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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 55-59

Minimally invasive predictable esthetic restorations using ceramic veneers: A case series


1 Department of Conservative Dentistry, ITS Centre for Dental Studies and Research, Ghaziabad, Uttar Pradesh, India
2 Consultant Endodontist, Davangere, Karnataka, India
3 Consultant Endodontist, Bangalore, India
4 Department of Conservative Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Date of Submission17-Jul-2020
Date of Decision25-Mar-2021
Date of Acceptance20-Apr-2021
Date of Web Publication9-Aug-2021

Correspondence Address:
Dr. Vidhi Kiran Bhalla
Department of Conservative Dentistry, ITS Centre for Dental Studies and Research, Ghaziabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_28_20

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  Abstract 


The dental profession is perpetually in the search of restorative options that fulfill the criteria of being natural in appearance and at the same time long-lasting. Technological advances in ceramics and adhesive techniques have made it possible to achieve natural esthetic results with conservative intervention for the rehabilitation of anterior teeth. Smiles can be transformed painlessly and conservatively with quick and long-lasting results with the appropriate use of the porcelain laminate veneers. The finished ceramic surface elicits excellent tissue response. In short, the current ceramic veneers are esthetically superior, conservative, and durable. The present article reports on three cases where ceramic veneers have been used for the esthetic correction of anterior teeth.

Keywords: Anterior, ceramic, esthetic, restorations, veneers


How to cite this article:
Bhalla VK, Prasad S, Chockattu SJ, Goud K M. Minimally invasive predictable esthetic restorations using ceramic veneers: A case series. Int J Oral Health Sci 2021;11:55-9

How to cite this URL:
Bhalla VK, Prasad S, Chockattu SJ, Goud K M. Minimally invasive predictable esthetic restorations using ceramic veneers: A case series. Int J Oral Health Sci [serial online] 2021 [cited 2021 Nov 28];11:55-9. Available from: https://www.ijohsjournal.org/text.asp?2021/11/1/55/323530




  Inroduction Top


Adhesive bonding techniques in combination with tooth-colored restorative materials have revolutionized the field of restorative dentistry.[1] Magne and Belser have suggested numerous indications for ceramic veneers as minimally invasive restorations to optimize tooth form and position, closure of interdental spaces, replace discolored or unesthetic composite resin restorations, restore teeth with incisal abrasion or tooth erosion, and also to mask or reduce tooth discoloration.[2]

Enhancement of anterior esthetics presents a challenge to the dentist. Diastema and tooth malalignment are due to a discrepancy between tooth material and jaw size. While fixed orthodontics remains the treatment of choice for correction of malocclusions, adult patients in general remain hesitant to accept this treatment option due to the longer duration of orthodontic treatment and a reluctance to wearing a fixed orthodontic appliance.[3],[4] In select cases, veneers may be considered an adjunct to orthodontic treatment to improve the overall esthetics; these include cases where malocclusion is associated with intrinsic discoloration and/or discrepancies in tooth size and shape, such as peg-shaped laterals or malformed centrals.[3],[4]

A major selling point of ceramic veneers in the requirement of superficial preparation within the enamel and the adhesive luting that facilitates restorations with minimal loss of healthy tooth structure. In addition, their esthetics, durability, predictability, and biocompatibility have made them an established option for restoring anterior teeth.[6]

The present article highlights three cases treated using ceramic veneers, emphasizing the key protocols that are mandatory in achieving successful results.[5]


  Case Reports Top


Case report 1

A 27-year-old female patient reported to the outpatient department of Conservative Dentistry and Endodontics with the chief complaint of gaps in between the upper front teeth, with a desire to close these spaces. Intraoral examination revealed teeth with diastema of 2 mm between the central incisors with mild fluorosis stains [Figure 1]a. Oral hygiene was satisfactory. The various treatment options were explained to the patient, from which the patient opted for a restorative solution that was long-lasting.
Figure 1: (a) Preoperative view of Case 1. (b) Intra-oral mock-up with APT. (c) Depth-cut grooves through APT. (d) After removal of APT. (e) Tooth Preparation for veneer. (f) Procured ceramic veneers from laboratory. (g) Rubber dam isolation. (h) Postcementation. (i-m) adhesive protocol for veneer cementation. (n) Postcementation following removal of rubber dam. (o) Follow-up at 3 months (labial view). (p) Follow-up at 3 months (lateral view)

