Esthetic Excellence

Laura Kelly, CDT

Immediate Past President and Accredited laboratory
technician, AACD

Betsy Bakeman, DDS

Featuring

Accredited Fellow and Chair, American Board of

Cosmetic Dentistry

M. Johnson Hagood, DDS

Accredited dentist, AACD

Kenneth F. Hovden, DDS

Accredited dentist, AACD

Nelson Rego, CDT

Accredited laboratory technician, AACD

John Roberts, DDS

Accredited dentist, AACD

Michelle Robinson Weber

Accredited laboratory technician, AACD

A supplement to a Montage Media publication

 The Benchmark
of Esthetics
Laura Kelly, CDT*

F
or several decades, the American Academy of Cosmetic Dentistry
(AACD) and its members have pursued higher standards in dental
care. The dentists and dental technicians comprising the Acad-
emy’s membership strive not only to enrich their personal understand-
ing of cosmetic dentistry and their individual skills, but also to provide
a new benchmark in quality and esthetics for their patients as well. For
continued professional growth, these practitioners rely on the counsel of
their colleagues and additional training they receive at the yearly AACD
scientific session.
Many AACD members elect to further distinguish their talents by
seeking accredited status from the Academy. Accredited members
of the AACD have successfully completed a rigorous testing process
that involves written, oral, and clinical requirements—most specifically
the completion and documentation of specific clinical cases. As shown
in the Supplement that follows, these cases encompass a variety of
treatment modalities and must meet quality standards and protocols
as defined by the American Board of Cosmetic Dentistry®.
The American Board of Cosmetic Dentistry does not endorse any par-
ticular clinical technique or style, nor does it endorse particular products or
materials. It is acknowledged that Accreditation success is not dependent
on the technique or the materials used, but on the excellence of the final
result. The applicants featured herein have utilized Ivoclar Vivadent adhe-
sive materials and ceramics to support them throughout the Accreditation
process. Ivoclar Vivadent has a longstanding history among the esthetic
dental community not just for the quality of its restorative solutions, but
also for its focus on educating dentists and ceramists on their optimal use
during daily practice. Ivoclar Vivadent’s sponsorship of this Supplement is
another example of the company’s interest in supporting dental profes-
sionals within the Academy and those aspiring to achieve Accreditation.
On behalf of the many technicians and dentists who rely on Ivoclar
Vivadent for its leading role in educating dental professionals, we thank
you for your support. Together we offer our congratulations to the
AACD’s latest group of Accredited Members, and for their continued
pursuit of excellence in dentistry.

* Immediate Past President, and Accredited Member, American Academy of

Cosmetic Dentistry; President, LK Dental Studio, San Ramon, California.

THE BENCHMARK OF EstheticS

table of contents
i
PREFACE: The Benchmark of Esthetics
Laura Kelly, CDT

03 The Road to Success:

American Academy of Cosmetic Dentistry Accreditation
Betsy Bakeman, DDS

05 Comprehensive Restoration of Anterior Crown Length and

Proportion Using a Direct Resin Veneer Technique
Kenneth F. Hovden, DDS

09 Esthetic Enhancement of the Maxillary Anterior Region

Using a Feldspathic Porcelain System: Laboratory Protocol
Michelle Robinson Weber

17
Laboratory Procedures in the Esthetic Restoration
of Maxillary Lateral Incisors
Nelson Rego, CDT

21
Esthetic Enhancement and Pathologic Occlusion Using Six
All-Ceramic Crown Restorations
M. Johnson Hagood, DDS

25 Anterior Esthetic Restoration Using a Direct Resin

Veneer Technique
John Roberts, DDS

Sponsored by an unrestricted educational grant provided by Ivoclar Vivadent

Table of Contents • 1
6652_AACD_Achieve_Ad.indd 1 10/17/08 10:53:24 AM
THE ROAD TO SUCCESS:
American Academy of Cosmetic Dentistry Accreditation
Betsy Bakeman, DDS*

F
or practitioners with an interest in advancing their education and
skills in the area of esthetic or cosmetic dentistry, the American
Academy of Cosmetic Dentistry’s (AACD) Accreditation process
provides an incomparable framework for growth, study, and learning.
The AACD’s Accreditation process is unique in that it requires dentists
or technicians to implement what they have learned and to demonstrate
a level of proficiency as dictated by the American Board of Cosmetic
Dentistry. The amount of time and effort necessary to attain the required
level of proficiency varies based on an individual’s exposure to and par-
ticipation in advanced education, as well as his or her pre-existing clinical
skills. Regardless of one’s starting point, successfully achieving Accred-
ited status in the AACD requires time, dedication, and true effort. By
completing this process, AACD Accredited members are able to apply a
variety of esthetic skills that demonstrate their ability to deliver optimal
oral healthcare using direct and indirect restorative procedures.
The Accreditation testing process comprises three parts: a written
examination, clinical case submissions, and an oral examination. The
written examination tests foundational knowledge in cosmetic dentistry
and is administered at the AACD’s annual scientific session. Once the
clinician or technician passes the written examination, he or she has
five years to fulfill the additional requirements.
The clinical case submissions and evaluations form the heart of the
testing process. Individuals demonstrate, through the use of preop-
erative and postoperative photographic documentation, clinical and
diagnostic excellence in all phases of cosmetic dentistry. The protocol
dictates that the cases that are submitted offer a comprehensive mix
of cosmetic treatment solutions that skilled dentists and technicians
should be able to execute when providing esthetic dentistry. The five
required case types for clinicians are:

Bakeman • 3
 Esthetic Excellence
• C ase Type 1. This presentation involves
six or more indirect restorations within the
maxillary arch, treating at least the incisors
and canines. The key to delivering an opti-
mal case presentation is in ensuring that
the clinician’s ability to create an open,
working, and successful rapport with the
laboratory technician is evidenced from
start to finish.
• Case Type 2. This case involves one or
two indirect restorations in the maxillary
anterior region treating incisors, and the
adjacent teeth must have no indirect res-
torations. The challenge with this case
type is in evaluating the clinician’s ability to
match the natural surrounding dentition.
• Case Type 3. In this presentation, the cli-
nician demonstrates an ability to deliver
esthetic results via a fixed partial den-
ture (FPD) or implant-supported restora-
tion. The FPD should contain at least one
pontic that replaces a maxillary incisor or
canine. If an implant restoration is placed,
it should include a root form implant into
the maxillary anterior edentulous space.
A radiograph must also be submitted to
show the space or failing tooth prior to
implant placement.
• Case Type 4. This case consists of an
anterior direct resin (Class IV or diastema
closure) restoration, in which the dentist’s
ability to blend composite resin with the
natural dentition is evaluated.
• Case Type 5. This case involves six or
more direct resin veneers, with the clinician
treating at least the maxillary incisors and
canines. Case Type 5 tests the dentist’s abil-
ity to create an optimal esthetic result using
direct composite resin materials.
Mastery of the five required clinical case
types ultimately allows clinicians to provide
their patients with a broad range of treatment
solutions. Laboratory technicians must com-
plete the first three case types with the addi-
tion of supplementary bench photography. The
oral examination completes the process, allow-
ing clinicians to review their cases with a team
of Accreditation Examiners, defend their treat-
ments, and provide solutions to a hypothetical
clinical case.
4 • THE ROAD TO SUCCESS
In summary, Accredited members have
demonstrated a commitment to the art and
science of delivering dentistry that transcends
the customary boundaries of our profession.
Patients can be assured that Accredited
AACD dentists and technicians have demon-
strated a high level of skill and expertise in
providing a variety of treatment solutions as
they relate to esthetic dentistry.
Congratulations to the 20 newly Accredited
members who were honored this past year
at the AACD Annual Scientific Session held in
New Orleans, Louisiana:
Duane H. Beers, DMD
Jorge R. Blanco, DDS
Tim M. Bradstock-Smith, BDS
Steven H. Brooksher, DDS
David S. Eshom, DDS
Richard W. Featherstone, DDS
Michael K. Forth, DDS
Tannaz T. Goodjohn, DDS
M. Johnson Hagood, DDS
Emil Hawary, DDS
Kenneth F. Hovden, DDS
Ted J. Murray, DDS
Nelson A. Rego, CDT
John C. Roberts, DDS
Michelle Y. Robinson Weber
Troy Allen Schmedding, DDS
John W. Simmons, IV, DMD
Jenny C. Sun, DDS
William H. Swearingen, DDS
Scott R. Wehrkamp, DDS
In celebrating individual achievement, the
Academy also celebrates the standard of
excellence that Accreditation represents.
The individuals honored remind us that we
must all determinedly recommit to education
and the pursuit of excellence. We must work
together to continue to elevate the standard
for optimal esthetics, the standard for serv-
ing the best interests of our patients, and
the standard for maintaining ethics of the
highest order.
.
* AACD Accredited Fellow; Chair, American Board of Cos-
metic Dentistry; Private practice, Grand Rapids, Michigan.
Comprehensive Restoration
of Anterior Crown Length
and Proportion
Using a Direct Resin Veneer Technique
Kenneth F. Hovden, DDS*

