a c c re d i t a t i o n essentials
I N T HIS S ECTION :
• Clinical Case Report: Direct Veneers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .page 36
• Interview with the Candidate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .page 42
• Examiner’s Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .page 43
by
Robert W. Erlach, D.D.S.
Dr. Robert Erlach graduated from
the University of California at San
Francisco School of Dentistry in
1986. He then joined the U.S.
Army and completed a 1-year
General Dentistry Residency before
serving in Korea and in the 82nd
Airborne Division. Dr. Erlach main-
tains a private practice in Santa
Rosa, California, with an emphasis
on cosmetic dentistry. He still serves
as a Lieutenant Colonel in the U.S.
Army Reserves. He and his wife,
Josephine, enjoy travel, hiking, and
scuba diving.
36 THE JOURNAL OF COSMETIC DENTISTRY • WINTER 2002
“Reprint with permission, Journal of Cosmetic Dentistry, ©2009
American Academy of Cosmetic Dentistry, All Rights Reserved.
Telephone (608) 222-8583; Fax (608) 222-9540; www.aacd.com”
CLINICAL CASE REPORT: DIRECT VENEERS
INTRODUCTION
Enhancing or rehabilitating a smile using directly sculpted and polished com-
posite resin veneers can be one of the most rewarding challenges in cosmetic den-
tistry. Direct resin veneers give the cosmetic dentist full control over color, con-
tour, and surface texture. Occlusion must be carefully studied in advance to min-
imize unfavorable forces on these restorations and ensure that they will provide
years of service. The result can be a fabulous smile that is gratifying for both the
patient and the dentist.
H I S TO RY
The patient is a 14-year-old female with a history of asthma. She carries a
Proventil® inhaler, but does not need it on a regular basis. A local pedodontist and
orthodontist referred her. The orthodontist had been forced to remove her brack-
ets early due to severe decay of the upper anterior teeth. Although she had been
warned in advance of the consequences of her poor home care, the patient and her
mother were horrified to see her smile when the upper brackets came off.
C L I N I CA L DATA
Upon clinical examination, no soft or hard tissue pathology was noted either
externally or within the oral cavity. Her temporomandibular joint and associated
musculature was free from pain and she had good range of motion with no para-
functional habits. Her occlusion was class I molar and class I cuspids with 3 mm
vertical and 3 mm horizontal overbite. Some minor rotations remained in the
upper anterior segment after early removal of the orthodontic appliances. Her
upper lip was thin relative to her lower, which was full and symmetrical.
The patient presented with long-standing moderate to severe gingivitis, which
was compounded by a tendency for mouth breathing. The etiology was plaque and
poor oral hygiene. All upper anterior teeth were ravaged by caries, both facially
and interproximally. Additionally, the weakened facial surfaces were severely
stained and had been damaged by removal of her brackets.
VOLUME 17 • NUMBER 4
 a c c re d i t a t i o n essentials
D I AG N O S I S 4. Direct resin restorations of deep 13. ViscoStat® (Ultradent; South
interproximal caries #7M, #8M,D; Jordan, UT)
• Facial caries ##4-13 with interprox-
#9M,D; and #10M. 14. Optibond Solo Plus (Kerr; Orange,
imal caries #6M, #7M,D; #8M,D;
5. Direct resin veneers to lengthen CA)
#9M,D; #10M,D; and #11M.
and align ##4-13. 15. Optilux 400 curing light
• Recurrent decay around occlusal
6. Replacement of direct compos- (Demetron; Danbury, CT)
composites #12MO, #13O.
ites on #12, #13 occlusal. 16. Apollo 95E PAC light (DMD;
• Moderate to severe gingivitis with
7. Reinforcement of home care. Woodland Hills, CA)
swollen papillae. Unesthetic gingi- 17. Bard Parker (Franklin Lakes, NJ)
val contours. #12 and #15 blade
• Short clinical crown of upper bicus- A R M A M E N TA R I U M 18. Thompson Dental Mfg. Co.
pids. 1. Alginate (Teledyne; Elk Grove (Missoula, MT) #6 Composite
Village, IL) and stone for diagnos- instrument
T R E AT M E N T P L A N tic models 19. IPC instrument (Cosmedent;
2. 35 mm camera (Yashica Dental Chicago, IL)
The goal of this patient’s treatment
Eye III [Kyocera Corp; Tokyo, 20. A s t r o p o l ( I v o c l a r / Vi v a d e n t ;
was to restore her smile in a manner
Japan]) Amherst, NY) polishing cups,
that would provide a beautiful and
3. Oroscoptic 4.2X loupes wheels, and points
durable result. The treatment 4. Diamond burs #5856L-016, 21. Point 4 microhybrid composite
sequence was as follows: #8856-018, 8392-016 (Brasseler; (Kerr)
1. Diagnostic photos and study Savannah, GA) 22. Renamel microfill composite
casts. These were used for analysis of 5. ET9 and ET9F finishing burs (Cosmedent)
tooth and face proportions, as well as (Brasseler) 23. Creative Color opaquers and tints
to study occlusal considerations. 6. Diamond finishing strips (Cosmedent)
2. Oral hygiene instruction and pro- (Brasseler) 24. Enamelize and Flexibuff disks
phylaxis. No subgingival calculus was 7. #245 Carbide bur (Midwest Dental (Cosmedent)
evident, but poor oral hygiene and Products Corp.; Des Plaines, IL) 25. FlexiDisks and FlexiStrips
severe inflammation of gingiva are not 8. #6 Latch type round bur (Cosmedent)
compatible with excellent results. This (Midwest) 26. Gingival retraction cord
would be our biggest challenge. 9. #7408 bur (Midwest) (Ultradent)
3. Gingivectomies as needed to 10. Caries detector (Kuraray; Beth- 27. Perforated stock trays (COE;
improve height-to-width ratio. This page, NY) Chicago, IL)
will also be necessary to improve gingi- 11. Mylar strips 28. 35% phosphoric acid (Ultradent)
val form. 12. Cut stainless steel matrix strips

