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Ceramic Laminate Veneers: clinical procedures with a multidisciplinary approach

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Complex cases with high esthetic needs represent a challenge for clinicians. A multidisciplinary approach is vital to achieve the planned result. New technological devices are needed to facilitate the collaboration between the clinical team members and to develop a fluent and effective diagnostic and therapeutic pathway. This article describes a well-defined protocol for the treatment of complex esthetic cases with the use of ceramic laminate veneers. The protocol involves different branches of dentistry: periodontal therapy, mucogingival surgery , restorative dentistry, orthodontics, and prosthodontics. Each step of the protocol should be executed in a very strict order: intra-and extraoral esthetic analysis of the patient, with photographs ; digital previsualization by means of Digital Smile Design (DSD); clinical previsualization by means of a mock-up; orthodontic, mucogingival, and endo-dontic treatments, if needed; minimally invasive tooth preparation, driven by a mock-up and silicone indices; manufacture of ceramic laminate veneers; try-in and adhesive cementation. In this article , this protocol is illustrated by a clinical case report in which all the above-mentioned steps were carried out. The finalization was obtained by means of state-of-the-art adhesive techniques and ceramic laminate veneers. The correct use of modern materials, in combination with rigorous adhesive procedures , allows for a minimally invasive and highly esthetic treatment, with adequate function and a perfect integration that is in harmony with the patient's face. (Int J Esthet Dent 2017;12:2-24)
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 12 • NUMBER 4 • WINTER 2017
CLINICAL RESEARCH
Ceramic laminate veneers: clinical
procedures with a multidisciplinary
approach
Marco Veneziani, DDS
Private Practice, Vigolzone (PC), Italy
Active member of Accademia Italiana di Conservativa e Restaurativa (AIC)
Active member of Italian Academy of Esthetic Dentistry (IAED)
Visiting Professor at the University of Pavia (2007 –2012)
VENEZIANI
CLINICAL RESEARCH
Correspondence to: Dr Marco Veneziani
Via Roma 57, 29020 Vigolzone (PC), Italy; Tel/Fax: +39 0523 870362, Mobile: +39 3351 435187;
Email: marco.veneziani@nesh.biz, veneziani.mar@gmail.com
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Abstract
Complex cases with high esthetic needs
represent a challenge for clinicians. A
multidisciplinary approach is vital to
achieve the planned result. New techno-
logical devices are needed to facilitate
the collaboration between the clinical
team members and to develop a fluent
and effective diagnostic and therapeutic
pathway. This article describes a well-
defined protocol for the treatment of
complex esthetic cases with the use of
ceramic laminate veneers. The protocol
involves different branches of dentistry:
periodontal therapy, mucogingival sur-
gery, restorative dentistry, orthodontics,
and prosthodontics. Each step of the
protocol should be executed in a very
strict order: intra- and extraoral esthet-
ic analysis of the patient, with photo-
graphs; digital previsualization by means
of Digital Smile Design (DSD); clinical
previsualization by means of a mock-up;
orthodontic, mucogingival, and endo-
dontic treatments, if needed; minimally
invasive tooth preparation, driven by a
mock-up and silicone indices; manufac-
ture of ceramic laminate veneers; try-in
and adhesive cementation. In this arti-
cle, this protocol is illustrated by a clin-
ical case report in which all the above-
mentioned steps were carried out. The
finalization was obtained by means of
state-of-the-art adhesive techniques
and ceramic laminate veneers. The cor-
rect use of modern materials, in com-
bination with rigorous adhesive proced-
ures, allows for a minimally invasive and
highly esthetic treatment, with adequate
function and a perfect integration that is
in harmony with the patient’s face.
(Int J Esthet Dent 2017;12:2–24)
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CLINICAL RESEARCH
means of enamel mega abrasion), class
V cavities, class III and IV cavities (small,
medium or large), and minor modifica-
tion of color or shape.
Indirect techniques, on the other
hand, provide remarkable advantages:
Maximum esthetic result due to the
high dimensional stability and color
stability of ceramics.
Optimal control of tooth dimension,
shape, contact points, layering,
finishing, and polishing.
Try-in and esthetic evaluation on the
hydrated tooth prior to the start of
cementation procedures.
Indirect techniques are indicated when
treating multiple complex restorations,
endodontically treated teeth with a ma-
jor loss of sound tissue, complete crown
fracture, major shape modifications,
dental crowding, very young uncoop-
erative patients, and patients with high
esthetic demands.
Among indirect techniques, ceramic
laminate veneers represent a well-docu-
mented, effective, and predictable treat-
ment option.4,5 An indirect technique
may be considered the first treatment
choice when an adequate amount of re-
sidual sound tissue exists. The classifi-
cation by Magne and Belser6 (Table 1)
describes three main indications:
Type I: teeth where bleaching was
ineffective.
Type II: major morphologic modifica-
tions.
Type III: extensive restorations in
adult patients.
Innovative preparation designs for por-
celain laminate veneers are much less in-
vasive than conventional complete-cov-
Introduction
Modern restorative dentistry is essential-
ly based on adhesion. This allows it to
comply with three vital parameters: es-
thetics, function, and sound tissue pres-
ervation. The correct use of composite
and ceramic materials with rigorous
adhesive procedures allows for a mini-
mally or even noninvasive (ie, additive)
approach that is innovative, highly es-
thetic, and predictable in terms of both
result and long-term prognosis.
Modern dentistry should be in keeping
with biomimetics or bioemulation con-
cepts:1,2 Restorations should reproduce
the physiologic behavior of the natural
tooth as far as possible, with biologic,
biomechanic, functional, and esthetic
integration.3 Different treatment options
may be considered when esthetic adhe-
sive restorations in the anterior region are
required: direct composite restorations,
composite or ceramic laminate veneers,
and metal-free crowns (lithium disilicate,
zirconia, alumina). The choice between
direct and indirect techniques should be
based on several criteria: tooth vitality
preservation, minimum loss of sound tis-
sue, a minimally invasive approach to-
ward the gingival complex, esthetic de-
mands, patient age, financial cost, and
total treatment time. Further parameters
are: the number and extent of involved
teeth, type of function, antagonist teeth
situation, feasibility of functional and an-
atomical recovery of the restored tooth,
and biomechanical resistance of the re-
stored tooth.
Direct techniques provide the maxi-
mum preservation of residual sound
tissue. They are indicated in the follow-
ing conditions: white spots (treated by
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erage crown preparations. Edelhoff and
Sorensen7 quantified, with a gravimetric
analysis, the amount of tooth structure
removed during these preparations:
Porcelain laminate veneers required ap-
proximately one-quarter to one-half the
amount of tooth reduction of convention-
al complete-coverage crowns.
Achieving optimal and predictable re-
sults with the use of veneers cannot be
taken for granted. Success comes from
correct planning and accuracy in per-
forming every single step of the treatment.
Many adult patients present with
a combination of situations; the ideal
treatment is a multidisciplinary, mono-
professional approach or, better still,
an interdisciplinary approach. The best
esthetic result largely depends on the
ability of the members of the multidis-
ciplinary team to work together. Efficient
communication between team members
can present a challenge due to the re-
quirement for continuous communica-
tion between the different specialists.
Prosthodontist, orthodontist, periodon-
tist, and dental technician need to work
together because understanding the
various phases of the treatment is fun-
damental to achieving the desired re-
sult. Today, the use of new technologies
such as Digital Smile Design (DSD)8 can
improve the communication process be-
tween specialists. The previsualization
of the final result can be a motivational
key, not only to start the treatment, but al-
so to keep the patient involved through-
out the process.
