Fig 1. Smoking is the single worst thing a patient can do to rapidly age direct laminates. How to rejuvenate aging direct veneers by Martin Goldstein, DMD
Wolcott, CT As readers of Parkell Today may already know, I’m a huge fan of direct composite veneers for patients who aspire to a more attractive smile yet can’t afford a full ceramic rehab.
Unlike some dentists on the seminar circuit, my practice is firmly rooted in middle class America. I don’t have a single supermodel patient. No cast-members of daytime soaps either. While some cosmetic gurus have patients who fly in from Singapore for their cosmetic work - my patients are more likely to be flying in from their job (often their second job) on their way to their child’s soccer game. And for most of them, the cost of 6-14 porcelain veneers is out of the question.
Direct composite veneers have made me a hero to some of these patients. With composite I can offer a dramatic improvement in appearance ... in a single appointment ... at a price they can live with.
Of course, I always explain that there are some limitations to composite veneering.
o The results will look good, but not as good as ceramic veneers fabricated by a master ceramist.
o Plaque has a harder time establishing itself on porcelain than composite, so composite veneers will require careful homecare.
o Unlike porcelain, composite veneers will require occasional polishing at recall to restore the luster.
o And probably most important, they’ll have to refurbished or replaced in 5-8 years.
If you’re interested in adding direct composite veneers to your cosmetic armamentarium, take a peek at an earlier article I wrote discussing the four-hour cosmetic rehabilitation. (Editor: posted at www.parkell.com under “Tech. Articles”)
In this article, I want to show how I rejuvenated some composite laminates that had seen better days. By the way, this may be one of the few “cosmetic” articles you ever read that includes an anterior denture tooth!
Cheryl is an attractive working mother, who has poor insurance coverage, and lives on a modest income. Until recently, she was also supporting an expensive live-at-home daughter.
About five years ago I veneered Cheryl’s anteriors using Epic-TMPT. She was delighted with the results. But in the intervening years dental care hadn’t exactly been the focus of her life. An all-acrylic RPD (replacing #5,7,12) had broken several times at the lateral incisor. Each time we repaired it rather than replaced it, because she simply couldn’t afford the cost of a new prosthesis.
But the last time her RPD fractured, it also broke the proverbial camel’s back. Cheryl might also have felt that a modest splurge was in order, as her daughter had recently begun working.
Whatever the motivation, she asked how much a metal partial denture would cost ... and while we were about it, could we do something to “brighten” her smile? Heavy smoking had taken a toll on her composite veneers (figure1). Fortunately, she has since broken the habit. Smoking is the number 1 cause of diminished appearance when it comes to direct composite veneers. I make this very clear to patients before placing them.
I quoted her $2000 for everything, assuming we didn’t discover secondary caries - and she jumped at the opportunity.
Here’s the resurfacing procedure in a nutshell -
1) Using a thin chamfer diamond point, I removed the facial contours of #6,8,9 and 10, trying to keep the preparations entirely in composite and enamel. I extended the margins into fresh enamel or dentin to assure a good seal.
The final preps look pretty much like traditional veneer preps (only slightly shallower) (fig 2 ).
2) During tooth preparation dentin was exposed at the gingival margins of #6 and 11. This meant that rehab would involve bonding fresh composite to three different substrates (1) old composite, (2) enamel and (3) dentin.
3) All five teeth were etched for 5 seconds with 35% phosphoric acid. The amount of etching at 5 seconds is minimal, however some studies suggest that it may help the bond to enamel. One thing for certain, a short acid treatment will help remove skuz that might otherwise compromise the bond. The teeth were rinsed well and lightly dried. Though I used a self-etch bonding agent, I did not attempt to keep the acid off the dentin. Studies suggest that a short acid treatment of dentin does not impair the bond.
4) I applied Brush&Bond to both the dentin and enamel on all five teeth. Though I attempted to keep it off the residual composite, I’m sure I got some onto the old resin where it met the exposed tooth structure. This posed no problem. Brush&Bond adheres to old resin - though not with the tenacity of Add&Bond.
I allowed the Brush&Bond to sit on the teeth for 20 seconds then lightly blew each of them for 10 seconds, and light cured them for about 5 seconds each.
5) I applied a thin coat of Add&Bond to the composite surfaces I planned to rebuild. (figs 4&5) Add&Bond is a bonding agent specifically developed to graft fresh composite to old composite. It does not bond to dentin. That’s why I applied my bonding agent to the dentin first.
Once the dentin was protected by the resin hybrid layer, I didn’t have to be particularly careful about restricting the Add&Bond to the composite surface. Like any unfilled resin, Add&Bond adheres nicely to dentin bonding agents or etched enamel. If I’d done it the other way around (applied Add&Bond before the dba), any Add&Bond that slopped onto the dentin would prevent the subsequent bonding!
6) After allowing Add&Bond to sit on the teeth for 10 seconds I began applying Epic-TMPT.
