20-3 jcd 2 - aacd

Volume 20 • Number 3 Fall 2004 • The Journal of Cosmetic Dentistry 57

ACCREDITATION ES S E N T I A L S

INTRODUCTION

Creating a smile with indirect porcelain veneers and crowns can be a wonderful experience for both dentist and patient, or it can be a disaster. Many dentists consider porce-lain restorations on anterior teeth as a panacea for a patient’s smile problems. Excellent operative technique in addition to proper communication with a talented and artistic labo-ratory technician can create a wonderful, lifelike improve-ment in a patient’s smile with porcelain restorations.1,2 In recent years, technology has advanced dramatically in terms of recreating enamel with porcelain. The trend in all-ceram-ic restorations has been away from traditional foil or refrac-tory techniques and toward pressed ceramic systems.3 As more and more patients demand the “perfect smile,” more and more companies have responded with better, more life-like materials that are kinder to hard and soft tissue once in place. But in the end, no matter the material used, it all comes down to the artistic talents and technical ability of the dentist and the laboratory technician to create that “per-fect,” lifelike smile for the patient. You can’t just prepare the teeth and tell the laboratory you want “pretty veneers”1; you must communicate to the laboratory each and every aspect of what you envision the final restoration will be like; in this way, the technician can truly begin with the end in mind and provide the patient and dentist with a wonderful result. This case shows how taking the extra step can help to ensure that the final result is truly something of which both the dentist and the patient can be proud.

The trend in all-ceramic restorations has been away from traditional foil or refractory techniques and toward

pressed ceramic systems.

Dr. David Finley graduated from the Louisiana State University (LSU) School of Dentistry in 1985 and has maintained a private general dental practice in Monroe, Louisiana, for 19 years. A great believer in continuing education, he joined the AACD in 2000 and has completed advanced cosmetic continuums at LSU. He and his wife, Valerie, have five children.

byDavid D. Finley, D.D.S.

Accreditation Clinical Case Report, Case Type I: Six or More Indirect Restorations

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58 The Journal of Cosmetic Dentistry • Fall 2004 Volume 20 • Number 3


HISTORY

The patient was a 28-year-old female orthodontic assistant in ex-cellent health (Fig 1). Although she had been through many years of orthodontic treatment, she was still unhappy with her smile (Fig 2). She presented with anterior teeth of vari-ous shades due to past endodontic treatment on tooth #7 and direct resin veneers on teeth #9 and #10. The axial inclinations of the lateral incisors were flared, the right cuspid had been rotated to decrease its la-bial prominence, and the midline was off to the left by approximately 1 mm. Her teeth were very short and wide and the left central was 1.5 mm wider than the right central. She had a large amount of translucency in the incisal one-third of the incisors, which gave them a gray cast. Gingi-val architecture was uneven, which further accentuated the size discrep-ancy of the central incisors. The pa-tient wanted a more uniform shade, canines that were less prominent,

teeth that showed more length, and a whiter smile.

CLINICAL EXAMINATION

The clinical examination revealed the following (Figs 3-7):

• short upper anterior teeth with a poor height-to-width ratio on the centrals1,2

• past history of endodontic treat-ment of #7

• past history of direct resin ve-neers on #9 and #10

• excellent periodontal health

• midline discrepancy

• Class I occlusion with group function in lateral excursions

• right cuspid very prominently positioned labially

• lateral incisor axial inclinations flared labially and distally

• left central incisor wider than the right central incisor

• very flat incisal smile line

• well-developed buccal corridor (this enabled us to concentrate on the six anterior teeth in our restorative efforts as we would not have to widen the arch or fill the buccal corridor restor-atively)

• uneven gingival architecture with gingival heights of the right central and right cuspid more apical than the left central and cuspid.

Shading analysis revealed teeth with a high level of translucency, multiple shades on different teeth, a dark root canal tooth, and overall dull tooth surface. Surface anatomy was minimal and facial surfaces very flat due to multiple orthodontic ex-periences and subsequent removal of orthodontic bonding resin and fa-cial polishing.

DIAGNOSIS

The diagnosis for this patient was a fairly straight and broad but unat-tractive smile due to poor color of

Figure 1: 1:10 full-face, before: Photo revealed a dull, almost aged-looking smile due to short teeth and a

flattened smile line.