The aim of this article is to present a
clinical case report demonstrating an
accurate operative protocol for the reali-
zation of ceramic veneers with a multi-
disciplinary approach on the basis of
the most recent clinical and scientific
evidence. The operative sequence is
structured as follows:
Intra- and extraoral esthetic analys-
is of the patient, with static photo-
graphic documentation and dynamic
video filming.
Digital previsualization by means of
DSD.8
Clinical previsualization by means of
a mock-up9 or aesthetic pre-evalua-
Table 1 Classication of the indications for ceramic laminate veneers by Magne and Belser6
TYPE I WHITENING RESISTANT TEETH
Type I A: Grade II and IV discoloration from tetracycline
Type I B: Lack of response to external or internal bleaching
TYPE II IMPORTANT MORPHOLOGICAL CHANGES
Type II A: Conoid-shaped teeth
Type II B: Closing diastemas and interdental triangles
Type II C: Increasing length and incisal prominence
TYPE III EXTENSIVE RESTORATIONS (ADULTS)
Type III A: Extensive coronal fractures
Type III B: Extensive loss of enamel due to erosion and wear
Type III C: Acquired and generalized malformations
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tive temporaries (APTs),10 based on
a diagnostic wax-up.
Evaluation and treatment of endo-
dontic, mucogingival, and/or ortho-
dontic problems, where necessary.
Minimally invasive preparation,
driven by both the mock-up and the
silicone keys made on the wax-up.
Manufacturing of ceramic veneers
(feldspathic or lithium disilicate).
Try-in and adhesive cementation
under rubber dam isolation.
Case report
Clinical procedures
A 40-year-old female patient complained
of hypersensitivity in the maxillary teeth
and was concerned about gingival re-
cession. She was very motivated and
keen to improve her smile (Fig 1). Clin-
ical examination showed cervical abra-
sions with moderate asymptomatic gin-
gival recessions in the mandibular arch.
Fig 1 Initial frontal view of the patient’s face.
Table 2 Esthetic checklist by Magne and Belser6: esthetic fundamental (objective and subjective) criteria
Fundamental objective
criteria
Fundamental subjective
criteria (esthetic integration)
1. Healthy gingival tissue
2. Interdental closing
3. Dental axis
4. Zenith gingival contour
5. Balance of gingival levels
6. Level of interdental contact
7. Relative dental dimensions
8. Essential characteristics of
tooth shape
9. Dental characterizations
10. Surface texture
11. Color
12. Configuring the incisal edge
13. Line of the lower lip
14. Symmetry of the smile
1. Changes in the tooth shape
2. Teeth layout and position
3. Coronal relative length
4. Negative space
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In the maxillary arch, however, severe
gingival recessions were present, espe-
cially on the canines and first premolars,
with deeper cervical abrasions that led
to hypersensitivity.
Esthetic analysis, based on funda-
mental objective and subjective esthetic
criteria (Table 2),6 highlighted disharmo-
ny and a lack of balance of the dento-
labial, dental, and gingival complex
(Figs 2 to 5). From a periodontal per-
spective, the patient showed good oral
hygiene habits, although her brushing
technique was too aggressive:
Non-carious cervical lesions were
present, caused by an abrasive/ero-
sive mechanism. Consequently, the
gingival margin was altered – mainly
on the canines and premolars, and
moderately on the lateral incisors.
Wide diastemas were present be-
tween the lateral incisors and canines
in both arches, and between the ca-
nines and first premolars in the maxil-
lary arch.
Fig 2 Initial frontal view of the patient’s smile. An
inverse smile line can be observed.
Fig 3 View of maxillary anterior teeth showing
inadequate relative dimensions among teeth, non-
carious cervical lesions, wear of incisal margins,
and flat incisal line with loss of embrasures.
Fig 4 Maxillary occlusal view. Wide diastemas
can be found between the lateral incisors and ca-
nines, and between the canines and first premolars.
Fig 5 Mandibular occlusal view. Wide diastemas
can be found between the lateral incisors and ca-
nines.
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Inadequate relative dimensions of the
teeth were found: the central incisors
were small and hardly predominant
compared to the lateral incisors; all
incisors had an improper height/width
ratio – the recessions on the canines
and premolars had altered the coro-
nal proportions.
The teeth suffered from a loss of buc-
cal volume and surface texture; their
color was characterized by low value
and moderate chromaticity.
The incisal margins were flat due to
wear. The incisal embrasures were
lost, resulting in an inverted smile line
that caused esthetic disharmony.
The patient’s occlusal situation showed
a good molar class I, with proper anterior
overjet and overbite. The interproximal
contacts in the posterior sectors were
adequate. The curve of Spee was flat
and needed no modification.
A multidisciplinary treatment plan was
elaborated:
A nonsurgical periodontal treatment,
with motivation and improvement of
the homecare routine.
A full set of intraoral photographs,
video clips, and study models were
collected. DSD previsualization would
guide the wax-up and the subsequent
clinical previsualization with a direct
mock-up.
Mucogingival surgery to recreate an
anatomic cementoenamel junction
(CEJ) and achieve proper root cover-
age in the maxillary lateral sectors.
Orthodontic treatment with transpar-
ent aligners to optimize space as a
function of the prosthetic plan (DSD-
driven orthodontics).
A second mock-up, with a final check
of the treatment plan.
Prosthetic procedure, with teeth prep-
aration driven by a mock-up.
In the maxillary arch, the creation of
six ceramic laminate veneers from ca-
nine to canine, plus two additional ve-
neers on the mesial aspect of the first
premolars. In the mandibular arch,
the creation of six ceramic laminate
veneers from canine to canine.
Try-in and adhesive luting of the ve-
neers.
Esthetic analysis and DSD
DSD8 is a recent digital previsualization
technique that allows the clinician to:
Efficiently plan the treatment of simple
or complex esthetic cases.
Improve the communication between
the dental team members involved in
the treatment.
Obtain better communication with and
increase the patient’s involvement in
the planning of his or her smile, and
achieve better patient motivation and
understanding of the advantages of
the proposed treatment.
Enhance the predictability of the
whole treatment thanks to a digital
project, which guides the actual clin-
ical treatment.
DSD is based on a clear intra- and ex-
traoral photographic protocol, leading to
a thorough esthetic analysis of certain
elements in a specific sequence:
1. Facial analysis.
2. Dentofacial analysis.
3. Dentolabial analysis (incisal edge
position, incisal display during smile,
smile line, buccal corridor).
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4. Dentogingival analysis.
5. Dental analysis (inter- and intra-tooth
relationships).11,12 All the records are
arranged in a slideshow by means of
general presentation software (Key-
note for Apple users; PowerPoint
for PC users) or dedicated software
(eg Digital Smile System, DSS; cara
Smile, Heraeus Kulzer) that will lead
to the creation of a digital preview of
the smile.
This approach allows for the sharing of
the treatment plan among team mem-
bers (also via the internet), and for creat-
ing a captivating visual presentation of
the treatment solution. The digital pro-
ject may be tested and approved even
before starting the actual treatment.
Making video clips of an interview
with the patient allows the clinician to
collect further details that might not be
observed from the photographs due to
their limitations. Video clip integration
provides the opportunity for a dynamic
analysis. In addition, three-dimensional
(3D) digital models of the mouth can be
included.
While defining and planning a pa-
tient’s smile, it is important to follow fun-
damental esthetic criteria (Table 2), and
the concept of morphopsychology or
“Visagism.”13 Visagism applies the prin-
ciples of visual art to the creation of a
custom smile design that can express
the patient’s personality and lifestyle.