Dental patients who request esthetic

enhancement or require restorative
care can often be managed through
multiple treatment options, each with
its ideal indications. While direct com-
posite resins are often overlooked as
viable treatment alternatives in com-
plex cases, resin materials can allow
the clinician to modify tooth color,
width, length, shape, and guidance,
with minimal preparation. This case
depicts the use of a direct resin tech-
nique used to veneer nine teeth in the
anterior maxilla, with optimal esthet-
ics and function.

HOVDEN • 5
 Esthetic Excellence
Figure 1. Preoperative appearance demonstrates Figure 2. Preoperative radiographic evaluation demonstrates interproximal
compromised esthetics and function in both the bone loss and decay.
maxillary and mandibular regions.
C
ontemporary adhesive dental tech-
niques enable the clinician to effectively
replicate the desired tooth shade, con-
tour, and appearance. Composite resin materi-
als have also improved, allowing the success-
ful restoration of function and esthetics with
minimal wear to the opposing dentition; natural
looking esthetics can also be developed using a
simplified, minimally invasive technique. Unlike
most prosthetic solutions, today’s compos-
ite materials (eg, 4 Seasons, Ivoclar Vivadent,
Amherst, NY) can be used with predictable
results to augment the existing tooth structure
with clinically reversible results.1,2
Case Presentation
A 26-year-old male patient presented with car-
ies, Type III periodontal disease inclusive of
multiple 5-mm and 6-mm pockets, bleeding
upon probing, and heavy calculus (Figures 1
and 2). Caries risk assessment was conducted
and confirmed the patient was at considerable
risk for caries; the patient was prescribed an at-
home mouth rinse (ie, Cari-Free, Oral BioTech
LLC, Albany, OR) to reduce his caries risk.
Many of the posterior teeth were non-
restorable and required extraction. Multiple
teeth also required direct restorations.3-6 Once
these clinical requisites were completed, it
was necessary to pursue the fabrication of
diagnostic models and further posterior reha-
bilitation with the use of implants and fixed
prosthetics. Esthetically, the maxillary ante-
rior teeth demonstrated interproximal caries,
facial decalcification with caries, malposition-
ing, and poor crown width-to-length ratios.
6 • COMPREHENSIVE RESTORATION OF ANTERIOR CROWN LENGTH
Treatment Plan
The initial treatment plan consisted of root
planing in all four quadrants, followed by
thorough hygiene instruction and implemen-
tation of the caries prevention program. Non-
restorable teeth would require extraction,
and a direct resin veneer protocol was sched-
uled to restore teeth #5(14) through #13(25).
Reparation of the buccal corridor deficiency,
unesthetic tooth rotations, and malpositioned
dentition—in addition to treatment of the areas
of decalcification and caries-and-core were
also required. Endodontic therapy was nec-
essary for tooth #15(27), followed by a post
buildup and its restoration with a full-coverage
crown. Gingival crown lengthening was nec-
essary in the anterior segment to improve the
existing width-to-length ratios and raise central
tissue levels to be harmonious with the exist-
ing level of the maxillary right lateral incisor.
The second phase of treatment would consist
of fabrication of implant CT guides to identify
the position of posterior implants, for creation
of a surgical guide, and for implant placement
to replace teeth #18(37) and #19(36) prior to
their prosthetic restoration.
Clinical Procedure
Preliminary impressions were captured and
models were fabricated. From these models,
an ideal waxup was created based on smile
design fundamentals. This was accomplished
with an electric waxer and die wax. A silicone
matrix was then created to guide the direct
bonding technique.
Figure 3. The maxillary anterior region Figure 4. Preoperative view demon- Figure 5. Although the posterior man-
was scheduled for restoration using a strates the presence of rotated lateral inci- dibular dentition required extraction,
direct composite resin veneer protocol. sors, malpositioned canines, and decay. unesthetic alignment was also present.

The soft tissue was first recontoured using
an Er:YAG laser following the administration
of local anesthesia. Tissue levels were modi-
fied to be harmonious with tooth #7(12). All
tissue modification was performed for the
soft tissue only and never extended below the
cementoenamel junction. The laser-treated
tissues were allowed to heal for one week.
Smile design was based upon the posi-
tion of the maxillary left central incisor, and
teeth #6(13) through #8(11) were treated at
the first restorative visit (Figure 3). One week
after laser tissue contouring, the direct veneer
protocol was initiated (Figures 4 through 7).
With putty incisal and facial matrices from the
diagnostic waxup, areas that required enam-
eloplasty were identified to eliminate poten-
tial show through. Areas with decalcification
and caries were removed, and the teeth were
micro-etched to maintain a minimally invasive
preparation design.
Once each tooth was prepared, the silicone
matrix was used to assist in the composite
buildup procedure. The teeth were etched
with a 35% phosphoric acid material for
30 seconds, rinsed for 30 seconds, and air
dried. A desensitizing agent was applied for
30 seconds on the dentin and blotted dry with
a microbrush. The bonding agent (ExciTE, Ivo-
clar Vivadent, Amherst, NY) was then applied,
air dried, and cured.
With the putty matrix in place, 4 Seasons
Bleach Medium (Ivoclar Vivadent, Amherst,
NY) was used to recreate the lingual aspect
and incisal edge of the tooth. An A3.5 den-
tin shade was then applied wherever
dentin structures were missing. A thin rib-
bon of Incisal Clear (4 Seasons, Ivoclar Viva-
dent, Amherst, NY) was then placed around
the dentin lobes and adjacent to the incisal
edge to create some translucency in the cen-
tral and lateral incisors. Next, an A3 Enamel
shade was placed over the gingival third
and feathered into the middle and incisal
thirds. The tooth was then brought to full con-
tour with a Medium Value shade. Each layer
was contoured with sable brushes dipped in
modeling resin and cured for 20 seconds. Fol-
lowing the application of a detoxifying solution
(ie, Deox, Ultradent, South Jordan, UT), a final
cure was performed on each tooth for 40 sec-
onds prior to finishing and polishing.
At the subsequent visit, the maxillary left
canine, lateral incisor, and central incisor had

Figure 6. A retraction cord was used in Figure 7. A conservative preparation Figure 8. Facial view of the completed
the maxillary right quadrant, and the decal- design was applied in the maxillary direct veneers. The mandibular teeth
cified tooth structures were prepared. left quadrant were scheduled for subsequent care.