Figure 1: Full-face before. Figure 2: Correction of misalignments and

enhancement of buccal corridors was desirable
(unretracted before smile 1:2 view).

VOLUME 17 • NUMBER 4 WINTER 2002 • THE JOURNAL OF COSMETIC DENTISTRY 37

 a c c re d i t a t i o n essentials
P R E PA R AT I O N speed handpiece. The preparations instrument (Cosmedent) and the
were checked with a caries detector mylar matrix. At this stage, a single
Three weeks prior to preparation,
(Kuraray) and residual caries removed. “prep shade” composite was chosen
diagnostic photos and impressions
Marginal enamel was beveled using an that later could be etched and
were taken to document and study the
8392-016 medium flamed-shaped dia- veneered along with the facial and
case (Figs 1-4). Prophylaxis was com-
mond (Brasseler). The facial enamel incisal surfaces.
bined with oral hygiene instructions. It
was severely decalcified, but this would Smile analysis consisted of a careful
was made clear to the patient that the
be prepared at a later step. study of preoperative photos to deter-
gingival inflammation had to be
The interproximal lesions were mine desired incisal edge positions,
reduced markedly prior to restoring her
restored two at a time. Mylar matrix gingival zeniths, and contact points in
case. The mother and patient were
strips were placed to protect adjacent harmony with the patient’s lip line.
motivated and returned for two addi-
surfaces, and then the dentin and Measurements on the study models
tional visits for reinforcement of oral
enamel were etched for 15 seconds suggested that an additional 1.5-2 mm
hygiene and rubber cup polishing using
with 35% phosphoric acid. After of clinical crown length was desirable.
a fluoride paste. Although not elimi-
washing thoroughly, the preparations Desired length-to-width ratio of 1.2
nated, the gingival inflammation was
were gently air-dried to rid them of would improve the proportions of the
reduced significantly. The irregular
excess moisture. Optibond Solo Plus patient’s teeth, as the central incisors
gingival architecture did not change
(Kerr) was applied with agitation for were nearly as wide as they were long.
and gingivectomies would be necessary
20 seconds to the etched but slightly A longer, tapering ovoid or square
to improve height-to-width ratios of
moist preparations. Treated prepara- tapering tooth form was the goal. With
all the teeth. It was decided to proceed
tions were cured for 6 seconds from gingival recontouring, 1 mm of addi-
with the case.
facial and lingual using a PAC light tional length could be gained and an
Preparation started on the four
(DMD). Tetric Flow A2 was applied to additional 1 mm of length added to the
upper anterior teeth by treating the
the dentin surfaces as a liner to ensure incisal edge of the restorations.
interproximal decay on #7M, #8D,
excellent adaptation of the restora- The gingival contouring was done
#8M, #9M, #9D, and #10M as separate
tions to the tooth/resin interface. on ##7–10 using a #15 Bard-Parker
class III restorations. A rubber dam
Point 4 A2 microhybrid composite scalpel, followed by ViscoStat®
was placed from teeth ##5-12. Decay
(Kerr) was condensed into the prepa- (Ultradent) for hemostasis (Fig 5).
was removed with a 245 carbide bur
rations and sculpted with an IPC Because the patient’s tissues were still
and #6 round bur (Midwest) on a slow-

