Porcelain Laminate Veneers: Restorative Management

A 21-year-old woman presented to the author’s office for a cosmetic evaluation of her anterior teeth (Figure 1). After having braces twice, the patient’s chief complaints included dissatisfaction with the overall esthetics of her teeth, as well as visually apparent decay. The patient had conventional orthodontics from ages 11 to 14. She admitted she had not worn her retainer after completion. As a result, her teeth had shifted over time. Also evident was recurrent decay on her upper anterior teeth after removal of her brackets. The resins that had been placed previously were now discolored with open margins and showed evidence of recurrent decay. At age 19, the patient began using Invisalign^® (Align Technology, www.invisalign.com) and was not happy with the outcome. She told the author she wanted something more "permanent and beautiful"—she was unhappy with the spaces between her teeth and overall appearance.

The medical history was unremarkable. The patient denied having had any significant medical treatment and medication use. She was healthy with no contraindications to dental treatment.

Temporomandibular Joints: The maximum opening was 42 mm, normal range of motion was normal, and there was no deviation on opening. No clicking, popping, or crepitus could be detected in either joint. Load test findings were negative.

Extraoral: Within normal limits. The findings from the oral cancer screening were negative.

Intraoral: Within oral limits.

Periodontal: Generalized mild gingivitis. The patient reported a smoking history (two to three cigarettes daily). The probing depths were within normal limits with no bleeding on probing. Gingival architecture was symmetrical, and no adjustments were needed for any restorative or cosmetic treatment.

Biomechanical: Recurrent decay around the resin placed on tooth No. 14. New decay was evident on tooth No. 15. All other restorations were acceptable.

Functional: The patient had very acceptable function.

Dentofacial: The patient had maxillary tooth size discrepancies. Teeth Nos. 9 to 11 appeared too long as compared with teeth Nos. 6 to 8 in full-smile photographs. There were unacceptable and failing facial resins on teeth Nos. 7 to 10 and unacceptable color.

Risk assessment is a key part of any treatment plan from the most simple to the most complex. In this particular case, the only risk factor was the patient’s behaviors. Due to previous treatment failures, compliance issues, and the state and position of the existing dentition, the author determined that a more aggressive approach was appropriate.

All treatment options and goals were discussed with the patient. As with any case, the most conservative approach was presented first and then further options were shared. The first was the placement of 8 to 10 direct resin veneers. Although a challenging treatment choice, if executed with precision, direct resin veneers could yield an incredible esthetic result, while still maintaining a conservative approach. The second treatment option was the placement of 10 indirect porcelain veneers.

The patient and author chose the indirect restorations for multiple reasons. The rotations, uneven spacing, axial inclinations, and gingival height discrepancies would present major challenges clinically, especially when relying on direct bonding for the final restorations. Second, the patient’s compliance and social history (smoking) were also factors, all of which would have had much less of an impact on indirect restorations as they would on direct resin restorations.

Phase 1: Diagnostic Wax-Up

A complete facial evaluation, intraoral and extraoral photographs, upper and lower study models, and a facebow transfer were performed for a diagnostic wax-up (Figure 2, Figure 3, Figure 4, Figure 5 and Figure 6 ). The case was mounted in maximal intercuspal position because there was no altering of the vertical dimension and the joints and occlusion were stable. After submission, the laboratory returned a wax-up (Figure 7), a matrix to fabricate provisionals, along with a facial and incisal reduction guide. After the patient accepted the wax-up, the author began treatment.

Phase II: Restorative

Prior to preparing teeth and after trusting that the patient had not smoked in 30 days, fluoride was dispensed for 2 weeks prior to ZOOM™ (Discus Dental, www.discusdental.com) in-office bleaching of the lower arch. Bleaching was performed; as a result, a significant shade change was obtained. The patient was then ready to begin treatment of her upper arch.

The teeth were anesthetized with 7.² cc 4% Septocaine^® with epinephrine 1:100,000 (Septodont, www.septodontusa.com). Once adequate anesthesia was obtained, depth cuts were prepared using Alpen depth cut burs (Colténe Whaledent, www.coltene.com) in three planes: gingival one third, middle one third, and incisal one third. A coarse green-stripe diamond was used to prepare these teeth initially to ensure uniform reduction was obtained on all three planes. A distinct chamfer was achieved. The preparations were finished and smoothed with red-stripe finishing burs. An aluminum oxide wheel was used to round any corners, as well as smooth the incisal portion of the preparation. Prior to finishing, the reduction guides were inserted to confirm adequate facial and incisal reductions. Stumpf shade photographs were taken to communicate the shade of the prepared teeth to the laboratory.

