Dr. Ross W. Nash

	A young man presented with a central diastema, which he desired to close.

	The lateral incisors were slightly malformed. Though orthodontic treatment was considered, cosmetic bonding was selected by the patient for its immediate effect. In addition, with cosmetic bonding, tooth contours and shade could be controlled.

	My experience tells me that 10 years is a reasonable life expectancy for a direct composite veneer. The patient was happy with the plan to place direct composite resin veneers for the maxillary central and lateral incisors.

Fig. 1                                                                                                              Fig. 2

	Figure 1 shows the patient’s four maxillary anterior teeth before treatment. To improve tissue heights, tissue contouring was achieved using a diode laser (Picasso dental laser, AMD Lasers) as shown in Figure 2.

Fig. 3                                                                                                                Fig. 4

	Facial contouring to correct for slight rotation of the right central incisor was accomplished with a fine diamond bur (878KF012, Alpen) (Fig. 3). Incisal contouring was also accomplished with the same bur (Fig. 4). The minimally-prepared teeth are shown in Figure 5.

, a universal composite of the latest generation of nano-hybrid composites by COLTENE. It was developed with a special focus on high, long-lasting gloss, shade esthetics and handling convenience. The shade assortment comprises three opacities: three opaque masking shades, seven universal Duo Shades suitable for single shade restorations and two translucent shades for optimal enamel imitation.

Fig. 5                                                                                                        Fig. 6

Fig. 7                                                                                                              Fig. 8

	The right central incisor was isolated using a celluloid strip. Enamel etching gel (Etchant Gel S, COLTENE) was applied for 10 seconds and thoroughly rinsed (Figs. 6-7). The tooth was lightly dried using a water and oil free air/water syringe. The etched surface can be seen in Figure 8. 

Fig. 9                                                                                                             Fig. 10

	A seventh-generation bonding agent (ONE COAT 7 UNIVERSAL, COLTENE) was liberally applied with an applicator tip and air thinned (Figs. 9-10). The bonding agent was light cured for 10 seconds with an LED curing light (

	Fig. 11                                                                                                                 Fig. 12

	Fig. 13                                                                                                                  Fig. 14

	A composite instrument was used to place the composite (shade Bleach) from the lingual to the proximal (Fig. 12). This increment was light cured for 10 seconds with the LED curing light (Fig. 13). The same shade of composite was applied to the facial surface and contoured with a composite instrument (Fig. 14). This increment was light cured for 20 seconds (Fig. 15). Finally, a translucent shade of composite (Bleach Trans) was applied to the entire facial surface and light cured (Figs. 16-17).

	A fine diamond bur (878KF012, Alpen) was used for additional contouring (Fig. 18).


	Fig. 15                                                                                                                 Fig. 16

	Fig. 17                                                                                                                Fig. 18

 SwissFlex™, COLTENE) were used to help complete the contouring (Fig. 19). Alpen ShapeGaurd polishers - diamond impregnated polishers that are strong in polishing yet gentle on surfaces - were used to finish the polish. These polishers are engineered to adapt to any surface and distribute uniform pressure for fast, easy finishing and polishing. They are autoclavable for enhanced lifespan. The pink disc is used first (Fig. 20) and then the blue disc (Fig. 21) leaves a high gloss. Proximal surfaces were highly polished using aluminum oxide strips (Alpen SwissFlex, COLTENE) as shown in Figure 22.


	Fig. 19                                                                                                                Fig. 20


	Fig. 21                                                                                                                Fig. 22

	The second central incisor was built in the same fashion. Since the proximal surfaces of the first direct veneer were highly polished, I was able to build the adjacent composite veneer directly against it.

	After contouring, a composite spatula was used to “torque” the teeth slightly apart and the new composite was released from the previously polished surface. With this technique, a tight contact was achieved. After complete polishing was achieved for the left central incisor in the same fashion as the right central, the lateral incisors were completed (Fig. 23).


	Fig. 23                                                                                                                Fig. 24

	In Figure 24, you can see the finished case at the post-op appointment. The patient was extremely happy with the result and told me it had made a positive change in his life.

Articles

Dr. Ross Nash outlines how delivering esthetic results without causing discomfort is possible - with the right technique.

