Minimally invasive porcelain veneers - BACD...candidate for elective dental treatment. (see Figures...

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JCD international journal of cosmetic dentistry vol.7 no.1 summer 2018 33 Diagnosis and treatment plan On the patient’s first visit, a preliminary examination was carried out. Radiographs and photographs were taken for treatment planning purposes. No caries was detected and there were no restorations present indicating a low risk for future caries development. Oral hygiene was of a very good standard with no plaque or calculus deposits present. She is a regular attendee to the dentist and hygienist. TMJ and muscle examination were clear. 1 She was motivated and ready to make a change. As a whole, the patient presented as a suitable candidate for elective dental treatment. (see Figures 1-12) Aesthetic diagnosis: Smile Design Using the smile analysis described by Orr the following issues were identified: 2,3 Introduction and main complaints In cosmetic dentistry, we seemed to have fallen out of love with porcelain veneers. The trends in recent years seem to be short term orthodontics and composite bonding. This case report highlights a beautiful indication for porcelain veneers using materials and techniques du jour with a good dollop of minimal invasiveness at the heart of it. The patient was a 30 year old who presented complaining of gaps between her upper and lower front teeth. Her main priority was the upper teeth. Minimally invasive porcelain veneers Dr Joe Bansal BDS, RDT Figure 1

Transcript of Minimally invasive porcelain veneers - BACD...candidate for elective dental treatment. (see Figures...

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Diagnosis and

treatment plan

On the patient’s first visit, apreliminary examination was carriedout. Radiographs and photographswere taken for treatment planningpurposes. No caries was detectedand there were no restorationspresent indicating a low risk forfuture caries development. Oralhygiene was of a very good standardwith no plaque or calculus depositspresent. She is a regular attendee tothe dentist and hygienist. TMJ andmuscle examination were clear.1

She was motivated and ready tomake a change. As a whole, thepatient presented as a suitablecandidate for elective dentaltreatment. (see Figures 1-12)

Aesthetic diagnosis:

Smile Design

Using the smile analysis describedby Orr the following issues wereidentified:2,3

Introduction

and main complaints

In cosmetic dentistry, we seemed tohave fallen out of love with porcelainveneers. The trends in recent yearsseem to be short term orthodonticsand composite bonding. This casereport highlights a beautifulindication for porcelain veneers

using materials and techniques dujour with a good dollop of minimalinvasiveness at the heart of it. Thepatient was a 30 year old whopresented complaining of gapsbetween her upper and lower frontteeth. Her main priority was theupper teeth.

Minimally invasive porcelain veneers

Dr Joe Bansal BDS, RDT

Figure 1

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Figure 2 Figure 3

Figure 4 Figure 5

Figure 6 Figure 7

Figure 8 Figure 9

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4. Six lower veneers to close thediastemas

5. Orthodontic treatment to evenlyredistribute the spaces to allowthe placement of minimallyprepared veneers on the lowerfront six teeth.

Treatment option discussion

The patient was made aware of therelative invasiveness of thetreatment options presented and ofthe possible maintenance andlongevity associated with the variousoptions. Following this, the patientchose option 2 for the upper arch.She liked the idea of having fullerand wider teeth against the idea ofaligned narrow teeth that theorthodontic option would give her.

For the lower arch, due to financialreasons, she chose option 1 for thetime being but indicated that shewould like to proceed with option 5when funds allowed.

Her treatment was based upon theAPT (Aesthetic Pre-EvaluativeTemporaries) technique4,5 whichbases the preparation design withrespect to the final tooth positionand shape. This ensures an evenand equal thickness of preparationmeaning a uniform thickness ofmaterial. More importantly, itensures a minimally invasiveapproach with a preparationpredominantly in enamel. The mostrecent study has shown that in longterm studies of veneers preparedusing the APT technique, a higherlong term success rate is seen whenthe preparation is in enamel, etched

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• Normal to low lip line• Smile line in following with

lower lip• Incisal edge position at correct

level• Dental midline co-incident with

facial midline• Height to Width proportion of the

upper central incisors are 0.68(Narrow with respect to ideal of0.7 to 0.8) and the upper lateralincisors are 0.59

• Multiple diastemas present inbetween the upper front 6 teeth

• Multiple diastemas present inbetween the lower front 6 teeth

• Buccal corridors well developed• Gingival pattern harmonious• Tooth shade Vita A1.

