Step Approach to Esthetic Excellence: Every Detail Matters
Adamo E. Notarantonio, DDS
Abstract: Social media has flooded the Internet with beautiful "before and after" photographs of porcelain restorations. While these images can help promote the benefits of cosmetic dentistry, one of the problems this can lead to is patients mistakenly assuming that such restorations are simple to achieve. They may fail to realize that multiple steps need to be taken to attain such esthetic results, with each step requiring meticulous attention to detail. What some patients may not appreciate is the precision that goes into every step and which is critical to achieving long-term success. From preparation design and material choice, to selecting the correct bonding protocol and cements, no steps in the restorative process can be overlooked or deemed less important than others. The case presented describes a smile rehabilitation with proper isolation and cementation protocols.
In today's world where so much is dictated by speed, the importance of precision may tend to get overlooked. Modern technology allows almost everything to be done at a pace that seemed impossible in the past. This mindset has carried over into clinical dentistry, and in some instances this can be a positive, but in others it may prove to be troublesome. In the author's view, one of the areas this can be problematic is when cementing porcelain restorations. To ensure the success of these restorations, proper isolation, chemical treatment of the restorations and dental tissues, and proper bonding protocols and techniques are crucial. Clinicians must understand that no step can be overlooked, and every step should be carried out with the utmost precision and accuracy.
The 36-year-old patient, a dentist herself, presented to the author's office for a cosmetic consult. She was unhappy with the shapes and color of her existing teeth, as well as multiple older resin restorations that were evident on her teeth (Figure 1 and Figure 2). After a thorough diagnosis and treatment planning in the periodontal, biomechanical, functional, and dentofacial aspects, a decision was made to move forward with 10 maxillary porcelain restorations.
The first appointment comprised a full diagnostic photograph series, digital scans (iTero®, Align Technology, Inc., itero.com), and a facebow transfer (Kois Dentofacial Analyzer, Panodent, panodent.com). The scans, photographs, and specific instructions for the wax-up were sent to the ceramist at the dental laboratory for fabrication of a diagnostic wax-up. A detailed conversation between the clinician and patient revealed the exact parameters she was looking for, and these were communicated through photographs to the ceramist (Figure 3). A diagnostic wax-up was returned from the laboratory (Figure 4). A silicone matrix was fabricated from the wax-up in order to create the provisional restorations.
Following the preparations and necessary impressions, a provisional was fabricated via the existing wax-up (InstaTemp® Max, Sterngold, sterngold.com). Because patients undergoing this treatment are usually numb at the time of insertion, the author typically does not perform evaluation of the provisional restorations until 24 to 48 hours later. In this case, the patient returned 24 hours later for photographs and a thorough evaluation, which included any necessary adjustments. Once the provisionals were approved (Figure 5), photographs and an impression were sent to the ceramist so he could replicate the shape, size, and position of the restorations exactly.
When the restorations were returned, they were tried on the models and evaluated for any modifications prior to the insertion appointment (Figure 6 through Figure 8). The laboratory was given specific instructions to not treat the intaglio surfaces prior to returning the restorations. These particular restorations were made from lithium-disilicate porcelain. When received, they were treated with Porcelain Etchant 9.5% Hydrofluoric Acid (BISCO, bisco.com) (Figure 9), rinsed, and silanated with two-part silane.
On the day of insertion, the patient was anesthetized and the provisionals were removed. Each preparation was air-abraded with an air abrasion system (PrepStart™, Zest Dental Solutions, zestdent.com) using 50-micron aluminum oxide particles. The restorations were tried in for fit and esthetics. Upon removal, the restorations were cleaned with Uni-Etch® (BISCO) 32% phosphoric acid etchant with benzalkonium chloride (BAC), rinsed, dried, and re-silanated.
The author considers isolation to be a critical step in achieving ideal bonding. His isolation protocol of choice is individual tooth isolation utilizing heavy-gauge latex rubber dam (Nic Tone, nic-tone.ro). Primary clamps were placed on the second molars, and the teeth were isolated individually from the upper right second molar to the upper left second molar. Veneers were placed two at a time starting with the central incisors. To ensure complete isolation and that there would be no impeding of seating from the rubber dam, accessory clamps (B4 Brinker, Coltene Whaledent, coltene.com) were utilized. As is the author's custom, a final try-in prior to cementation was completed following isolation (Figure 10).
The tooth surfaces were etched with Uni-Etch 32% phosphoric acid etchant with BAC for 15 seconds. The preparations were thoroughly rinsed and blot-dried with a cotton roll to avoid desiccation. Two separate coats of All-Bond Universal® (BISCO) were applied, scrubbing the preparations for 10 to 15 seconds between each coat and not light-curing between each coat. Excess solvent was evaporated with hot air by air-drying for 20 seconds followed by a 10-second light-cure.
The veneer was lined with Porcelain Bonding Resin (BISCO), a HEMA-free, unfilled resin that acts as a wetting agent. The veneer was filled with translucent veneer cement (Choice™ 2, BISCO) (Figure 11) and seated (Figure 12). Each veneer was tack-cured for 3 seconds, excess cement was removed, and a final cure of 40 seconds per surface was completed. The accessory clamps were removed and moved to the adjacent two teeth (Figure 13 and Figure 14), and the same protocol was followed for all remaining teeth.
Following removal of the rubber dam, excess cement was evaluated under a 3D dental microscope (PromiseVision 3D, Seiler, seilermicro.com). Occlusion was adjusted and the patient was dismissed. The patient returned in 1 month for postoperative follow-up and photographs, which revealed a highly esthetic, successful outcome (Figure 15 and Figure 16).
Delivering beautiful esthetic dentistry is not a two-step, "before and after" process. Multiple steps along the way must be delivered with precision and accuracy to ensure long-term success. It is important to not overlook the "little things," such as bonding materials and protocols, as well as luting procedures and cements.
The author thanks the ceramist on this case, Julian Cardona, CTG, of Guayaquil, Ecuador.
This article was commercially supported by BISCO.
About the Author
Adamo E. Notarantonio, DDS
Clinical Instructor, Honors Aesthetic Program, New York University College of Dentistry, New York, New York; Private Practice, Huntington, New York; Fellow, International Congress of Oral Implantologists; Fellow, American Academy of Cosmetic Dentistry