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Esthetic Rehabilitation of Worn te ot
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Abstract long-term success is determined by
ss e n c e
fo r
adhesive quality of the laminate veneers.
Bonded porcelain restorations are a pre- This case presentation demonstrates
dictable and durable treatment option restoration of anterior dentition where
with which not only esthetic appearance the wear of incisal edges posed a neg-
but also the strength and function of teeth ative effect on the smile of the patient.
can be re-established. One of the most Before bonded porcelain veneers were
important issues of today’s dentistry is adhesively cemented, incisal length-
the preservation of sound enamel. Fol- ening with direct resin composite and
lowing biomimetic principles, employ- gingival contouring was performed. By
ing minimally invasive applications and using the mock-up technique, minimal
adhesive technologies are of paramount preparations were made with the outline
importance for successful restorations. ending in enamel only. For cementation
The mock-up technique is advised for of these restorations, step-by-step ad-
delicate removal of the required space hesive procedures are presented.
for thin porcelain veneers minimally. Be-
sides minimally invasive preparation, (Eur J Esthet Dent 2011;6:298–313)
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Introduction porcelain restoration is determined on
ss e n c e
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the adhesive quality to these surfaces.
The incidence of non-carious tooth A number of clinical studies have con-
wear has shown an increase particularly cluded that bonded porcelain laminate
among the young population.1 Also, the veneer restorations delivered good re-
percentage of adults presenting tooth sults (over 90% survival) over a period of
wear increases from 3% at the age of 20 10 years.3-6 Among the failures, different
to 17% at the age of 70 years.1 The pro- kinds of fracture types were observed:
gressive nature of wear, especially when cohesive fractures of the ceramic or ad-
dentin is involved, requires instruction, hesive failures between the tooth and
monitoring, prevention, and restoration the restoration surface. The majority of
of the tooth material loss. the failures were however observed in
Several treatment options can be the form of fractures of the restoration.3
proposed to restore the loss of tooth Adhesive failures are rarely seen when
structure of anterior teeth. Full crowns enamel is the substrate.3-6 In princi-
have been proposed for many years ple, bond strengths of luting cements
as the treatment option of first choice. to enamel are usually up to 40 MPa,
However, this technique is considered sometimes even exceeding the cohe-
today as an invasive approach. Since sive strength of the enamel itself.7 Other
macro-retention is needed for such res- failures seen with laminate veneers are
torations, substantial removal of sound related to microleakage.3-6 Marginal de-
dental tissues are required. Due to the fects were often noticed when the lami-
great progress in adhesion to dental tis- nate veneers ended in existing direct
sues over the past few decades, more composite restorations.5 However, with
conservative restorative techniques can the new composite surface conditioning
be employed. The preservation of den- techniques examined with in vitro stud-
tal hard tissues can be achieved with ies, the problem of failures involving ad-
predictable results by using laminate hesive cementation to aged resin com-
veneers over full crown preparations.2 posite restorations could be solved.8-10
When the color of the substrate (teeth) Unfortunately, the clinical studies often
is clinically acceptable, thin porcelain do not provide information on the con-
laminate veneers (0.3–0.7 mm) can be ditioning of such underlying composite
used to correct shape, surface struc- restorations.3-6
ture, texture, and the position of the The present case report describes
teeth. However, it is not always possible the treatment of wear in the anterior
to mask intensive discolorations with dentition with thin porcelain laminate
thin laminate veneers. One of the most veneers. Important steps of the treat-
important steps with these delicate res- ment procedures included communica-
torations is the adhesive procedure to tion with the patient, gingival alignment,
both the tooth substrate and existing minimal preparations using the mock-up
restorations on the tooth as well as the technique, and surface conditioning of
cementation surface of the restorative different substrates during bonding of
material. The success of the bonded such thin laminates.
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Fig 1 Natural smile of the patient before treat- Fig 2 Intraoral anterior view of teeth before treat-
ment. ment.
Fig 3 Incisal lengthening of teeth from 12 to 22 Fig 4 Natural smile of the patient with direct com-
with direct composite restorations. posite restorations.
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mally invasive preparation of hard dental As an alternative to orthodontics,
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tissues using depth cutting burs, 5) ce- periodontal plastic surgery is recom-
mentation of the bonded porcelain res- mended to optimize gingival contours
torations, and 6) follow-up controls. before restorative treatment procedures
take place and is among the first objec-
Incisal lengthening with tives during treatment planning.14 Bone
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Fig 7 Waxup for mock-up technique. Fig 8 Photo-polymerization of the temporary com-
posite mock-up.
Fig 9 Removal of the excess of composite material. Fig 10 Intraoral anterior view of mock-up.