Treatment plan

and consent

Miss RW presented with a well-maintained healthy dentition. Therewere no functional issues presentwhich boded well for elective dentaltreatment. To aid with the treatment

planning process, I discussed thecase with a dental technician Iregularly use to gain a secondopinion from a technical point ofview. There were a few possibleways to tackle this case. Theoptions we presented to the patient were:

Upper arch

1. Orthodontic treatment toredistribute the spaces distally inthe arch

2. Six minimally prepared veneers tothe upper front teeth to close thediastemas

3. Composite bonding to the upperfront six teeth to close thediastemas.

Lower arch

1. No treatment as primary concernwas upper arch

2. Orthodontic treatment toredistribute the spaces distally inthe arch

3. Composite bonding to the lowerfront six teeth to close thediastemas

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Figure 10 Figure 11

Figure 12

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to enamel and subsequently bondedto enamel.6 The prerequisite of thediagnostic wax up was to have anadditive approach.

During the time between the initialand second consultations, the patienthad begun tooth whitening with herown dentist. When she presented tostart treatment, her shades wereBL3/BL4 using an Ivoclar ChromoscopShade Guide and B1/B2 using theVita Shade Guide.

Clinical stages

Records appointment

Silicone impressions were takenusing a two-stage technique7

together with a facebow transfer tocreate baseline records and tofacilitate a diagnostic wax up. ADenar facebow and transfer jig wereused in conjunction with apolyvinylsiloxane registration paste(Doric Bite, Schottlander).

The standard set of BACDAccreditation photographs weretaken using a Canon 5D Digital SLRusing a Canon 100mm macro lensand a Canon MR14EX ring flash. Therecords (impressions, facebowtransfer, bite registrations andphotographs) and treatmentprescription were sent to thelaboratory for processing.

The prescription was for an additivediagnostic wax up. As the toothproportions are narrow (0.59 to0.68), we were able to widen theteeth without changing the lengthwhilst creating ideal proportions.Miss RW exhibits feminine extra oralfeatures such as voluminous lips

and curves. By widening the teeth,round line angles, open curvedembrasures would create a smile infitting with the patient’s features.8

Another issue discussed with thetechnician was of how many teeth torestore? The diastemas were inbetween the front six teeth. On onehand, taking into account thepatient’s age and unrestored state ofher teeth, we would be thinking on thebasis of being minimally invasive. Onthe other hand, the notion of treatingsix anterior teeth is not without itsown aesthetic complications ofunderdeveloped buccal corridors.9 Wedecided that as the upper front sixteeth were proportionately smallalready, we would initially create awax up on these teeth. Depending onhow they looked via a direct wax uptransfer would dictate whether or notwe would plan to include the firstpremolars in the treatment plan. Asthe palatal surfaces and lower incisorswere to be untouched during thetreatment process, this would put thiscase in the simple category.10 Eventhough no occlusal changes were tobe made, a facebow was used tominimise the risk of any midline orocclusal plane cants on the wax up.

Review appointment

Once the wax up was received, itwas re-evaluated prior to the reviewappointment. Using the same criteriaas our initial diagnosis, the wax upwas found to be highly satisfactoryand no changes were proposed. Thepatient was invited to a reviewappointment for her to assess thewax up. These were shown to her ona Denar articulator and met with herapproval.

A putty stent was used to transferthe wax up intraorally using atemporary crown and bridge material(Quick Temp, Schottlander). Thiswas done without using anyadhesive, to ensure easy removal.The intraoral mock up was assessedfor shape, length, position, functionand phonetics. No amendmentswere made. The patient was veryhappy with the proposed changes.The number of teeth treatedappeared to look harmonious withthe rest of her smile and extra oralfeatures. The upper front six teethdid not look overwhelming oroverpower her buccal corridor. Thepatient was happy with the proposalof treating just these teeth. Theheight to width ratio of the centralincisors was now 0.74 and thelaterals were now 0.65. The organicchange in ratio had given a fullerappearance to her smile. Carefulremoval of the intraoral mock upallowed us to appraise the relativethickness of the material. From this,I was able to assess the relationshipbetween the preparation and finaltooth shape and contour.