HOVDEN • 7
 Esthetic Excellence

Figure 9. Postoperative occlusal appear- Figure 10. The posterior dentition were Figure 11. Postoperative view of the
ance following direct composite resin res- extracted prior to implant placement and anterior region following predictable resto-
toration of the maxillary anterior dentition. prosthetic rehabilitation. ration with a direct resin veneer protocol.

direct veneers placed using the aforemen-
tioned techniques. Both first premolars had
buccal decalcification but were positioned
well in the arch, so facial resins were placed
to conceal the decalcifications. The maxil-
lary right second premolar also had a direct
resin veneer placed to overcome its buccal
corridor deficiency.
The patient returned for additional visits to
fine-tune line angles, complete final polishing,
and obtain definitive photographs and radio-
graphs (Figures 8 through 11). Throughout
the procedure, the importance of proper oral
hygiene was reinforced.
Conclusion
This case demonstrates smile improvement
using direct resin veneers and conservative tooth
modification. As the procedure progressed, the
patient underwent not only an esthetic transfor-
mation but also an oral health awakening. His
home hygiene improved dramatically, as did his
perception of overall facial esthetics. The patient
was very pleased with his new smile and antici-
pated completion of the posterior protocol in
order to return the patient to normal function.
References
1. Peyton J. Direct restoration of anterior teeth: Review
of the clinical technique and case presentation. Pract
Proced Aesthet Dent 2002;14(3):203-210.
2. Erlach R. Accreditation clinical case report: Direct
veneers. J Cosmet Dent 2002;17(4):36-41.
3. Blank J. Creating beauty with your own two hands: A
simplified approach for direct veneers. J Cosmet Dent
2002;17(4):49-56.
4. Rufenacht C. Fundamentals of Esthetics. Chicago, IL:
Quintessence Publishing; 1990.
5. Goldstein R. Esthetics in Dentistry. 2nd ed. Hamilton,
London: B.C. Decker Inc; 1998.
6. Dawson P. Evaluation, Diagnosis, and Treatment of
Occlusal Problems. 2nd ed. St Louis, MO: CV Mosby
Company; 1989.
* Adjunct Assistant Professor of Endodontics, Uni-
versity of the Pacific School of Dentistry, San Fran-
cisco, California; Clinical Instructor, Hornbrook Group;
Faculty, IDEA; Director, Bay Area Aesthetic Masters
Hornbrook Group Study Club; private practice, Daly
City, California. Accredited member of the AACD.

Clinical Tip
“ I use a ‘feathering’ technique when applying the A3
4 Seasons Enamel shade over the incisal layer around
the dental lobes. This allows me to create a more natural
shade transition in the middle and incisal thirds.”
–Kenneth F. Hovden, DDS

8 • COMPREHENSIVE RESTORATION OF ANTERIOR CROWN LENGTH

esthetic Enhancement
of the Maxillary
Anterior Region
Using a Feldspathic Porcelain System:
Laboratory Protocol
Michelle Robinson Weber*

Patient confidence is often dictated by

the esthetics of his or her smile. Dental
professionals thus have a responsibil-
ity to ensure that any restorative treat-
ment given is of the highest possible
quality. The dental technician’s role in
the restorative process is to provide
esthetic restorations that blend in well
with the natural dentition. This pre-
sentation describes the use of a sys-
tematic laboratory fabrication process
as means of delivering full-coverage
crowns for seamless integration with
the patient’s natural dentition.

Robinson Weber • 9
 Esthetic Excellence
A
patient’s smile can have a significant
impact on his or her quality of life. Both
professional and personal relationships
can be either enhanced or diminished by the
condition of one’s teeth. The clinician and
dental technician have the ability to improve
a patient’s confidence and, therefore, over-
all well-being by providing a means to correct
the length, shade, function, and shape of not
only the individual teeth, but as they relate to
each other in the entire smile. In the anterior
maxilla, these goals are directly influenced by
the ability of the restorative team to achieve
a harmonious transition between the natural
dentition and esthetic dental restorations. As
shown in the presentation that follows, when a
single tooth or teeth is required, this challenge
is magnified, as a proper shade match will be
critical to postoperative success.
Case Presentation
A middle-aged female patient presented with
the desire to revitalize her smile. The anterior
dentition had been worn over the years and
several diastemata were present (Figure 1).
Additional tooth length was desired by the
patient in the anterior region, combined with
diastema closure, straightening, and whiten-
ing. The patient also expressed a preference
that her smile maintain a natural appearance.
The tissue height on both central incisors was
raised approximately 1 mm using an 810-nm
soft tissue diode laser (eg, Odyssey, Ivoclar
Vivadent, Amherst, NY). Due to the presence of
existing restorations, the premolar teeth were
prepared for full-coverage restorations. The
canines and central incisors were reduced using
more conservative techniques to accommodate
lABORATORY Tip
“Once the restorations are refined and ready to glaze, I like to
steam the porcelain to remove any debris, and then thin the
Universal Glaze Paste with a Glaze Medium using a small
stain brush to provide the best possible luster.”
–Michelle Robinson Weber
10 • ESTHETIC ENHANCEMENT OF THE MAXILLARY ANTERIOR REGION
three-quarter veneers. Lastly the lateral incisors
were prepared for full-coverage crowns to close
the diastemata and replace the existing com-
posite restorations. All contacts were broken to
ensure the ceramist had control over porcelain
layering interproximally and at the embrasures;
postoperatively this would deliver a more bal-
anced smile.
An impression of the prepared teeth was
made, and the teeth were provisionalized.
The impression—and all related diagnostic
information—was subsequently conveyed to
the dental laboratory for use throughout the
restorations’ fabrication.
Laboratory Protocol
A feldspathic porcelain (ie, IPS InLine, Ivoclar
Vivadent, Amherst, NY) was selected for use
in a refractory technique. The photographs
and model of the provisional restorations
were to be closely followed for shape, length,
and function (Figures 2 and 3). The clinician
had also requested a “contact lens effect,”
since the shade of the prepared dentition was
uniform and light in color. Additional informa-
tion received from the clinician included a final
tooth shade with a slight color variation for the
canines. Approximately 1 mm of incisal trans-
lucency and medium surface texture were
also required.
Refractory Models
The fabrication of models for this case began
with the pouring of all impressions using
die stone (ie, Yellow Prima Rock Die Stone,
Whip Mix, Louisville, KY). The models, with
the exception of the working model, were all
allowed to harden. Next, they were trimmed,
Figure 1. Preoperative view demon- Figure 2. A diagnostic model with the Figure 3. Once the teeth were prepared
strates the presence of esthetic spacing, desired crown length and tissue contours and impressions transferred to the labora-
tooth wear, discoloration, and short clini- evidenced following laser treatment. tory, a working model was created to
cal crown length. ensure development of optimal function.

