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A dental professional becomes a veneer patient.
During the initial presentation for esthetic treatment, most patients have a hard time describing what is bothering them specifically but they are easily able to point out what they do not like in general terms, such as not white enough, not straight enough, etc. The patient in this case study, like an increasing number of esthetic patients, brought magazines to show the treating dentist celebrity women whose smiles she admired, as well as a photograph of her daughter's teeth, whose tooth shape she hoped to emulate. Unlike many patients, however, this patient was well versed in the dental profession, being a dental hygienist.
When the author met the patient, she was hesitant to follow through with the work required for this case. She had very high expectations that she was not sure could be met. Her main concern was that her veneers be lifelike and that the amount of translucency be in keeping with her natural teeth.
The author explained to her that in his experience, with traditional shade tabs, it is hard to match natural teeth precisely. They can be used as a general guide, but will not provide the kind of detail the patient was seeking. In his opinion, to achieve the kind of appearance she was hoping for, he would need to overlay clear and enamel colors on top of the porcelain to bring the bright color she wanted to life.
Then they discussed the shape of her teeth. She was extremely particular about the shape she wanted and had brought a photograph of her daughter to show him because she liked the shape of her teeth and thought that was what she wanted, as well. The author then made the veneers square/round in the incisal edge corner shape, but upon trying the veneers in, the patient decided that a square/square incisal corner shape would look better.
After following that prescription, the author had to agree that the veneers looked much better. The communication between the patient, clinician, and technician paid off. In fact, with most cases, the author finds it best to send a picture of the bisque-bake restorations to the clinician so that he and the patient can see them and decide if they like the way they look beforehand.
The patient in this case, a 53-year-old woman, was a dental hygienist with anterior veneers that had been placed about 15 years earlier. Due to her professional awareness, smile esthetics were important and acutely noticeable to her. When examining her case, the co-author noticed gingival embrasures; misalignment; tooth No. 11 was longer than tooth No. 6; the lip line on the right side was higher than on the left side; there was a gap between tooth Nos. 8 and 9; and the teeth were slightly dark in appearance.
The case was classified as rehabilitation and would need special treatment planning in order to ensure its success. Radiographic examination was unremarkable and the tissue health was very good. To clarify patient expectations, a preoperative consultation between the patient, clinician, and technician was scheduled at the laboratory, where a prescribed format would be used for instructional purposes.
In this setting the technician was able to evaluate the patient's facial features and smile line as well as what about her color and shape were distasteful to her. In discussing her likes and dislikes, the team was able to determine tooth length, contour, smile design, the protrusion of teeth Nos. 8 and 9, and the balance objective that would best suit the patient's preferences and facial aspects. It was also decided at this time to adjust the interproximal margins deeper to allow for a better emergence contour. Using a variety of tools, the patient was able to choose what she wanted before preparation and temporization.
A smile view (Figure 1) gives the technician invaluable information about the patient's situation. In this study, he noticed that he would need to close her “black triangles;” increase tooth Nos. 6, 7, and 8 incisally; correct her mid-line; correct the incisal third of tooth No. 11; and create a slightly brighter color overall. With his shade tool in hand (Figure 2), the technician verified with the patient that a Bleaching 2 color for the incisal and body area of her centrals was acceptable. Despite deep transparency, the patient did not want quite that much color for the laterals and canines and through good communication, they decided on a base A1 (Figure 3) shade. In the second step, after the temporaries were placed, they were able to choose her preferred smile design and incisal corner shape (Figure 4).
In a rehabilitation design case, stump color can create a problem, especially if it is dark (Figure 5). In our study patient's case, her stump color was light and, therefore, not of concern when considering color for her ceramic veneers. Following the wax-up and pressing cycle, the technician divested, and then checked the fit to the die of the GC Press™ veneers (GC America, www.gcamerica.com) (Figure 6). After the dentin porcelain was layered (Figure 7) the veneers were tried in the mouth to see the proportion of the fit. Next, GC Initial™ porcelain (GC America) was applied as a second stage build-up to create lobe and a 3-dimensional appearance using dentin and matching translucency (Figure 8).
Tried on the cast model, the bisque-bake veneers displayed unique texture details with final contouring that followed the innate shape and direction of the teeth (Figure 9). By using his technical skills, the technician created natural-looking beauty, not “piano” teeth. The six veneers were placed on a mirror (Figure 10) for a different view and then Nos. 6, 8, and 11 were tried in for fit and to check the proportion between teeth and to check the patient's mid-line (Figure 11). Mesial symmetry between teeth Nos. 8 and 9, as well as fit, was checked next (Figure 12). During the next bisque-bake try-in stage for the six units, the mid-line and horizontal line were corrected (Figure 13). Glazing and polishing appearance was checked on the cast model (Figure 14), and the finished restorations were cemented with RelyX™ Veneer cement (3M ESPE, www.3mespe.com) (Figure 15). A portrait smile was then photographed (Figure 16). Among the changes created: teeth Nos. 8 and 9 changed to square/square in shape, teeth Nos. 7 and 10's open embrasure was closed and a round/round shape was created between the incisal area. To finish, teeth Nos. 6 and 11 were less pointy in shape.
Communication between patients, clinicians, and technicians is always easier with the right tools and setting. In order to truly understand what the patient wants, there should be open discussion about what is and is not possible given the patient's features. And, in searching for case perfection, the technician should be given an opportunity to use his skills. All of the characteristics that make a patient unique must be respected—such as facial views, how they talk, how they smile—and match their smiles to that uniqueness. In this case, the restorations exceeded the patient's expectations.
This case was presented courtesy of Dr. Edward Domina, private practice, Frankfort, Illinois.
About the Authors
Luke Kahng, CDT
LSK121 Oral Prosthetics
Edward Domina, DDS