Case C
A 40 year old male patient presents with fractured incisal edges and anterior maxillary spacing. The patient is concerned about his appearance and hence presented to explore possible treatment options to address his chief complaint.

Past Medical History: None Contributory. The patient is not on any medication nor does he have any known drug allergies.  A radiograph was taken to evaluate periodontal health which was within normal limits.

Possible treatment options to address this issue include:

• • Veneers from Teeth # 7-10
  • Anterior ceramic crowns from teeth #7-10

It was agreed upon that veneers, rather than ceramic crowns, would be used to treat his condition. This is usually a more conservative option since very little tooth structure is actually removed.  Additionally, it is usually more aesthetically pleasing.

In the preparation, a 0.5 mm reduction is performed on the facial surface while a 1-1.5 mm reduction is performed on the incisal surface. The finishing margin is usually a 0.5 mm supragingival chamfer. The preparation is done under local anesthetic infiltration. It is recommended a matrix is fabricated prior to the preparation which will be used for making the temporary veneers.

Final impressions were taken using impregum and a counter model impression taken in alginate. This was sent to the laboratory for the veneer fabrication. The temporary veneers were made with Luxatemp using the impression matrix originally taken. Following their return from the dental lab, the veneers were ready to be cemented.

The temporary veneers were removed from the preparations and the teeth were polished using pumice without fluoride and rinsed with water. The veneers were tried-in to evaluate their fit. They were etched using hydrofluoric acid for about a minute and silane coupling agent painted on them and allowed to air dry. The prepared teeth were also etched using phosphoric acid for 15-20 seconds, rinsed with water and air dried. Bonding agent was applied to the etched surface and cured. The veneers were then cemented permanently and excess cement was removed from the margins and finished using finishing strips and finishing burs. The patient’s occlusion was checked and slight adjustments were made. Post-operative instructions were provided and the patient was delighted with the result.

Maintenance of good oral hygiene is of great value for any restoration.
This would involve frequent flossing and brushing using the correct technique.  The patient should therefore be aware of this in order to have a long lasting restoration.

Miscellaneous
One very challenging aspect of using composite restorative material in restoring class II lesions is establishing contact with this material. This elective program has helped me learn techniques to avoid this problem. This will be discussed as follows:

• • The preparation of a class II lesion is made
  • The matrix band is put in place and secured
  • The tooth is pre-wedged to cause slight separation between teeth
  • Cavity is etched with phosphoric acid, rinsed and dried
  • A bonding agent is applied to cavity walls and cured for 15 seconds
  • Matrix band is slightly loosened and burnished against the adjacent tooth.
  • Bisfil (an unfilled resin) is injected into the proximal box and left uncured
  • Composite beads (small round composites that have been pre-cured) are placed into the proximal box with the uncured bisfil
  • Using a plastic instrument, the composite bead is pushed into the proximal box and against the adjacent tooth.  This is then cured using the curing light.
  • Then, the remainder of the preparation is filled incrementally, curing after each increment. The final restoration is adjusted and polished

Such restorations restored in this manner usually have a very tight contact. This helps prevent food packing into the interproximal space that may give rise to recurrent decay.

Porcelain Veneers in Cosmetic Dentistry are typically only about 1 millimeter thick (the thickness of several pieces of paper).  Therefore, minimal tooth structure is removed for their placement.  The results can be quite dramatic.

39 year old female patient presented to the dental office for continued cosmetic treatment. Previously maxillary porcelain tooth veneers were cemented. Patient presented for cementation of mandibular anterior veneers. Observed cementation of 10 mandibular anterior veneers [teeth #20-29] with Nexus clear cement. Nitrous administered 75% oxygen. Several carpules of carbocaine and lidocaine given. Temporaries removed. Pumiced teeth to remove pellicle layer. Etched veneers and teeth. Bonding agent placed on teeth and veneers. Nexus clear cement placed on teeth. All 10 veneers placed in continuum. Excess cement removed and veneers shaped. Occlusion adjusted. Pt was satisfied.

 N.D., New York University College of Dentistry, Observation