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te which on ot
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ture no consensus is available on
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preparation-restoration complex is more
fracture resistant. Hui et al17 concluded
that the window preparation was the
strongest and most conservative resto-
ration. However, in a cyclic loading test
between natural teeth and different lami-
nate restorations with different prepara-
tions, no significant differences were
found.18 Moreover, in a clinical study,
after 2.5 years no difference was seen
Fig 11 Mock-up view during smiling. Note the im-
between the overlap or window prepa-
balance of tooth 23 in relation to the lip line. ration.19 The incisal overlap preparation
was used in this case report, as the den-
tal technician has maximum control of
the esthetic characteristics and translu-
cency. In this case, overlap preparation
was carried out by removing the direct
composite restorations only.
An additive diagnostic waxup (Fig 7)
was used to minimize the reduction of
sound tooth structure and to compen-
sate for the severe loss of tooth sub-
stance. Using the diagnostic waxup
transferred to a vacuum mold (Copy-
plast 2 mm, Scheu-dental, Iserlohn,
Fig 12 Length of tooth 13 corrected. Germany) (Fig 8) for the mock-up tech-
nique, a maximum control on reduction
is created by only removing a thin layer of
enamel or existing resin composite res-
toration that was necessary for the thick-
ness of the porcelain laminate veneer
(Figs 9–13). The mock-up was made of
a flowable resin composite (Grandio-
flow, Voco, Cuxhaven, Germany) as the
composite is easily adapted to the form
of the mold.
A chamfer preparation of approxi-
mately 0.5 to 0.8 mm is usually advised
for the outline of ceramic veneers.3,20,21
However, a uniform preparation of the
Fig 13 Length of the anterior teeth follows the buccal surface was not preferred as
lower lip line. enamel thickness was varying in the
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buccal region of the incisors.21 It has
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been reported that laminates bonded
on sound enamel have a good survival
rate since the enamel adhesion is ex-
cellent.7 Therefore, standard depth cut-
ting burs are not advised for laminate
veneer preparation,7 particularly not in
older patients where enamel thickness
is decreased.22 In this case, a minimally
invasive restoration with a preparation
depth of 0.1 to 0.3 mm in the cervical
region and 0.3 to 0.7 mm in the buccal Fig 14 Preparation of the depth grooves on the
region was preferred (Figs 14 to 16). The temporaries.
aim was to confine the preparation to
enamel wherever possible, especially at
the finishing line (Figs 18 to 20).
Cementation procedures
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Fig 17 Preparation with coarse diamond bur after Fig 18 Finishing cervical margins under micro-
removal of the temporaries. scope with ultrafine fine diamond bur.
Fig 19 Anterior view after preparations. Fig 20 Marginal view of the prepared teeth.
Fig 21 Porcelain laminate veneers ready for Fig 22 View of the thin porcelain laminate veneers.
cementation.
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Table 1 The brand names, type, manufacturers and compositions of the materials used in this casetreport.
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Product name Type Manufacturer Chemical composition
en
Miris2 Microhybrid Coltène-Whaledent Aromatic and aliphatic dimethacrylate
resin GmbH, Langenau, resin, Ba-Al-glass, pyrogenic SiO2 com-
composite Germany posite, camphorquinone
Table 2 Surface conditioning sequence of the inner surface of the porcelain laminate veneers.
Table 3 Surface conditioning sequence for the tooth and/or restoration complex.
3 Air abrasion of existing resin composite restorations using silicium dioxide (CoJet Sand)
7 Adhesive application on both the tooth and resin composite (no photo polymerization)
9 Photo-polymerization (5 s)
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Fig 23 Porcelain laminate veneers to be treated Fig 24 Hydrofluoric acid etching of the laminate.
with hydrofluoric acid and silane.
with good control of contamination. A increases the surface area and the pen-
shade match with the color of the select- etration of resin into the micro-retentions
ed cement was established through the of the etched surfaces, thereby promot-
try-in pastes. With no discoloration of the ing the adhesive bonding.26
underlying teeth, translucent cement of- After etching the laminates with hydro-
fered the best result. fluoric etching gel, a neutralizing agent
(IPS Ceramic Neutralizing powder, Ivo-
Surface conditioning of ceramic clar Vivadent) was used to neutralize
the acidic inner surface of the laminate
After cleaning the try-in cement paste, veneers. After etching with hydrofluoric
ceramic laminates were conditioned acid, a significant amount of crystalline
using a 5% hydrofluoric acid (IPS Ce- debris precipitates on the ceramic sur-
ramic etching gel, Ivoclar Vivadent, face.27 The debris contaminates the ce-
Schaan, Liechtenstein) (Figs 23–24). It mentation surface, as the access to the
is known that hydrofluoric acid selective- undercuts is then diminished. In a micro-
ly dissolves the glass or crystalline com- tensile bond strength test, it was found
ponents of the ceramic and produces a that ultrasonic cleaning was necessary
porous irregular surface.23-25 The micro- to remove the debris from the etched
porosities in the ceramic increases the surface.27 Therefore, the ceramics were
surface area and leads to micromechan- subsequently ultrasonically cleaned.