This will ensure harmony between the
restoration and the patient’s general ap-
pearance, values, and attitudes. Achiev-
ing harmony between psychology, teeth,
and face may be defined, in a word, as
beauty. A dedicated online software
package (Visagismile) can help the clin-
ician to create a customized personal
smile design for each patient.
In this clinical case, the digital project
(Fig 6) led to an increase of final den-
tal volumes by means of an adequate
redistribution of diastemas. This was
made possible by a calibrated digital
Facial mid-line
Bipupillary line
Upper lip
Lower lip
Horizontal plane
Occlusal
plane
Digital
ruler
Fig 6 DSD: virtual treatment planning with digital previsualization. The design of the new dental profile
is guided by the “facial cross,” by extraoral parameters (bipupillary line, lower and upper lips) and by
the relationship of rectangles. The amount of the required modifications can be measured by means of a
calibrated digital ruler. The obtained measurements will guide the dental technician while performing the
wax-up. The final result can be previewed by superimposing custom dental shapes on both intraoral and
full-face photographs, thus greatly improving communication with the patient.
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ruler that allowed for the quantification of
the amount of the modifications needed
on every single tooth to obtain an anter-
ior sector in harmony with the patient’s
lips, surrounding tissue, face, and per-
sonality.
Traditional DSD sequences were inte-
grated using ClinCheck software (Align
Technology), which allowed for a real 3D
control of movement sequence, and a
0.1-mm level of precision in movement
and space opening.
Wax-up and clinical previsualiza-
tion (1st mock-up or APT)
By transferring the “facial cross” from
the digital project to the plaster model
it is possible to transfer the information
about 3D positioning of the mouth. This
is of great help to the dental technician
during the wax-up phase as it makes it
more predictable. Any surgical, ortho-
dontic, and restorative procedure will be
esthetically guided by the wax-up.14 The
wax-up allows for the creation of helpful
tools to guide the different procedures
for the overall treatment: surgical, ortho-
dontic, implant, and preparation guides.
In this case, three silicone indices
were obtained from the wax-up: 1) a
complete index for the creation of the
mock-up and temporary restoration; 2)
a palatal index; 3) and a buccal index,
horizontally sectioned as a book. The
latter two were used as references dur-
ing the preparation phase (Fig 7).
The next step is to convert the two-
dimensional (2D) digital project into a
3D mock-up, which may be either direct
or indirect, depending on the case. The
mock-up9 or APT10 provides a clinical
preview of the final restoration. This step
is critical in that it evaluates the final vol-
ume of the restorations according to es-
thetics and function, and thus validates
the digital project. A direct mock-up is
created with the use of a silicone index
(at least 95 shore in hardness), with
self-curing composite resin (Structur 3,
Voco) injected into the index, which is
then positioned on the teeth (Fig 8). The
Fig 7 DSD-driven wax-up of maxillary (from premolar to premolar) and mandibular (from canine to ca-
nine) anterior groups. Three silicone indices were obtained from the wax-up: (a) a complete index for the
creation of the mock-up and temporary restoration; (b) a palatal index; (c) a buccal index, horizontally
sectioned as a book. The latter two were used as references during the preparation phase.
c
a
b
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mock-up is then finished and polished
directly intraorally (Fig 9). Photographs
should be taken and shown to the pa-
tient. The mock-up should remain in situ
for the time required (at least 1 week)
for “deprogramming” the patient from
the previous situation.9 The ultimate
objective is to obtain the patient’s ap-
proval and the clinician’s evaluation of
the project. If corrections are needed,
they should be made in this step, either
by directly modifying the mock-up or by
modifying the wax-up and creating a
further mock-up. Once the mock-up is
clinically satisfactory, the following step
of the treatment may be performed.
Mucogingival surgery
Where cervical lesions are associated
with treatable gingival recessions, a
correct treatment plan involves a first re-
storative step to provide an adequate
anatomical CEJ. A surgical step then
follows, during which the recessions
are recovered to rebalance the gingival
scalloped morphology.15
In the case presented here, the perio-
dontal treatment started with periodontal
debridement, oral hygiene instruction,
and patient motivation. The next step
began only once all the periodontal in-
dices (PI, BOP, CAL, PD) had elicited
adequate periodontal health and a satis-
factory homecare routine (especially the
brushing technique).
In teeth 14, 13, and 24, since an an-
atomical CEJ could not be found, the
level of maximum root coverage (MRC)
was predetermined according to a well-
defined technique.16 MRC is defined
as the line that the gingival margin will
reach and, after maturation, stabilize af-
ter surgery. Composite resin adhesive
restorations were performed under rub-
ber dam isolation, then accurately fin-
ished and polished to recover the ana-
tomical CEJs. In a successive session,
the surgical correction of mucogingival
defects was performed.
A multiple coronal lateral flap tech-
nique17 was used (Fig 10a). After
measuring the depth of the recession,
oblique incisions were cut, converging
toward the center of rotation (usually
the canine). The flap was then raised
according to a defined protocol (partial/
full-partial thickness) with no relaxing
Fig 8 Direct mock-up molding with rigid silicone
index (95 shore).
Fig 9 Clinical previsualization (mock-up) of the
maxillary anterior teeth after intraoral finishing and
polishing.
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incisions. The epithelium of the ana-
tomical papillae was removed and the
root surfaces adequately conditioned.
Bilaminar grafts were taken from the
palate and, once the epithelium was
removed, sutured on teeth 14 and 23
(Fig 10b). Suspended sutures were
made with 6-0 absorbable polylac-
tic acid-polyglycolic acid (PLA-PGA)
thread (Fig 10c). After complete heal-
ing, a thorough morphological recovery
of the periodontal and dental complex
was obtained, showing a harmonious
gingival margin and adequate propor-
tion among the clinical crowns of the
treated teeth (Fig 10d).
Orthodontic diagnosis and
treatment plan
Preprosthetic orthodontic treatment is a
key phase in the multidisciplinary pro-
tocol, especially in the following situa-
tions:18
In case of rotations, in order to avoid
dentinal exposure during the prep-
aration of severely rotated or tipped
teeth.
To align the gingival height by means
of tooth intrusion or extrusion.
To redistribute space, and to center
each tooth in its DSD and mock-up
planned volume.
Fig 10 Multiple coronally advanced flap in the maxillary left quadrant. (a) After measuring the depth of
the recession, oblique incisions are cut, converging toward the center of rotation (ie, the canine). (b) After
removing the epithelium on the papillae, a bilaminar graft is taken from the palate and, once the epithelium
is removed, sutured on tooth 23. (c) With proper passivation, the flap is coronally advanced. A 6-0 absorb-
able PLA-PGA suspended suture is performed. (d) After tissue maturation, a complete coverage of gingival
recessions can be observed.
a b
c d
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In the presented case, after soft tissue
maturation in the maxillary arch, ortho-
dontic records were collected to evalu-
ate and visualize the necessary move-
ments. The main aspects analyzed were:
Whether or not to improve the inter-
cuspation in the lateral sectors.
The need for modification of the an-
terior tooth line.
The movement needed in both arch-
es to proceed to a good finalization.
The most effective and efficient
device needed in order to obtain
such movements, with respect to the
patient’s esthetic needs.
The cephalometric analysis and lateral
views (Fig 11a and b) show a class I
occlusion with proper overjet and nor-
mal divergence. No temporomandibular
joint (TMJ) pain was reported. Protrusive
and lateral guidance appeared inade-
quate due to the parafunction, leading
to severe wear of the anterior sector.
