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treatment are usually numb at the time of insertion, the author typically does not perform evaluation of the provisional restorations until 24 to 48 hours later. In this case, the patient returned 24 hours later for photographs and a thorough evaluation, which included any necessary adjustments. Once the provisionals were approved (Figure 5), photographs and an impression were sent to the ceramist so he could replicate the shape, size, and position of the restorations exactly. Final restorations When the restorations were returned, they were tried on the models and evaluated for any modi cations prior to the insertion appointment (Figure 6 through Figure 8). e laboratory was given speci c instructions to not treat the intaglio surfaces prior to returning the restorations. ese particular restorations were made from lithium disilicate porcelain. When received, they were treated with Porcelain Etchant 9.5% Hydro uoric Acid (BISCO, bisco. com) (Figure 9), rinsed, and silanated with two-part silane. On the day of insertion, the patient was anesthetized and the provisionals were removed. Each preparation was airabraded with an air abrasion system (PrepStart™, Zest Dental Solutions, zestdent.com) using 50-micron aluminum oxide particles. e restorations were tried in for t and aesthetics. Upon removal, the restorations were cleaned with Uni-Etch® (BISCO) 32% phosphoric acid etchant with benzalkonium chloride (BAC), rinsed, dried, and re-silanated. Isolation protocol e author considers isolation to be a critical step in achieving ideal bonding. His isolation protocol of choice is individual tooth isolation utilizing heavy-gauge latex rubber dam (Nic Tone, nic-tone. ro). Primary clamps were placed on the second molars, and the teeth were isolated individually from the upper right second molar to the upper left second molar. Veneers were placed two at a time starting with the central incisors. To ensure complete isolation and that there would be no impeding of seating from the rubber dam, accessory clamps (B4 Brinker, Coltene Whaledent, coltene.com) were utilized. As is the author’s custom, a nal try-in prior to cementation was completed following isolation (Figure 10). e tooth surfaces were etched with Uni-Etch 32% phosphoric acid etchant with BAC for 15 seconds. e preparations were thoroughly rinsed and blot-dried with a cotton roll to avoid desiccation. Two separate coats of All-Bond Universal® (BISCO) were applied, scrubbing the preparations for 10 to 15 seconds between

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Fig 10. Dry try-in prior to cementation after isolation with rubber dam and B4 accessory clamps

Fig 9. 9.5% hydrofluoric acid being applied to intaglio surface of veneer

Fig 12. Veneers Nos. 8 and 9 seated following 3-second tack-cure

Fig 11. Veneer being loaded with veneer cement

Fig 14. Veneers Nos. 6 and 7 following cementation protocol

Fig 13. Teeth Nos. 6 and 7 isolated with accessory clamps in preparation for veneer insert

Fig 16. Postoperative upper arch, retracted view with black contraster

Fig 15. Full smile, postoperative. Patient was exceedingly pleased with her rejuvenated smile and the aesthetic outcome achieved with 10 maxillary lithium-disilicate porcelain veneer restorations

Conclusion Delivering beautiful aesthetic dentistry is not a two-step, “before and after” process. Multiple steps 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. u Acknowledgement: e author thanks the ceramist on this case, Julian Cardona, CTG, of Guayaquil, Ecuador.

each coat 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. e veneer was lined with Porcelain Bonding Resin (BISCO), a HEMA-free, un lled resin that acts as a wetting agent. e veneer was lled with translucent veneer cement (Choice™ 2, BISCO) (Figure 11) and seated (Figure 12). Each veneer was tack-cured for 3 seconds, excess cement was removed, and a nal cure of 40 seconds per surface was completed. e accessory clamps were removed and moved to the adjacent two teeth (Figure 13 and Figure 14), and the same protocol was followed for all remaining teeth. Following removal of the rubber dam, excess cement was evaluated under a 3D dental microscope (PromiseVision 3D, Seiler, seilermicro.com). Occlusion was adjusted and the patient was dismissed. e patient returned in 1 month for postoperative follow-up and photographs, which revealed a highly esthetic, successful outcome (Figure 15 and Figure 16).

Disclosure: is article was commercially supported by BISCO.

About the author Adamo E. Notarantonio , DDS

Clinical Instructor, Honors Aesthetic Program, New York University College of Dentistry, New York, New York; Private Practice, Huntington, New York; Fellow, International Congress of Oral Implantologists; Fellow, American Academy of Cosmetic Dentistry

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