We are living in the golden age of dentistry. New

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1 C O S M E T I C D E N T I S T R Y Upgrading Dr Elliot Mechanic, BSc, DDS We are living in the golden age of dentistry. New techniques and improved technology have brought more predictable, easier to use, and superior results to all facets of dentistry. looking teeth and dentists began learning how to properly diagnose, treatment plan and communicate exactly what they required to their dental labs and specialists. Dentist s are now thinking outside the box, working intensely, committed to pushing the barriers of esthetic dentistry to new heights. By assuming that we don t know everything we manage to learn more. Reality television with programming like Extreme Makeover and The Swan have brought esthetic dentistry and how it can dramatically change people s lives to the forefront of public awareness. The media and public are hungry to learn and see the results of dentistry. When I attended dental school in the 1970 s few people spoke of cosmetic dentistry. Today we realize that the appearance of a person s teeth can dramatically influence how he/she is perceived by others. By altering tooth shape, size, length, and color we can influence perception of age, personality, and projected self-confidence. In my early years of dental practice we simply took an impression, sent it off to a dental lab technician and hoped for the best result the technician could come up with. When we referred a patient to a specialist we left the treatment up to the specialist and accepted the result as being all that was possible. However by the 1980s, not everyone was content with store bought teeth. They actually wanted nice natural FIGURE 1 Test issue of Clin D Oeil. In 1982, I was treating patients who were asking; Can you make my teeth look better? Can you make them look straighter? Can you change their color? Fortunately, dentists around the world were being asked the same questions by their own patients who wanted beautiful teeth. New materials and techniques appeared. This article follows the history of the first set of porcelain veneers I placed on a 23-year-old aspiring actress in We have now known each other for 22 years and in 2003, I had the experience of upgrading these veneers on this now 43-year-old to try and accelerate her midlife acting career. THE CONCEPT OF UPGRADING Times change and so does technology, pushing our skills to even greater heights. Advances in cosmetic dentistry enable us to upgrade older restorations that although over the years may have served us well, can now be made to appear more life like. Patients often ask us; How long will the restoration last? Should we in turn be asking them; How long will you last? In dentistry our work is deemed to last indefinitely through the abuse of diet, variations in oral hygiene, destructive oral forces and by numerous other ways in which we mutilate our teeth. This has caused dentists to become inse- 12 oralhealth April 2005

2 C O S M E T I C cure perfectionists often dealing with unreasonable expectations. We know that our new computer, new clothing, new car is a limited time purchase and that we will one day wish to upgrade it. We don t expect these things to last forever. Why should dentistry be different? Dentistry is one of the most rapidly changing medical sciences in which new porcelain technologies can now mimic natural dentition. By bonding a longer porcelain veneer to the original tooth we can add length to short, worn teeth, making them look younger and stronger. Veneers can cover stained, discoloured teeth, be applied to whiten and brighten the entire smile and be fabricated to exactly match the existing teeth. We must assume that tomorrow s dental technology will be better than today s. D E N T I S T R Y more was heard of this technique for a decade as the interest of the dental profession was focused on improving the composite resin materials used for direct application to the etched enamel.3 PORCELAIN VENEERS The use of veneers in dentistry is not a new concept. Dr. Charles Pincus in 1923 used veneers to alter the tooth shape of various Hollywood movie stars creating illusions for motion pictures.1 He veneered Shirley Temple s baby teeth to make her appear older and created glamorous smiles for stars with less than perfect dentitions. He fabricated these veneers by baking a thin layer of porcelain onto platinum foil and applied them to the actors teeth with a denture adhesive powder. These veneers were not permanently bonded. The stars could not eat with their veneers and wore them for performing only. This is how the term Hollywood Smile came to be known. The roots of modern concepts of veneering began over half a century ago. In 1955, Bounocore spoke of bonding.2 In the 1960s Bowen and others developed composite resin restorations. In 1972, Dr. Alain Rochette published a paper describing acid etch bonding of porcelain to enamel. However nothing FIGURE 2 FIGURES 3A,B,C,D April 2005 oralhealth 13