Figure 2: 1:2 full smile, frontal view, before: Note the flattened, almost reversed smile line.

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ACCREDITATION ES S E N T I A L SFINLEY

Figure 6: 1:1 retracted left lateral view, before: Note the distally inclined cuspid and slightly flared lateral incisor.

Figure 5: 1:1 retracted right lateral view, before: Note the distally inclined cuspid, the slightly flared lateral incisor,

and the dark color of the right lateral incisor, due to past endodontic treatment.

Figure 7: 1:2 occlusal view, before: Note the shallow facial embrasures and the flattened facial anatomy due

to multiple orthodontic experiences and subsequent removal of bonding resin.

Figure 3: 1:2 retracted frontal view, before: A frontal view revealed a myriad array of axial inclinations of the six maxillary anterior teeth, multiple colors of teeth, an uneven gingival architecture, and a very prominently

displayed right cuspid.

Figure 4: 1:1 retracted frontal view, before: A close-up frontal view revealed central incisors of uneven size and

poor proportions.

teeth; flared axial inclinations; and a very flat, almost reversed smile line.

TREATMENT PLAN

The treatment plan for this pa-tient was as follows:

1. Development of a composite mock-up on study casts to evaluate proper tooth mor-phology and tooth length for



best esthetics, proper gingival contours, and improved smile line.

2. Preparation of teeth #6, #8, #9, #10, and #11 for indirect layered Authentic veneers and #7 for an Authentic layered full crown (Figs 8-12).

3. Using the composite mock-up model, fabrication of a Sil-Tech putty anterior incisal template and a Copyplast reduction guide (pinhole preparation guide) to help in proper tooth reduction at the preparation appointment.1,2

4. Fabrication of a vacuum-formed Copyplast stent1,2 lined with extra-light-viscosity Aquasil polyvinyl siloxane im-pression material for creation of accurate temporaries from mock-up (an impression was taken of the mock-up using the stent as a tray to create more accurate detail inside the stent for temporary fabrication).

ARMAMENTARIUM

• Aquasil heavy-body and light-body VPS impression material (Dentsply Caulk; Milford, DE)

• brown mini polishing point (Shofu; San Marcos, CA)

• Die Keen green stone (Mod-ern Materials, Heraeus Kulzer; Armonk, NY)

• Denstone white lab plaster (Modern Materials, Heraeus Kulzer)

• Tofflemire stainless steel matrix band (Teledyne Water Pik; Fort Collins, CO)

• KS1 and KS2 burs (Brasseler; Savannah, GA)

• generic gross reduction dia-mond bur

• Ellman varitip #118B (Ellman International; Hewlett, NY)

• Sensimatic Electrosurge, model 600SE (Parkell Electronics, Farmingdale, NY)

• 8A composite carver (Cosme-dent; Chicago, IL)

• diamond composite polishing paste, 1.0 micron and .5 micron (Ultradent; South Jordan, UT)

• Soflex 1.9 mm finishing strips (3M; St. Paul, MN)

• Clearfil liner bond 2V primer A and B (Kuraray; New York, NY)

• Gluma desensitizer (Heraeus Kulzer)

• Clearfil Photo Bond universal bonding agent and catalyst (Ku-raray)

• KCP 1000 Plasma arc curing light (American Dental Tech-nologies, Southfield, MI)

• G.U.M. fine unwaxed floss (Sun-star Butler; Chicago, IL)

• Accufilm indicator liquid and articulating paper (Parkell)

• Superoxol (EPR Industries Chemists; Pennsauken, NJ)

• electronic digital caliper

• stainless steel surgical blade #12 (Miltex; York, PA)

• vacuum-formed Copyplast stent for temporary fabrication (Scheu Dental; Iserlohn, Ger-many)

• vacuum-formed Copyplast pin-hole preparation guide (Scheu Dental)

• Vanilla Bite Registration (Discus Dental; Culver City, CA)

• Esthet X flowable composite shade A1 (Dentsply Caulk)

• Fit-Checker silicon (G.C. Dental Products; Tokyo, Japan)

• Super Snap black coarse polish-ing discs (Shofu)