pinned as needed, and based. The working
model was then poured using the same die
stone and a pre-drilled base plate (Zeiser base
plate, Servo Dental, Northbrook, IL) with pins
placed into the prepared impression. Once the
material hardened, the model was removed
from the impression. All excess stone was
removed with a lathe. The dies were sepa-
rated using a diamond disc (#911H, Brasseler
USA, Savannah, GA) and trimmed with a #8
carbide bur. The models were duplicated and
the dies were degassed prior to articulation
(Stratos, Ivoclar Vivadent, Amherst, NY) to the
facebow and bite.
Porcelain Fabrication
Prior to building any part of the restorations, an
incisal matrix was fabricated from the provisional
model in order to avoid overbuilding. Once the
refractory dies had cooled from burnout, they
were ready for a wash/foundation firing using an
equal mix of B1 and A1 body porcelains on the
facial, incisal, and occlusal surfaces of the dies.
An Opal Effect 2 porcelain was applied around
the marginal area to create the contact lens
effect (Figure 4). Thin layers of porcelain were
placed on the water-soaked dies, then lightly
tapped to ensure smooth, even coverage to the
prepared areas. The porcelain was then touched
with tissue paper to remove any moisture and
placed into the porcelain furnace (ie, Programat
P100, Ivoclar Vivadent, Amherst, NY) for firing.
The dies were fired to 925°C.
Once firing was complete, the dies were
again soaked in water, then placed back into
the duplicating tray. Referring to the incisal
edge matrix, the first buildup was performed
using a mix of the same B1 and A1 porcelains.
This mix was built up onto the incisal areas to
form the internal lobes. The premolar dentin
structure was built up and Occlusal Orange
porcelain was applied to the central fossa
area. Porcelain was blotted with a tissue to
remove excess moisture. No condensing
was performed. A porcelain knife was used
to cut through the contact area to separate
each tooth, and the dies were fired again to a
maturation temperature of 915°C. Once cool,
the dies were placed back onto the duplica-
tion tray and onto the articulator, then closed
into the incisal matrix to verify that the lobes

Figure 4. Porcelain buildup was com- Figure 5. A combination of B1 and A1 Figure 6. Evaluation of the incisal buildup
menced, using the silicone template porcelains (IPS InLine, Ivoclar Vivadent, and lobe appearance following initial
to enable precise reproduction of the Amherst, NY) was used to form the inter- porcelain firing.
desired contours, length, and width. nal lobes prior to firing.

Robinson Weber • 11
 Esthetic Excellence

Figure 7. The lingual-incisal aspects of Figure 8. Contours and incisal edges Figure 9. Light translucency and color
teeth #7 through #10 were built up to were corrected, and a Light Mammelon effects were carefully evaluated prior to
allow esthetic internal effects. porcelain was used to create flickers of final contouring.
internal characterization.

had not been over-built and were in the cor-
rect position (Figures 5 and 6).
The dies were again soaked in water to
accept the next porcelain application. The
body porcelain mix was applied as it was previ-
ously to compensate for shrinkage. The lingual
aspects of teeth #7 through #10 were built up
to create a “canvas” on which to apply the
internal effects (Figure 7). The dentin struc-
ture was built up on the canines as well as
the premolars using the body porcelain mix.
Stain was used in the central fossa areas of
the premolars to create more depth. All units
were separated with a porcelain knife, the
interproximal areas were touched up, and the
porcelain was fired again to 915°C.
The fired buildup was placed onto the
duplication tray and onto the articulator, then
placed against the incisal matrix to ensure that
the incisal edges and lobes were correct. The
contours and incisal edges of teeth #7 through
#10 were corrected with Opal Effect 1 and
Opal Effect 2 porcelains (IPS InLine, Ivoclar
Vivadent, Amherst, NY). The Light Mammelon
porcelain was used to enhance the lobe detail
and create light “flickers” of internal charac-
terization. A small amount of Amber was used
for additional characterization (Figure 8). The
porcelain was then fired again at 915°C.
The cooled dies were placed into the tray
and the contours were evaluated using the
incisal matrix. A micro diamond disc was used
to remove a small amount of excess porce-
lain from the mesial and distal edges prior to
continuing. Following an evaluation of color
and effects (Figure 9), the final contour was
created, alternating Enamel 1 and Effects 1
and 2 (IPS InLine, Ivoclar Vivadent, Amherst,
NY) over the entire surface of the teeth. The
lingual aspects were completed in the same
way—again, keeping within the form of the
matrix with the exception of compensation for
shrinkage. A small amount of Neutral Enamel
was beaded across the incisal edges with
a brush to create halos within the finished
porcelain (Figure 10). This brush technique
enabled the fabrication of refined restorations
that required minimal contouring with a bur.
The teeth were separated with a porcelain
blade, and a small amount of porcelain was
added to the contact areas. The porcelain was
then fired once more.

Figure 10. Enamel effects were added to Figure 11. Postoperative view of the final, Figure 12. Postoperative appearance
the lingual and facial surfaces, and care glazed restorations. Note the “contact demonstrates harmonious integration and
was taken to refine the restoration using lens” effect and natural translucency a natural, lifelike appearance.
a brush technique. achieved using the refractory technique.

12 • ESTHETIC ENHANCEMENT OF THE MAXILLARY ANTERIOR REGION

Contouring
The cooled restorations were each tried in on
the model individually, beginning with teeth
#8 and #9 in order to maintain the correct
midline. The porcelain was marked with mark-
ing tape and any heavy contact areas were
relieved with a diamond bur. Each restoration
was placed in the tray one at a time, and the
contacts were adjusted accordingly. In addi-
tion to using articulating tape, each restora-
tion was tried in with mylar strips as well. The
adjacent teeth were removed and placed into
the tray to verify all contacts again. Finally, all
pieces were tried in together.
The complete model was placed on the
articulator, and any necessary adjustments
were made for centric relation. Protrusive and
canine movements were also checked, and
final contouring was achieved by using a com-
bination of a #850 diamond bur and microdisc
(Brasseler USA, Savannah, GA). Final mor-
phology was refined using a flame-shaped
diamond bur and perikymata were created by
lightly sweeping the bur horizontally across
the surface.
Final Glaze
The restorations were fired to 830°C and then
left to cool. A diamond-impregnated wheel
was used to lightly refine the glazed surface
and areas of the restorations that would con-
tact the patient’s lips and create natural wear.
Finally, a Robinson bristle brush and a medium
porcelain polishing paste were used to bring
the porcelain to a medium luster.
The restorations were steam cleaned and
divested using glass beads at 80 psi. Any
remaining porcelain around the marginal
areas were removed with the impregnated
rubber wheel prior to fitting to master dies.
Once the restorations were seated to the
master dies, the margins were checked
under magnification. The master dies were
then placed back into the duplicator tray and
all restorations were carefully placed; small
adjustments were made to the contacts as
necessary. Lastly, the restorations were fit to
the solid model, at which time the margins,
contacts, and occlusion were verified once
more. All restorations were re-polished with
a bristle brush and polishing paste to shine
any areas that had been adjusted (Figure 11).
Prior to delivery of the case, the intaglio sur-
faces of the restorations were lightly sand-
blasted with 50 µm aluminum oxide, then
etched for one minute using a ceramic hydro-
fluoric porcelain etch. They were rinsed with
water, placed in a neutralizing solution for
30 seconds, soaked in a cup of alcohol in an
ultrasonic cleaner for an additional 5 minutes,
and air dried. The entire case was then evalu-
ated, packed for delivery, and cemented by
the clinician prior to occlusal adjustments as
needed (Figure 12).
Conclusion
By diligently following each step of the treat-
ment plan, the restorative team was able to
significantly improve the patient’s quality of
life. During fabrication, careful attention must
be paid to details of color, contour, and shape.
Taking care to accommodate for porcelain
shrinkage and continually verify fit, the labora-
tory technician may provide esthetic restora-
tions that blend in seamlessly with the natural
surrounding dentition.
* Dental technician, CMR Dental Laboratory, Idaho Falls,
Idaho. Accredited member of the AACD.
Robinson Weber • 13
 Esthetic Excellence

Balancing Simplicity
and Versatility

Case 1
Dr. Nick Addario, Chula Vista, CA.
Mr. Andre Michel, Dana Point, CA.