Important point: Brush&Bond must be cured before composite is applied - but Add&Bond is different. It should be cured along with the overlying composite. If you light cure Add&Bond before building the composite, there will be a dramatic drop in the quality of the bond.
7) I proceeded to veneer the 5 teeth with Epic-TMPT exactly as I did 5-years before. Central incisors first - because they’re critical to the esthetic success ... then the lateral ... and finally the cuspids. (See sidebar “Why Epic-TMPT for veneers?”)
8) Impressions were taken for the RPD, and the patient was dismissed.
So far, the patient had spent 2 hours in the chair. That included not just the refurbished veneers, but also a new composite restoration on #6 (caries were found following veneer re-preparation), plus the impressions for the removable partial denture; the whole package.
9) A week later the RPD framework was tried in (figs 6&7).
10) Another week later, the finished RPD was inserted. A problem was immediately obvious (fig 8). When Cheryl smiled, the lateral denture tooth stood out because of its shade and facial contour.
11) Rather than send the RPD back to the laboratory and attempt to communicate what I was looking for, I decided to modify the tooth myself.
Using a plain vanilla diamond burr, I reduced the acrylic tooth by about 1mm. I seated the prosthesis in the mouth and applied Add&Bond to the cut surface. After waiting 30 seconds, I rebuilt the tooth to contour using A1 Epic-TMPT.
12) That was the same shade I had used for her direct veneers, so I expected this to resolve the shade problem. It didn’t (fig 9). Epic-TMPT is an unusually translucent composite. In veneers this translucency is a plus because it allows excellent vitality without a lot of time-consuming layering or characterization. When it’s used in restorations, Epic tends to assume the color of the surrounding tooth, so precise shade-matching isn’t necessary.
However, the translucency allowed show-though of the denture tooth’s base color. As a result, the value of the lateral was too high. So I simply darkened the acrylic slightly, using a neutral gray stain (fig 11) (Minute Stain, George Taub) .
Done! (fig 12)
(For more information about Add&Bond, click here.)
Why Epic®-TMPT for veneers?
In the frenetic world of resin technology, new materials are introduced every month. Yet I chose Epic-TMPT, which has been on the market now for more than a decade.
Epic-TMPT isn’t the only composite I use. It isn’t even the only composite I use for direct veneers. However, I often find myself turning to Epic when I’m attempting a cosmetic rehabilitation and economy is a major concern.
Here are my reasons -
1) Excellent cosmetics - Epic-TMPT’s shades are consistent from batch to batch. Furthermore its translucency gives the teeth excellent vitality - without shade-layering - or surface staining - or any of the exotic tricks used by the cosmedontists. I use just a single shade (A1, A2 or B1) for most of my three hour cosmetic rehabs. This satisfies the majority of the patients.
2) Speed of placement - Though it’s not a flowable, Epic-TMPT softens as it warms on the tooth. This assures good conformation to the surface. I can create respectable contacts easily using simple Mylar strips.
This ability to quickly conform to the tooth dramatically speeds the buildup. I can have a tooth seamlessly enveloped in EPIC resin in little more than 10 minutes (For the technique see Special Report #47 - www.drgoldsteinspeaks.com). That’s much faster than I could do it dragging and pushing a stiffer, non-slumping resin, which demands meticulous placement in order to ensure uniform coverage.
While the newer, nanomer based composites promise greater longevity, the time needed to place such veneers necessitates fee considerations that counter the intent of rapid cosmetic rehabs.
3) Extremely easy to finish - Epic sculpts quickly with finishing burs, and when it comes to polishing - nothing polishes as easily and to such a high shine.
4) A decade of experience - Assuming normal hygiene, an Epic-TMPT rehab will maintain its appearance for 5-7 years. A re-bond like the one in this article should last as long or possibly longer due to improvements in bonding and magnification, allowing more accurate finishing of the veneer margins.
Dr. Goldstein is a 1977 graduate of the University of Connecticut School of Dental Medicine and practices general dentistry in a group setting in Wolcott, Conn. He enjoys promoting the cosmetic side of his practice and has found it helpful to incorporate digital photography into his daily routine as a practice builder. Recently, Dr. Goldstein has been appointed to the staff of Contributing Editors at Dentistry Today. In addition to writing for Dentistry Today, Dr. Goldstein also writes for DentalTown, Contemporary Esthetics and Dentistry, the UK’s version of Dentistry Today.
Doctor Goldstein can be contacted at martyg924@cox.net or at his office at 203-879-4649. He is available for speaking engagements on both digital imaging in dentistry and the use of high tech methodology to further the cosmetic practice.
His step-by-step technique article discussing Direct Bonded Veneers (Report #47: The Three-Hour Cosmetic Rehabilitation) can be found here [PDF format]
For a summary of Dr. Martin Goldstein's upcoming lectures and courses, go to
http://www.drgoldsteinspeaks.com
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