Figure 3: Facial and interproximal decay would Figure 4: Improvement in oral hygiene and health
need to be treated concurrent with esthetic plan would be critical in this case (retracted before
(unretracted before right lateral 1:2 view). facial 1:1 view).

38 THE JOURNAL OF COSMETIC DENTISTRY • WINTER 2002 VOLUME 17 • NUMBER 4

 a c c re d i t a t i o n essentials
somewhat edematous, a #1 gingival
retraction cord (Ultradent) saturated
with aluminum chloride was packed in
the sulcus to retract the tissue and pre-
vent seepage of crevicular fluids onto
the preparations. I have found that
using a new scalpel blade for each
tooth, followed by application of
ViscoStat® prior to preparation, yields
a predictable result with virtually no
postoperative discomfort. In combina-
tion with an impregnated cord, tissue
was managed yielding good visibility
and complete moisture control.
Because the midline was deter-
mined to be acceptable and tooth
width would not be changed, it was
decided to prep one tooth at a time.
Preparations were accomplished using
Brassler course round end diamonds,
creating a light chamfer at the gingival
margin, interproximally and overlap-
ping the incisal edge. In this case, a
chamfer margin was chosen over a
long bevel to ensure that all superficial
decalcification was removed near the
margin. A gingival chamfer also would
aid in precise margin placement,
which was needed in this case to
enhance moisture control. The incisal
edge was prepped in such a way as to
mimic a basic mamelon pattern and
break up any straight line (Fig 6). Due
to the extensive facial decay, some
areas were prepped into dentin and the
preparations appeared much like those
for indirect porcelain veneers.
Interproximal margin placement
extended to a point where the margin
would not be obvious if a color demar-
cation was present between tooth and
resin. The preps were polished with a
fine chamfer diamond.

Figure 5: Gingivectomies to improve gingival Figure 6: The incisal edges were prepped to avoid
contours and height-to-width ratios. the appearance of a horizontal line.

A2 Point 4
T1 Point 4
A2 Renamel MF
A1 Renamel MF

Figure 7: Mamalon development was sculpted into Figure 8: Layers were placed to mimic the natural
each direct veneer and cured. tooth structure.