Nevertheless, muscle excursion in later-
al and protrusive movements was within
normal range, as was maximum open-
ing. Maxillary and mandibular incisor in-
clination was also within normal range,
and the interincisal angle did not show
any relevant change. The projection of
the maxillary incisal margin on the nasal
spine was good, so no modification of
the anterior teeth line was necessary.19
The planned movements were ob-
tained with transparent aligners (Invis-
align, Align Technology).20,21 The Clin-
Check software is effective in simulating
the space opening among maxillary
and mandibular incisors, starting from
the mesiodistal dimensions previewed
with the DSD and the initial wax-up.22
Different options may be analyzed and
virtually tested by means of 3D software.
Perfect communication among team
members is ensured by simulations that
are easily understandable, and by the
possibility of sharing previews via the
internet. Once the simulation fulfills the
clinical objectives, the aligners can be
manufactured.
Rectangular vertical attachments were
applied, according to the ClinCheck soft-
ware, to achieve a better movement of
the incisors. Treatment lasted 7 months,
needing 14 aligners (Fig 12). No rening
phase was necessary. Finally, the patient
was given two removable retainers and
was instructed to wear them for at least
3 months to maintain the result.
Fig 11 (a and b) Lateral views showing a stable molar class I, with proper anterior overjet.
a b
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Second mock-up and bleaching
treatment
At the end of the retention phase, a sec-
ond mock-up was created of the new
position of the teeth on the base of a
wax-up. The mock-up was obtained with
a direct technique, by molding the self-
curing composite resin in a rigid silicone
index taken on the new wax-up.
The final project fully satisfied the pa-
tient’s esthetic expectations and was
correct from a clinical point of view. De-
finitive restorations then became a con-
trolled process, with minimal modifica-
tions compared to the mock-up.
A bleaching treatment (chairside
power bleaching, and home bleaching
for 2 weeks) was performed to achieve
a more favorable color of the dental sub-
strate.
Preparation driven by mock-up
(ie, by additive final volume of the
restorations)
The preparation phase should be mini-
mally invasive, providing just enough
Invisalign orthodontic treatment: 14 aligners for 7 months
Before After
by Dr F. Federici Canova
Fig 12 Orthodontic treatment with space redistribution. Teeth movements were planned with the Clin-
Check software and were obtained with 14 Invisalign aligners. The treatment was carried out in 7 months.
Fig 13 Creation of depth grooves on the buccal
surface of the maxillary teeth. Round diamond burs
are the ideal depth cutters. The depth of the cut is
calculated by halving the difference between the
diameter of the bur and that of the shaft.
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space for the ceramic restorations, as
a function of the ceramic material prop-
erties, dental substrate color, need for
dental contour modification, and occlus-
al relationship.
The mock-up was used as a guide for
the minimally invasive prosthetic prep-
aration, creating calibrated depth cuts
directly on the composite.9,23,24
In the maxillary arch, six veneers were
planned (from canine to canine), and two
additional veneers on the mesial aspect
of the first premolars. In the mandibular
arch, six veneers were placed (from ca-
nine to canine).
Fig 14 Horizontal grooves 0.5- to 0.7-mm deep
are created between the middle and incisal thirds
of each facial surface. Scalloped grooves 0.3-
to 0.5-mm deep are created between the middle
and cervical thirds. Each depth groove is marked
with a pencil.
Fig 15 Maxillary teeth: step-by-step tooth preparation driven by the mock-up. Removal of the tooth
structure between the guiding grooves is performed with round-ended, slightly tapered diamond burs.
Preparation is performed both on the facial surface (a) and at the incisal margin (b). Prepared surfaces
are finished with fine grit burs (c), and polished with silicone points (d). The horizontally sectioned silicone
index obtained from the wax-up is used to double check for facial clearance (e).
a b c
d e
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In an adhesive preparation driven by
a mock-up, the clinician should deal with
two parameters:
The amount of tooth volume in-
crease, planned with the mock-up.
The thickness of the veneer, accord-
ing to mechanical properties, sub-
strate color, or planned color.25
The extent of tooth reduction (P) is repre-
sented by the difference between extra
volume (EV) and veneer thickness (LT):
P = EV - LT.10 The preparation is guided
by calibrated horizontal depth grooves:
a straight one in the middle third of the
Fig 16 Final veneer preparation in the maxillary
arch after polishing.
crown, and a scalloped one in the cervi-
cal third. Depth cuts are obtained with
two round diamond burs (Fig 13), pro-
viding a 0.3- to 0.5-mm deep groove in
the cervical third, a 0.5- to 0.7-mm deep
groove in the middle third, and at least
1.5 mm for incisal coverage (Fig 14).9,26
Once every remainder of the mock-up
has been removed, tooth reduction is
verified with the silicone indices ob-
tained from the final wax-up (Fig 15a
to e). The buccal index is horizontally
sectioned as a book at the incisal, mid-
dle, and cervical thirds. The palatal in-
dex is used to assess the 1.5-mm incisal
clearance.6 The prepared incisal margin
should preferably show a butt-joint con-
figuration or a palatal mini chamfer.27
The margin should never be placed in-
side the palatal concavity because that
is where the highest functional stress ex-
ists.28 In the cervical and interproximal
areas, a slight chamfer (0.3to0.5 mm)
is acceptable. Every angle should be
rounded, and the preparation should
be adequately finished and polished
(Figs 16 to 18). Care should be taken
to keep the tooth reduction inside the
thickness of the enamel. The critical
Fig 17 Mandibular teeth: step-by-step tooth preparation driven by the mock-up.
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dentinoenamel junction (DEJ) should
also be preserved.24 The DEJ could be
regarded as a fibril-reinforced bond with
a very high fracture toughness.29
In case of dentinal exposure, whether
accidental or unavoidable, the dentin it-
self should be immediately sealed with
a dental adhesive system before taking
the impression. Immediate dentin seal-
ing (IDS) improves the bond strength of
indirect restorations.30-34
To prevent crack onset inside the
veneers, the ceramic veneer thickness
should be at least three times that of
the luting composite material (ceramic/
composite ratio of thickness > 3) at the
facial location.35-37 It is also important
to obtain a good internal fit of the restor-
ation (approximately 100 µm).
Impression and
provisionals
An impression should be taken with the
double retraction cord technique.6 A first
compressive cord (Ultrapak No.000, Ul-
tradent) is positioned in the sulcus be-
fore finishing the preparations, and left
in situ during the impression. A second
continuous deective cord (GingiBRAID
0n, Dux Dental/Kerr, Pentron) is impreg-
nated with aluminum chloride and pos-
itioned in the sulcus for a few minutes,
then removed in a single step before
applying the light body impression ma-
terial. The impression material should
be either polyether or polyvinylsiloxane,
used with a simultaneous dual-viscosity
(medium and light body) technique. Op-
tical impressions may also be used in
association with a thoroughly or partially
digital workflow.
The provisional restoration should be
made using a direct technique. The sili-
cone index, obtained from the wax-up,
should be used to mold a self-curing
composite material in the same morphol-
ogy obtained with the previsualization
mock-up.10,38,39 The direct provisional
restoration, after intraoral finishing and
polishing, will be macromechanically
retained on the prepared teeth until the
luting session.
Laboratory procedure: manufac-
ture of ceramic laminate veneers
Master models should be obtained with
three different casts from the same fi-
nal impression. The dental technician
performs multiple sets of individual
dies (original, stone replica, refractory
replica), a non-separable model, and a
soft tissue (alveolar) model. The multidie
technique allows for the construction of
laminate veneers on removable refrac-
tory dies in a stone master cast.6,40
A final wax-up is performed, recre-
ating the shape validated with the final
mock-up. At this point, the material to
be used for the final restorations is cho-
Fig 18 Final veneer preparation in the mandibu-
lar arch after polishing.
