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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 34-37

Lithium disilicate (IPS” e.Max computer-aided design) veneers for the esthetic rehabilitation in a young adolescent

Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital (University of Delhi), Delhi, India

Date of Submission16-Mar-2022
Date of Acceptance04-May-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Puja Sabherwal
Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital (University of Delhi), Delhi - 110 095
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohs.ijohs_5_22

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Dental fluorosis is a developmental disturbance of enamel wherein the patients often present with esthetic concerns. Previously available approaches for the management of dental fluorosis included composite restoration, microabrasion, bleaching, resin infiltration and/or use of full crowns. For young permanent teeth, it is desirable to follow a treatment plan that efficiently addresses both anatomic and esthetic concerns. Keeping in mind, a minimally invasive approach, lithium disilicate in its modern formulations (IPSTM e.Max CAD) fabricates thin veneers with 0.1–0.7 mm thickness with greater fracture toughness and biaxial strength. Lithium disilicate has high esthetic properties, and the material requires minimal tooth preparation. The advent of newer technology has led to a period of evolution with esthetic dentistry leading the forefront. The present report elucidates a novel approach depicting the use of maximal esthetics (E-Max) lithium disilicate veneers in a young adolescent with moderate fluorosis to provide a minimally invasive esthetic outcome with 6 months' follow-up.

Keywords: Dental fluorosis, dental veneers, lithium disilicate, minimally invasive dentistry

How to cite this article:
Tyagi R, Kalra N, Khatri A, Yangdol P, Goyal T, Sabherwal P. Lithium disilicate (IPS” e.Max computer-aided design) veneers for the esthetic rehabilitation in a young adolescent. Int J Oral Health Sci 2022;12:34-7

How to cite this URL:
Tyagi R, Kalra N, Khatri A, Yangdol P, Goyal T, Sabherwal P. Lithium disilicate (IPS” e.Max computer-aided design) veneers for the esthetic rehabilitation in a young adolescent. Int J Oral Health Sci [serial online] 2022 [cited 2022 Dec 1];12:34-7. Available from: https://www.ijohsjournal.org/text.asp?2022/12/1/34/350996

  Introduction Top

Dental fluorosis is a developmental disturbance of enamel caused by an overexposure of fluoride. The clinical presentation ranges in severity determined by time, dose, duration of exposure, and several other contributory elements. The enamel is fully functional with the presence of opaque striations and a mottled appearance in milder cases while porosity, pitting, and dark discoloration manifest more often in severe cases of dental fluorosis.[1] Several treatment methods have been proposed to address the esthetic concerns of fluorosis, including the placement of veneers or full crowns, composite restoration, microabrasion, bleaching, and/or resin infiltration.[2] With evolving technology, dentistry is currently undergoing a period of renascence with esthetic dentistry leading the forefront. As newer materials have emerged in the market, the disadvantages of full coverage crowns have been minimized with more conservative approaches being introduced.[3] Lithium disilicate (2SiO2eLi2O) dental ceramics were first introduced in 1988 with reformulations resulting in IPS” e. Max introduced in 2006.[4] The major distinguishing feature involves the fabrication of thin veneers with 0.1–0.7 mm thickness with greater fracture toughness and biaxial strength. Along with high esthetical properties, the material requires minimal tooth preparation which makes it desirable for use in young permanent teeth.[5] The present case report elucidates the use of maximal esthetics (E-Max) lithium disilicate veneers in a young adolescent with moderate fluorosis to provide a minimally invasive esthetic outcome.

  Case Report Top

A 12-year-old girl presented to the department of pedodontics and preventive dentistry with a chief compliant of yellowish discoloration in the upper front tooth region [Figure 1]a. A detailed case history of the patient was obtained. No relevant medical history was detected. The patient belonged to a village in the outskirts of Uttar Pradesh. On clinical examination, the presence of generalized dental fluorosis was diagnosed and was graded as Grade 3 according to Dean's Fluorosis Index-Modified Criteria (1942). Ellis Class I fracture was detected on the maxillary right central incisor. A treatment plan was formulated for esthetic rehabilitation which included Lithium Disilicate ceramic veneers with e. Max computer-aided design (CAD), the procedure was explained to the parents and informed consent was taken for the same.
Figure 1: (a) Preoperative frontal view. (b) Tooth preparation for lithium disilicate (IPS” e.Max CAD) veneers

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Designing, fabrication, and treatment process