Before After successful tooth replacement with an IPS

e.max bridge.

Case 2
Dr. Michael R. Sesemann, Omaha, NE.
Mr. Lee Culp, Bradenton, FL.

Implant components After placement of an implant-supported IPS

e.max crown restoration.

14 • Balancing Simplicity and Versatility

With IPS e.max®, dental professionals have a system for fabricating either lithium dis-
ilicate, high-strength glass-ceramic or zirconium oxide restorations. Its clinical perfor-
mance combines esthetics and strength for any region of the mouth, enabling clinicians
to provide their patients with beautiful, natural smiles. The ability of dental technicians
to achieve a predictable shade match in even challenging combination cases makes IPS
e.max a valuable treatment option for numerous AACD members and alumni.

Case 3
Dr. Tom Trinkner, Columbia, SC.
Mr. Matt Roberts, Idaho Falls, ID.

Before After placement of IPS e.max lithium disilicate

and zirconia restorations.

Case 4
Edward Lowe, Vancouver, BC.
Mr. Nelson Rego, Santa Fe Springs, CA.

Before After esthetic replacement of gold intracoronal

restorations with IPS e.max inlay/onlay.

IPS E.max • 15
 Esthetic Excellence

16 • Anterior AEsthetic Restoration Using a Direct Resin Veneer Technique

Laboratory
Procedures
In the Esthetic Restoration of Maxillary
Lateral Incisors

Nelson Rego, CDT*

While creating esthetic full-mouth rehabilitations

can be an exhilarating experience, it is single-
tooth replacement that presents a greater technical
challenge—and ultimately, reward—to the ceramist.
Successfully blending a single restoration with the
adjacent tooth structures requires not only one’s abil-
ity to identify the innate qualities of the natural tooth,
but then to imperceptibly mimic them in dental ceram-
ics. This situation presentation details a case where a
severely discolored lateral incisor was replaced with
a laminate veneer in order to provide a harmonious,
esthetic result.

REGO • 17
 Esthetic Excellence
Figure 1. Preoperative view demonstrates discolor-
ation in tooth #7 and, therefore, an unesthetic shade
match in the anterior region.
L
aboratory technicians are challenged
to replicate natural esthetics on a daily
basis. Further complicating the charge
to recreate the multiple shades and nuances
of natural teeth via a porcelain medium is the
need to precisely match the existing dentition
when treating only one or two teeth within the
esthetic region. Today’s dental materials have
given clinicians and technicians a large array of
options for restoring the anterior teeth; these
include ceramic materials that mimic enamel
in both wear resistance and appearance. This
case presentation demonstrates the labora-
tory protocol used for the restoration of ante-
rior lateral incisors with unrestored teeth sur-
rounding the restorations.
Case Presentation
Clinical Examination
A 38-year-old female patient presented with
an existing porcelain veneer on tooth #7(12)
(Figure 1). The patient had whitened her teeth
using an at-home system and, while she was
Figure 3. The ceramist was challenged to recreate
translucency and luster of the natural dentition using
a predictable technique and material protocol.
18 • LABORATORY PROCEDURES IN THE ESTHETIC RESTORATION OF MAXILLARY LATERAL INCISORS
Figure 2. The patient was instructed to cease at-
home whitening in order to secure accurate shade
data for fabrication of the porcelain veneer.
satisfied with the existing bleached result,
a shade discrepancy was evident within
the anterior dentition. Although orthodontic
treatment was presented as an option to cor-
rect the patient’s tooth alignment, the patient
was satisfied with the minor misalignment
present. Her primary concern was about the
shade of the single lateral, and a porcelain
laminate veneer was selected to repair the
existing esthetics.
Once the at-home whitening protocol was
discontinued, shade information was captured
and transferred to the laboratory (Figures 2
through 4). The abutment tooth was then pre-
pared with a chamfer margin, and the prepara-
tion was polished to ensure elimination of any
sharp line angles. The provisional restoration
was fabricated and seated, and impressions
were forwarded to the laboratory to facili-
tate fabrication of the definitive prosthesis.
Laboratory Protocol
A Class IV die stone was poured and allowed
to harden for 24 hours. Careful attention was
Figure 4. Closer evaluation of the discolored lateral
incisor demonstrated the extreme shade variation
evident in that single tooth.
Figure 5. The desired tooth contour was waxed up
on the working model to ensure proper width-to-
length ratios prior to porcelain layering.
paid to the water-powder ratio in order to
ensure proper expansion. The working mod-
els were fabricated and mounted on an artic-
ulator; the approved provisional restorations
were also mounted on the opposing model.
A matrix was created and used to evaluate
the facial and proximal reduction. The dies
were carefully trimmed, and all undercuts
were blocked out with an undercut wax
material. A full-contour waxup was then cre-
ated (Figure 5). At this time, the contacts
were waxed into place, and the margins
were sealed with a minimal shrinkage margin
wax (Figure 6).
The waxed laminate was sprued and
invested using the speed press technique,
and pressed in IPS Empress Esthetic (Ivo-
clar Vivadent, Amherst, NY), using an
EOC-1 Ingot (Figures 7 and 8). This ingot
was selected because of its optical proper-
ties and high opacity, which would conceal
the underlying shade of the prepared tooth
structures. Once the laminate was cooled
and divested, it was evaluated for fit and
layering commenced.
Figure 7. The incisal cutback procedure was
initiated to ensure development of esthetic
incisal translucency.
Figure 6. The preparation was evaluated and
blocked out as needed.
Porcelain Layering Procedures
Following careful evaluation of the digital
shade map and preoperative photographs, the
porcelain buildup was cut back to allow the
author to create the many-faceted nuances
that would be required to ensure a natural-
looking integration. A foundation bake was
readied with a small amount of stain and glaze
paste, and fired at 770˚C. The laminate was
layered with Incisal White and Bamboo pow-
ders (IPS Empress, Ivoclar Vivadent, Amherst,
NY) to create the esthetic dispersion of colors
that were present in the natural dentition, and
fired at 840˚C. The laminate was checked with
the matrix to ensure that the effects were in
the proper positions, and a final layer of MT
incisal was added to create the translucency
that was so clearly demonstrated by the natu-
ral dentition.
Evaluation, Contouring, and Seating
The laminate veneer was temporarily
cemented to the stone die using Systemp.link
(Ivoclar Vivadent, Amherst, NY) to facilitate
Figure 8. The laminate veneer was built to contour
on the working model.
REGO • 19
 Esthetic Excellence