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sen. To obtain biomimetic restorations
that emulate the biomechanical and op-
tical properties of the natural tooth (Ta-
ble 3), ceramics should be the material
of choice (feldspathic ceramic baked
on refractory, layered computer-aided
design/computer-aided manufacture
[CAD/CAM] or pressed lithium disili-
cate).
In the maxillary arch, veneers were
made in feldspathic ceramic, layered
and baked on refractory (Fig 19). This
type of solution provides the highest es-
thetic result, yet it does not allow any
change once removed from the refrac-
tory. For this reason, the diagnostic path
is of critical importance for the treatment
strategy, as it allows a precise definition
of the shape and volume of the restor-
ations before their manufacture.
In the mandibular arch, restorations
were made in layered pressed lithium
disilicate (IPS e.max Press, Ivoclar Vi-
vadent), since their manufacture is sim-
Table 3 Mechanical properties of the natural tooth compared with composite and ceramic materials.
Ceramic has a stiffness similar to enamel, so it is the best material (more biomimetic) with which to restore
the enamel itself
Elastic
modulus
(GPa)
Knoop
hardness
(kg/mm2)
Linear TCE
20°–50°
(x10-6/C°)
Termal conductiv-
ity (cal/sec/cm2
(C°/cm))
Strength (MPa)
Tensile Compressive
Dentin 13.2–18.6 68 10–15 0.0015 98 297
Composite 4.5–20.1 22–80 25–68 0.0025 34–62 200–345
Enamel 83.0 343 10–15 0.0022 10 400
Ceramic
64–400
(70–96
feldspath-
ic, lithium
disilicate)
460 8–13.5 0.0025 40 150
Fig 19 Feldspathic ceramic laminate veneers
baked on refractory (maxillary teeth).
Fig 20 Pressed and layered lithium disilicate ve-
neers (mandibular teeth).
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pler for the dental technician, and modi-
fications are possible after the baking
(Fig 20).
Try-in and adhesive cementation
In order to evaluate the marginal adap-
tation, contact points, shape, color, and
final esthetic integration, the veneers
should be tried in with dedicated try-in
pastes (with similar color shades as for
the respective composite cements), or
with glycerine gel.
The adhesive cementation takes
place in the following session. The oper-
ative field is isolated by means of rubber
dam from premolar to premolar. A sup-
plementary rubber dam clamp (Ivory or
Hu-Friedy No.212) is used to retract the
dam on each tooth. Veneers are tried in
again and then luted one by one, start-
ing from the central incisors and ending
with the canines. Extreme care should
be taken with the adhesive luting pro-
cedure (Fig 21)6,41:
1. Ceramic surface conditioning: 9%
hydrofluoric acid (HF) application for
60 to 90 s for feldspathic porcelain, or
5.5% HF for 20 s for lithium disilicate;
ultrasonic cleaning in an alcohol bath
for 5min; silane application (coupling
agent between the silica particles of
ceramic and those of the composite
cement), heated in the oven at 100°C
for 1 min; bonding application (just
before placing the veneer in position);
air blowing of excess; no light curing.
2. Dental substrate conditioning: accu-
rate cleaning with soft brushes and
a mix of pumice and 2% chlorhexi-
dine solution; airflow with glycine
powder; protection of adjacent teeth
with U-shaped steel matrix bands,
held in place by two wooden wedges;
acid etching of enamel with 35% or-
thophosphoric acid for 30 s; applica-
tion of bonding, accurately removing
the excess with air blow and suction.
Fig 21 Adhesive luting procedure of the ceramic veneers on the dental substrate.
Ceramic and tooth surface adhesive treatment
After
9% hydrofluoric acid
Ultrasonic alcohol bath
Silane
Etch-and-rinse 3-step technique Heated
composite
Insertion Removal
of the excess
Light curing
4–6 min
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A microhybrid light-curing restorative
material, adequately heated in an oven,
is used as the luting material. As an al-
ternative, dedicated light-curing resin
cements may be used. The restoration
is then seated gently by pushing with the
finger, and the excess material removed
accordingly. In the case of butt-joint in-
cisal margin preparation, a frontal inser-
tion path may be used. In the case of
mini-chamfer preparation, the insertion
path will be coronoapical.
A delicate margin finishing and pol-
ishing should be performed. Slight ex-
cess is removed with a box carver, or
a No.12 scalpel blade; then, if neces-
sary, low-grit diamond burs and flexible
blades (40 and 15 µm) are used on a
reciprocating handpiece. Finally, com-
posite polishers, cups, and synthetic
brushes with diamond paste are used.
Once the rubber dam is removed,
occlusal relation should be checked in
maximum intercuspation, then in lateral-
ity and during protrusive movements.
Fig 22 Frontal view of the final result after cemen-
tation of the maxillary laminate veneers.
Fig 23 Frontal view of the final result after cemen-
tation of the mandibular laminate veneers.
Fig 24 (a) Initial frontal view, before treatment. (b) Frontal view of the final result, at 2-month recall.
Optimal morphologic, functional, and esthetic integration can be observed, as well as excellent periodontal
response.
a b
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Conclusions
The final photographs show optimal
morphologic, functional, and esthetic in-
tegration, with excellent periodontal re-
sponse (Figs 22 and 23). The functional
and esthetic improvement can be ap-
preciated by comparing the before and
after treatment photographs (Fig 24a
and b). The smile line is harmonious,
and the teeth provide ideal lip support
(Figs 25 and 26). The patient was ex-
tremely satisfied with the result. Psycho-
logical improvements were also seen,
as there was an increase in the patient’s
self-confidence (Fig 27).
The scheduling of each treatment
phase – also thanks to new, useful virtual
tools such as DSD (Fig 28) – represents
an effective means for clinician–patient
communication, and may provide reli-
able help for the whole dental team.
The diagnostic and therapeutic pro-
tocol described in the present clinical
case showed how, by combining dif-
ferent fields of dentistry (hygienic and
periodontal therapy, restorative, mucog-
ingival surgery, orthodontic, and pros-
thetic therapies), an excellent final result
Fig 25 Rest position with ideal exposure of the
central incisors.
Fig 26 Full smile with a harmonious smile line.
Fig 27 Frontal view of the face, showing an ideal
relationship between the teeth and the face.
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can be achieved (Fig 29). Following this
workflow that encompasses accuracy
and precision at every step, the treat-
ment with veneers resulted in a highly
predictable and professionally gratifying
restoration.
Acknowledgment
I am proud to thank all my esthetic team: Dr Fabio
Federici Canova for the orthodontic treatment and
for his invaluable assistance in the drafting of this
article, and the dental technicians, F. Pozzi and
A. Quintavalla (PR Italy), for their excellent work.
Thanks also to Dr L. Madini (BS) for the English
language assistance.
Fig 28 Full-face photographs at different treatment stages: preoperative (a), digital preview (b), clinical
preview (mock-up) (c), and final result (d).
Fig 29 Lateral view of the smile, with an ideal
dentolabial relationship.
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References
1. Bazos P, Magne P. Bio-
emulation: biomimetically
emulating nature utilizing a
histo-anatomic approach;
structural analysis. Eur J
Esthet Dent 2011;6: 8–19.
2. Bazos P, Magne P. Bio-
Emulation: biomimetically
emulating nature utilizing
a histoanatomic approach;
visual synthesis. Int J Esthet
Dent 2014;9: 330–352.
3. Tirlet G, Crescenzo H, Cres-
cenzo D, Bazos P. Ceramic
adhesive restorations and
biomimetic dentistry: tissue
preservation and adhesion.
Int J Esthet Dent 2014;9:
354–369.
4. Dumfahrt H, Schäffer H.
Porcelain laminate veneers.