Prior to the preparationappointment, the case wasdiscussed with the technician. Themain points were a review of theintraoral mock up and thickness ofmaterial/ preparation. We discussedthe material choice for the final caseand decided upon IPS E.Max(Ivoclar). This was chosen becauseof the technician’s skill set andpredictability in the final result. Asthe colour of her teeth was towardsthe high value end already, wewould use a high translucency ingotto allow the natural colour of theunderlying tooth to show through.11

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As per the technique described asthe APT Technique,4,5 the wax up wastransferred intraorally using atemporary crown and bridgematerial. I chose Quick Temp ShadeA3 (Schottlander) to allow contrastand visibility between the tooth andmaterial. Using a pencil, theintraoral mock up was marked inthree planes: cervical, mid-body andincisal. Using a 0.5 mm Depth CutBur (M270, Schottlander), cuts weremade into the intraoral mock up overthe pencil lines. The depth cuts wereassessed for thickness and area of

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Preparation appointment

Local anaesthetic (SeptanestArticaine 4% + 1:200,000Adrenaline, Septadont) wasadministered via buccal infiltrationusing The Wand STA (DPS). AnOptragate (Ivoclar) dam was placedfor soft tissue retraction.

A preoperative tooth shade (Vita B1,BL3/BL4 Ivoclar Chromoscop) wastaken prior to preparation using aTruShade (Optident). As thepreparations were anticipated to bein enamel, a pre-operative shade

would eliminate any false readingsfollowing desiccation related to toothisolation. A preoperative impressionof the upper arch was taken usingDoric Easy First (Schottlander).Dental loupes were used for thetreatment (4x Orascoptic).

Preparation guides were used toassess and plan the preparation. Asthis was an additive case, theamount of preparation required wasminimal and in the enamel layer. Noaesthetic pre re-contouring wasnecessary4. A facial and palatalguide was used to assess this.

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Figure 13 Figure 14

Figure 15 Figure 16

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Figure 17

Figure 18

Figure 19 Figure 20

Figure 21 Figure 22

preparation. It was easy to see thecuts were still within enamel. (seeFigures 13-17 and Figures 18-22)

A pencil was used again to mark intothese prepared areas. For the finalpreparation, a round ended tapereddual grit diamond bur (Komet 6844,West One) was used to prepare intothe wax up. This has the benefit ofhaving a medium (red) grit at the tipand a coarse (green) grit on theshank. Once the pencil marks weregone, the preparations wereappraised using the facial andpalatal preparation guide.

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Figure 23

Figure 24

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Preparation refinement wasachieved using the same bur in aspeed increasing hand piece andmedium polishing discs (Super SnapRainbow, Shofu). An interproximalfinishing strip (fine and medium grit)(Komet WS37F and WS37EF, WestOne) was used in the contactsbetween the laterals/canine/firstpremolar to smooth any edges aswell as allow a thin amount ofimpression material to flow throughto aid the technician.

Clinical photographs were taken ofthe preparations to assess on a largecomputer screen (iMac, Apple) priorto final impressions. The views wereusing a mirror to assess the path ofinsertion and any undercuts from anocclusal aspect as well as 1:1 ratioimages using a cropped DSLR(Canon 450D). (see Figures 23-27)By using the APT Technique, the finalpreparations were in enamel. Themargins were supragingival

following gingival contours. Theteeth were polished and cleaned.Preparation shades were taken usingTruShade (Optident) using a handdrawn shade map and clinicalphotography. The shades weresimilar to the pre-operativemeasurements (Vita B1, BL3/BL4Ivoclar Chromoscop).