• Sil-Tech® putty impression material (Ivoclar Vivadent; Am-herst, NY)

• Flow It® flowable composite (Pentron; Wallingford, CT)

• Luxatemp shade A1 (Zenith/DMG; Englewood, NJ)

• Triad II light-curing machine (Dentsply)

• Authentic porcelain (Microstar Corp.; Lawrenceville, GA)

• Choice resin luting cement (Bisco; Schaumburg, IL)

• porcelain etch gel (Pulpdent Products; Watertown, MA)

• NSB porcelain-polishing points #W116DG, #W16DM, #W12D (Brasseler)

• Dialite wheels #L26DRM, #L26DGXF (Brasseler)

• hydrocolloid impression mate-rial (Stevenson Dental Research; Somis, CA)

• Palaseal (Heraeus Kulzer)

PREPARATION APPOINTMENT

Local anesthesia consisting of one carpule of lidocaine 2% with epi-nephrine 1:100,000 and one carpule of marcaine .5% with epinephrine 1:200,000 was administered. Upon onset of profound anesthesia, teeth ##6–11 were prepared using a ge-neric gross reduction diamond and a Brasseler KS1 diamond. The use

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Figure 11: 1:1 retracted left lateral view, after: Note the corrected axial inclinations, the gradual blending of

gingival chroma, and the proper incisal embrasure shapes.

Figure 9: 1:1 retracted frontal view, after: The final results show balanced proportions and subtle yet natural

chromatic and internal characterizations.

Figure 12: 1:2 occlusal view, after: Final restorations exhibited corrected facial embrasures and natural facial

anatomy.

Figure 10: 1:1 retracted right lateral view, after: Note the corrected axial inclinations, the gradual blending of

color, the masking of the dark tooth #7, and proper incisal embrasure shapes.

Figure 8: 1:2 retracted frontal view, after: Final restorations for teeth ## 6–11 show corrections of all axial inclinations, even gingival architecture, improved incisal edge position, and a harmonious arrangement of teeth

with slight central incisor dominance.

of the reduction templates (pinhole preparation guide) ensured proper tooth reduction. Preparations were extended to .5 mm subgingival with a 1.0 mm chamfer margin on the facial. An old 8A composite instru-ment was used to reflect and protect the gingiva during preparation.

The preparations extended lin-gually over the incisal edge ending in a 1.0 mm shoulder just above the cingulum on tooth #6 and ##8–11.



The teeth were prepared in such a fashion as to give the laboratory 2 mm of incisal and 1.5 mm (as mea-sured with the pinhole preparation guide) of facial room to develop subtle internal characterizations within the porcelain. Tooth #7 was prepared for a full-coverage Authen-tic crown with a 1.5 mm chamfer on the facial and a 1.0 mm shoul-der on the lingual. Facial reduction on tooth #7 was slightly more than on the other preparations, to allow the laboratory more room to mask out the dark color of this root canal-treated tooth. All previous restor-ative resin was removed and caries detection stain was used to ensure the removal of all decay. There was a slight amount of decay under the facial composite on teeth #7 and #9 but this did not affect the prepara-tion design.

Preparations were polished with Shofu brown mini points to round off any sharp line angles or point angles on the preparation. Stump shades were chosen and photo-graphs were taken of the prepara-tions with stump guides in view for the laboratory’s use. An Ellman varitip was used in a Parkell elector-surge to place a small microtrough around each prepared margin ex-tending just apical to the margin. A small amount of gingival contouring was also done with the electrosurge on teeth #7, #9, #10, and #11. Super-oxol was used to control any slight hemorrhage or gingival seepage. The Superoxol was rinsed off thoroughly before impressions were taken to prevent any bubbles in the impres-sion material.

Two hydrocolloid impressions were taken. A Vanilla Bite Registra-tion and a stick-bite registration were

taken and photographed in position in the mouth. A copyplast template was used to create temporaries on the prepared teeth using Luxatemp shade A1. The template had been lined with extra-light-body Aqua-sil impression material and used to take an impression of the mock-up. This created very accurate temporar-ies with deep facial embrasures and accurate gingival emergence pro-files. The temporaries were removed from the prepared teeth and margins were trimmed and polished with Shofu discs. After fit and contours of the splinted temporaries were confirmed, their exterior surface was glazed with Palaseal in a Triad light-cure machine for six minutes.1,2 Three coats of Gluma were painted over each preparation to decrease postoperative sensitivity and the temporaries were seated with flow-able composite. Postoperative home care instructions were given and the patient was scheduled to return in three weeks to seat the restorations.