A retrospective evaluation
after 1 to 10 years of service:
Part II – Clinical results. Int J
Prosthodont 2000;13: 9–18.
5. Fradeani M, Redemagni
M, Corrado M. Porcelain
laminate veneers: 6- to
12-year clinical evaluation
– a retrospective study. Int
J Periodontics Restorative
Dent 2005;25: 9–17.
6. Magne P, Belser U. Bonded
Porcelain Restorations in the
Anterior Dentition: A Biomi-
metic Approach. Chicago:
Quintessence, 2002.
7. Edelhoff D, Sorensen JA.
Tooth structure removal
associated with various
preparation designs for
anterior teeth. J Prosthet
Dent 2002;87: 503–509.
8. Coachman C, Calamita M.
Digital Smile Design: A tool
for treatment planning and
communication in esthetic
dentistry. Quintessence Dent
Technol 2012;35: 101–109.
9. Magne P, Belser UC. Novel
porcelain laminate prepar-
ation approach driven by a
diagnostic mock-up. J Esthet
Restor Dent 2004;16: 7–16.
10. Gurel G, Morimoto S, Calam-
ita MA, Coachman C, Sesma
N. Clinical performance of
porcelain laminate veneers:
outcomes of the aesthetic
pre-evaluative temporary
(APT) technique. Int J Peri-
odontics Restorative Dent
2012;32: 625–635.
11. Fradeani M. Evaluation of
dentolabial parameters as
part of a comprehensive
esthetic analysis. Eur J
Esthet Dent 2006;1: 62–69.
12. Mclaren EA, Cao PT. Smile
Analysis and Esthetic
Design: “In the Zone”. Inside
Dentistry;5: 44–48.
13. Paolucci B, Calamita M,
Coachman C, Gurel G, Shay-
der A, Hallawell P. Visagism:
The Art of Dental Composi-
tion. Quintessence Dent
Technol 2012;35: 187–200.
14. Gurrea J, Bruguera A. Wax-
up and mock-up. A guide
for anterior periodontal and
restorative treatments. Int J
Esthet Dent 2014;9: 146–162.
15. Zucchelli G, Gori G, Mele M,
et al. Non-carious cervical
lesions associated with gin-
gival recessions: a decision-
making process. J Periodon-
tol 2011;82: 1713–1724.
16. Zucchelli G, Mele M, Stefani-
ni M, et al. Predetermination
of root coverage. J Periodon-
tol 2010;81: 1019–1026.
17. Zucchelli G, De Sanctis M.
Treatment of multiple reces-
sion-type defects in patients
with esthetic demands.
J Periodontol 2000;71:
1506–1514.
18. Norris RA, Brandt DJ, Craw-
ford CH, Fallah M. Restora-
tive and Invisalign: a new
approach. J Esthet Restor
Dent 2002;14: 217–224.
19. Andrews WA. AP relationship
of the maxillary central inci-
sors to the forehead in adult
white females. Angle Orthod
2008;78: 662–669.
20. Lagravère MO, Flores-Mir
C. The treatment effects of
Invisalign orthodontic align-
ers: a systematic review.
J Am Dent Assoc 2005;136:
1724–1729.
21. Rossini G, Parrini S, Cas-
troflorio T, Deregibus A,
Debernardi CL. Efficacy of
clear aligners in controlling
orthodontic tooth movement:
a systematic review. Angle
Orthod 2015;85: 881–889.
22 Levrini L, Tieghi G, Bini V.
Invisalign ClinCheck and
the Aesthetic Digital Smile
Design Protocol. J Clin
Orthod 2015;49: 518–524.
23. Magne P, Perroud R, Hodges
JS, Belser UC. Clinical
performance of novel-design
porcelain veneers for the
recovery of coronal volume
and length. Int J Periodontics
Restorative Dent 2000;20:
440–457.
24. Magne P, Magne M. Use of
additive waxup and direct
intraoral mock-up for enamel
preservation with porcelain
laminate veneers. Eur J
Esthet Dent 2006;1: 10–19.
25. Coachman C, Gurel G,
Calamita M, Morimoto S,
Paolucci B, Sesma N. The
influence of tooth color on
preparation design for lami-
nate veneers from a minimal-
ly invasive perspective: case
report. Int J Periodontics
Restorative Dent 2014;34:
453–459.
26. Magne P, Hanna J, Magne
M. The case for moderate
“guided prep” indirect porce-
lain veneers in the anterior
dentition. The pendulum of
porcelain veneer prepar-
ations: from almost no-prep
to over-prep to no-prep.
Eur J Esthet Dent 2013;8:
376–388.
27. Garber D. Porcelain laminate
veneers: ten years later. Part
I: Tooth preparation. J Esthet
Dent 1993;5: 56–62.
24
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 12 • NUMBER 4 • WINTER 2017
CLINICAL RESEARCH
28. Magne P, Versluis A, Douglas
WH. Rationalization of incisor
shape: experimental-numer-
ical analysis. J Prosthet Dent
1999;81: 345–355.
29. Lin CP, Douglas WH.
Structure-property relations
and crack resistance at the
bovine dentin-enamel junc-
tion. J Dent Res 1994;73:
1072–1078.
30. Bertschinger C, Paul SJ,
Lüthy H, Schärer P. Dual
application of dentin bond-
ing agents: effect on bond
strength. Am J Dent 1996;9:
115–119.
31. Jayasooriya PR, Pereira PN,
Nikaido T, Tagami J. Efficacy
of a resin coating on bond
strengths of resin cement to
dentin. J Esthet Restor Dent
2003;15: 105–113.
32. Magne P. Immediate dentin
sealing: a fundamental pro-
cedure for indirect bonded
restorations. J Esthet Restor
Dent 2005;17: 144–154.
33. Magne P, Kim TH, Cascione
D, Donovan TE. Immedi-
ate dentin sealing improves
bond strength of indirect
restorations. J Prosthet Dent
2005;94: 511–519.
34. Burke FJ. Survival rates for
porcelain laminate veneers
with special reference
to the effect of prepar-
ation in dentin: a literature
review. J Esthet Restor Dent
2012;24: 257–265.
35. Magne P, Kwon KR, Belser
UC, Hodges JS, Douglas
WH. Crack propensity of
porcelain laminate veneers:
A simulated operatory
evaluation. J Prosthet Dent
1999;81: 327–334.
36. Magne P, Versluis A, Douglas
WH. Effect of luting compos-
ite shrinkage and thermal
loads on the stress distribu-
tion in porcelain laminate
veneers. J Prosthet Dent
1999;81: 335–344.
37. Schmidt KK, Chiayabutr Y,
Phillips KM, Kois JC. Influ-
ence of preparation design
and existing condition of
tooth structure on load to
failure of ceramic laminate
veneers. J Prosthet Dent
2011;105: 374–382.
38. Messing MG, Sher JH. A clin-
ical technique for temporiza-
tion of teeth to receive porce-
lain laminate veneers. J N J
Dent Assoc 1994;65: 29–33.
39. Mitrani R, Phillips K, Escude-
ro F. Provisional restoration of
teeth prepared for porcelain
laminate veneers: an alterna-
tive technique. Pract Proced
Aesthetic Dent 2003;15:
441–445.
40. Sheets CG, Taniguchi T.
A multidie technique for
the fabrication of porcelain
laminate veneers. J Prosthet
Dent 1993;70: 291–295.
41. Krämer N, Lohbauer U,
Frankenberger R. Adhesive
luting of indirect restorations.
Am J Dent 2000;13(Spec
No):60D–76D.
... DSD is based on a clear extraoral and intraoral photographic protocol, which is necessary for the esthetic analysis of some specific elements [14]: ...