Expasyl (Kerr) was used around thepreparations. It was initially syringedaround the margins and a preoperative impression was reinsertedover this to compress the Expasylinto the sulcus to aid retraction. Thiswas washed off afterwards. Aworking impression of the upperarch using a two stage techniquewas taken using Doric Quick Time(Schottlander) in a stock tray(Orthodontic Impression Trays,Orthocare). A separation wafer(Doric, Schottlander) was used forthe heavy body preliminaryimpression. Bite registrations usingDoric Bite (Schottlander) were taken.

The impression was checked undermagnification and light prior toapproval.

Temporisation

To enable the patient to appreciateand appraise the aesthetic changes,the provisional restorations placedwould be based upon the diagnosticwax up.12,13

Small areas of etch (Spot EtchTechnique) were placed on the facialaspects of the preparation towardthe gingival margin. These were leftfor 15 seconds and washed anddried. A fifth generation single bottlebonding agent (Prime and Bond NT,Dentsply) was used over the wholeprepared surface. A thin layer wasused with any excess blotted offusing a dry microbrush. This was airdried and light cured.

The putty stent based upon the waxup was checked and cleaned using acotton pellet with alcohol following

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Figure 27

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to be Vita B1. This information wasconveyed to the technician viaemail, photographs and a telephoneconversation.

Laboratory work

The case was to be made using IPSE.Max (Ivoclar). The technician wasadvised to copy the provisionalrestorations based upon the originalwax up. No changes were to bemade. The ingot used was a HighTranslucency BL3/BL4. The veneerswere made to full contour and a cutback technique was used to inlayincisal edge effects.

Fitting appointment

Once the veneers were back, theywere tried on the models andassessed for fit and appearance(shape, position, contour). Pictureswere taken at 1:1 ratio using a cropbody DSLR (Canon 450D) to checkfor marginal fit. The preparationguides were used against theveneers to assess correlation to thewax up. I was very satisfied with thelaboratory work.

Local anaesthetic (SeptanestArticaine 4% + 1:200,000Adrenaline, Septadont) wasadministered via buccal infiltrationusing The Wand STA (DPS). AnOptragate (Ivoclar) dam was placedfor soft tissue retraction. A rubberdam was not used as we were ableto obtain very good levels ofmoisture control and access with theOptragate dam. The provisionalrestorations were checked for anychanges (wear, chips, generalcondition) and they looked good.These were carefully removed due totheir very thin nature. A short fineflame bur (F397, Schottlander) was

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its use earlier in the appointment.Once dried and ready, Quick Tempshade B1 (Schottlander) wassyringed into the stent and over thepreparation margins. The stent wasseated into the mouth using positivepressure. The excess material whichflowed out of the upper parts of thestent was a guide to whether thematerial had set. The excess, oncecured, was carefully removed andthe stent was gently eased off.

The provisional restorations werebonded upon the preparations.Initially, any excess flash andmaterial were carefully removedusing hand scalers. The marginswere assessed under magnificationand by the use of a periodontalprobe. Due to the nature of the puttystent, minimal finishing wasrequired. An occlusal assessmentwas made using 40 micronarticulating paper (Bausch) and noadjustment was necessary. Theprovisionals were cleaned andpolished using a rubber polishingbrush (Jiffy Brush, Ultradent) andglazed using Quick Temp Glaze(Schottlander). An impression of theprovisional restorations was takenusing Doric Easy First (Schottlander).Postoperative photographs weretaken. Postoperative instructionswere given to the patient. Peroxyl(Colgate Palmolive) was given for thepatient to use betweenappointments.

Lab work preparation

The impressions were disinfectedand stored in sealed bags. Thelaboratory prescription was writtenand the technician was advised topour models for now, and wait untilthe review appointment. A USB Stick

with images of the case (preoperative, shades, preparation andprovisional restorations) was sentwith the case. Preparation shadesand a shade map were sent with theprescription.

Provisional restoration review appointment

The patient was called a few daysafter the preparation and she wasdoing well. There was a generalfeeling of tiredness after the longpreparation appointment butotherwise no major issues withsensitivity or tenderness. A reviewappointment was arranged 10 daysafter the preparation to assess theprovisional restorations.