Tooth preparation

Shade matching was performed using the vita classic shade guide and A1 shade was selected. Minimal tooth preparation was begun using porcelain veneer preparation burs as shown in [Figure 1]b. Initially, depth orientation grooves were placed in the gingival and incisal half of the labial surface followed by 1 mm of tooth reduction. To maintain the natural contour of the tooth and to ensure uniform thickness of the veneer, facial reduction was done using a round-end tapered diamond. An “elbow preparation” type of extension was created on the proximal surface, just short of breaking the contact. Incisal reduction of 1 mm was done leaving a butt finish line configuration. This provides a positive seat for luting and helps achieve lingual translucency. To attain a definitive margin and to ensure the correct positioning of the veneer while cementing, the gingival margins of the tooth preparation were kept equigingival. All the internal line angles were rounded to reduce the stresses in the margins of the veneers.

Impression recording

The putty reline technique was used and full-arch impressions were recorded using polyvinyl siloxane (Aquasil soft putty/regular set, Dentsply, Germany) [Figure 2]a. In the dental laboratory, the maxillary and mandibular impressions were poured, dies were formed, and veneers from lithium disilicate (IPS” e. max CAD; Ivoclar Vivadent AG) were fabricated [Figure 2]b, [Figure 2]c, [Figure 2]d.
Figure 2: (a) Full-arch impressions were made using polyvinyl siloxane (Aquasil soft putty/regular set, Dentsply, Germany) using putty reline technique. (b-d) Fabrication of lithium disilicate (IPS” e.Max CAD) veneer on the cast CAD-CAM technology. CAD-CAM: Computer-aided design-computer-assisted manufacture

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Try-in procedure was carried out to verify marginal adaptation, shade, contour, and alignment and veneers were found to be satisfactory.

Cementation of computer-aided design-computer-assisted manufacture veneer

The internal surfaces of the veneers were conditioned by the application of 9.5% hydrofluoric acid (Porcelain Etch; Ultradent, South Jordan, Utah) for 1 min, followed by a silane coupling agent (Ultradent Products, South Jordan, UT, USA) for 60 s and air-dried. Isolation of the teeth and the adjacent tissues were done using rubber dam, cotton rolls, and high-speed evacuator. Veneer cementation was performed individually for each tooth. Each prepared tooth was etched by the application of 37% phosphoric acid (Total Etch; Ivoclar Vivadent AG, Schaan, Liechtenstein) for 15 s, after which it was rinsed and dried. This was followed by the application of a bonding agent (Tetric N-Bond, Ivoclar/Vivadent, Schaan, Liechtenstein), polymerized for 40s. Dual-cure resin cement (RelyX™ U200, 3M ESPE, St. Paul, MN, USA) was used for luting the veneers. Excess was removed using an explorer, and interdental cleaning done by flossing. The luting resin was cured with the curing light for 40 s each on each tooth. Final finishing and polishing were done [Figure 3]a and [Figure 3]b.
Figure 3: (a) Postoperative frontal view. (b) Patient smile at the end of the treatment

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  Discussion Top

The field of dental ceramics has evolved rapidly over the last few decades. Lithium disilicate (2SiO2eLi2O) first introduced in 1988, has advanced from a heat-pressed core material marketed as IPS_ Empress 2 (Ivoclar Vivadent, Lichtenstein) to IPS” e. Max CAD manufactured in 2006, designed specifically for CAD-computer-assisted manufacture use.[6],[7] The e. Max CAD in partially crystalized form contains 40% lithium metasilicate crystals, while in fully crystalized form it is composed of 70% fine grain lithium disilicate crystals. A “blue state” of the material, composed of lithium metasilicate has superior properties such as ease of milling, decreased bur wear, and high edge stability.[6],[7] The partially crystallized form of the material exhibits moderate flexural strength of 130 MPa while the flexural strength of the fully crystalized form is 262–360 MPa, which has been shown to be superior to other leucite reinforced dental ceramics.[6],[7],[8],[9] IPS_ e. Max CAD addresses various esthetic needs by being available in several shades (standard A through D) and three levels of translucency (medium opacity, high translucency, and low translucency).[6] Lithium disilicate has a distinctive property, called “Umbrella Effect” by Magne et al., that allows light to cross the material and be adsorbed that provides high esthetical properties and a more conservative dental preparation.[10],[11] The mechanical and optical properties are summarized as given in [Table 1].[6],[7],[8],[9],[13]
Table 1: The mechanical and optical properties of lithium disilicate (IPS” e.Max CAD)