... In situations of tooth malposition, DSD helps us to quantify the amount of the modifications needed on every single tooth to obtain an anterior sector in harmony with the patient's dentition. [14] This approach allows to measure the residual enamel tissue after tooth preparation, if an important quantity is eliminated and the dentin is exposed, bonding will be compromised and porcelain veneers will not be indicated. ...
... On the one hand, veneers are the most conservative solution mainly indicated for intact teeth with very slight malposition in order to preserve the enamel tissue necessary for the bonding. Therefore, with the advances in dental ceramics and adhesive systems, porcelain veneers are considered as a much more conservative treatment in terms of preparation, they give satisfactory and lasting esthetic results and they have shown a very important survival rate [14,29]. Edelhoff and Sorensen measured, with a gravimetric analysis, the amount of tooth structure removed during different preparation designs for many types of prostheses. ...
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Tooth malposition can negatively affect the appearance of a person’s smile. In these cases, it is essential to conduct a comprehensive clinical and radiological examination to determine the type and extent of the tooth malposition before selecting the appropriate treatment option. Orthodontic treatment is generally used to correct mild to severe malocclusions. In cases where the tooth malposition is associated with other dental issues such as tooth discoloration, ceramic restorations may be a suitable alternative.
... The use of these veneers also results in highly esthetic outcomes. 2,[4][5][6] However, although both composite resin and ceramic veneers are used to restore anterior teeth, determining which approach to use in a particular situation is still challenging. 2 When selecting the proper material for diastema closure, the clinician should take into consideration the patient's age, tooth position in the arch, substrate color, occlusal stability, parafunctional habits, treatment time, and financial constraints. ...
... 7 Therefore, diastema closure is based on careful planning and often requires a multidisciplinary approach, encompassing fields such as orthodontics, periodontics, and restorative dentistry. 4,8,9 In patients with small or missing teeth, orthodontic movement may cause a volume loss on the buccal surface and muscle hypotonicity of the upper lip. Consequently, facial esthetics can be impaired; in addition, orthodontic treatment is timeconsuming. ...
... 21 However, clinicians should be aware of contraindications, including severe bruxism, parafunctional habits, exposure to heavy occlusal forces, or severe tooth malpositioning. 4,20 In such cases, an GENERAL DENTISTRY September/October 2023 interdisciplinary approach may be required, including orthodontic treatment for correction of alignment and a diagnosis of deleterious habits. 15 Patients with microdontia should undergo gingivoplasty to achieve symmetric gingival architecture. ...
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Determining the appropriate technique for diastema closure is challenging, and the decision must be evidence based. The objective of these case reports is to describe different approaches to diastema closure using direct and indirect techniques, focusing on the characteristics of the patient and clinical requirements to guide treatment. In the first case, a 16-year-old patient had multiple diastemas in the maxillary anterior dentition. The clinical evaluation revealed microdontia of the lateral incisors and malpositioned teeth. The treatment included tooth whitening and placement of composite resin veneers using a direct technique. In the second case, a 54-year-old patient displayed a disharmonious and esthetically compromised smile due to small teeth, color changes, multiple diastemas, incisal wear, and severe dentogingival disproportion. Based on the patient's expectations, the patient's age, and the presence of a "black triangle" interdental space, a multidisciplinary restorative treatment was proposed, including gingivoplasty, tooth whitening, and placement of ceramic laminate veneers using an indirect technique. Both approaches achieved successful esthetic rehabilitation and diastema closure with minimal intervention. The choice of procedure and restorative material, as well as the need for tooth preparation, varied based on the clinical requirements, patient expectations, and financial constraints. Careful treatment planning avoided lengthy and inefficient procedures.
... (8) Hoy en día las preparaciones de las carillas de cerámica son mínimamente invasivas, dando estabilidad del color, función, forma y estética de los dientes anteriores dando un resultado estético a largo plazo y conservando las estructuras dentarias. (9,10) El uso de las carillas de cerámicas en la zona estética está dada por el grosor del esmalte, diseño de preparación, oclusión, grado de destrucción dental, vitalidad del diente y el material cerámico utilizado y experticia del restaurador. (11) Las indicaciones de las carillas se pueden usar en los siguientes casos: dientes descoloridos, fluorosis, amelogénesis imperfecta, restauración de dientes defectuosas con fracturas y desgastes, morfología anómala del diente, diastemas y mal posiciones leves. ...
... (17) Varios estudios describieron el protocolo para la preparación de las carillas de cerámica, recomendando la creación de ranuras de profundidad de 0,3 a 0,5 mm en el tercio cervical, de 0,5 a 0,7 mm en el tercio medio, con una preparación cervical en chaflán de 0,3 mm y una reducción incisal de 1 a 1,5 mm. (10,22) En el caso clínico presentado, las preparaciones fueron mínimamente invasivas para maximizar la adhesión y la longevidad clínica, ya que la exposición de la dentina puede causar microfiltraciones y fracturas adhesivas. ...
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The esthetic problem of defective resin restorations in the anterior sector leads to psychological, esthetic, functional and periodontal soft tissue problems. Smile design is a current issue in restorative dentistry, the search for beauty is what motivates us to obtain an esthetically pleasing smile. The present clinical case reports a 34-year-old female patient, with no medical history, where defective resin veneers were observed in the anterosuperior sector, where lithium disilicate veneers were planned. The objective of this clinical case study was to determine the esthetic results with digital planning in the anterior area with lithium disilicate veneers. This research reveals that lithium disilicate veneers offer remarkable esthetic results, improving dental appearance in a versatile and long-lasting manner, which positively impacts patients' self-image and confidence. Digital anterior planning for changes from defective resin veneers to lithium disilicate is a highly promising strategy in esthetic dentistry. The combination of digital technology and the use of lithium disilicate offers outstanding esthetic and functional results, with greater preservation of tooth tissue and increased patient satisfaction
... She gave a history of spacing between anterior teeth 11/12 from orthodontics. Her major concern was an unesthetic appearance when smiling (29)(30)(31) 1. Digital smile imaging and designing help patients visualize the expected final result before treatment starts, enhancing the treatment's predictability. ...
... 3. Digital imaging improves dentist diagnosis and treatment plan by aesthetic visualization of patient's problem through digital analysis of facial, gingival and dental parameters that will analyze the smile and the face in an objective and standardized manner. (29)(30)(31) ...
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Nowadays, the application of digital technologies and devices are widely used in dentistry. The explanation of the innovative and advanced digital technology for designing and fabricating the provisional restorations transfers to final restorations. Computer-aided design/computer-aided manufacturing (CAD/CAM) in digital dentistry has numerous advantages and greater efficiency and accuracy over the conventional techniques. The digital smile design (DSD) is used for esthetic dentistry especially in case of veneer and can be improved the effectiveness and efficiency of dentist to patient and dentist to technician communication. However, the applications of DSD and CAD/CAM require an understanding of the principal concept and digital technology to create the precise and esthetic outcome of the final restoration.
... (Int J Esthet Dent 2023; 18:330-344) A considerable number of cases have been published on esthetic rehabilitation through crown lengthening surgery and laminate veneers. 4,6 Most of these cases implement digital technology solely as a separate step in the entire workflow, often for the initial smile design or for the fabrication of the restoration. 6,11 However, there is a paucity of studies in the literature reporting on the control of the periodontal-restor ative interface in interdisciplinary treatments through a digital workflow. ...
... Assessment of the peri odontal tissue is an essential part of smile esthetics, especially where there is an exposure of free gingiva during smile. 4 An un even gingival line, short clinical crowns or increased soft tissue exposure can reduce the attractiveness of the smile, regardless of the veneer placement. ...