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Upper and lower diagnostic impressions were made using alginate (DPI Imprint, India) and poured with dental stone. Diagnostic wax-up was done over the maxillary anterior teeth to analyze the size, form, and proportion of the teeth using recurring esthetic dental proportion.[7] This was presented to the patient, and an approval was taken. Two silicone indexes were made over the diagnostic wax-up using putty rubber base impression material (Soft Putty Vinyl Polysiloxane [VPS] Impression Material, 3M ESPE, India). Using shade guide (VITA classical A1-D4® shade guide, VITA Zahnfabrik, Germany), the shade was selected (A2) before tooth preparation. Photographs were taken (Canon EOS 60D DSLR with 100 mm F/2.8 Macro USM Prime Lens and MR-14EX II Macro Ring Lite, Japan) for communication with the laboratory.

Temporization material (ProTemp™ 4, 3M ESPE, India) was injected into one of the silicone indexes and placed over unprepared teeth to obtain intraoral mock-up, called as “Aesthetic preevaluative Temporary” (APT).[6] They were evaluated both by dentist and the patient, and final approval was taken [Figure 1]b.

Tooth preparation sequence

Depth orientation grooves were placed using the depth cutting bur (Shofu Porcelain Veneer Kit, Japan) on the facial surface through the temporaries [Figure 1]c. The depth cutting bur was kept in three different orientations, namely cervically, midfacially, and incisally, to follow the facial convexity and to keep the preparation to a minimum. Once the desired depth was achieved, the remaining part of APT was removed [Figure 1]d, following which a supragingival chamfer finish margin was produced using medium finishing chamfer bur (Shofu Porcelain Veneer Kit, Japan).

Labial reduction was then completed till the depth cuts were imperceptible. The preparation was taken lingually by keeping the bur at an angle of almost 60° toward the palate, producing an “Elbow-like cut” or “Dog-leg preparation,” so as to hide the veneer margin in the embrasures. Butt-joint margin was given incisally. Finally, all line and point angles were rounded to reduce the internal stresses [Figure 1]e. The second silicone index was used to assess adequacy of tooth reduction.

Following tooth preparation, soft tissue management was done using gingival retraction cord before impression making. An appropriate stock tray was selected and coated with tray adhesive (VPS Tray Adhesive, 3M ESPE, India). Using VPS impression material of putty (Soft Putty VPS Impression Material, 3M ESPE, India) and light body consistency (Express™, Light body VPS Impression Material, 3M ESPE, India), impression was made by two-step double mix impression technique using polyethylene sheet as the spacer. Impression was then disinfected with 2% glutaraldehyde solution (Korsolex® Rapid, Raman and Weil Pvt. Ltd., Mumbai, India) as per manufacturer's instructions and sent to laboratory for fabrication of laminate veneers with lithium disilicate ceramics (IPS e.max® Press, Ivoclar-Vivadent, Liechtenstein). The extraoral mock-up, along with photographs of APT, was sent to the laboratory. The technician was also guided with regard to the veneer shade.

A set of provisional veneers (ProTemp™ 4, 3M ESPE, India) were fabricated utilizing the putty index. The provisionals were finished, polished, and luted to the teeth after spot etching and using flowable composite (Filtek Z350 XT Flowable, 3M ESPE, India).

Veneer cementation

Once ceramic veneers were procured from laboratory [Figure 1]f, the provisional veneers were removed. The surfaces of prepared teeth were cleaned and pumiced to remove any remnants of provisional luting cements. Veneers were tried intraorally to assess fit, form, position, shade, and patient satisfaction. Rubber dam isolation (Heavy 6” × 6” rubber dam sheet, Sanctuary™ Dental Dam, Columbia Life Sciences, India; and HYGIENIC® Brinker clamp #B4, Coltene, India) was done, and Teflon tape (m-seal®, India) was placed to protect the adjacent teeth from inadvertent etching and bonding.[Figure 1]g. The post cementation figures are shown in [Figure 1]h, [Figure 1]i, [Figure 1]j, [Figure 1]k, [Figure 1]l, [Figure 1]m.

Intaglio surface of veneers was treated with 9.6% hydrofluoric acid (Porcelain Etch, Ultradent Products Inc., USA) [Figure 1]i for 10 s and rinsed thoroughly, followed by application of 2 coats of silane coupling agent (Silane, Ultradent Products Inc., USA) for 1 min [Figure 1]j and then drying. Next, bonding agent was applied and left uncured (Adper™ Single Bond 2, 3M ESPE, India) [Figure 1]k.