The provisional restorations wereassessed using the same criteria asthe initial diagnosis.2,3 The patientwas very happy with appearance(shape, position and contour) andcolour. On examination, gingivalhealth was very good as thepreparations were supragingival. Anocclusal assessment was done butno adjustments were necessary.Clinical photographs were taken andshown to the patient to discuss thefinal restorations.

We discussed the case by goingthrough the images on the screen.The patient exhibited small areas ofhypo-calcification on the firstpremolar cusp tips. She was askedas to whether or not she would alsolike this effect on the canines andshe declined. Shades and colourmapping were discussed usingSmile Design and the clinicalphotographs.14 The patient was keenon having natural effects in the finalveneers. The final colour chosen was

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used to score through the QuickTemp and a Brassler Crown Spreaderwas used to carefully remove theprovisional restorations. Hand andultrasonic scalers were used toremove any smaller remnants.

The preparations were then polishedusing a rubber polishing brush (Jiffy,Ultradent), cleaned usingchlorhexidine and a cotton pellet,with extra care being taken at thegingival margins. The teeth werethen washed and dried.

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Figure 29 Figure 30

Figure 31 Figure 32

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about 3mm in length. A decision wasmade to re-prepare the two centralsto obtain the best end result. Thecemented veneers were carefullydrilled off to ensure the preparationswere kept in enamel only.

Once tooth was clear of veneer andcement, new impressions were takenas per the preparation visit.Provisional restorations were placedas per original preparation visit. Thecase was sent back to the laboratoryfor the remake of the upper centralincisor veneers. Fortunately thepatient was very understandingabout the scenario.

Once the remade veneers were back,they were checked and the fittingwas redone as per the originalappointment outlined above. Theveneers were fitted in twos, i.e.centrals first, left lateral and caninefollowed by the right hand side. Thecement was cleaned up as they werebonded in to minimise the workrequired in the final clean up. Handscalers were used to clear themargins of cement, floss (Glyde) andinterdental separation strips (Komet,

JCDinternational journal of cosmetic dentistry

The veneers were first tried in dry tocheck the marginal fit. A fine probewas used to assess marginalintegration. 1:1 ratio pictures weretaken on a cropped body DSLR(Canon 450D) to review on a largescreen to verify marginal fit. Themarginal fit was very good. Theveneers were tried in individuallyand together to assess anyinterproximal interferences of whichthere were none. They were tried inagain to assess a cementation order.(see Figures 28-32)

The veneers were then removed andtried in using water to assess colour.Due to the thin nature of theveneers, they became semitranslucent with the use of water.The colour match and integrationwas very good. The overall look ofthe veneers was highly satisfying.Pictures were taken and a mirror wasused to allow the patient to reviewthe veneers prior to cementation.The patient gave approval for finalcementation. The fit surface wasetched using Porcelain Etch (9%Hydrofluoric Acid, Ultradent). Asilane primer was used (Monobond

Plus, Ivoclar) to prime the veneersfor the bonding agent (OptiBond FLAdhesive, Kerr). A thin layer wasplaced and any excess was blottedoff using a dry microbrush.

The cementation order as assessedduring the try in was to cement thecentrals first followed by left lateraland canine followed by right lateraland canine. The central incisors wereetched using Phosphoric Acid 35%(Ultradent) and washed and dried.Prime and Bond NT (Dentsply) wasapplied to the preparations anddried and light cured. TranslucentVariolink II (Ivoclar) was used a lightcure only cement. The cement wasplaced into the veneer and wasgently placed over the preparedtooth. Excess was removed usingmicrobrushes. Short bursts of lightcure were used to cure the cementaround the margins to aid easyremoval (Ivoclar Vivadent).15

During the cementation on the upperright central, too much pressure wasapplied in the cervical regioncreating a marginal fracture. Thefracture was clearly visible being justdistal of the gingival zenith. It was

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West One) were used in theinterproximal areas.

The veneers were initially tacked inplace with spot curing. Once cleanup was complete, a final cure wascarried out. De-Ox (Oxygen BarrierSolution, Ultradent) was usedaround the margins in the final cure.

An interproximal finishing strip (finegrit) (Komet WS37EF, West One) wasused in the contact areas. Exposed

margins were polished using a finedisc (Super Snap Rainbow, Shofu)and a rubber polishing brush (Jiffy,Ultradent).