How to Perform Minimally Invasive Cosmetic Bonding

How to perform minimally invasive cosmetic bonding

	While more dentists are utilizing digital impressions in their offices and some are milling restorations on site, there are still many, like me, who prefer conventional impressions.

	By using an impression material that can be scanned by the laboratory or scanned in the dental office and the image sent to the laboratory, many advantages of digital technology can be gained. 

BONASCAN by DMP is a new polyvinal siloxane impression material that can be digitally scanned. A conventionally fabricated restoration can be fabricated by pouring up the impression and making a hard model, but if the dentist wants to use the digital feature they have two options:

Speed up the restoration process as the lab would get the file the same day and can start working on the case. This technique can:

	- Improve communication with the lab as a discussion can be had while both looking at the digital file. 

	- Improve efficiencies for the lab, saving them time and money as they can skip the step of pouring a model and using a powder or spray to scan the model into their system. 

	- Allow the use of desktop digital scanners, which are less expensive, smaller and easier to use than CAD/CAM systems. 

	- Allow the dentists to work with a restorative material, not limited by the CAD/CAM software programs that only work with certain milling machines.

	- Eliminate the potential for impression distortion during the shipping, handling and model-pouring stages, leading to better clinical outcomes.

 Take the traditional impression, send it to the lab, ask the lab to directly scan the impression and have them send you the file. This technique can:

	- Improve efficiencies for the lab, saving them time and money as they can skip the step of pouring a model and using a powder or spray to scan the model into their system.

	- Eliminate the potential for distortion during the model-pouring step, leading to better clinical outcomes.

	- Allow the dentist to get a digital file for their records. 

	- Allow the dentist to focus on patient care and not worry about operating and maintaining CAD/CAM systems. 

	- Allow the dentist to participate in digital technology with no upfront investment in digital equipment.

 show the facial and occlusal views of a madibular molar that I prepared for a full crown.

, you can see a close up view of the final impression taken with BONASCAN impression material. A light body was used to express around the margins and a heavy body was placed in the impression tray and seated directly over the light body. After five minutes, the impression was removed and evaluated.  A provisional crown was fabricated and the patient was reappointed for seating.

       Fig. 1                                                            Fig. 2                                                                       Fig. 3  

	The impression was sent to the laboratory (Peter Kouvaris, New York City) and a lithium disylicate (e.max, Ivoclar Vivadent) crown was prescribed using digital technology. In the lab, Peter scanned the impression and developed the digital information (

       Fig. 4                                                                   Fig. 5                                                                     Fig. 6  

 shows a digital image of the teeth in occlusion. Peter designed the crown using digital technology.

	The crown can be seen designed on the model from the facial view in 

. The crown was milled and Peter added surface staining for esthetics. The final restoration can be seen on a mirrored surface in 

                    Fig. 7                                                                                               Fig. 8                         

	While not a necessary step, Peter fabricated a 3D-printed model of the teeth to verify the fit and occlusion. In 

 the printed model is shown and the crown is seated on the model in 

                    Fig. 9                                                                            Fig. 10                    

	The crown and printed model were returned to my office. At the seating appointment, the provisional crown was removed and the final crown was tried in. Contacts, margins and occlusion were evaluated and no adjustments were needed. The crown was bonded to place using a self-adhesive resin cement (Fusion-ZR Dual Cure Resin Cement, Taub Products). It can be seen in place from the facial view in 

 shows the excellent fit of the digitally fabricated crown.

     Fig. 11                                                                   Fig. 12                                                              Fig. 13  

	For the dentist who would like to take advantage of digital technology to produce restorations but prefers conventional impressions, a scannable impression material can fill the gap in technology.  

A new impression material that might make the jump to digital dentistry a little less jarring. 

While more dentists are utilizing digital impressions in their offices and some are milling restorations on site, there are still many, like me, who prefer conventional impressions.

How to bridge the gap between traditional and digital impressions

	A young woman presented with a desire to enhance her smile.

	Figure 1 shows her smile before treatment. A retracted view illustrates that she had developmental enamel defects that resulted in decalcified surfaces (Fig. 2). Some areas had white spot lesions and others had brown areas where the white spots had incorporated stain over time. The incisal view in Figure 3 shows well-aligned teeth. Clinical and radiographic examination revealed excellent dental health with no periodontal disease or caries.