Teeth surfaces were etched using 37% orthophosphoric acid (N-Etch, Ivoclar-Vivadent, India) for 30 s [Figure 1]l and rinsed, followed by bonding agent application [Figure 1]m. Veneers were positioned carefully and cemented with translucent veneer cement (RelyX™ Veneer, 3M ESPE, India). Luting procedures were carried out initially over the central incisors, followed by lateral incisors, and finally canines. Tack-curing of 5 s was done to stabilize the position of laminates, and excess cement was removed using scalpel blade #12 and dental floss. Final curing was carried out for 60 s staring from palatal, then proceeding with labial and proximal surfaces [Figure 1]n. At 3-month recall visit, tissue response was satisfactory [Figure 1]o and [Figure 1]p.

Case report 2

A 31-year-old female patient reported to outpatient department of Conservative Dentistry and Endodontics with a chief complaint of gaps between her upper front teeth [Figure 2]a. The patient had undergone orthodontic treatment 2 years ago and was not willing for the same treatment again. She had reported wearing the retention appliance for 18 months, and that the she was advised on a restorative option for the midline gap by her orthodontist. The patient accepted the option of ceramic veneers from teeth 12–22. Shade selection was done (A2).
Figure 2: (a) Preoperative view of Case 2. (b) Depth-cut grooves through APT. (c) Tooth Preparation for veneer. (d) Rubber dam isolation. (e) Postcementation. (f) Postcementation following removal of rubber dam. (g) Preoperative view of Case 3. (h) Depth-cut grooves through APT. (i) Tooth Preparation for veneer. (j) Rubber dam isolation. (k) Postcementation. (l) Postcementation following removal of rubber dam

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Following tooth preparation [Figure 2]b and [Figure 2]c, rubber dam isolation was done [Figure 2]d, and a similar bonding protocol was followed for veneer cementation [Figure 2]e and [Figure 2]f.

Case report 3

A 36-year-old female patient reported to outpatient department of Conservative Dentistry and Endodontics with a chief complaint of misshapen teeth with gaps in the upper front teeth [Figure 2]g. The patient was given option of ceramic veneers from 12 to 22, and her approval and consent were taken aided by intraoral mock-up [Figure 2]h. Tooth preparation was done, followed by veneer cementation under rubber dam isolation [Figure 2]i, [Figure 2]j, [Figure 2]k, [Figure 2]l.


  Discussion Top


Patients' demands for predictable and long-lasting treatment options for unesthetic anterior teeth have been steadily matched with the continuing technological advancements in dental material science and adhesive dentistry. Historically, a treatment option for the esthetic correction of anterior teeth had been achieved the provision of full-coverage crowns. However, this approach is undoubtedly the most invasive and involves substantial removal of sound tooth structure with possible adverse effects on the underlying pulp and periodontium.[6],[8] Studies conducted by Edelhoff and Sorensen have concluded that tooth preparations for ceramic veneers sacrificed 3%–30% of tooth structure by weight and accounted for up to one-quarter to one-half the amount of tooth reduction as compared to a conventional complete-coverage crown.[9]

Resin composite veneers can be used to mask tooth discoloration and/or to correct unesthetic tooth form and/or position. However, such restorations have limited longevity and are susceptible to discoloration, wear, and marginal fractures, reducing thereby the esthetic result in the long-term. In the quest for more durable esthetic options, porcelain veneers that were introduced in the 1980s were able to fulfill the needs of an esthetic and biologically compatible restoration.[6],[8]

Regarding tooth preparation, current evidence supports removal of minimal tooth structure and restricting the preparation entirely in enamel to improve the ceramic bonding. The use of “Aesthetic preevaluative temporaries” (APT) is helpful in visualizing and analyzing the final outcome and allows for a minimal preparation in enamel.[6] In all the above clinical cases, a conventional veneer preparation technique was followed which requires 0.5–0.9 mm reduction of incisal-half and 0.3–0.5 mm reduction on gingival-half of the facial surface. Gordon Christensen stated that 0.75 mm is the optimum amount of enamel that should be removed.[10] Incisally, a butt joint preparation design was given in all the three cases. Deisi Carneiro de Costaa et al. conducted a meta-analysis of incisal preparation designs for porcelain laminate veneers and concluded that butt joint is the most preferred incisal preparation design.[11]

