A Step-by-Step Approach to Aesthetic Excellence: Every Detail Matters

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Dr. Adamo Notarantonio is a highly accomplished dentist with an extensive educational background. He graduated from the State University of New York at Stony Brook School of Dental Medicine in 2002, where he earned honors in both removable and fixed prosthodontics.

His commitment to excellence in cosmetic dentistry led to his accreditation by the American Academy of Cosmetic Dentistry in 2011, and subsequently, he achieved the prestigious Fellowship status in the AACD, becoming the 80th person globally to attain this distinction. Dr. Adamo’s dedication to the field was further recognized when he was invited to serve as a consultant and examiner for the Accreditation and Fellowship processes within the Academy.

In 2016, he was honored with the Rising Star Award from the AACD, highlighting his exceptional contributions to cosmetic dentistry. Dr. Adamo’s active involvement in the field is demonstrated by his re-election to the American Board of Cosmetic Dentistry® and his role as the immediate past chairman of the ABCD. Additionally, he was recently appointed as the Accreditation Chairman of the American Academy of Cosmetic Dentistry.

Dr. Adamo’s pursuit of advanced dental knowledge includes completing programs at the Kois Center under the guidance of Dr. John Kois and undertaking The Dawson Academy Core Curriculum. He has also earned fellowship status in the International Congress of Oral Implantologists. His expertise and research contributions have been acknowledged through publications in multiple dental journals, and he has been a sought-after lecturer, both nationally and internationally, covering topics such as CAD/CAM dentistry, implant dentistry, cosmetic dentistry, composite dentistry, and dental photography.

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Abstract

Social media has flooded the internet with beautiful before and after’s of porcelain restorations. The problem with that, however, is each step taken to achieve that is often overlooked. What some may not understand is that precision in every step is critical in achieving long term success. From prep design and material choice, to choosing the correct bonding protocol and cements, no step should be overlooked or deemed less important. This case will focus on a full smile design with proper isolation and cementation protocols.

In a world where everything is dictated by speed, the importance of precision tends to be left by the waste side. In today’s world, technology allows us to do many things at a pace that in the past seemed impossible. This mindset has carried itself over into clinical dentistry and in some instances can be a positive, but in others, may prove to be a severe problem. In the authors opinion, one of the areas this can be problematic is when cementing porcelain restorations.

To ensure the success of these restorations, proper isolation, chemical treatment of the restorations and dental tissues, and proper bonding protocols and techniques are crucial to ensure long term success of this porcelain restorations. No step should be overlooked, and every step should be carried out with the utmost precision and accuracy.

Case 

This year old dentist presented to my office for a cosmetic consult. She was unhappy with the shapes and colour of her existing teeth, as well as the multiple old resin restorations evident on her teeth (Figures 1 & 2). After a thorough diagnosis and treatment plan in the areas of periodontal, biomechanical, functional and dentofacial, a decision was made to move forward with ten porcelain restorations. 

The first appointment consisted of a full diagnostic photo series, digital scans (iTero) and a face bow transfer (Kois Dentofacial Analyzer, Panodent, panodent.

The scans, photos and specific instructions for the wax up were sent to the ceramist in order to fabricate a diagnostic wax up. A detailed conversation with the patient revealed the exact parameters she was looking for, and that was communicated through photographs to the ceramist (Figure 3). A diagnostic wax up was returned from the laboratory (Figure 4). A silicone matrix was fabricated  from the wax up in order to create  the provisional restorations. Following the preparations and necessary impressions, a provisional was fabricated via the existing wax up (Instatemp Max, Sterngold, www.sterngold.com). Evaluation of the provisional does not happen until twenty-four to forty-eight hours later due to the fact that the patient is usually numb at the time of insertion.

The patient returned 24 hours later for photographs and a thorough evaluation with any necessary adjustments. Once the provisionals are improved (Figure 5), photographs and an impression are sent to the ceramist so he can replicate the shape, size and position exactly. 

When the restorations are returned, they are tried on the models and evaluated for any changes prior to the insert appointment (Figure 6). The laboratory is given specific instructions to not treat the intaglio surfaces prior to the returning them. These particular restorations were made from lithium disilicate porcelain. When received, they were treated with Porcelain Etchant 9.5% Hydrofluoric Acid (Bisco) for 20 seconds (Figure 7, rinsed and silanated with two part silane (Bisco). On the day of insertion, the patient was anaesthesized and the provisionals were removed. Each preparation was air abraded with a Prep start (Danville) using 50 micron aluminum oxide particles. The restorations were tried in for fit and aesthetics. Upon removal, the restorations were cleaned with Uni-etch, 32% Phosphoric acid etchant with Benzalkonium chloride (Bisco), rinsed, dried and re-silanated.

In the author’s opinion, isolation is critical for ideal bonding to be achieved. That being said, the authors isolation protocol of choice is individual tooth isolation utilising a heavy gauge latex rubber dam (Nictone). Primary clamps were placed on the second molars and the teeth were isolated individually from the upper right second molar to the upper right second molar. Veneers were placed two at a time starting with the central incisors.

In order to ensure complete isolation and no impeding of seating from the rubber dam, accessory clamps (B4 Brinkner, Coltene Whaledent) were utilised. A final try in prior to cementation is always completed following isolation (Figure 8). The tooth surfaces were etched with with Uni-etch, 32% Phosphoric acid etchant with Benzalkonium chloride (Bisco) for fifteen seconds. The preparations were thoroughly rinsed and blot dried with a cotton roll to avoid dessication.

Two separate coats of All-Bond Universal (Bisco, www.bisco.com) , scrubbing the preparations for 10-15 seconds between each 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 Choice 2 translucent veneer cement (Bisco) (figure 9) and seated (Figure 10).

Each veneer was tack cured for 3 seconds, excess cement was removed and a final cure of forty seconds per surface was completed. The accessory clamps were removed and moved to the adjacent two teeth (figure 11 & 12) and the same protocol was followed for all remaining teeth. Following removal of the rubber dam, excess cement was evaluated under a 3-d microscope (Seiler Promise Vision 3D). Occlusion was adjusted and the patient was dismissed. The patient returned in one month for post operative photographs (figure 13 & 14).

Conclusion

Delivering beautiful aesthetic dentistry is not a two step, before and after process. Each step 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 procedures and cements.