When the restorations were returned, they were tried on the models and evaluated for any modifications prior to the in-sertion appointment (Figures 6). The laboratory was given specific instructions to not treat the intaglio surfaces prior to returning the restorations. These particular restorations were made from lithium-disilicate porcelain. When received, they were treated with Porcelain Etchant 9.5% Hydrofluoric Acid (BISCO, bisco. com) (Figure 7), rinsed, and silanated with Bis-Silane (BISCO) a two-part silane.
6. Final restorations on models in three different views.
7. 9.5% hydrofluoric acid being applied to intaglio surface of veneer.
On the day of insertion, the patient was anesthetized and the provisionals were removed. Each preparation was air-abraded with an air abrasion system (PrepStart™, Zest Dental Solutions, zestdent.com) using 50-micron aluminum oxide particles. The restorations were tried in for fit and esthetics. Upon remov-al, the restorations were cleaned with Uni-Etch® (BISCO) 32% phosphoric acid etchant with benzalkonium chloride (BAC), rinsed, dried, and re-silanated with Bis-Silane (BISCO, bisco. com).
The author considers isolation to be a critical step in achiev-ing ideal bonding. His isolation protocol of choice is individu-al tooth isolation utilizing heavy-gauge latex rubber dam (Nic Tone, nic-tone.ro). Primary clamps were placed on the second molars, and the teeth were isolated individually from the upper right second molar to the upper left second molar. Veneers were placed two at a time starting with the central incisors. To ensure complete isolation and that there would be no impeding of seating from the rubber dam, accessory clamps (B4 Brinker, Coltene Whaledent, coltene.com) were utilized. As is the author’s custom, a final try-in prior to ce-mentation was completed following isolation (Figure 8).
8. Dry try-in prior to cementation after isolation with rubber dam and B4 accessory clamps.
The tooth surfaces were etched with Uni-Etch 32% phosphor-ic acid etchant with BAC for 15 seconds. The preparations were thoroughly rinsed and blot-dried with a cotton roll to avoid desiccation. Two separate coats of All-Bond Universal® (BISCO) were applied, scrubbing the preparations for 10 to 15 seconds between each coat and not light-curing between each coat. Excess solvent was evaporated with hot air by air-drying for 20 seconds followed by a 10-second light-cure.
The veneer was lined with Porcelain Bonding Resin (BISCO), a HEMA-free, unfilled resin that acts as a wetting agent. The veneer was filled with translucent veneer cement (Choice™ 2, BISCO) (Figure 8) and seated (Figure 10). Each veneer was tack-cured for 3 seconds, excess cement was removed, and a final cure of 40 seconds per surface was completed. The accessory clamps were removed and moved to the adjacent two teeth (Figures 11-12), and the same protocol was fol-lowed for all remaining teeth.
9. Veneer being loaded with veneer cement.
10. Veneers Nos. 8 and 9 seated following 3-second tack-cure.
11. Teeth Nos. 6 and 7 isolated with accessory clamps in preparation for veneer insert.
12. Veneers Nos. 6 and 7 following cementation protocol.
Following removal of the rubber dam, excess cement was evaluated under a 3D dental microscope (PromiseVision 3D, Seiler, seilermicro.com). Occlusion was adjusted and the patient was dismissed. The patient returned in 1 month for postoperative follow-up and photographs, which revealed a highly esthetic, successful outcome (Figures 15-16).
13. Full smile, postoperative. Patient was exceedingly pleased with her rejuvenated smile and the esthetic outcome achieved with 10 maxillary lithium-disilicate porcelain veneer restorations.
14. Postoperative upper arch, retracted view with black contraster.
Delivering beautiful esthetic dentistry is not a two-step, “be-fore and after” process. Multiple steps along the way must be delivered with precision and accuracy to ensure long-term success. It is important to not overlook the “little things,” such as bonding materials and protocols, as well as luting proce-dures and cements.
The author thanks the ceramist on this case, Julian Cardona, CTG, of Guayaquil, Ecuador.
ABOUT THE AUTHOR
Adamo E. Notarantonio, DDS
Clinical Instructor, Honors Aesthetic Program, New York Univer-sity College of Dentistry, New York, New York; Private Practice, Huntington, New York; Fellow, International Congress of Oral Implantologists; Fellow, American Academy of Cosmetic Dentistry