Figure 9. Postoperative lateral view of the definitive Figure 10. Note the harmonious integration and
restoration following cement cleanup. natural-looking shade match achieved.

final contouring. Various diamonds and rub-
ber wheels were used to provide an esthetic
surface luster, with care taken to the reflec-
tive and deflective areas. The matrix of the
approved provisional restoration was used to
ensure that the final contours of the definitive
restoration closely matched those commu-
nicated by the temporary. The laminate was
lightly stained and baked once. The final polish
was accomplished using a soft bristle brush
and paste to achieve the prescribed gloss.
The restoration was returned to the clinician,
where it was inspected for fit and shade on
the model. The provisional was then removed
and the preparation was cleaned with chlor-
hexidine and rinsed. A resin cement material
(Variolink Veneer, Ivoclar Vivadent, Amherst,
NY) was applied to the internal surface of the
laminate. The value shading of this cement
was a benefit in matching the single-tooth res-
toration to the adjacent dentition. The veneer
was positioned, excess cement was removed,
and the restoration was spot polymerized with
a 2-mm tacking tip. Occlusion was verified,
adjustments made as necessary, and a porce-
lain polishing kit was used to render the final
appearance of the restoration following defini-
tive polymerization (Figures 9 and 10).
Conclusion
Matching a single laminate veneer to a patient’s
existing dentition can lead to a high level of satis-
faction, since in this instance the laboratory tech-
nician is challenged to create a restoration that
blends imperceptibly with the natural dentition.
A pressed ceramic was selected accordingly,
based on the ingot’s ability to deliver optimal
opacity to mask the underlying substructures,
with a natural luster and incisal translucency.
* Laboratory Technician, Santa Fe Springs, California.
Accredited member of the AACD.

laBORATORY Tip
“Using a Sil-Tech matrix, I can inject wax into the prepa-
ration models and verify if sufficient reduction is present
prior to beginning the fabrication process, reducing the
need for remakes and eliminating potential error.”
–Nelson Rego, CDT

20 • LABORATORY PROCEDURES IN THE ESTHETIC RESTORATION OF MAXILLARY LATERAL INCISORS

Esthetic
Enhancement
and Pathologic
Occlusion
Using Six All-Ceramic Crown Restorations
M. Johnson Hagood, DDS*

All-ceramic restorations such as IPS

Empress (Ivoclar Vivadent, Amherst,
NY) enable clinicians to predictably
and successfully address their patients’
increasing esthetic expectations. The
following presentation demonstrates
a clinical protocol used to place IPS
Empress restorations in a patient
with compromised anterior esthetics
and wear. The provisional restora-
tions served as a “trial therapy” that
enabled the clinician to resolve the
esthetic expectations of the patient as
well as the occlusal concerns present.