3 C O S M E T I C D E N T I S T R Y To the best of my knowledge, the concept of porcelain veneers reappeared in 1982 as an offshoot of research in creating a bond between the Maryland bridge and tooth structure using composite resins. Dr. R. Van Thomson restated that if metal can be bonded, why not porcelain? The work of Dr. Rochette was resurrected! Myron s labs of St. Joseph, MO, were the first dental lab to teach and license porcelain veneers which they named Chameleon. 4 There was little initial marketing done and one heard of Chameleon veneers only in trade magazines. By 1984 there were approximately 200 Chameleon licensed dental labs each paying a royalty to Myron s. One of the first dental labs trained to fabricate Chameleon veneers was Shaw Labs of Toronto, Canada. The Chameleon veneer was developed using Halmatica porcelain, a feldspathic porcelain used for porcelain fused to metal crowns. This porcelain was very strong, translucent, and had good adhesion to the underlying tooth. The porcelain was fired on refractory dies developed by modifying FIGURE 4 Fashion model: lateral incisors slightly shorter than centrals, square/round incisal edges, moderate incisal embrasures, rounded canines gives a slightly worn, non-dominant look, a neutral, natural, non-threatening look. very safe, likeable, natural looking dentition, slight irregularities can add a bit of excitement. Whipmix A-63 (Whip Mix Corporation, Louisville, KY) investment. Chameleon veneers required multiple firings. The first created a dried out cracked look created by the expansion of the porcelain. This was the washbake and had a dry riverbed effect. A second firing then sealed the cracks. The porcelain was then built out to full contour using more Halmatica porcelain. Porcelain veneers presented dentistry with several advantages. They were esthetic, color stable, strong, biocompatible, did not absorb fluid, and presented the possibility of longevity in a dental restoration. The disadvantages of porcelain veneers is that they required multiple appointments, were difficult to repair, were technique sensitive, and the color was difficult to modify once the veneer was placed. They required tooth preparation and were more costly than resin veneering. The learning curve to produce Chameleon veneers was easy as the lab did most of the work. The success rate was very high and the veneers caused very little tissue irritation. The veneers were very strong and had a failure rate of only 2-3 percent. The veneers probably were strong because very little tooth reduction was done and they were 100 percent bonded to enamel. Today we often reduce the tooth significantly, bonding to dentin. MY FIRST VENEERS In 1982, I was treating a number of musicians. A drummer in a popular rock band brought his girlfriend to see me. She was a young actress who had the looks, desire, and talent yet something was missing. Her teeth! Not that anything was fundamentally wrong with them but appearance wise they were small and crooked as they never had the benefit of orthodontic treatment. Her face was used on the test issue of a then new fashion magazine Clin D oeil FIGURE 5A Teeth as they appear Computer-generated imaging. FIGURE 5B Initial Waxup no increase to length incisally. 14 oralhealth April 2005

4 C O S M E T I C D E N T I S T R Y FIGURE 7 Modified wax-up altered dimension and length. barely prepared and techniques and materials did not exist to my knowledge for veneer temporization. When the six veneers returned from the lab the teeth were etched and the veneers placed using a paste created by diluting composite resin with bonding agent. The Chameleon veneers gave a miraculous result and our patient developed new-found confidence. Call it luck (or was it the teeth?) but her film and television career started to bloom. FIGURES 6A,B Initial Luxatemp provisions. (Fig. 1) but was not chosen because of her teeth. Other publicity photos required that her teeth be improved through airbrushing. I had just learned of Myron s Chameleon veneers from my technician at Shaw labs as they were looking for a patient to test them on. I had the perfect one! Once presented with the possibility of quickly improving the appearance of her teeth she eagerly consented to treatment. The initial teeth to be veneered (Fig. 2) were of uneven shape with the central and lateral incisors larger then the corresponding one on the opposite side. The