Occlusion was checked using 40micron articulating paper (Bausch)and no adjustments were necessary.

Postoperative instructions weregiven. The patient was very happywith the initial result. (see Figures 33-37)

Review appointments

The patient was seen initially at 10days after the initial appointment.Miss RW was very happy with theoutcome.

There were no postoperativesymptoms following the previousappointment. Postoperativeradiographs were taken to assess fitand some remnants of cement wereseen and subsequently cleared.

The patient was reviewed at 8 and 17weeks after the fitting to assess softtissue integration and maturation.Gingival tissue maturation andpapillary infill at this stage has reallycreated a beautiful end result. Shewas seen by the hygienist to starther on-going care and maintenanceof her new smile.

The final postoperative clinicalphotographs were taken at the 17week review. The patient was veryhappy with the end result. (seeFigures 38-49)

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Figure 35 Figure 36

Figure 37

Figure 38

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Figure 39 Figure 43

Figure 40 Figure 45

Figure 41 Figure 47

Conclusion and

personal reflection

An excellent aesthetic outcome wasachieved for the patient who wasvery happy with the end results. Thepatient has felt an overall increase inconfidence in herself and feels betterfor having been through the process.

The salient feature of this caseexhibited that veneers, when donein a minimally invasive manner, can

produce a beautiful natural lookingresult. Not only was this minimallyinvasive in the actual materialthickness and degree of preparation,but also in the number of teethtreated. I believe, that had thispatient undergone orthodontictreatment, the final result would nothave looked as good or beautiful asit does with this result.

The patient’s curves and voluptuousfeatures sit well with the teeth thatappear when she smiles.Porcelain veneers, when done in amanner that reflects today’smaterials and techniques, still canprovide a valid and excitingtreatment option.

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References

1. Spear F. Occlusion Part 6:(2012)Muscle and TMJExamination, Online ClinicalCourses, www.speareducation.com

2. Orr CG. (2005a) 12 Steps to SmileDesign. Part 1: MacroaestheticElements. Aesthetic Implant Dent2005; 7: 16-22.

3. Orr CG. (2005b) 12 Steps to SmileDesign. Part 2: MicroaestheticElements. Aesthetic Implant Dent2005; 7: 14-20.

4. Gurel G. Predictable, precise andrepeatable tooth preparation forporcelain laminate veneers.Practical Periodontal AestheticDent 2003; 15: 17-24.

5. Magne P, Besler U. Novelporcelain laminate preparationapproach driven by a diagnosticmock up. J Esthetic RestorativeDent 2004; 16: 7-18.

6. Gurel et al. Clinical performanceof porcelain laminate veneers:outcome of aesthetic pre-evaluative temporary (APT)Technique. Int J PeriodonticsRestorative Dent 2012; 32: 624-635.

7. Gomez-Polo M et al. Influence oftechnique and pouring time ondimensional stability of polyvinylsiloxane and polyetherimpressions. Int J Prosthodontics2012; 25: 353–356.

8. Chiche G, Pinault A. Esthetics offixed anterior prosthodontic1994.

9. Smallwood T. Six veneers: the“un-magical” number. J CosmeticDent 2005; 21: 142-149.

10.Orr CG. Case difficulty assessment in cosmetic dentistry.Presentation at AACD San DiegoConference 2006.

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11.Ritter RG, Culp L. Ingot selectionfor aesthetic restorations usingcontemporary pressed ceramics.Practical Procedures in AestheticDent 2002; 14: 473-478.

12.Spoor R. Predictableprovisionalisation achievingpsychological satisfaction, formand function. Practical Proceduresin Aesthetic Dent 2004 16: 443-440.

13.Orr CG. (2005c) Successfultemporisation for adhesivedentistry. Restorative andAesthetic Practice 2005; 7: 10-19

14.Chiche G, Aoshima H. SmileDesign: A Guide for Clinician,Ceramist and Patient. 2004.

15.Ivoclar Vivadent. Two simplifiedcementation protocols usingVariolink II: the brush or wavetechnique.

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