HAGOOD • 21
 Esthetic Excellence
S
ince the time of their introduction to the
dental industry and its professionals, IPS
Empress (Ivoclar Vivadent, Amherst, NY)
all-ceramic restorations have offered a new
dimension in anterior restorative dentistry.
While providing esthetics with optical charac-
teristics similar to tooth enamel, IPS Empress
crowns are composed of a homogeneous
leucite-based ceramic, which scatters light
like a natural tooth and ensures that these res-
torations blend in with the adjacent dentition.
Restorations fabricated in IPS Empress mate-
rial exhibit life-like translucency as well. In the
case that follows, IPS Empress full-coverage
crowns will be used to improve the appear-
ance of the patient’s smile while restoring her
to pathologic occlusion.
Case Presentation
A 30-year-old female patient presented for
esthetic enhancement of her maxillary and
mandibular dentition (Figures 1 and 2). Clini-
cal examination revealed the presence of a
PFM crown on tooth #9(21), diastemata in the
maxillary arch, and slight to moderate wear of
the incisal surfaces of the mandibular incisors
(Figures 3 and 4). The patient was in excel-
lent periodontal health. The patient’s skeletal
relationship had a Class III tendency and the
mandibular incisors were retroclined. There
were no stable holding contacts between the
lower incisal edges and lingual surfaces of
the maxillary incisors.
The location of the wear—predominantly on
the facial surfaces of the mandibular incisors—
was indicative of tooth loss occurring during
functional movement of the mandible. Trial
therapy and evaluation would thus be neces-
sary to determine if occlusal correction would
resolve the pattern of wear on these teeth.
Figure 1. Preoperative view of diastemata Figure 2. While the gingival architecture
and incisal edge positions of the maxillary was symmetric, the patient’s smile was
anterior teeth, which created disharmony. not esthetically pleasing.
22 • ESTHETIC ENHANCEMENT AND PATHOLOGIC OCCLUSION
The Class III skeletal tendency combined
with the tooth-arch discrepancy of the maxil-
lary arch created a path of closure that gen-
erated excessive frictional force between the
lingual surfaces of the maxillary incisors and
the incisofacial surfaces of the mandibular inci-
sors. A conservative approach to treatment
would utilize orthodontic therapy to facilitate
an efficient closure path to maximum intercus-
pation that did not create premature loading of
the teeth. However, the patient, duly informed,
declined orthodontic treatment. A restorative
option that would serve to address both the
functional and esthetic concerns involved por-
celain restorations on the six maxillary anterior
teeth. An efficient path of closure to maximum
intercupsaton would be facilitated by hollow-
ing the lingual surfaces of the anterior teeth
to accommodate the patient’s mandibular inci-
sors during function. A secondary functional
goal of treatment would be to create stable
centric stops on all teeth.
Treatment Sequence
A diagnostic workup was fabricated; it was con-
firmed that both the esthetic deficiencies and
occlusal problems could be resolved through
the placement of full-coverage restorations
on teeth #6(13) through #11(23), and occlusal
equilibration. IPS Empress was selected as the
restorative material of choice, not only for its
esthetic qualities but for its low wear potential.
The provisional restorations would be used as
a template for directing treatment outcomes
esthetically, phonetically, and functionally.
A vacuum-formed template was constructed
on the diagnostic cast for use as a reduction
guide during preparation and for fabrication of
the provisional restorations. An occlusal index
was also fabricated to aid in positive seating of
Figure 3. Occlusal view of the maxillary
arch preoperatively revealed the PFM
crown on the maxillary left central incisor.
Figure 4. The PFM crown on tooth #9(21) restricted
natural light transmission around the gingival margins.
the template on a working model during indi-
rect fabrication of the provisional restorations.
Teeth #6 through #11 were prepared con-
ventionally, except that minimal tooth struc-
ture was reduced in the cingulum areas and
slightly more reduction was performed on
the incisal two-thirds of the lingual surfaces in
order to hollow them and thus better accom-
modate the envelope of function.
The crown on tooth #9 was first removed, and
then gross reduction of the other preparations
was performed with diamond burs. Retraction
cord was placed in each sulcus, leaving 0.2 mm
to 0.5 mm of tooth structure visible between
the margin and the cord. The preparations were
then refined with fine diamond burs used in
a mid-speed handpiece. Following polishing of
the preparations to eliminate any surface irregu-
larities, alginate impressions were made of the
maxillary arch and immediately poured with fast-
setting dental plaster.
Indirect provisional restorations were pro-
cessed in acrylic, trimmed, and tried in to per-
mit adjustment of occlusion. Equilibration was
finalized and included the establishment of
appropriate anterior guidance. The provisional
restoration was then separated into individual
units and polished with a Robinson bristle brush.
Figure 6. View of the IPS Empress Figure 7. Polishing cups and points were
all-ceramic crowns seated on the model used for initial polishing, and the restora-
prior to try in and cementation. tions’ final luster was created.
Figure 5. The provisional restorations enabled the
patient to provide feedback on esthetics, fit, func-
tion, and phonetics.
The provisional restorations were cemented
and the final impressions were taken the fol-
lowing week (Figure 5).
At the final impression appointment, the
patient provided feedback with regard to
the shade, contour, phonetics, comfort, and
esthetics of the provisional restorations. This
information was conveyed to the dental labo-
ratory to aid in the fabrication of the definitive
restorations. An alginate impression of the
maxillary arch with the seated provisional res-
torations was then taken; it would be poured
in stone and mounted against the working
model on an articulator: 1) to guide the optimal
occlusion of the provisional restorations and 2)
to aid the laboratory technician in predictably
reproducing the desired occlusion, contour,
and incisal edge position in the definitive resto-
rations. Following the completion of all impres-
sion making, the provisional restorations were
recemented and the patient was excused.
Laboratory Instructions
A work order accompanied by an esthetic
checklist, color mapping, preoperative and
provisional images, casts of the diagnostic
Figure 8. Occlusal view of the IPS
Empress crowns postoperatively. Minimal
occlusal adjustment was necessary.
HAGOOD • 23
 Esthetic Excellence
Figure 9. Postoperative view of the enhanced
esthetics achieved through the IPS Empress crowns
and their integration.
workup, and provisional restorations were sent
to the dental laboratory. These data would be
essential in ensuring the desired results with
the IPS Empress crowns.
Finishing
The crowns were inspected upon their return
from the dental laboratory and were well-adapted
to the model (Figure 6). The facial index fabricated
in the laboratory against a mounted model of the
provisional restorations fit precisely against the
facial contour of the definitive all-ceramic resto-
rations. The internal surfaces of the IPS Empress
crowns had a uniform frosted appearance indica-
tive of well-etched surfaces.
At the delivery appointment, the patient
was anesthetized, the provisional restorations
were removed, and the teeth were cleaned.
The crowns were tried in with Variolink II Try-
In paste (Ivoclar Vivadent, Amherst, NY). The
patient was given the opportunity to assess
the restorations and the appropriate cement
shade (ie, transparent) was determined.
The crowns were then cleaned and etched
with 37.5% phosphoric acid gel left on for
one minute and then rinsed. This process
removed any surface contamination and acidi-
fied the porcelain surface, which increased the
efficacy of a silane coupling agent. A freshly
mixed silane coupling agent was applied fol-
lowing drying in order to increase the bond
strength between porcelain and resin cement
and to decrease microleakage.
All teeth to be bonded were cleaned and
rinsed, and a retraction cord was placed in each
sulcus to ensure a dry, uncontaminated field.
The teeth were etched with 37.5% phosphoric
24 • ESTHETIC ENHANCEMENT AND PATHOLOGIC OCCLUSION
Figure 10. View of the patient’s smile following
treatment demonstrates improved proportion and
harmony with her lips.
acid gel for 15 seconds, rinsed, and left wet. A
wetting agent (eg, Tubulicid Red, Global Den-
tal, Bellmore, NY) was applied to wet and disin-
fect the etched surfaces. Dentin primers were
mixed, and five to seven coats were applied to
each preparation. Once fully dried, the prepa-
rations were light cured for 30 seconds per
surface. Pre-Bond resin (Bisco, Schaumburg,
IL) was applied to the preparations. Transpar-
ent-shaded dual-cure cement (eg, Variolink II,
Ivoclar Vivadent, Amherst, NY) was mixed and
placed in each crown. The crowns were seated
and each was spot-cured in the center facial
surface with a 3-mm curing tip.
Excess cement was brushed and flossed
away, and final curing was accomplished with
60 seconds per surface for each tooth. Fur-
ther cement removal was accomplished using
an H6/H7 scaler and Bard Parker #12 blade.
The cervical and interproximal surfaces were
finished using diamond finishing burs and
carbide finishing burs with an air-water mist.
All margins and tooth surfaces were carefully
inspected for overhangs and roughness and
were then polished (Figures 7 through 10).
Additional treatment would consist of minor
restorative care, routine examinations and
prophylaxis, and monitoring of tooth wear.
Conclusion
The esthetic results were very satisfying.
By simultaneously addressing the patient’s
esthetic and functional concerns, a successful
long-term prognosis could be ensured.
* Private practice, Vero Beach, Florida. Accredited mem-
ber of the AACD.
Anterior
esthetic
Restoration
Using a Direct Resin Veneer Technique
John Roberts, DDS*

By challenging clinicians to deliver

esthetic restorations using a vari-
ety of restorative materials, forward-
thinking dental professionals are
exposed to an expanded armamen-
tarium. Of the case types required for
accreditation, the delivery of natural-
looking direct resin veneers in the
anterior region represents a level of
mastery different from any other type
of skill demonstrated in the opera-
tory. This presentation demonstrates
the use of composite resins to create
natural, lifelike results using a direct
chairside technique.

Roberts • 25
 Esthetic Excellence
E
sthetic dentistry demands a certain
level of mastery when using a variety of
restorative materials in order to obtain
the desired final result. Skill in preparation
design and cementation of porcelain veneers
alone are not the only qualifications of a good
cosmetic dentist. In addition to the mastery
of indirect porcelain restorations, compos-
ite expertise remains a necessary skill in the
armamentarium. Very few dentists develop the
skill and the art of the direct composite tech-
nique for the purpose of veneering six or more
anterior teeth. For a majority of dentists, more
predictable, esthetic results can be obtained
easier and faster with porcelain restorations
(eg, IPS Empress or IPS e.max, Ivoclar Viva-
dent, Amherst, NY). While esthetic treatment
solutions often call for the use of indirect resto-
rations, there are certainly indications for direct
protocols. These may include (but are not lim-
ited to) addressing esthetic concerns in young
patients, treatment of patients who wish to
avoid aggressive tooth preparation, or patients
in need of transitional materials during multidis-
ciplinary protocols. Understanding composite
resins and the associated layering techniques
well enough to block out and develop consis-
tent shade, translucency, and characterization
will certainly provide an opportunity to create
naturally undetectable restorations as an alter-
native to porcelain veneers.
Case Presentation
A 32-year-old female patient presented for smile
enhancement (Figure 1). A clinical examination
Figure 1. Preoperative appearance demonstrates
the presence of gingival decay and short clinical
crown length.
26 • Anterior Esthetic Restoration Using a Direct Resin Veneer Technique
with necessary radiographs and a profes-
sional cleaning indicated that no soft or hard
tissue pathology were evident. Although the
patient had previously undergone orthodontic
treatment (ie, Invisalign, Align Technologies,
Santa Clara, CA) in addition to esthetic crown
placement, fillings, and routine care, Class I
occlusion and Class III skeletal tendencies
remained evident (Figure 2). Minimal, if any,
wear patterns existed in the enamel. Function-
ally, satisfactory guidance was evident during
right, left, and protrusive excursions. No bal-
ancing or working interferences were noted in
the posterior region.1,2 No history or complaint
of temporomandibular disorder, pain, popping
or crepitis upon maximum opening, or lateral
or protrusive excursions were noted (Figure 3).
Facial symmetry was evident, with no midline
shift. A mild cant was present on the left side,
with low tissue in the gingival architecture.
Short central and lateral incisors resulted in a
reversed smile line and poor esthetic propor-
tions (Figure 4). The buccal corridor appeared
satisfactory (Figure 5). The patient did not feel
comfortable with the white and brown spots
visible on the anterior dentition, and desired
greater incisal length, improved phonetics,
and enhanced esthetics.
The patient’s periodontal health was excel-
lent. Tooth #13(25) was restored with a pro-
visional crown and required replacement
with a definitive porcelain restoration. Ade-
quate composite restorations were present
on teeth #2(17) through #5(14), and #9(21),
#12(24), #15(27), #18(37) through #23(32),
and #26(42) through #31(47). Teeth #1(18),
#16(28), #17(38), and #32(48) were missing.
Figure 2. Preoperative appearance of the patient’s
smile revealed anterior staining and unesthetic
incisal characterization.
 Clinical Tip
When patients present with dark underlying structures, a
specialty dentin shade (eg, B1 Dentin, 4 Seasons, Ivoclar
Vivadent, Amherst, NY) should be placed on the cervical
aspect and tapered towards the incisal edge to create the
desired body shade, while adding strength to the underly-
ing incisal length. Enamel Effects shades (White and Blue)
can then be used to develop internal characterizations.
–John Roberts, DDS