Models were poured with Die Keen lab stone; and models, stick-bite, and mock-up were sent to the laboratory for use in fabrication of the restorations.

Analysis of the restorations revealed a bond failure between the

flowable resin and the porcelain.

FIRST SEAT APPOINTMENT

Three weeks after the preparation appointment the patient was seen to seat the restorations. Anesthesia was obtained with carbocaine; the tem-poraries were removed by cutting a slot in the facial of each temporary and a spoon excavator was torqued

in the groove to separate the halves of each temporary. The restorations were tried in, and appeared to fit well. The patient was shown the restorations in her mouth and she approved them. Each preparation was etched with 37% phosphoric acid and then rinsed and left slightly moist. Liner Bond 2V (parts A and B) were mixed and applied to the preparations for 20 seconds each and then allowed to sit undisturbed for 20 seconds. The Liner Bond was then blown dry to remove solvent and light-cured for 20 seconds with a plasma arc curing (PAC) light. The restorations were rinsed and dried. Equal parts of Photo Bond catalyst and universal bonding agent were then mixed and painted onto the internal surfaces of each restoration and onto the preparations. Each was blown dry until no “wiggle” was noted and then light-cured with the PAC light for 20 seconds. Each resto-ration was filled with flowable com-posite (Pentron Flow It shade A1) and seated on its appropriate pre-pared tooth. When all restorations had been placed and seated firmly, they were held in place as the PAC light was used to cure the compos-ite. A Miltex #12 scalpel blade was used to remove any excess flowable composite from the margins. Mar-gins were polished with Ultradent composite polishing paste and oc-clusion was adjusted with fine dia-monds and Brasseler Dialite points. The patient was shown the restora-tions; she liked the final result and was dismissed.

A few months later I decided to begin the AACD Accreditation pro-cess and began looking for cases that might meet the criteria. This indirect restoration case was already

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“complete,” so I decided to evaluate it. Photographic evaluation revealed a nice result when compared to the preoperative condition. I entered the case in the next Smile Gallery Com-petition and it earned a silver medal. After passing the written examina-tion I began to review cases that I thought would meet the Accredita-tion criteria, and I realized that I had not taken any postoperative radio-graphs of this indirect case. At the patient’s next recare appointment we took radiographs and I was both absolutely horrified and mystified by what I saw. The margins of the restorations appeared to be open, as if the cement had disappeared. I told the patient, “I like the way the veneers look, but there has always been something that has bothered me, and I wasn’t sure what it was un-til now. On the x-ray, I see we have a problem. I would like to correct it but I want to think of this as an op-portunity for us to make your smile

look even better.” She agreed to be-gin again.

PRIOR TO RETREATMENT

I began a process of analyzing photographs of the “interim” case and noted the following (Fig 13):

1. the central incisors were too wide at the incisal

2. the lateral incisors still had a definite axial inclination that flared laterally

3. the cuspids were too dominant

4. the emergence profile of all the restorations was too bulky

5. the shade match was good and the porcelain characterization and finish were nice.

Next I had the laboratory do a wax-up that addressed these new concerns. When the wax-up arrived I evaluated it and modified it slightly by making the emergence profile even less bulky. I also moved the facial line angles toward the center

on each incisor to make the teeth appear slightly narrower. The wax-up was duplicated in stone and two vacuform stents were created. Poly-vinyl siloxane impression material was placed inside one stent and an impression was taken of the wax-up to ensure accurate temporary fabri-cation. The other stent was modi-fied for use as a pinhole preparation guide. Then I scheduled the patient to resume treatment with these changes in mind.