	The patient communicated that whitening procedures she had tried were not successful and actually made the appearance worse by causing the white spots to stand out more. My experience tells me that white spot lesions such as these are often near the surface of the enamel and enameloplasty can sometimes remove them. However, the teeth actually appear a darker color due to less coverage of the underlying dentin. Resurfacing of the tooth surface is desired in many of these cases. It can be accomplished with direct composite resin veneers 

or indirect composite or ceramic laminates. 

	While direct restorations can usually be accomplished at a lower cost to the patient, it requires the clinician to have artistic abilities. By using an indirect process, an artist can be chosen by the dentist. I have found that a ceramic laminate routinely outlasts my direct or indirect composite veneers by a factor of two and resists stain better. Preparation for these thin veneers can be minimally invasive and usually does not require temporary restorations.

	The patient chose 10 porcelain laminates for her smile makeover.

	No anesthetic was necessary and the tooth surface was refined using a fine finishing diamond bur with water spray. Preparation involved removing the defective enamel and providing draw. 

	Figure 4 shows the final preparations. The patient was happy with the improved appearance after this minimal enamel removal and was excited about having a bright new smile after her veneers were placed. In Figure 4, you can see the prepared teeth from the retracted facial view. Figure 5 shows the prepared teeth from the incisal view.

	Final impressions were taken with a PVS impression material and an opposing impression and bite registration were taken. No provisional restorations were needed as the patient was happy with her new smile after preparation (Fig. 6).

	The final impressions and bite registration along with photographic images of the patient were sent to the dental laboratory (daVinci Laboratory) with the request to fabricate thin veneers with lithium disylicate (e.Max, Ivoclar). Shade OM2 (Vita 3D shade guide) was chosen by the patient. The veneers can be seen photographed on a mirror surface in Figure 7. The internal etched surfaces are shown in Figure 8.

	Again, no anesthetic was required for placement. The six anterior teeth were isolated using thin metal strips and enamel etch was applied (Fig. 9). The etching gel was left in place for ten seconds (Fig. 10) and thoroughly rinsed (Fig. 11) and the etched surfaces were dried with oil-free air from an air/water syringe (Fig. 12).

	A self-adhesive light-cured resin cement, FUSION-Zr Multi-purpose Veneer Cement (Taub Products), was applied directly to the etched surfaces. The right central incisor veneer was placed using a cotton plier. 

	The first veneer can be seen in place in Figure 13. The other five veneers were placed (Fig. 14) and excess veneer cement was teased away from the margins with an applicator tip (Fig. 15). 

	The veneer cement was cured with an LED curing light (Fig. 16). A #12 surgical blade was used to removes excess cured cement in the interproximal areas (Fig. 17) and floss was worked into the contact areas where possible (Fig. 18).

	The premolar veneers were placed in the same fashion. A carbide finishing bur (ET2 bur, Brasseler) was used to remove excess cured resin at the margins of each veneer (Fig. 19). Where floss could not be worked into the interpoximals, a separating strip was used to remove excess composite cement (Fig. 20). After all interproximal areas were cleared, they were checked with floss (Fig. 21).

Dr. Ross Nash outlines how he enhanced one patient’s smile with a minimally invasive technique.

How to place porcelain veneers with minimal preparation

	Mary presented with a desire to enhance her smile. Her main concern was the malalignment of her maxillary and mandibular anterior teeth. She was comfortable with the color of her teeth. Clinical and radiographic examination revealed excellent dental health, free of periodontal disease or caries.

	While full orthodontic treatment or clear aligner treatment was discussed, she was particularly interested in the 

 because of its speed of treatment and removable design.

Read more from Dr. Nash: How to efficiently place a cemented implant crown

	The Inman Aligner was invented by Don Inman of 

 in Coral Springs, Florida. It was designed specifically to correct alignment for the six anterior teeth when there is crowding of 3 mm or less.

	Most cases can be completed in six to 18 weeks. It requires some interproximal stripping (IPR) and sometimes minor reshaping of the teeth. Small spheres of composite bonded to the tooth (buttons) are sometimes needed to stabilize the bows during tooth movement. The device is a single appliance that is removable. It must be worn 16 to 20 hours a day and adjustments are made to the teeth every two to three weeks. Permanent retention is necessary, and can be accomplished with a clear removable retainer or a bonded fixed wire retainer.