ical interlocking of the resin composite. Hydrofluoric acid etching was followed
The number and size of the leucite crys- by silanization. Using hydrofluoric acid
tals at the surface influences the forma- etching with silane, high bond strengths
tion of microporosities as a result of acid could be created even exceeding the
etching. Leucite dissolves better than cohesive strength of ceramic and the
the surrounding glass components in bond strength of resin composite to
hydrofluoric acid. This porous surface enamel.28
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Fig 25 Silica coating of the direct composite res- Fig 26 A transparent strip placed around the
torations using an intraoral air-abrasion device. tooth before cementation.
Fig 27 Phosphoric acid etched surface of tooth 12. Fig 28 Application of the bonding agent on tooth 12.
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The process of silanization after hydro- face treatment, ess un-
e nc e
fo r
fluoric acid etching diminishes the sur- converted C=C double bonds. These
face tension of the ceramic. Silane is a unconverted double bonds can contrib-
coupling agent that couples the inorganic ute to the adhesion of the luting cement
particles present in the glass ceramics to to the existing composite restorations.
the organic matrix of the resin cements. Recent studies demonstrated that con-
The silanol molecules that are formed af- ditioning the composites with silica coat-
ter reaction with water react on the silica ing, followed by silanization, increased
surfaces, forming covalent bonds.29,30 the bond strengths of resin-based ma-
The organofunctional group polymer- terials to indirect composites when com-
izes with the monomer of the resin com- pared to acid etching and silanization,
posites with the carbon double bonds of or using airborne particle abrasion with
the silanol. Reported results were also alumina followed by silanization.8,9,30
stable after long term water storage and After preparation, surface treatment
thermocycling.25,29 After silanization, 1 of the teeth was achieved with 30 s
min was allowed for evaporation of the etching of the enamel (38% phosphoric
ethanol/alcohol and condensation reac- acid, Ultradent, USA), and rinsing fol-
tion of the coupling molecules. lowed by adhesive application (Excite,
Ivoclar Vivadent, Liechtenstein). The
Surface conditioning of the teeth/ adhesive was not polymerized separ-
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Fig 30 Intraoral view of thin porcelain laminate Fig 31 Intraoral view of thin porcelain laminate
veneers at baseline. veneers after 1.5 years of clinical service.
Fig 32 Gingival tissue integration around the thin Fig 33 Lateral view of the laminate veneers dur-
porcelain laminate veneers. ing smiling.
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ing both esthetic and reliable function in
ss e n c e fo r
the treatment of incisal wear. The diag-
nostic mock-up and the adhesive pro-
cedures were important for the outcome
achieved. Based on the available infor-
mation from clinical and in vitro studies,
a cementation protocol is proposed es-
pecially when composite restorations
exist next to the enamel.
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8. Özcan M. The use of chair- veneers with different prepa- materials to enamel surfaces.
side silica coating for dif- ration designs after exposure ss e n c e
J Dent Res 1955; 34:849–853.
fo r
ferent dental applications: to masticatory simulation. J 29. Blatz MB, Sadan A, Kern M.
a clinical report. J Prosthet Prosthet Dent 2005;94:32–39. Resin-ceramic bonding: a
Dent 2002;87:469–472. 19. Meijering AC, Creugers NHJ, review of the literature. J Pros-
9. Özcan M, Alander P, Vallittu Roeters FJM, Mulder J. Sur- thet Dent 2003;3:268–274.
PK, Huysmans MC, Kalk vival of three types of veneer 30. Matinlinna JP, Lassila LVJ,
W. Effect of three surface restorations in a clinical trial: Vallitu PK. Evaluation of five
conditioning methods to a 2.5-year interim evaluation. dental silanes on bonding
improve bond strength of J Dent 1998;26:563–568. a luting cement onto silica-
particulate filler resin com- 20. Christensen GJ. Have porce- coated titanium. J Dent
posites. J Mater Sci Mater lain veneers arrived? JADA 2006;34:721–726.
