Examination and Analysis 

A problem-focused examination of the anterior teeth with the aforementioned veneers that were placed just a few short hours ago was completed. No x-rays were taken on this day, and a comprehensive examination was not appropriate at this time. The questions to be answered were simple but the answers were not. What was wrong? What could be done? If something was wrong, how would I convey that to the doctor who treated Gina that morning? Should I consider doing something and assume the responsibility/liability that would occur immediately after touching the veneers? Do I send Gina back to the practitioner who placed the veneers? This was a medicolegal and ethical dilemma.

     Examination revealed improper axial inclinations, open margins, poorly shaped veneers, and gross cement excess (Figure 1). I went into my private office, called the treating dentist, and discussed the situation. I described what I saw and he said I should send her back to see what he could do. I told him I would suggest that and the decision would be hers to make. I felt I had fulfilled my obligation to a colleague; however, I had mixed feelings about it. I was troubled because I had already seen what he had done. When I spoke with Gina, she refused to go back. Now what? As you see, this is a true dilemma; you observe technically substandard care and yet do not want to be held liable if you touch the previous dentist’s completed case. 

     I empathized with this young woman and wanted to help her but at the same time protect myself from liability for what another practitioner had done. I wrote a simple statement describing the situation, what I would do on an emergency basis, and that this care was not a substitute for a comprehensive examination and future treatment to correct the problems. I concluded this statement with Gina, agreeing I would not be responsible if the laminates were to chip or break when I adjusted them. She signed the statement in the presence of my clinical assistant, who witnessed it. The "release of liability" statement I created is in Figure 2. 

     Without belaboring the point, the deficient margins and residual cement are some examples of what I saw (Figure 3). With some recontouring and repolishing, I was able to improve the existing veneers somewhat by correcting the shapes and axial inclinations, allowing Gina to go out without feeling embarrassed. The poor margins were not addressed at this time. A few days later, we took a complete history and performed a complete evaluation. This included a visual oral cancer screening and examination of all soft and hard tissues. A subsurface examination for abnormal tissues was performed with the VELscope (LED Dental). Periodontal evaluation was done with a 3-6-9-12-mm probe (Premier PerioWise [Premier Dental]), a full-mouth series of x-rays was taken, and diagnostic model impressions were made using an alginate substitute (Position Penta Quick VPS Alginate Replacement [3M ESPE]) in a stock tray (Originate Disposable Impression Tray [AXIS Dental]).

     It was apparent that this lovely young woman had many problems that needed care, in addition to her smile. However, she opted to deal with her veneers before taking care of the other necessary restorations. In order to determine what Gina wanted her smile to look like, we spent time reviewing photos of various smile designs, tooth shapes, and discussed shades and incisal translucencies. Dental terminology was avoided and a simple "I like it" or "I don’t like it" from Gina helped me to understand what her preferences were. A diagnostic aesthetic wax-up for 8 new veneers was created based on the information gathered during our conversation. She reviewed the wax-up and said she liked it.

 On insertion day, the veneers were tried in individually for overall fit and marginal integrity. All veneers were then tried together to be sure the contact areas were properly designed with no excess pressure that would disallow any veneer from seating properly. A water-soluble try-in gel (Prevue [Cosmedent]) was used to ascertain the shade of resin cement (Insure [Cosmedent]) used for cementation of the veneers. When Gina and I were satisfied with the preview, the veneers were removed, all try-in paste was washed out, and the veneers thoroughly cleaned. A prehydrolyzed silane ceramic primer (RelyX Ceramic Primer [3M ESPE] was brushed on the pre-etched inner veneer surfaces and allowed to dry. A thin layer of resin adhesive (Adper Single Bond Plus Adhesive [3M ESPE]) was brushed onto the silanated veneer surfaces and air-thinned. The selected shade of resin cement was placed in each veneer in an incisal-gingival direction and all veneers were placed in a covered storage container (ResinKeeper Mixing and Storage Palette [Cosmedent]) to keep the resin cement from setting prematurely.

     The temporaries were removed and the teeth cleaned with pumice (Consepsis Scrub [Ultradent Products]) in a prophy cup. Floss was used to remove any remaining prophy paste interproximally. A final surface cleaning was gently performed using a microetcher (MicroEtcher IIA [Danville]). Then, the prepared teeth were etched with a 35% phosphoric acid gel (Ultra-Etch [Ultradent Products]), rinsed, and dried. A thin layer of the resin adhesive was brushed onto the teeth, air-thinned, and cured. It is this author’s preference to insert both central incisor veneers simultaneously followed by 2 or 3 veneers at a time on one side, then the other side. Each veneer was tacked in place for 2 to 3 seconds with a halogen curing light (Optilux 501 [Kerr Demetron]), gross excess cement removed, and final curing for 60 seconds was done on each veneer. The gingival margins were cleared of any excess. 

     Because Gina had expressed a desire for "more rounded corners" while wearing her temporary restorations, the incisal angles were gently rounded with a very fine diamond (888-012VF [SS White]) and polished (Jazz P3S Porcelain & Metal 3-Step Polishing System [SS White]) to bring the porcelain back to a high luster. Her completed smile is seen in Figure 8, and even more telling are the before and after images seen in Figures 9 and 10. This case started out as a medicolegal and ethical dilemma, but ended with an excellent result that satisfied the patient, giving her a renewed sense of trust.

A Michigan State University surgeon is teaming up with a Lansing-area dental benefits firm on a clinical trial to create a simple, cost-effective saliva test to detect oral cancer, a breakthrough that would drastically improve screening and result in fewer people dying of the world’s sixth most common cancer.
Barry Wenig, a professor in the College of Human Medicine’s Department of Surgery and lead investigator on the project, is working with Delta Dental of Michigan’s Research and Data Institute to compile study data and recruit dentists. The study will enroll 100-120 patients with white lesions or growths in their mouths and tonsil areas to test as part of the clinical trial.
Wenig and his team will be looking for certain biomarkers previously identified by researchers at UCLA; the biomarkers have been shown in studies to confirm the presence of oral cancer. By creating a simple saliva test which could identify the biomarker’s presence, physicians and dentists would know which patients need treatment and which ones could avoid needless and invasive biopsies.
"Most white lesions are benign, so a majority of people who develop them are getting biopsies that are not needed," Wenig said. "Conversely, a simple test would allow us to identify those patients with malignant lesions and get them into treatment quicker."
Oral cancer has a poor survival rate linked to late detection, Wenig said: Only 60 percent of patients live beyond five years after diagnosis. Among black males, the survival rate is less than 38 percent.
"The key challenge to reduce the mortality and morbidity of oral cancer is to develop strategies to identify and detect the disease when it is at a very early stage," he said.
In addition to Delta Dental’s Research and Data Institute, which works with researchers from leading universities to monitor advances in science, Wenig is collaborating with PeriRx, a Pennsylvania company that will sponsor upcoming trials with the Food and Drug Administration.
"The results of this trial could be life changing for many people," said Jed Jacobson, chief science officer at Delta Dental and a licensed dentist. "It is a tremendous opportunity for the dental community to participate in what could be a groundbreaking research project."
Wenig and members of his team recently returned from southern California, where they met with UCLA colleagues, who are working to develop saliva diagnostic tests for other cancers as well.
"These tests are as noninvasive as it gets; patients simply need to spit into a cup," Wenig said. "The ease of the test will greatly expand our ability to effectively screen for the cancerous lesions.
"Right now, there are no early screenings available for most head and neck cancers."
The test also has the potential to accelerate health care savings, he added, since the number of biopsies can be dramatically reduced.