The strength and durability of the bond between the tooth, the veneer, and the luting composite are what actually determine the success of porcelain laminate veneers. The adhesive protocol for ceramic veneers depends on the type and microstructure of the porcelain.[6] In all the aforementioned clinical cases, lithium disilicate veneers were bonded as per the recommended protocol.[2] Rubber dam isolation was done in all the above three cases. A Cochrane systematic review concluded that dental restorations had a significantly higher survival rate under rubber dam isolation as compared to cotton roll isolation at 6 months. Thus, it is imperative that moisture control should be maintained throughout the cementation procedure to achieve maximum bond strength values.[12]

Light-cured resin cement was used for luting the veneers as they provide longer working time with improved color stability.[12] Lithium disilicate ceramics have high translucency due to their unique microstructure of large amounts of glassy phase and translucent crystals. Thus the shade of resin cement used influences the final esthetics of veneers. In the aforementioned three cases, since there was no underlying discoloration in dentin, and since try-in esthetics was deemed satisfactory, there was no need to use veneer cements to change the color, translucency, or chroma of veneers. As a result, translucent resin cement was used.[13]

One of the crucial advantages of ceramic veneer is that the periodontal reaction is minimal. The smooth and finished margins help to maintain good periodontal health and enable the patient to maintain satisfactory oral hygiene.[8]

Studies by Beier et al. have concluded that porcelain laminate veneers offer a predictable and successful restoration with an estimated survival probability of 93.5% over 10 years.[14] The introduction of acid-etch technique by Buonocore, the advent of resin luting cements and silane coupling agents have all contributed to the clinical success of all ceramic veneers. Overall, the longevity of ceramic veneers is good, provided that the right indications are considered, and the that recommended protocol be strictly followed, starting from tooth preparation, to adhesive protocol under strict isolation, and veneer cementation.[15]


  Conclusion Top


Since their introduction almost 20 years ago, ceramic veneers are considered as “state-of-the-art” in esthetic dentistry and have become the flagship of most esthetic-based practices. Their excellence in terms of their appearance and durability requires a strict adherence to the recommended protocol in case selection, tooth preparation, and adhesion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Edelhoff D, Prandtner O, Saeidi Pour R, Liebermann A, Stimmelmayr M, Güth JF. Anterior restorations: The performance of ceramic veneers. Quintessence Int 2018;49:89-101.  Back to cited text no. 1
    
2.
Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Quintessence Publishing Company; 2002.  Back to cited text no. 2
    
3.
Curry FT. Porcelain veneers: Adjunct or alternative to orthodontic therapy. J Esthet Dent 1998;10:67-74.  Back to cited text no. 3
    
4.
Spear FM. The esthetic correction of anterior dental mal-alignment conventional vs. instant (restorative) orthodontics. J Calif Dent Assoc 2004;32:133-41.  Back to cited text no. 4
    
5.
Vanlıoğlu BA, Kulak-Özkan Y. Minimally invasive veneers: Current state of the art. Clin Cosmet Investig Dent 2014;6:101-7.  Back to cited text no. 5
    
6.
Gürel G. The Science and Art of Porcelain Laminate Veneers. London: Quintessence; 2003.  Back to cited text no. 6
    
7.
Ward DH. Proportional smile design using the recurring esthetic dental (RED) proportion. Dent Clin North Am 2001;45:143-54.  Back to cited text no. 7
    
8.
Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. Porcelain veneers: A review of the literature. J Dent 2000;28:163-77.  Back to cited text no. 8
    
9.
Edelhoff D, Sorensen JA. Tooth structure removal associated with various preparation designs for anterior teeth. J Prosthet Dent 2002;87:503-9.  Back to cited text no. 9
    
10.
Christensen GJ. Have porcelain veneers arrived? J Am Dent Assoc 1991;122:81.  Back to cited text no. 10
    
11.
da Costa DC, Coutinho M, de Sousa AS, Ennes JP. A meta-analysis of the most indicated preparation design for porcelain laminate veneers. J Adhes Dent 2013;15:215-20.  Back to cited text no. 11
    
12.
Wang Y, Li C, Yuan H, Wong MC, Zou J, Shi Z, et al. Rubber dam isolation for restorative treatment in dental patients. Cochrane Database Syst Rev 2016;9:CD009858.  Back to cited text no. 12
    
13.
Hernandes DK, Arrais CA, Lima ED, Cesar PF, Rodrigues JA. Influence of resin cement shade on the color and translucency of ceramic veneers. J Appl Oral Sci 2016;24:391-6.  Back to cited text no. 13
    
14.
Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain laminate veneers for up to 20 years. Int J Prosthodont 2012;25:79-85.  Back to cited text no. 14
    
15.
Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent Clin North Am 1983;27:671-84.  Back to cited text no. 15
    


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