SECOND PREPARATION APPOINTMENT

Local anesthesia consisting of one carpule of lidocaine 2% with epinephrine 1:100,000 and one car-pule of marcaine .5% with epineph-rine 1:200,000 was administered. Upon onset of profound anesthesia, the “interim” veneers were removed by cutting a groove in the facial from gingival to incisal. A small separat-

Figure 13: 1:2 retracted frontal view, interim set of veneers: Although improvements were made with the overall smile and the patient was delighted with the results, smile analysis revealed a number of errors.

The central incisors were slightly too dominant, axial inclinations of some teeth were still not correct, and the

emergence profiles were slightly bulky.



ing instrument was placed in the grooves and torqued and each resto-ration half came off the preparations very easily.

Analysis of the restorations re-vealed a bond failure between the flowable resin and the porcelain. The resin remained bonded to the prepared tooth surface. This con-firmed my suspicions that my failure to re-etch the internal aspects of the restorations and not silanating them were probably the culprits in the failing margins.

Teeth ##6–11 were then prepared again to ensure that all flowable resin was removed, but the original preparation design was maintained. An old 8A composite instrument was used carefully to gently reflect gingival tissues and protect them from damage during preparation. Preparations were again polished with Shofu brownie points to elimi-nate any sharp point angles or line angles and to ensure a smooth sur-face. Stump shades were verified and rephotographed in the mouth for the laboratory’s use.

Because there was a very tight schedule to complete this case in time to submit it for Accreditation, I chose not to use electrosurgery and not to pack cord to prevent damage to the very healthy gingival tissues. This turned out to be beneficial, as the postoperative healing and matu-ration time of the gingival tissues proved to be very short. (I had used electrosurgery at the initial prepara-tion appointment due to a need to improve the gingival architecture.) Superoxol was used to control any slight hemorrhage or gingival seep-age. The Superoxol was rinsed off

thoroughly before impressions were taken to prevent any bubbles in the impression material. Preparations were dried very thoroughly. Im-pressions were taken with Aquasil heavy-body and light-body impres-sion materials. Light-body impres-sion material was syringed onto the preparations and was blown subgin-gival with an air syringe. Heavy-body impression material was placed in a stock tray and placed immediately over the light-body material and seated firmly. Three impressions were taken to provide the laboratory with different models to ensure ac-curacy of fit. Each impression was poured in Die Keen green stone. Two models and impressions went to the laboratory, one model and its im-pression stayed at the office.

With indirect porcelain restorations, the laboratory

communication phase is perhaps the most important phase of

treatment.

A bite registration was taken and a stick-bite registration was taken and photographed in the mouth. This stick-bite allowed the laborato-ry to visualize the patient’s midline and interpupillary line, enabling the ceramists to create restorations with the overall sense of harmony and horizontal perspective evident in an esthetic face.4 The copyplast vacuum-formed stent lined with impression material was used to create temporaries on the prepared teeth with Luxatemp shade A1. This copyplast impression template cre-ates very accurate temporaries with deep, accurate facial embrasures and

accurate gingival emergence pro-files. The temporaries were removed from the prepared teeth and margins were trimmed and polished with Shofu discs. After fit and contours of the splinted temporaries were confirmed, their exterior was glazed with Palaseal in a Triad light-cure machine for six minutes.

Three coats of Gluma were paint-ed over each preparation to decrease postoperative sensitivity and the temporaries were seated with flow-able composite. Postoperative home care instructions were given and the patient was scheduled to return the next day so that the temporaries could be evaluated when she was not anesthetized. The next day, the patient requested that the cuspids be made less prominent in their facial profile. This adjustment was made and an alginate impression and pho-tographs of the temporaries were taken for laboratory communica-tion. The patient was then scheduled for the next appointment two weeks later to evaluate the veneers.

LABORATORY COMMUNICATION

With indirect porcelain restora-tions, the laboratory communication phase is perhaps the most important phase of treatment.5 Without proper communication the technician has no idea what we want as the final outcome. With this patient’s first set of restorations, a lack of extensive communication resulted in a less-than-perfect outcome (the patient had loved the result because it was such a nice change, but the final smile could have been so much bet-ter). The consequence of inadequate communication with the laboratory

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means that luck plays a role in the outcome of the final restorations.