edges of the teeth were uneven and the teeth were discolored. We slightly modified the teeth with shallow preparations into enamel. Although it was claimed by Myron s that tooth preparation was not necessary it only made sense to do so as the veneer would assume some thickness. Tooth reduction would be beneficial to compensate for the thickness. No temporization was done as the teeth were The next 20 years were dentally uneventful aside from routine regular maintenance and the restoration of other teeth as required. My dental practice had developed to the point where I was placing porcelain veneers on a daily basis. However these Chameleon veneers were special to me. They were my first! THE UPGRADE In 2002, we began to discuss the possibility of upgrading her smile for a fresher and younger look. Although the nearly twenty-year-old veneers still appeared to be fine, much progress in esthetic dentistry had taken place over the years. Techniques for altering gum levels and the ability to widen and expand a smile allowed dentists to enhance facial appearances.5,6 Figure 3A illustrates the twenty-year-old veneers in the now forty-four year old patient. The teeth appeared to be fine and the gingival tissue totally healthy (Figs. 3B,C,D). However, the porcelain appeared to be tired looking and not as lifelike as today s porcelains. The teeth were rounded and soft looking resulting in a non threatening dentition, very different from the sharper more exciting tooth shapes that are popular today. April 2005 oralhealth 17

5 C O S M E T I C D E N T I S T R Y FIGURES 8A & B FIGURES 9A & B We can make teeth appear to be more youthful by increasing their length to width ratio and making the canines more pointed for a more active, fresher look. We progressively make the incisal embrasures larger and design our lateral incisors to be slightly irregular to add a bit of character7 (Fig. 4). Our aim was to slightly raise the gingiva apically and to create a fuller toothshape with square edges. A diode laser was used to alter the tissue level, the teeth were reprepared and provisionals were created using Luxatemp Fluorescence (Zenith, DMG, Englewood, NJ) {Fig 6A, 6B}. One of the most valuable tools we have today is computer generated imaging which gives our patient the ability to preview their new smile before actually beginning the procedure.8 This gives them the ability to suggest any changes they desire. Figure 5 illustrates the new look we wish to achieve. It can be easily added to and modified using Luxaflow Fluorescence (Zenith, DMG, Englewood, NJ) or any microfill composite and then glazed with Luxaglaze (Zenith, DMG, Englewood, NJ) which not only gives it a shine but adds to it s strength. A diagnostic waxup and putty template was created in order to fabricate our provisional (Fig. 5B). The patient initially wished to lengthen the teeth gingivally but not incisally. The 20-year-old porcelain veneers were removed by cutting through them with a diamond. It is amazing how strong the veneers actually are. The enamel bond was rock solid after 20 years and there was absolutely no redecay present. 18 oralhealth April 2005 The ability to simply and quickly create and modify provisional restorations has opened the door to predictable esthetic dental changes. As opposed to other plastic surgeries, dental temporization can give the patient a chance to preview their new smile, live with it for a while, show it to their family and friends and alter it as necessary. A well-made temporary is the key to an esthetic

6 C O S M E T I C D E N T I S T R Y restoration! It provides the lab with a blueprint for tooth length, width, thickness, arch position, midline cant, and occlusion. Once the patient has approved the temporary, the lab using silicone templates replicates it in porcelain. Although the new toothform created by the temporaries was a definite improvement over the original Chameleon veneers still something was missing. The teeth still appeared short and box like and the smile still appeared to be gummy. It is desirable for the lip to align with the gingival margins of the central incisors to expose 1 to 2mm of gingival. 9 It was decided that further modification to the gumline was necessary and that the teeth be lengthened incisally as well. A new waxup was created (Fig. 7). As we were not as yet violating the biological width we performed a further 1mm gingivectomy with our diode laser and altered the tooth preparation accordingly. 