VOLUME 17 • NUMBER 4 WINTER 2002 • THE JOURNAL OF COSMETIC DENTISTRY 39

 a c c re d i t a t i o n essentials
BONDING AND
SCULPTING
Adjacent teeth were protected with
a section of stainless steel matrix while
the tooth being bonded was etched
with 35% phosphoric acid for 15 sec-
onds. The prepped tooth was washed
with copious irrigation for 5 seconds
and excess moisture blown away. Due
to exposure of significant dentin,
Optibond Solo Plus (Kerr) was used to
bond the restorations. The adhesive
was applied to the slightly moist tooth
structure with a micro brush and agi-
tated for 20 seconds. Excess adhesive
and solvent were removed with a
stream of dry air, leaving a shiny sur-
face. All areas of the preparation were
cured for 6 seconds with a PAC light
(DMD).
The first layer of composite resin
applied was Point 4 A2 (Kerr), to
extend the incisal edge to approxi-
mately 1 mm short of its final position.
This would be my dentin replacement
material. It was chosen for its combi-
nation of strength and polishability.
Point 4 could have been used for the
entire restoration, but I prefer using a
microfill for the final facial surface.
The dentin layer was sculpted with a
washed, gloved finger (my favorite
sculpting instrument), IPC
(Cosmedent), and Thompson #6 to
mimic mamalon development and
leave room for translucent composite
at the incisal edge, between the
mamelons and at the incisal-inter-
proximal transition (Fig 7). This layer
was fully cured with a PAC light
(DMD). Next, a judicious amount of
Creative Color A2 opaquer (Cosme-
dent) was applied with a fine sable
40 THE JOURNAL OF COSMETIC DENTISTRY • WINTER 2002
brush to highlight the mamelon devel- identical fashion. The canines and
opment and mask the transition from premolars were done at a subsequent
tooth to microhybrid resin. The opa- visit and included gingivectomies to
quer layer was cured for 60 seconds improve the appearance of the buccal
with a standard halogen light. corridors.
To accentuate the incisal character,
Point 4 T2 microhybrid (Kerr) was FINISHING
used to build the incisal edge to full
The restorations were shaped with
length. The translucent composite was
an 8-fluted ET9 finishing bur
blended to the facial, interproximal,
(Brasseler) and Flexidisks (Cosme-
and lingual using a finger and IPC.
dent). A 12 fluted 7408 football-
Care was taken to leave 0.5 mm of
shaped bur (Midwest) was used to
room on the facial for the final layer of
shape the lingual slopes. When the
microfill resin. This layer was cured
final gross contours were achieved,
with a PAC light for 6 seconds from
Astropol points were used to define
facial and lingual.
facial developmental lobes and lingual
Renamel Microfill Resin A2
concavities. Gingival areas were fin-
(Cosmedent) was used to form the gin-
ished with Astropol cups. Fine
gival third of each tooth. Mylar matri-
Flexidisks combined with Brasseler
ces were placed interproximally and
diamond interproximal finishing strips
used to pull the microfill into the con-
were used interproximally, although
tact area flush with the margins of the
most of this finishing had been done
preparations prior to curing. The A2
previously. Careful attention was given
microfill was beveled to disappear at
to reproducing developmental lobes
the junction of the gingival and mid-
and avoiding overuse of disks, which
dle thirds of the tooth. Once shaped,
tend to flatten the facial surface. At
this layer was cured with a halogen
this point, we finished with the fourth
light for 60 seconds. The entire facial
appointment, took a series of photo-
surface was then veneered with
graphs, and made another appoint-
Renamel Microfill A1, again using the
ment to complete the case.
mylar matrices to pull the excess into
After evaluation of the mid-treat-
the contact area to seal the interproxi-
ment photos, some minor changes in
mal margins. Due to the prior contour-
contour were made and restorations
ing of deeper layers, the A1 final layer
taken to a polish with Astropol fine
had minimal thickness at the gingival
points and cups. Unfortunately, the
to yield a warmer A2 shade. Also, only
patient’s oral hygiene had slipped and
a thin layer was beveled to the incisal
final polish and evaluation had to be
so as not to mask the carefully placed
delayed. Oral hygiene was reinforced
incisal characteristics. This final layer
using an Oral B 3D (Gillette;
was cured using a halogen light for 60
Kronberg, Germany) electric tooth-
seconds. The resin layer placement is
brush and dental floss. After several
summarized in Fgure 8. The four upper
other visits to monitor the progress of
anteriors were sculpted and rough fin-
her home care, the final polish was
ished during this appointment in an
VOLUME 17 • NUMBER 4
 a c c re d i t a t i o n essentials

Figure 9: Patient, mother, and dentist were all Figure 10: A beautiful smile is a great social asset
thrilled with the results of treatment (full-face). (unretracted after smile 1:2 view).

