An indirect approach to direct composite resin veneers

In this article, Dr. Nash presents a novel treatment called a “direct/indirect” composite veneer.

Direct composite resin veeners are a viable solution for many anterior dental problems. The process requires not only excellent clinical technique but artistic skill. One of the foremost direct composite experts in the world is Newton Fahl, DDS, MS, of Brazil. When I was his host at the Holiday Dental Conference in Charlotte, North Carolina, a number of years ago, I watched him teach a hands-on program about direct composite veneers. I found his artistic skill to be amazing.

Just a couple of years ago, I saw Dr. Fahl lecture at the American Academy of Cosmetic Dentistry’s annual conference. He illustrated a technique he called a “direct/indirect” composite veneer. He showed a case where the tooth preparation allowed for a composite to be built directly without using etch or bonding agent. It was then removed from the prepared tooth, finished indirectly, and then bonded to the prepared tooth. This allowed for the benefits of both a direct and indirect veneer.

At that time, I thought to myself: I could use this process with a preformed composite laminate (e.g., Componeer, Coltene Dental Products). This would allow for a system where the dentist could combine clinical skills with preformed art. The ability to finish and polish the restoration indirectly and bond it to place using composite luting agents would make this process even more flexible.

Clinical example

In Figure 1, you can see a patient with a previously repaired left maxillary central incisor. The right central incisor has a worn incisal edge. The patient chose two direct composite veneers for the esthetic solution. After minimal preparation (figure 2), there was no proximal separation. I thought this would be a good case to try Dr. Fahl’s technique.

Figure 2: Both central incisors were mimimally prepared.

Another dental expert, (Mario Besek, DMD, of Zurich, Switzerland) developed the Componeer system to assist the dentist in applying direct composite veneers. A Componeer is a preformed composite laminate that is light cured under pressure, leaving almost no porosity. When a composite resin is added to the internal surface and light cured, it is just as if the two materials were layered freehand on the tooth; the juncture is imperceptible. Componeers come in two enamel shades, and any dentin or enamel shade can be used to add to the internal surface. Even though Componeers were designed to be placed and finished directly on the tooth like any other direct composite veneer, I decided to use them for Dr. Fahl’s technique.

The appropriately sized Componeer was chosen, and bonding resin was applied to the internal surface as a wetting agent. In this case, the WO enamel shade of Synergy composite (Coltene Dental Products) was added to the internal surface (figure 3). The composite laminate was seated, positioned on the prepared tooth, and light cured with an LED curing light (figure 4).

After the composite resin was fully cured, a black spoon was used to lightly tease the composite veneer from the tooth. The margins were finished and shaped with aluminum oxide discs (figure 5), and the facial surface was refined and polished. The internal surface was lightly abraded with a microetcher. In Figure 6, you can see that the composite veneer after try-in fit intimately to the prepared tooth.

The prepared tooth surface was treated with enamel etching gel for 10 seconds, rinsed thoroughly, and lightly air dried. A universal bonding agent (One Coat 7.0, Coltene Dental Products) was placed and light cured for 10 seconds. A lighter composite veneer cement (Opal White, Fusion-Zr Veneer Cement, Taub Products) was applied to the internal surface of the laminate, and the composite veneer was placed on the prepared tooth (figure 7).

Figure 7: The composite veneer is placed on the prepared tooth.

The excess veneer cement was removed with a brush, the composite laminate was held in place, and the veneer cement was light cured for 20 seconds from the facial and lingual surfaces. The minimal amount of cured excess veneer cement was removed with a small carbide finishing bur, and the margins were polished. The other composite veneer was fabricated in the same way. Occlusion was checked and adjusted, and final polishing was accomplished with aluminum oxide discs (Alpine, Coltene Dental Products).

Conclusion

In Figure 8, you can see the final result with direct/indirect composite veneers on both central incisors. The additional control achieved by using a preformed composite laminate to assist in the artistry of the veneer, combined with the freedom of contouring and finishing off of the tooth and ability to use varied shades of veneer cement to enhance color if needed, makes this a process I have used for a number of cases since Dr. Fahl introduced me to the idea. Thank you, Newton.

The final result with direct/indirect composite veneers on both central incisors" title="Figure 8: The final result with direct/indirect composite veneers on both central incisors">Figure 8: The final result with direct/indirect composite veneers on both central incisors

Practice management considerations: When a patient is calling about an esthetic solution

Debra Engelhardt-Nash

Let’s say a patient calls seeking a solution for her front teeth. She has an idea of a type of treatment that would give her the results she is looking for, and calls to inquire about the fee for that particular procedure. The patient may not be aware of all of her treatment options.

In this case, she be a “shopper,” calling several offices to get fees for the procedure she perceived was the answer for her, before she calls.

What should you do in these cases? Remember, the moment you answer the new patient call, you are beginning to validate the caller for making the right decision to contact you, and emphasizing that you’re the office for them. How do you make them feel confident and comfortable they have chosen the right office for their care?

Here are a few tips to help you set your practice (and your fees) apart:

• Avoid putting new patient calls on hold. This implies you are too busy for them or their calls don’t matter. If you tout that you give your patients personal attention, this is where to start.
• Listen more than you talk. Rather than beginning the conversation with telling the caller what procedures are going to be provided, find out what they want and tell them how your services will meet their needs. Never appear to be hurried or distracted. Document your conversation so everyone has the call history.
• Get permission to ask questions. “So that I may help you with your visit, may I ask you a few questions?” The most important question is “What inspired you to call?”
• Tell them what is special about your officeand make it personal. Why should the patient choose you? What differentiates your practice and your practitioner? Take time to endorse the doctor and explain the features of your office standards.
• Don’t turn away the shopper. If the caller asks how much you charge, avoid saying that you don’t quote fees over the phone. Let them know you will be happy to discuss fees with them if you could get more information.

Patients overwhelmingly choose a dentist based on the relationships we establish with them. The patient should begin to trust the doctor when she has her first interaction with the practice. She knows she called the right place for her treatment in the first moments of the initial call. It is an important step in differentiating the practice.

Ross W. Nash, DDS, maintains a private practice in Huntersville, North Carolina, where he focuses on esthetic and cosmetic dental treatment. He is an accredited fellow in the American Academy of Cosmetic Dentistry. Dr. Nash lectures internationally on subjects in esthetic dentistry and has authored chapters in two dental textbooks. He is cofounder of the Nash Institute for Dental Learning in Huntersville, North Carolina.

Debra Engelhardt-Nash is a trainer, author, presenter, and consultant, and has presented workshops, nationally and internationally, for numerous study groups and organizations. She is currently the vice-president/president elect for the National Academy of Dental Management Consultants, where she is a founding member and has served as president in the past. She was a contributing editor for Contemporary Esthetics and Restorative Practice magazine, Contemporary Dental Assistant magazine, and has written for a number of dental publications.