	Mary’s smile as she presented is shown in Figure 1. In the retracted view (Fig. 2) the malalignment is obvious. She was not concerned about the tipped maxillary premolars, but rather wanted to focus on the six anterior teeth. 

	In the incisal view of the maxillary teeth, you can see that the mal-alignment was almost completely confined to the left central and lateral incisor and canine (Fig. 3). The mandibular anterior had the opposite problem with most of the crowding being in the area of the right central, lateral and canine as can be seen in Figure 4. Mary decided that she wanted to have Inman Aligners to straighten her anterior teeth.

	Full maxillary and mandibular PVS impressions were taken, as well as PVS bite registration. These were sent to the Inman Orthodontic Laboratory for fabrication of maxillary and mandibular Inman Aligners. 

	They were returned with a printed model of the end result. Also included were preoperative study models with button locations marked and with a prescription designating the amount and location of interproximal stripping with precision diamond coated strips or discing with diamond discs.

	The illustration in Figure 5 shows the action of the Inman Aligner. The facial bow is powered by springs pulling it lingually and lingual bow is powered by springs pushing the teeth facially. Rarely is it necessary to adjust the appliance itself. The adjustments are made to interproximal areas of the teeth.

	When treating both arches, as in this case, it is sometimes necessary to align one arch at a time. This particular case lent itself to the patient wearing both appliances at once and Mary chose to do this. IPR was accomplished as prescribed and the appliances were delivered. 

	Figure 6 shows the aligners in place from the retracted facial view. The maxillary aligner at placement is shown from the incisal view in Figure 7. In Figure 8, the mandibular aligner is shown in place also from the incisal view.

	During the next twelve weeks, Mary wore the two Inman Aligners for at least sixteen hours a day. She presented to the office for additional IPR every two weeks. The Inman Aligner can be seen in place from the incisal view on the maxillary arch after twelve weeks in Figure 9.

	The mandibular aligner is shown in place after 12 weeks in Figure 10. Figure 11 demonstrates the maxillary incisal view showing the aligner removed. 

	Note that the left canine is still slightly rotated and a small diastema exists between the right lateral and central incisors. In Figure 12, you can see that the mandibular incisors are well aligned with only a slight diastema remaining between the right lateral and central incisors. In the retracted facial view in Figure 13, you can see that a much improved alignment has been achieved.

	An impression of the mandibular arch was made with a PVS impression material and it was sent to the Inman Lab requesting a clear aligner to finish the lower arch. The clear aligner is shown in place from the facial view in Figure 14 and the incisal view in Figure 15. 

	In only one week, the mandibular teeth were perfectly aligned. The small diastema between the maxillary left central and lateral incisors was closed using a direct composite resin addition (

	The final result can be seen from the retracted facial view in Figure 16. Bonded wire retainers were fabricated and placed. Figure 17 shows the bonded wire retainer in place for the maxillary arch and Figure 18 shows the mandibular bonded wire retainer. Mary’s new smile can be seen in Figure 19.

How to use the Inman Aligner for alignment corrections in anterior teeth.

How to simplify alignment and bonding for smile enhancement

	For placing cemented implant crowns in the past, I would place a cotton pellet over the implant screw, add temporary cement over the cotton pellet and cement the implant crown with either temporary cement or a final cement.

	Recently, I have discovered a more efficient technique. By using chlorhexidine gel (Go-Chx-Gel), 

, I can achieve a clean and well-sealed cemented implant crown.

	The patient in Figure 1 was ready for implant crown placement at tooth #14. In Figure 2, you can see the zirconia oxide implant abutment, the retaining screw and the IPS e.max crown ready for placement.

	After the healing abutment was removed, Go-Chx-Gel was used to clean and disinfect the implant site. The gel was delivered using the applicator supplied (

). After the leaving the gel in place for 30 seconds (

	The zirconia oxide abutment was placed and torqued (

) and Liquid Magic Resin Barrier was applied (

) and light cured for 20 seconds with an LED curing light (

). Liquid Magic sets in a “rubbery” state. No cotton pellet is needed over the screw head and the resin barrier can be easily removed when needed. It can be seen in Figure 9 after light curing.