Figure 11: Improved home care and ideal gingival Figure 12: Natural contours, finish, and internal
contours promote periodontal health color combine to create beautiful restorations
(unretracted right lateral 1:2 after). (retracted after 1:1 view).

achieved using the finest Flexidisks,
Astopol points and cups followed by
Enamelize (Cosmedent). Another
appointment was made for postopera-
tive photos 1 week later (Figs 9-12).
CONCLUSION
Remarkable esthetic and functional
results can be achieved with direct
resin veneer restorations. This proce-
dure gave this young lady a second
chance after poor oral hygiene during
the course of orthodontic treatment
taken to a high level of excellence.
Additionally, direct resin veneers
allow the cosmetic dentist to better
understand the process of smile design
from start to finish.
____________________
REFERENCES
1. Miller MB, ed. Direct resin veneers. Reality 15
Section 3, The Techniques, 2000.
2. Willhite C. Complex bonding. AACD Journal
Winter 1997, 16-23.
3. Willhite C. Dramatic smile makeovers using
direct resin veneers. Compend Cont Ed Dent
18(7):646-656, 1997.
5. Terry DA. Enhanced resilience and esthetics in a
class IV restoration. Compend Cont Ed Dent Supp
26:19-25), 2000.
6. Fahl. N, Jr. Achieving ultimate anterior aesthet-
ics with a new microhybrid composite. Compend
Cont Ed Dent Supp 26:4-13, 2000.
7. Moppe, KW, O’Malley M. The Renamel
Restorative System Illustrated Technique Guide (pp.
29-35). Chicago, IL; Cosmedent, rev. 1994.
8. Lee KK, Tam LE, McComb D. The fracture
resistance of dentin composite interfaces. AACD
Journal, Winter 1999, 17-22.
____________________
❖

ended in horror. Patient satisfaction is 4. Ubassy G. Shape and Color—The Key to Successful
Ceramic Restorations (pp. 197-210). Berlin,
incredible for this procedure when Germany; Quintessence Publishing, 1993.