When the restorations were re-made the laboratory received all preoperative photographs, preop-erative models, copies of mock-ups and wax-ups, preparation templates, photographs of preparations for stump shading, photographs of stick-bite for proper establishment of midline and horizontal plane, photographs of temporaries seated in the mouth, models of temporar-ies, bite records, shade-mapping in-structions, and shade map. They also received specific written and verbal communications about the patient’s likes and dislikes regarding her old teeth and her requirements for her new teeth.

EVALUATION AND SEATING APPOINTMENT

Before the patient arrived, each restoration was tried in on an un-touched model of the preparations that did not go to the laboratory; this creates a “point of accountabil-ity” with the laboratory.1,2 It was de-termined that each restoration fit the appropriate die in an excellent man-ner. Open margins could possibly have been prevented if this step had been performed with the first set of restorations.

The patient was anesthetized with carbocaine 3% and temporar-ies were removed. Air abrasion (KCP 1000) was utilized to make sure that all flowable resin was removed from the preparations and that the prepa-rations were clean. All abrasive pow-der was rinsed from the teeth and mouth with copious amounts of wa-ter. Superoxol was used on any tis-

sue that bled, to control hemorrhage and seepage. Each restoration was tried on preparations individually to ensure proper fit. Then restorations were tried in in combination to eval-uate interproximal contacts and con-tours. Parkell Accufilm liquid was used to evaluate contacts and a G.C. fit-checker was used to evaluate fit to preparations. Tight contacts were ad-justed with a fine red stripe Brasseler diamond finishing bur and polished with Dialite wheels. Any area that showed through the fit-checker was carefully relieved in the internal as-pect of the restoration with a small diamond.

Shade A1 and translucent try-in pastes were each used to try in the restorations. The translucent shade was chosen for cementation of the restorations. Radiographs were tak-en to evaluate margins and it was determined that each restoration had closed margins. The patient was shown the restorations and ap-proved them. Each restoration and prepared tooth was rinsed to remove the try-in paste. The internal aspect of each restoration was cleaned with Superoxol to remove any organic de-bris, re-etched with porcelain etch, rinsed, and dried. A frosty surface confirmed that the internal aspects of each restoration had maintained the etch from the laboratory. Silane was then painted onto the internal aspect of each restoration and dried.

The preparations were etched with 37% phosphoric acid for 15 seconds each, rinsed and lightly dried but left moist. Liner Bond 2V (A and B self-etching primer) was applied to each preparation for 20 seconds and thor-oughly air-dried to remove solvent

and light-cured with a PAC light for 20 seconds. Photo Bond catalyst and universal bonding agent were mixed and then applied to each prepara-tion, air-thinned, and light-cured with a PAC light for 20 seconds. A coat of Photo Bond was then applied to the internal aspects of each resto-ration and air-dried. This combina-tion of Liner Bond primer and Photo Bond bonding agent has a low film thickness and a high bond strength.1 Choice porcelain translucent luting resin cement was placed on a glass slab and spatulated to increase its flowability. Choice was selected due to its extremely high filler content (it is over 80% filler content and is very unlikely to become soluble and wash out).

The luting resin was then placed in each restoration and the restora-tions were placed on the prepared teeth beginning at the midline and working distally. Firm pressure was applied to all restorations down the long axis of each tooth simultane-ously and a PAC light was “waved” over the margins to begin the curing process.6 A #12 scalpel blade was used to remove resin at the margins of each restoration. Contacts were then separated with a stainless steel matrix band and flossed. The PAC light was then used to cure each tooth for 40 seconds from both the buccal and lingual aspects. Acces-sible margins were polished with composite polishing paste in a rub-ber prophy cup, and fine Soflex fin-ishing strips were used to polish in-terproximal margins. Occlusion was verified with Accufilm black articu-lating paper and adjusted with a fine diamond. Adjusted porcelain was polished with small Brasseler por-



celain-polishing points and wheels, and then with porcelain-polishing paste in a rubber cup.

SUMMARY

The final result when creating a smile with indirect porcelain restora-tions relies on many variables. Any shortcut in technique or breakdown in communication has the potential to create a possibly disastrous result. But even when the laboratory and the dentist are separated by thousands of miles, great results can be achieved when communication about the case flows both ways with trust and re-spect (Figs 14 & 15).