Minor gingival tissue correction would also
be required to improve the cant.3
Treatment Plan
After multiple treatment options were dis-
cussed with the patient, direct veneers were
selected to restore teeth #5 through #12 to
alter the smile line and the shade. Tooth #13
was also scheduled for crown replacement.
The following steps would be followed in the
treatment plan:
1) Continued periodontal maintenance and
good home care was expected, as it was
already habit for this patient.
2) Teeth #5 through #12 would be prepared
for veneers or veneer onlays.
3) A hybrid composite would be placed as
a base for the dentin shade and strength
in the final result.
4) Because the dentin structures were more
opaque and contained a more saturated
chroma, the use of a layered restorative
technique with calibrated translucencies
was selected to promote exceptional
esthetics and an accurate shade match.
5) An enamel-shaded microfill would be
placed over the dentin layer to be pol-
ished to a natural luster.
6) Maintenance of functional occlusion would
ensure that the new composite veneers
would last in the new length and shape.

Figure 3. Following orthodontic treatment, improved Figure 4. The position of the cusp tips on the pre-
lateral and protrusive guidance protected against molars was longer than the canine position during
occlusal interferences. preoperative evaluation.

Roberts • 27
 Esthetic Excellence
Figure 5. Maxillary occlusal view of full, rounded,
well-defined incisal edges.
Restorative Sequence
Discussion regarding tooth length and the
removal of the brown spots were of primary
importance because these were, essentially,
the patient’s primary concerns. Each tooth
was prepared and rebuilt individually so that
tooth form and position would not be lost
(Figure 6). The tooth preparation design was
maintained in a simple manner, with margins
maintained supragingivally, and the incisal
third of each tooth prepared more aggres-
sively to allow space for the development
of incisal shade and translucency. Care was
taken to extend the preparations into the
interproximal area far enough to eliminate
interproximal shadowing.4
Following rubber dam isolation, a clear plas-
tic strip was placed between each prepara-
tion to maintain optimal interproximal con-
tacts. Using the total-etch technique, the
teeth were etched with a 35% phosphoric
acid material for 15 seconds and rinsed thor-
oughly. A microbrush was used to absorb the
28 • Anterior Esthetic Restoration Using a Direct Resin Veneer Technique
Figure 6. Postoperative view. Note the improved
clinical crown length, tooth shape, and contour.
excess water on the bonding surface, and
an adhesive material (ie, ExciTE, Ivoclar Viva-
dent, Amherst, NY) was generously agitated
on the preparations for 20 seconds, then air
dried to evaporate any alcohol carrier in the
bonding agent.5 This layer was light cured for
20 seconds per tooth.
Shade B1 Dentin (ie, 4 Seasons, Ivoclar
Vivadent, Amherst, NY) was placed on the
cervical aspect and tapered towards the
incisal edge to establish the body color and
to provide strength to the addition in incisal
length.6 This also helped eliminate a transition
in color between the dentin body of the pre-
pared tooth and the desired length. This layer
became the functional surface on the lingual
aspect. Developmental lobes were subse-
quently formed in this layer and then stained.
Internal characterizations were then added to
give warmth and help decrease the natural
tendency of teeth to become too gray when
increased in brightness. Translucency was
instilled along the incisal edge to encourage
Figure 7. Incisal guidance and excursive move-
ments were also improved postoperatively.
recognition of the underlining characteristic
colors. The halo effect was formed by bevel-
ing back the incisal edge at the proper angle
to create a refracted line of light. Several lay-
ers of the final resin layer were removed and
replaced in an attempt to create proper tooth
contour (Figure 7). Canine guidance was then
developed on the lingual aspect.7 The Ben-
net shift was induced with mild pressure on
the balancing side of the mandible to ensure
all balancing and working interferences were
cleared.8 Protrusive occlusion was verified
prior to definitive finishing and polishing.
Interproximal resin was removed with
finishing strips and fine-fluted carbide burs
under copious water irrigation. Although the
facial surfaces were polished using disks with
varying grits, care was taken not to remove all
surface texture created during placement of
the enamel layer of composite resin.9
Conclusion
Often, the rebuilding of an entire anterior tooth
in composite is necessary in the field of den-
tistry for improved communication with the
ceramist. The clinician’s ability to “rough out”
the desired final results for a porcelain veneer
case in composite prior to preparation is a vital
skill for any practitioner that expects to excel in
esthetics. Understanding the optical properties
of composite resin also becomes mandatory
Figure 8. Postoperative view shows increased
clinical crown length and enhanced esthetics.
when the clinician is masking dark, underly-
ing tooth structures or attempting to create
uniformity in color of the preparations for a
porcelain veneer case.
References
1. Okeson JP. Management of Temporomandibular Dis-
orders and Occlusion. Fourth Edition. St. Louis, MO:
Mosby; 1998.
2. Dawson PE. Evaluation, Diagnosis, and Treatment of
Occlusal Problems. Second Edition. St. Louis, MO:
Mosby; 1989.
3. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prostho-
dontics. Carol Stream, IL: Quintessence Publishing; 1994.
4. Beagle JR. Surgical reconstruction of the interden-
tal papilla: Case report. Int J Periodont Rest Dent
1992;12(2):145-151.
5. Heymann HO, Bayne SC. Current concepts in dentin
bonding: Focusing on dentinal adhesion factors. J Am
Dent Assoc 1993;124(5):26-36.
6. Albers HF. Tooth Colored Restoratives. 7th ed. Ham-
ilton, Ontario: BC Decker, Inc, Alto Books Divison;
1985.
7. Manns A, Chan C, Miralles R. Influence of group func-
tion and canine guidance on electromyographic activ-
ity of elevator muscles. J Prosthet Dent 1987;57(4):
494-500.
8. Rufenacht CR. Fundamentals of Esthetics. Carol
Stream, IL: Quintessence Publishing; 1990.
9. Miller MB, Castellanos IR. Reality. Houston, TX: Reality
Publishing; 2001.
* Private practice, Idaho Falls, Idaho. Accredited member
of the AACD.
Roberts • 29
Esthetic Excellence