	Zero-G Bio Implant Cement was placed into the IPS e.max crown (

). Zero-G has a one-minute and 45-second working time with a full set at two minutes and 30 seconds. An LED curing light can be used to accelerate the set. Excess cement can be visualized around the crown and tissue (

). It is also radiopaque so it can be seen on a radiograph.

	Excess cured Zero-G was easily removed with a scaler (

). Floss was worked into the interproximal areas to remove cured cement there (

	The final restoration can be seen from the occlusal view (

	By using TAUB Products’ new implant cementation system, I was able to place an implant abutment and crown efficiently and quickly. 

	Up next: Detailed, step-by-step images allow you to become an implant expert too!

A guide for how to use TAUB Products’ new implant cementation system to place an implant abutment and crown efficiently and quickly.

How to Efficiently Place a Cemented Implant Crown

	 A young woman presented to my office for a consultation regarding her maxillary central incisors. She had porcelain veneers in place but was not satisfied with the color. Though she agreed that they looked good, she did not feel that they matched her adjacent teeth.  

	Figure 1 is a facial view of the first veneers in place. In the incisal view (Fig. 2), you can see that the veneers were used to close a central diastema. The reading from Vita Shade Light showed that the lateral incisors were 1M1 on the Vita 3D Shade Guide (Fig. 3).  

	Fig. 1                                                    Fig. 2  

	After a discussion with the patient regarding her expectations, I decided to remove her veneers and have new ones fabricated. I chose Peter Kouvaris of New York City to fabricate the new laminates from eMax ceramic based on my previous experience with his shade matching.

	Continue to the next page to read about the case and see the shade matching process.

	A preoperative impression was taken using Silginat alginate alternative impression material by Kettenbach. The previous laminates were carefully removed using a fine diamond bur (Brasseler) in a high speed handpiece with water spray. The prepared teeth can be seen from the facial view in Figure 4. The incisal view of the prepared teeth is shown in Figure 5. All prepared surfaces were in enamel.

	Fig. 4                                                    Fig. 5

	A final impression was taken with Panasil A-silicone impression material (Kettenbach) and an opposing impression was made with Silginat. A bite registration was taken using Futar by Kettenbach .  In the preoperative impression a multifunctional acrylic composite temporary material (VISALYS, Kettenbach) was injected into the area of the central incisors and placed back over the prepared teeth. After two minutes, the impression was removed leaving the provisional restorations on the teeth (Fig. 6).

	The provisionals were adjusted and polished and the patient was instructed to be very judicious in her oral home care because the temporary veneers were splinted together to help in retention. A Sonicare tooth brush was recommended.

	I sent the impressions and bite registration as well as photographs of the preoperative veneers, prepared teeth and provisional restorations to the lab. I asked that Peter use eMax ceramic to fabricate two ceramic laminate veneers to match the adjacent teeth.

	Continue to the next page to see the next steps.

	Upon arriving at our laboratory’s receiving area, the impression and bite registration were disinfected and the case was entered into our scheduling software in preparation for model work. Once the models were poured, the case was brought to me for its initial evaluation. I began by reviewing the case’s lab script along with its model work and the series of intraoral and facial photos provided for review. The photos most vital for color matching are the ones of the   teeth with a shade tab closest to the foundation color in front of them. Please note to make sure the shade tab’s designation is unobstructed and can be seen clearly as shown in Figure 3.

	Fig. 7                                                        Fig. 8

	Once the case was analyzed and approved for fabrication, a proper ingot was chosen and pressed to full contour. After divesting, the restorations were cleaned and returned to the master cast for inspection of accurate fit. When shaping the restorations, special attention is given to the line angles and surface texture in order to replicate the natural look and feel of the adjacent teeth. The attention was subsequently focused on the photos depicting the natural dentition and their color nuances. Noting the blue color’s intensity and position in the incisal area, the cream colored band framing the edge of the laterals provided me with a mapping for layering purposes. This should also be noted for staining if a monolithic restoration is prescribed. Needless to say the proper preparation, impression accuracy and photo documentation are all necessary to achieve desirable results in any restoration process.

	The eMax veneers can be seen on the working model in Figure 7. The intaglio etched surfaces are show on a mirror surface in Figure 8.

	Continue to the next page for the delivery steps.