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Acknowledgment

The author thanks Becky and Dennis Vasquez and their team of talented den-tal artisans at BECDEN Dental Labo-ratory in Draper, Utah, for their trust in my visions and respect for my talent; but most of all for the friendship that has grown through 18 years of working together.

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References1. Eubank J, Morley J, et al. Louisiana Acad-

emy of Continuing Dental Education, Louisiana State University School of Den-tistry, Cosmetic Dentistry Continuum, Level I, September–December 2001.

2. Eubank J, Morley J. Louisiana Academy of Continuing Dental Education, Louisiana State University School of Dentistry, Cos-metic Dentistry Continuum, Level II, June–July 2002.

3. Roberts M. Pressed ceramic technique. Dent Dialogue 2(2):114, 2002.

4. Tipton P. Aesthetic tooth alignment using etched porcelain restorations. Pract Proced Aesthet Dent 13(7):551–555, 2002.

5. Bargii, Nassir, The art and clinical applica-tion of porcelain bonded restorations [lecture]. Presented at the Dallas Midwinter Dental Conference, Dallas, TX, January 22, 1998.

6. Hornbrook D. The indirect aesthetic restora-tion: Optimal aesthetics through understand-ing the material [lecture]. Presented at the 19th Annual Scientific Session of the American Academy of Cosmetic Dentistry, Orlando, FL, April 30, 2003.

______________________❖

FINLEY

Figure 14: 1:10 full-face, after: Completed treatment shows a bright, vivacious smile, which matched the

patient’s personality.

Figure 15: 1:2 full smile, frontal view, after: The incisal edges now follow the lower lip and the smile is full and

has a slight central incisor dominance.



Dennis and Becky Vasquez are the owners of BECDEN Dental Laboratory, Inc., in Draper, Utah. They have both been in the profession for more than 37 years; Dennis’ expertise is in dental technology and Becky’s is in all aspects of dental office employment and practice management consulting. They can be reached at 888-344-9991 or [email protected].

byRebecca and Dennis Vasquez PARTNERING FOR SUCCESS

BECDEN Dental Laboratory was honored to partner with Dr. David Finley in his quest for Accreditation. Here are the fabrica-tion steps followed for his case.

STEP ONE: THE DIAGNOSTIC WAX-UP TECHNIQUE

This beginning step was critical to the success of the case and, as Dr. Finley discovered, should never be skipped. Using a ma-trix from the wax-up for temporization allowed both doctor and patient to see how the final restorations would look, and created an opportunity to communicate to us any changes desired in the final case. When the study models arrived, the technician reviewed all materials received from the doctor and called with questions regarding preparation design, tissue contouring, and smile design choice. Dr. Finley included a copy of the AACD Ac-creditation examination criteria for our reference. Models were marked, designating where tissue changes (if any) would be made, and where the lingual finish lines would be, making sure the line was above or below the point of contact when in occlu-sion. After evening out the arch form with a carving knife, a Sil-Tech® matrix, with a hole drilled in the incisal area, was made on the model. The model was prepared, using depth-cutting and tapered carbide burs, then warmed. With the matrix back in place, wax was injected to create the rough wax-up. Next, the wax-up was hand-carved to create the desired smile; and occlu-sion was verified in centric, protrusive, and lateral movements. An impression matrix for temporization and preparation index to ensure adequate reduction can also be fabricated, although they were not requested for this case, as Dr. Finley fabricated them in-office.

Lab Technician’s Comments for David D. Finley, D.D.S.



STEP TWO: THE AUTHENTIC™ WAXING TECHNIQUE

When the prepared case arrived at the laboratory it was evaluated to ensure that all necessary information was in-cluded: photographs, dentin (stump) shade, final shade mapping (Fig 1), study model, diagnostic wax-up, smile design choice, stick-bite, and desired length of centrals. The central length was entered into a Golden Shimbashi Excel spreadsheet (Dr. Larry Emmott, at LVI), which was printed for reference during waxing. The die models were evaluated for any undercuts or sharp edges, which were not found. A Sil- Tech matrix was made from the wax-up model and was used to verify adequate reduction and maintain correct incisal position. During the full con-tour waxing, 2X power magnification was used to seal and check the margins. Upon the completion of waxing, the case was checked with articulating paper for centric occlusion and excursive movements, then seated on the solid model to verify contacts and that there would be no

“black triangles.” Finally, the case was sprued to prepare for investing, pressing (using W+ ingots), and devesting.