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Initially, recommendations included use as inlay and onlay material, as an anterior veneering material; however, updated indications include partial and full crowns and three-unit fixed partial dentures.[6] The 2016 manufacturer's recommendations also highlight the use of IPS_ e. Max CAD for minimally invasive crowns (1 mm material thickness).[10]

Among the various treatment modalities proposed for esthetic corrections, full coverage crowns are most commonly used. However, the procedure involves the reduction of a large amount of healthy tooth structure leading to the removal of 63%–72% of coronal segment.[2] Moreover, on minimally prepared teeth, the placement of thick ceramic veneers may cause periodontal problems and compromised esthetics due to overcontouring.[12] Therefore, the use of lithium disilicate veneers is advantageous in a young permanent tooth as it allows the fabrication of thin veneers with 0.1–0.7 mm thickness. Consequently, it permits the tooth reduction to be minimally invasive and may also allow placement without tooth preparation. As the popularity of lithium disilicate (IPS” e. Max) grows, studies have employed the material in adult population; however, there has been limited research into its application for the young permanent tooth.[2],[3]

Assessing the cost–benefit ratio in the Indian scenario

The financial aspect in the present case was resolved by the use of partial self-funding by the treating dentist and the collaborating dental laboratories partners. This was done for optimal care and study purpose as the patient belonged to the lower socioeconomic strata. Such laboratory-doctor–patient partnerships can be a possible financial solution for the benefit of the patient undergoing treatment without the aid of a government scheme.

  Conclusion Top

In the era of esthetic dentistry, there has been a paradigm shift from conventional approaches to conservative techniques. Correction of the discoloration by a less invasive technique was achieved. Lithium disilicate (IPS” e. Max) veneers present a promising approach to the management of esthetic concerns in the case of a young permanent tooth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parent has given her consent for her images and other clinical information to be reported in the journal. The patient's parent understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mascarenhas AK. Risk factors for dental fluorosis: A review of the recent literature. Pediatr Dent 2000;22:269-77.  Back to cited text no. 1
Kaushik P, Singh R, Soujanya E, Prasad LK. Lithium disilicate ceramic veneers for esthetic restoration of anterior teeth: Two case reports. J Dent Res Rev 2020;7:142-6.  Back to cited text no. 2
  [Full text]  
Schmitter M, Seydler B B. Minimally invasive lithium disilicate ceramic veneers fabricated using chairside CAD/CAM: A clinical report. J Prosthet Dent 2012;107:71-4.  Back to cited text no. 3
Datla SR, Alla RK, Alluri VR, Jithendra Babu P, Konakanchi A. Dental ce- ramics: Part II C recent advances in dental ceramics. Am J Mater Eng Technol 2015;3:19-26.  Back to cited text no. 4
Martins JD, Lima CM, Miranda JS, Leite FP, Tanaka R, Miyashita E. Digital smile designing, pressing and stratifying ceramic lithium disilicateveneers to rehabilitate dental agenesis: A clinical report. Rev Gaúch Odontol 2019;67:e20190043.  Back to cited text no. 5
Vivadent Ivoclar. Scientific Documentaion IPS e.max. Liechtenstein: CAD; 2011.  Back to cited text no. 6
Li RW, Chow TW, Matinlinna JP. Ceramic dental biomaterials and CAD/CAM technology: State of the art. J Prosthodont Res 2014;58:208-16.  Back to cited text no. 7
Zarone F, Ferrari M, Mangano FG, Leone R, Sorrentino R. “Digitally oriented materials”: Focus on lithium disilicate ceramics. Int J Dent 2016;2016:9840594.  Back to cited text no. 8
Denry I, Holloway J. Ceramics for dental applications: A review. Materials 2010;3:351-68.  Back to cited text no. 9
Magne P, Magne M, Belser U. The esthetic width in fixed prosthodontics. J Prosthodont 1999;8:106-18.  Back to cited text no. 10
Willard A, Gabriel Chu TM. The science and application of IPS e.Max dental ceramic. Kaohsiung J Med Sci 2018;34:238-42.  Back to cited text no. 11
Gresnigt M, Ozcan M. Esthetic rehabilitation of anterior teeth with porcelain laminates and sectional veneers. J Can Dent Assoc 2011;77:b143.  Back to cited text no. 12
Leung BT, Tsoi JK, Matinlinna JP, Pow EH. Comparison of mechanical properties of three machinable ceramics with an experimental fluorophlogopite glass ceramic. J Prosthet Dent 2015;114:440-6.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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