	At the delivery appointment, the provisional veneers were removed and the new laminate veneers were tried in using Calibra try in paste (Dentsply/Sirona). The patient was asked to look in a mirror and she approved the new veneers. The veneers were removed and thoroughly cleaned with water spray from an air/water syringe and dried with oil-free air. A silane primer (Calibra Silane Coupling Agent, Dentsply/Sirona) was used to treat the etched intaglio surfaces (Fig. 9), allowed to dwell for twenty seconds and air dried.

	Fig. 9                                                           Fig. 10

	Celluloid strips were placed distal to both central incisors to protect the adjacent teeth. Phosphoric acid edging gel (Calibra, Dentsply/Sirona) was placed on the prepared enamel surfaces (Fig. 10), thoroughly rinsed after ten seconds (Fig. 11) and air dried (Fig. 12).

	Fig. 11                                                        Fig. 12

	Continue to the next page for the next steps.

	Bonding agent (Prime & Bond NT, Dentsply/Sirona) was applied to the prepared surfaces (Fig. 13) and air thinned (Fig. 14). The bonding agent was light cured for ten seconds with a LED curing light (Fig. 15). Veneer cement (Calibra Veneer,  Dentsply/Sirona) was applied to the silane treated internal surfaces (Fig. 16).

	Fig. 13                                        Fig. 14                                           Fig. 15

	The veneers were delivered to the teeth using a cotton plier (Fig. 17). A placement instrument (Veneer Stabilizer, Hu-Friedy) was used to lightly seat the veneers (Fig. 18). Excess resin cement at the margins was removed with a brush (Fig.19).

	Fig. 16                                        Fig. 17                                      Fig. 18

	The LED curing light was used to “tack” the cement for two seconds each tooth (Fig. 20). A celluloid strip was eased through the interproximal area between veneers (Fig. 21) and floss was worked through the distal contacts to remove unset cement (Fig. 22). The LED curing light was used to complete the cure by exposing the facial and lingual surfaces for 20 seconds each Figure 23.

	  Fig. 20                                         Fig. 21                                   Fig. 22

	A small carbide finishing bur was used to remove remaining excess resin at the margins (Fig. 24). A number 12 surgical blade was used to remove some excess resin at the interproximal margins (Fig. 25). An Enhance Cup (Dentsply/Sirona) was used to smooth and polish margins and remove excess resin on the ceramic surfaces (Fig. 26).

	  Fig. 23                                       Fig. 24                                     Fig. 25

	The final result is shown from the incisal view in Figure 27. The facial view after treatment can be seen in Figure 28. The patient's new smile is shown in Figure 29.

	Fig. 27                                                   Fig. 28

	By using team treatment, Peter and I were able to achieve a superb color match with ceramic veneers that mimicked the appearance the surrounding neighbors. It was my job to prepare the teeth properly, acquire accurate impressions, provide excellent photography, choose a shade and deliver the finished laminates.  Peter's job was to pour accurate models, produce the ceramic veneers and develop the color and contours to achieve the esthetic result.

One practitioner explains how he achieved superior color matching in laminate veneers.

How to color match with porcelain laminates

Dr. Ross Nash shows a technique to place multiple veneers simultaneously with excellent esthetics, using some products from Dentsply Sirona.

Technique: Placing multiple veneers at the same time with amazing esthetics

 I have been using multiple placement techniques in placing porcelain veneers. I first saw it illustrated by the late Dr. Robert Ibsen in the early 1980s. I watched Dr. Larry Rosenthal demonstrate multiple veneer placement on patients during our Ultimate Esthetic Practice continuum in New York City in the early 1990s.

While placing veneers one or two at a time can be effective, I find that it takes me longer and involves more adjustment. It is possible to place up to 10 veneers at once. For veneers on the ten teeth from second premolar to second premolar, I usually place six, two and two simply because of the field of view.    

Related: How to color match with porcelain laminates

	The placement process involves enamel etching, placement of a bonding agent, treating the internal etched surfaces of the veneer with a silane primer, placement of luting composite on the internal surfaces of the veneer, delivering the veneer to the tooth with cotton pliers or other instrument, lightly pressing the veneer to place with an instrument or finger, adding the other veneers one by one, removing excess resin with a brush where needed, tack curing, removing proximal and marginal excess where possible, final curing, removal of excess luting resin with carbide finishing burs and polishing.

	Click the next button to go step-by-step ... 