STEP THREE: THE AUTHENTIC CERAMIC TECHNIQUE

During the next two days our ceramist brought the res-torations to life in Authentic porcelain. Sprues were care-fully removed from the pressed restorations, making sure the restorations did not overheat during the process. The restorations were first seated on the working model to make any contact adjustments, then on the solid model to verify margins and, again, the avoidance of black tri-angles. Contours, midline, length, line angles, and occlu-sion were adjusted as needed. A Sil-Tech matrix was made of the lingual and incisal areas of the restorations and used as a guide during color mapping. Incisal, then facial surfaces were cut back, creating mammelons, which were stained internally, with blues, light orange, violet, and body stains. The case was fired to set the stain. Internal ef-fects porcelain in hues of “pearl,” “orange modifier,” and “Twen” (opal)(Microstar Corp.; Lawrenceville, GA) were added and fired. Next, the restorations were layered with a dentin shade at the gingival two-thirds with a combination of Incisal 58 (Microstar) and Twen used incisally for trans-lucency. Contours were again adjusted and porcelain was added to mimic the diagnostic wax-up. Requested surface texture (designated by an enclosed photograph from Dr. Finley) was added with a diamond bur and the restora-tions were ready for staining. A stain liquid was applied to the inside of the restorations and they were placed on dies painted A1, the patient’s dentin (stump) shade, to allow the proper color to show through during staining. Stains to match Dr. Finley’s enclosed shade mapping were ap-plied and fired. Glaze was applied and the case was fired twice more to achieve the desired results. Another quality control check was performed on the solid model to verify margins and contacts before polishing the restorations us-ing the Dialite rubber wheel, and polishing kit (Brasseler USA; Savannah, GA), to smooth and polish the reflective areas. Finally, the restorations were sandblasted on 20psi and etched.

After one last inspection by several sets of eyes, the res-torations were placed in a cosmetic presentation box for delivery to an anxiously waiting Dr. Finley.

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Figure 1: A detailed shade map, specific detailed written instructions, and a copy of the AACD Accreditation criteria

sheet accompanied the laboratory prescription with the case to the laboratory.



Dr. Olson is a 1983 graduate of the University of Maryland, Baltimore, Col-lege of Dental Surgery, and has been in private practice in Southern Maryland for 20 years. He achieved Accredited member status in the American Acade-my of Cosmetic Dentistry in 1998, be-came an Examiner the following year, and currently serves as chair of the Ac-creditation Committee.

In 1999 he received his fellowship in the Academy of General Dentistry and was named by Washingtonian Maga-zine as one of the metro area’s top gen-eral dentists in 1997, and top general and cosmetic dentists in 2003. He vol-unteers with the State of Maryland’s Donated Dental Service and the AACD’s Give Back a Smile Program. Dr. Olson lives with his wife, Sharon, and five-year-old twins outside Annapolis.

byBradley Olson, D.D.S.

Dr. Finley chose an excellent case for his Case Type I, six or more indirect restorations, but one that was not with-

out challenge. A reverse curve is never esthetic and, when com-pounded with lip asymmetry, an endodontically treated tooth, varying axial inclinations, and a malpositioned cuspid, the chal-lenge is greater.

Careful diagnosis and a well-designed treatment plan com-bined with excellent laboratory communication resulted in the creation of a beautiful smile. The transition from anterior to pos-terior while treating only the six teeth is impressive. The cuspids became less prominent by addressing the cant and harmoniz-ing them into the arch rather than making the bicuspids more prominent. This illustrates that, although the buccal corridor is vital to successful smile design, treating more teeth is not always required. The color on the lateral incisor is well-blended and the smile design principles have been addressed even with the lip asymmetry. The examiners did note the gingival asymmetry that remained, but considered it to be a minor fault and passed the case unanimously.

Dr. Finley demonstrated a command of esthetic principles and a harmony with the laboratory artist that made a marked improvement in his patient’s smile.

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Examiners’ Perspective for David D. Finley, D.D.S.

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