Prior to taking the final impression, Expasyl^® (Kerr Corporation, www.kerrdental.com) was placed in the gingival sulcus of all prepared teeth. Comprecaps (Colténe Whaledent) were then placed over the teeth, and the patient was instructed to close for 3 minutes. After time elapsed, the Expasyl was rinsed thoroughly, and the teeth were dried prior to impressions. A full-arch upper metal tray was used to obtain the impression. Flexitime^® light-body polyvinyl siloxane (Heraeus Kulzer, www.heraeus-dental-us.com) was syringed over the prepared teeth, and a putty material was placed in the tray. After 5 minutes, the impression was removed, inspected, and set aside on the counter. A facebow transfer, stick bite, and centric-relation bite registration using a Lucia jig and Futar^® bite material (Kettenbach, www.kettenbach.com) was completed. The stick bite and facebow transfers were photographed for the laboratory. The provisionals (Figure 8), which were fabricated with PERFECtemp II (Discus Dental) in B1 and finished outside the mouth, were then cemented using a spot-etch technique (small dot of 35% phosphoric acid). The occlusion was checked and adjusted in centric, lateral, and protrusive movements. The patient was given postoperative instructions and asked to return to the office in 48 hours for evaluation and adjustments to the provisionals, if needed.

On return in 48 hours, the patient said she was happy with the shape, size, and function of the provisionals. Photographs and a duplicate alginate of the provisionals were taken.

On the day of insertion, the patient was anesthetized with 7.2 cc 4% Septocaine via infiltration. The provisionals were removed easily, and the underlying preparations were cleaned with Consepsis™ (Ultradent, www.ultradent.com). A reduction coping was placed on tooth No. 9 (Figure 9), and a slight facial reduction was performed with a finishing bur as per the laboratory’s instructions. After reduction, the final veneers were tried in two at a time with Choice™ translucent try-in paste (Bisco, www.bisco.com). Once all veneers were placed, a 1:1 photograph was taken at three angles to confirm proper value, hue, and chroma of each veneer, as well as a 1:2 smile photograph to ensure that the patient’s requests were met. The patient evaluated the veneers in a mirror and was satisfied with the Results. The veneers were removed, rinsed, and dried thoroughly. A 5% HF acid was used to etch veneers. They were rinsed and dried, followed by a thin layer of silane. They were placed aside out of light.

To prepare for final cementation, a size 00 cord dipped in clear hemostat liquid was placed in each sulcus of teeth Nos. 4 to 13. The veneers were to be placed two at a time in the following order: Nos. 8 and 9, 6 and 7, 10 and 11, 4 and 5, and finally 12 and 13. Using that same sequence, the teeth were treated as follows: etched with 15% phosphoric acid for 15 seconds, then rinsed with water for 30 seconds. They were blot-dried with cotton rolls to avoid desiccation. Gluma^® (Heraeus Kulzer) was applied as a rewetting agent and blot-dried as well to avoid desiccation. Clearfil^® SE primer (Kuraray Dental, www.kuraraydental.com) was applied in three coats and air-dried thin. Two layers of bonding agent were applied—air-dried thin and then cured for 15 seconds each using a bluephase^® light (Ivoclar Vivadent, www.ivoclarvivadent.com). Translucent resin cement (Choice) was placed in each veneer and then put on the proper teeth. As each pair was placed, they were "tack-cured" under the soft mode of the light for 2 seconds. Excess cement was removed with a sickle scaler. Floss was carefully used to ensure contacts were not bonded closed. Each restoration was given a final cure for 15 seconds. To avoid any bleeding, the retraction cord was left in until all of the veneers were placed. Finally, the occlusion was adjusted with a red-stripe football finishing bur, the facial margins were polished with a white-stripe finishing bur, and followed by a yellow-stripe finishing bur where needed. The patient was given specific postoperative instructions to allow for gingival healing. The patient returned 4 weeks later for final photographs (Figure 10, Figure 11, Figure 12, Figure 13, Figure 14 and Figure 15).

The final Results surpassed the patient’s expectations. In addition, by clearly understanding the patient’s dental, medical, and social histories, the treatment was designed to ensure the best long-term functional result, as well as to provide an excellent esthetic result. This result not only enhanced the smile but also addressed the biggest risk factor—patient compliance. At the patient’s request, she is on a 4-month recare program, and she has successfully completed smoking cessation, which has drastically improved her oral hygiene. This case was a complete success in every shape and form.

Laboratory support and ceramics was completed by Hak Joo Savercool, Optident Labline, Eugene, Oregon.

Adamo Notarantonio, DDS
Private Practice
Huntington, New York