VOLUME 17 • NUMBER 4 WINTER 2002 • THE JOURNAL OF COSMETIC DENTISTRY 41

 a c c re d i t a t i o n essentials
by
Corky Willhite, D.D.S., F.A.A.C.D.
Dr. Willhite has been in private practice
since he graduated from LSU School of
Dentistry in 1979. He quickly became
interested in cosmetic dentistry and pursued
hundreds of hours of continuing education.
Many of these courses were sponsored by
the A.D.A. and the A.G.D., organizations
in which he still maintains membership. In
1990 he attended his first AACD Annual
Meeting and hasn't missed one since. He
achieved Accreditation and, as his slide col-
lection grew, was asked by his colleagues to
share his knowledge. One thing led to anoth-
er, and he is flattered to have had the oppor-
tunity to lecture across the country and
internationally, as well as publish articles on
cosmetic dentistry. In the meantime, he has
served in several leadership positions in the
AACD, as well as 2 years as President of
the Louisiana Chapter. Since 1995 he has
served as an Examiner for Accreditation
and in 1999 was elected to the first Board of
Governors. In 1997 he achieved his
Fellowship, and in 1998 he was invited to
join the faculty in the Department of
Prosthodontics at LSU, where he is an
Assistant Clinical Professor. He believes in
giving back to the community and regularly
donates dentistry to those in need. Over the
years, his practice has evolved to provide
almost exclusively cosmetic and restorative
services. Dr. Willhite lives in New Orleans
with his wife and two "mostly enjoyable"
teenagers.
42 THE JOURNAL OF COSMETIC DENTISTRY • WINTER 2002
INTERVIEW WITH THE CANDIDATE
I N T E R V I E W W I T H R O B E R T W. E R L A C H , D. D. S .
B Y C O R K Y W I L L H I T E , D. D. S .
QUESTION
What were the main reasons that led you to treat this patient with direct resin veneers,
as opposed to porcelain?
ANSWER
This case could have been done either way. The patient’s occlusion was ideal for
direct veneers but enough tooth structure had been damaged by decay that the preps
needed to be aggressive anyway. She had been treatment-planned for individual
composite restorations by her referring dentist. I decided to take on the case pro
bono when her oral hygiene improved. I was looking for a dramatic case for
Accreditation and the patient and her mother understood the time commitment. It
was a good deal for all involved.
QUESTION
How often do you utilize direct resin in your practice? What percentage of ‘smile
makeover type’ cases are direct?
ANSWER
Direct resin is my bread and butter in posterior cases. I favor using it for anteri-
or cases when only a few teeth are involved because I usually can get the best match
of color and contour. The condition of the teeth and the patient’s occlusion are key
in my decision. I do about 25% of my smile makeover cases with direct resin.
Although I would love to do more cases like this, I do only two or three cases a year.
When the teeth are in good shape or if the patient is thinking about a more exten-
sive smile makeover in the future, direct resin is a great choice.
QUESTION
How long did it take you to complete this case?
ANSWER
Approximately 12 hours of chair time. I also spent that much time on smile
analysis, photography, reviewing slides, and working with the patient on improving
her oral hygiene. You have to want it!
VOLUME 17 • NUMBER 4
 a c c re d i t a t i o n essentials
QUESTION
Would you do anything differently if
you were starting over?
ANSWER
Although this was a tough case for
Accreditation, I had the luxury of
already having completed a good
direct veneer case before I started this
one. I was happy to help this patient
out and I thought a dramatic ‘before-
and-after’ would help my overall pres-
entation.
QUESTION
Did you give the patient any incentives
to be cooperative with the extra time
demands of an Accreditation case?
EXAMINER’S PERSPECTIVE
Dr. Erlach’s Direct Resin Veneers
case is the type that all Examiners like
to see because it is a “slam dunk” in the
sense that, although it may not be per-
fect, there are so many things right and
so few that are questionable. In fact,
there was unanimous agreement to
pass this case. The only issues that
were even mentioned as minor faults
had to do with tooth #7 and tooth #10.
These gingival contours could have
been a bit more rounded (#7 is very
tapered) especially as a gingivectomy
was done on ##7-10 anyway. (Note
that minor faults may not even be vis-
ible unless the image is magnified as,
for example, in a presentation room.)
The axial inclination of #7 is not
ideal either, as it appears the tooth’s
VOLUME 17 • NUMBER 4
ANSWER
This was a pro bono case. The
patient and her mother were extreme-
ly understanding and cooperative
about the time commitment.
QUESTION
Do you have any words of wisdom for
candidates about to start their direct resin
veneers case?
ANSWER
Start preparing early. Unlike the
laboratory-fabricated cases, you have
to do it all. Gain some knowledge and
experience through continuing educa-
tion and restoring your patient’s teeth
a few at a time. Once you have devel-
inclination is out of alignment with
the adjacent teeth. The “before” pho-
tographs show that this was pre-exist-
ing and this is considered by the exam-
iners. It would have been considered a
more major fault if it hadn’t been pres-
ent preoperatively and had been creat-
ed as a result of the treatment.
This brings up an important issue
that calls for more explanation. A dif-
ficult case that provides dramatic
“before-and-after” pictures doesn’t get
“bonus” points of any sort just because
of its difficulty level. If a very difficult
case is treated so well that it meets the
criteria as described in A Guide to
Accreditation Criteria (available from
the AACD Executive Office), it will
pass just as a less difficult case would.
WINTER 2002 • THE JOURNAL
oped a system that works for you, you
just need to find a case to do 6 to 10
teeth. Try to find an easier case than
this one, but don’t be afraid to go for it.
Also, I found that studying the
Accreditation examination criteria
was useful for all my cases. The
Examiners really do apply the criteria
when they grade the cases.
____________________
But if a tough case doesn’t meet the
criteria, it will fail, no matter how big
an improvement was achieved. All
candidates are encouraged to select
cases carefully and to avoid choosing
the more difficult ones for their
Clinical Case Reports.
With all the details that have to be
attended to as one works toward
Accreditation, it’s foolish to increase
the work and pressure, as well as the
risk of failure, by treating an extremely
difficult case. This case demonstrates
not only excellent direct resin veneers,
but great case selection, as well. The
importance of that can’t be empha-
sized enough!
____________________
OF COSMETIC DENTISTRY 43