Fig. 1 Laminate veneers photographed on a mirror surface

watched a YouTube video where Dr. Michael Apa

 of New York City illustrated a multiple placement technique using a flowable composite as the luting agent and placing it directly on the teeth instead of inside the veneer. When I tried the technique, I found it to be more efficient than the technique I outlined above. The fact that the veneer can be carried to the mouth dry reduces the possibility of mishandling or dropping.

Step-by-step: How to create an esthetic smile with design principles

	Not all composite resin cements are suited for this technique. Some are too viscous and some have too short a working time in ambient light. I found 

, an ideal material for this process. Its viscosity is flowable in nature and it possesses a “stay-put” property that allows the restoration to stay in place for clean up before curing. 

 shows ten ceramic laminate veneers ready for placement and photographed on a mirror surface.

	The six prepared maxillary anterior teeth are shown from the facial view in 

. All eight laminates were tried in using try-in paste (Calibra, 

) and they were approved by the patient. The try-in paste was thoroughly rinsed out and a silane primer (Dentsply Sirona) was applied to the etched internal surfaces of the laminates.

	It was decided to place the six anterior veneers at once and then the two premolar veneers together one side at a time. Metal inter-proximal matrixes were placed distal to both canine teeth to protect the adjacent premolars from the adhesive chemicals. A line of phosphoric acid etching gel (Dentsply Sirona) was placed on the prepared surfaces using a syringe (

) and quickly brushed across the surfaces allowing it to dwell for ten seconds before thoroughly rinsing with water from an air/water syringe and lightly air drying.

, Dentsply Sirona) was liberally applied to the prepared and etched surfaces (

) and blown thin with air from an air/water syringe.

	The bonding agent was light cured with a LED curing light (

, Dentsply Sirona) for ten seconds per tooth (

Fig. 6 Calibra luting composite syringed onto tooth surfaces

	Calibra light cured luting composite was delivered to the prepared tooth surfaces with its syringe tip (

	The right central incisor laminate was placed on the tooth surface (

	An instrument was used to lightly press each veneer to place (

. A brush was used to remove excess luting composite at the marginal areas (

Fig. 12 Instrument used to verify seating

	The metal matrix strips were removed from the inter-proximal areas distal the canines. The instrument was again used to verify the seat of each laminate veneer (

). The “stay put” property of Calibra aids in the positioning.

	The LED curing light was used to “tack” the laminates to place with a quick two second burst of light (

). Floss was used to remove excess proximal composite at this stage. A number 12 surgical blade was used to aid in removing inter-proximal excess.

	Final light curing for 10 seconds on facial and lingual surfaces of each laminate finished the cure (

).  The premolar veneers were applied in the same fashion.

	A small carbide finishing bur was used to remove excess cured luting composite at the margins. An Enhance Cup (Dentsply Sirona) was then used to polish all margins (

 shows the incisal view of the six anterior laminate veneers in place. The facial view of the finished case can be seen in 

	With this technique, I found that my delivery time and clean up was less than for my previous process. I found the Calibra kit with try-in pastes, multiple colors of luting composite, silane primer and phosphoric etching gel a complete system for placing laminate veneers. The viscosity allows for the above technique with direct placement on the prepared teeth. The material has a “stay put” property that assists in multiple placement. 

	In this article, I will demonstrate smile design principles that can help in achieving esthetics in a smile. The patient was a young woman who had benefitted from porcelain veneer placement to achieve a better smile. 

 you can see her smile as she presented to me. She had porcelain veneers in place on teeth numbers 8, 9 and 10. The clinician who place these restorations was obviously talented and achieved an excellent color match and marginal integrity as well as good anatomy. In a photograph the patient brought with her (

), you can see her original smile before treatment. The left maxillary central incisor had an incisal edge fracture that had been smoothed off. She also exhibited a central diastema.

Fig. 1                                                                      Fig. 2

More from the author: How to restore Class V restorations with EPIC-TMPT

	In nature, the average adult maxillary central incisor is 10 mm long. The ratio of width to length is normally 70 to 80 percent. So the average width is about 7.5 mm. The maxillary central incisor should be about 1.6 times as wide as the adjacent maxillary lateral incisor and the central incisors should be as close to mirror images as possible. 

In this article, I will demonstrate smile design principles that can help in achieving esthetics in a smile.

Dr. Ross W. Nash

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