10 A new Luxatemp Fluorescence provisional (Zenith, DMG, Englewood, NJ) was fabricated. This appeared to have the look that we desired. (Figs. 8A & B) Final impressions were taken with Honigum (Zenith, DMG, Englewood, NJ). Our dental lab was sent the final impressions, a model and photos of the temporary, a face bow transfer, stick bite, stump color and specifications for the shade and detailing we desired in the final restoration. To reproduce natural dentition with ceramics, the material used should mimic the same optical properties as natural teeth. IPS Empress (Ivoclar Vivadent, Amherst, NY) was chosen primarily because it has a proven track record and can be extremely esthetic, as it can be cut back and layered with various shades of porcelain. 11 Empress (Ivoclar Vivadent, Amherst, NY), a leucite reinforced glass ceramic, tends to allow the natural tooth colour from within to blend seamlessly with the restoration as it has excellent transluscency. Empress (Ivoclar Vivadent, Amherst, NY) has high flexural strength, excellent fit and provides low wear to the opposing dentition The IPS Empress (Ivoclar Vivadent, Amherst, NY) porcelain veneers were fabricated using a multilayering technique. A TC1 ingot was chosen as the basic shade, as the patient s teeth were in the Vita A range. Some neutral and clear porcelain was fired around the margins to make them appear to be invisible. The incisal edges were built with super opal porcelain with transparent blue added to the mesial and distal corners. When the veneers were tried in the patient s mouth it was immediately clear that we had achieved what we set out to do. We had created younger, fuller, brighter looking teeth that appeared to blend naturally into the patient s face. The central incisors appeared fuller and perfectly symmetric. The lateral incisors shorter and slightly different from each other, giving the smile character. The incisal edges were square on the mesial corner and rounded on the distal. The incisal embrasures were only moderately open creating a Hollywood Smile. The teeth were treated with Allbond II (Bisco Dental Products; Scaumberg, IL) and the veneers luted into place with Variolink clear (Ivoclar Vivadent, Amherst New York) (Figs. 9A & B). CONCLUSION Times change, as does technology. People change too! The restoration that at one time appeared to be the ultimate may today look dated and tired. It is both fascinating and educational to look back at the work we have provided to our patients and be able to evaluate how it can be improved and and how we have learned and improved over the years. The restorations that we are placing today appear to be lifelike and restore dentition as nature intended it. How can today s restorations possibly be improved upon? One thing is certain... they will! OH Dr. Elliot Mechanic practices esthetic dentistry in Montreal, Canada. He received his Bachelor of Science (1975) and Doctor of Dental Surgery (1979) degrees from McGill University. Dr Mechanic is a contributing consultant on Cosmetic Dentistry to Oral Health Journal. Dr. Mechanic wishes to thank his friend and Partner in Smiles Camille Halaby (CRH Oral Design, Montreal, Quebec) for his awesome creative lab work. Oral Health welcomes this original article. REFERENCES 1. George Freedman and Gerald McLaughlin: Color Atlas of Porcelain Veneers, Ishiyaku EuroAmerica Inc. 2. Bounocore, M.A: A simple method of increasing the adhesion of acrylic fillings to enamel surfaces. J Dent Res, 34: , Rochette, A.L: A ceramic restoration bonded by etched enamel and resin for fractured incisors. J Prosth Dent, 33(3): March, Conversation with Tim Sigler, president of Myron s International, Kansas City, MO. 5. Tjan AH, Miller GD: Some Esthetic Factors in a Smile, Journal of Prosthetic Dentistry, (1984), pp 51: Chiche G, Kokich V, Caudill R: Diagnosis and Treatment planning of Esthetic problems, In Chiche G, Pinault A, eds. Esthetics of anterior fixed prostodontics. Chicago, Quintessence, pp 33-52, Mechanic E.: Smile Design, A patient s guide, EC Dental Solutions 8. Mechanic E.: Creative uses of dental imaging JACD, Spring 2004, Vol. 20, pp Kokich V.: Esthetics: The Orthodontic-Periodontic Restorative Connection 10. Kois, JC: Altering Gingival Levels: The Restorative Connection Part I: Biologic Variables, Journal of Esthetic Dentistry, 1994, 6(1): Christensen, G: Ceramic Veneers: State of the Art, JADA, Vol. 130, July, 1999, pp Imai Y, Suzuki S, Fukushima S: Enamel wear of modified porcelains. Am J Dent 2000; 13: Rumi, Ch. Lehner, A Petschelt and M. I Pelka: Wear and Antagonist Wear of Ceramic Materials, Policlinic for Operative Dentistry, University of Erlangen, Germany, Asbtract 3178, Journal of Dental Research 2000, Vol 79, pp Frankie Sulaiman, John Chai, Lee M. Jameson, Wayne T. Wozniak: A Comparison of the marginal Fit of In-Ceram, IPS Empress and Procera Crowns. The International Journal of Prosthodontics, Vol 10, Number 5, 1997, pp April 2005 oralhealth 21