Med 2005;16:21–27. 1991;122:81. 31. Roulet JF, Soderholm KJ,
10. Özcan M, Barbosa SH, Melo 21. Ferrari M, Patroni S, Balleri Longmate J. Effects of treat-
RM, Galhano GAP, Bottino P. Measurements of enamel ment and storage condi-
MA. Effect of surface con- thickness in relation to tions on ceramic/composite
ditioning methods on the reduction for etched lami- bond strength. J Dent Res
microtensile bond strength of nate veneers. Int J Peri- 1995;74:381–387.
resin composite to composite odontics Restorative Dent 32. Özcan M, Vallittu PK. Effect of
after aging conditions. Dent 1992;23:407–413. surface conditioning meth-
Mater 2007;23:1276–1282. 22. Atsu SS, Aka PS, Kucukes- ods on the bond strength of
11. Magne P, Belser U. Novel men HC, Kilicarslan MA, luting cement to ceramics.
porcelain laminate prepara- Atakan C. Age-related chang- Dent Mater 2003;19:725–731.
tion approach driven by a es in tooth enamel as meas- 33. Breschi L, Mazzoni A,
diagnostic mock-up. J Esthet ured by electron microscopy: Ruggeri A, Cadenaro M,
Restor Dent 2004;16:7–18. implications for porcelain Di Lenarda R, De Stefano
12. Gurel G. The science and laminate veneers. J Prosthet Dorigo E. Dental adhesion
art of porcelain laminate Dent 2005;94:336–341. review: Aging and stability of
veneers. Chicago: Quintes- 23. Calamia JR. Etched porcelain the bonded interface. Dent
sence Publishing Co, 2003. facial veneers: a new treat- Mater 2008;24:90–101.
13. Chang LC. Effect of bone ment modality based on sci- 34. Nakabayashi N, Kojima K,
crest to contact point dis- entific and clinical evidence. Masuhara E. The promotion
tance on central papilla N Y J Dent 1983; 53:255–259. of adhesion by the infiltra-
height using embrasure 24. Kramer N, Lohbauer U, tion of monomers into tooth
morphologies. Quintessence Frankenberger R. Adhesive substrates. J Biomed Mater
Int 2009;40:507–513. luting of indirect restorations. Res 1982;16:1240–1243.
14. Chu SJ, Tan JHP, Stappert Am J Dent 2000;13:60–76. 35. Paul S, Schärer P. The
CFJ, Tarnow DP. Gingival 25. Brentel AS, Özcan M, Val- dual bonding technique: a
zenith positions and levels of andro LF, Alarça LG, Amaral modified method to improve
the maxillary anterior denti- R, Bottino MA. Microtensile adhesive luting procedures.
tion. J Esthet Restor Dent bond strength of a resin Int J Periodontics Restorative
2009;21:113–121. cement to feldspatic ceramic Dent 1997;17:537–545.
15. Wang HL, Greenwell H. after different etching and 36. Magne P, Kim TH, Cascione
Surgical periodontal ther- silanization regimens in dry D, Donovan TE. Immediate
apy. Periodontology 2000 and aged conditions. Dent dentin sealing improves
2001;25:89–99. Mater 2007;23:1323–1331. bond strength of indirect
16. Livaditis GJ. Comparison 26. Kumbuloglu O, Lassila LV, restorations. J Prosthet Dent
of monopolar and bipolar User A, Toksavul S, Vallittu PK. 2005;94:511–519.
electrosurgical modes for Shear bond strength of com- 37. Magne P, Versluis A, Douglas
restorative dentistry: a review posite resin cements to lithium WH. Effect of luting compos-
of the literature. J Prosthet disilicate ceramics. J Oral ite shrinkage and thermal
Dent 2001;86:390–399. Rehabil 2005;32:128–133. loads on the stress distribu-
17. Hui KK, Williams B, Davis 27. Magne P, Cascione D. Influ- tion in porcelain laminate
EH, Holt RD. A comparative ence of post-etching clean- veneers. J Prosthet Dent
assessment of the strengths ing and connecting porcelain 1999;81:335–344.
of porcelain veneers for inci- on the microtensile bond 38. Magne P, Kwon KR, Belser
sor teeth dependent on their strength of composite resin to UC, Hodges JS, Douglas
design characteristics. Br feldspathic porcelain. J Pros- WH. Crack propensity of
Dent J 1991;171:51–52. thet Dent 2006;96:354–361. porcelain laminate veneers:
18. Stappert CF, Ozden U, 28. Buonocore MG. A simple a simulated operatory
Gerds T, Strub JR. Longevity method of increasing the evaluation. J Prosthet Dent
and failure load of ceramic adhesion of acrylic filling 1999;81:327–334.
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