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Aim: To describe a digital workflow utilizing 3D printing technology to guide esthetic crown lengthening and control tooth preparation. Clinical considerations: After the initial intraoral and face scans, an esthetic treatment plan was performed digitally based on the patient's personality and face type using artificial intelligence-based 3D smile design software. A 3D-printed tray relined with silicone over a 3D-printed model was used for the mock-up. A 3D-printed guide was implemented to assist esthetic crown lengthening by incorporating, simultaneously, information about the desired free gingival line and the alveolar bone level. Based on the initial planning, a set of reduction guides was 3D printed to check and correct the tooth preparation. Prior to the start of construction of the final monolithic restorations, their design was verified using 3D-printed prototypes. A stabilization splint was digitally designed and 3D printed to protect and maintain the final result. Conclusions: Technologic advances can improve the predictability of an interdisciplinary esthetic approach. Digital planning can be transferred to clinical reality using a digital workflow, utilizing a set of appropriate 3D-printed guides, which can help to control clinical procedures based on the initial planning. Clinical significance: By following the proposed step-by-step workflow, clinicians can achieve predictable results through an interdisciplinary approach, guiding both the periodontal plastic surgery and the restorative treatment after an individualized CAD/CAD procedure for 3D-printed guides.
... It is important to know that dental software is becoming more and more performant to provide professionals with a greater diversity of previsualizations. The use of smile design software allows for interdisciplinary collaboration between practitioners, and this seems to improve the decision-making process, ultimately decreasing the amount of intra-oral adjustment, remake rates, and the overall dissatisfaction of the patient [21][22][23]. A fully digital workflow may be more reliable than conventional techniques and make use of planning software such as digital smile design. ...
... A fully digital workflow may be more reliable than conventional techniques and make use of planning software such as digital smile design. However, significant monetary and time investments are needed to use these techniques, which may not be feasible for a general dentist [22,23]. ...
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Introduction: Several methods are currently available for providing a preview of the prosthodontic treatment, including computer simulations, 3D models, wax-ups, and mock-ups. The aim of this study is to compare the aesthetic aspects and assessment of conventional versus digital prefigurative methods. Methods: The study included 5 patients and 3 observers, for each of whom a wax-up was made in both the conventional and digital techniques. The analog method, which implied a mock-up molding with a silicone matrix of the wax-up, was compared to a digital workflow, which consisted of a mock-up milling from a digital design. The patient's clinical mock-ups were recorded with digital photographs and assessed for nine different criteria by three observers. Results: The analysis has shown a balanced assessment of the aesthetic criteria without any significant difference between the analog and digital prefigurative methods. Conclusions: Between the two wax-ups (conventional and digital), there were some variations in smile and dental criteria; however, the obtained data were very similar. When it comes to the smile criteria, the general average grades of the mock-ups conducted using the conventional method are slightly higher than the ones using the digital technique.
... Ceramic dental laminate veneers are a well-documented and predictable treatment for modifying the shade of whitening-resistant teeth, improving the shape of teeth with acquired malformations and loss of facial enamel, correcting minor rotations, and closing moderate diastemas [15][16][17][18]. Contemporary dental ceramic systems have improved mechanical and optical properties [19][20][21]. ...
... Ceramic dental laminate veneers are a well-documented and predictable treatmen for modifying the shade of whitening-resistant teeth, improving the shape of teeth wit acquired malformations and loss of facial enamel, correcting minor rotations, and closin moderate diastemas [15][16][17][18]. Contemporary dental ceramic systems have improved me chanical and optical properties [19][20][21]. ...
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An esthetically pleasing smile is a valuable aspect of physical appearance and plays a significant role in social interaction. Achieving the perfect balance between extraoral and intraoral tissues is essential for a harmonious and attractive smile. However, certain intraoral deficiencies, such as non-carious cervical lesions and gingival recession, can severely compromise the overall aesthetics, particularly in the anterior zone. Addressing such conditions requires careful planning and meticulous execution of both surgical and restorative procedures. This interdisciplinary clinical report presents a complex case of a patient with esthetic complaints related to asymmetric anterior gingival architecture and severely discolored and eroded maxillary anterior teeth. The patient was treated using a combination of minimally invasive ceramic veneers and plastic mucogingival surgery, resulting in a successful outcome. The report emphasizes the potential of this approach in achieving optimal esthetic results in challenging cases, highlighting the importance of an interdisciplinary team approach in achieving a harmonious balance between dental and soft tissue aesthetics.
... Lamina veneer restorations are aesthetic restorations that allow to improve the form, position and color characteristics of the teeth. Lamina veneer restorations are an aesthetic treatment that can be preferred in the presence of position disorder in the teeth, the presence of diastema between the teeth in the aesthetic area, the presence of discoloration, and the teeth where the aesthetic harmony is impaired due to trauma (30,31). ...
... Seramik lamina veneer restorasyonlar, adeziv tekniklerin kullanılması ile anterior dişlerin renk, form ve pozisyonlarının değiştirilmesi amacı ile kullanılırlar. 1,2,3 Seramik lamina veneer restorasyonlar adeziv olarak simante edilirler ve simantasyonda rezin simanlar kullanılır. Seramik lamina veneer restorasyonlarda klinik başarı, diş dokusu ile rezin arasındaki bağlantının ve kompozit rezinin pürüzlendirilmiş porselene ideal olarak bağlanmasının sağlanması ile yakından ilişkilidir. ...
... Com o desenvolvimento do fluxo digital, os procedimentos que antes eram mais lentos e burocráticos passaram a ser realizados com mais facilidade, velocidade, previsibilidade, segurança e respeitando os anseios dos pacientes (PEÇANHA; TONIN; FERNANDES, 2020). Nessa perspectiva, a incorporação da tecnologia na Odontologia melhorou a comunicação entre diversas especialidades odontológicas, laboratórios e paciente e foi facilitada pela inclusão dos recursos fotográficos e filmográficos, tecnologia do scanner, fresagem de peças e impressão de modelos em três dimensões (3D)(VENEZIANI, 2017;PEÇANHA;TONIN;FERNANDES, 2020). Além disso, especialidades como Ortodontia, Implantodontia e Prótese têm passado por modificações substanciais nas etapas de protocolos clínicos e materiais, quando se utilizam do fluxo digital(DAWOOD et al., 2015).A implementação da Odontologia digital na prática clínica não está voltada apenas a equipamentos. ...
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Objective: To assess the scientific evidence related to the efficacy of clear aligner treatment (CAT) in controlling orthodontic tooth movement. Materials and methods: PubMed, PMC, NLM, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Knowledge, Scopus, Google Scholar, and LILACs were searched from January 2000 to June 2014 to identify all peer-reviewed articles potentially relevant to the review. Methodological shortcomings were highlighted and the quality of the studies was ranked using the Cochrane Tool for Risk of Bias Assessment. Results: Eleven relevant articles were selected (two Randomized Clinical Trials (RCT), five prospective non-randomized, four retrospective non-randomized), and the risk of bias was moderate for six studies and unclear for the others. The amount of mean intrusion reported was 0.72 mm. Extrusion was the most difficult movement to control (30% of accuracy), followed by rotation. Upper molar distalization revealed the highest predictability (88%) when a bodily movement of at least 1.5 mm was prescribed. A decrease of the Little's Index (mandibular arch: 5 mm; maxillary arch: 4 mm) was observed in aligning arches. Conclusions: CAT aligns and levels the arches; it is effective in controlling anterior intrusion but not anterior extrusion; it is effective in controlling posterior buccolingual inclination but not anterior buccolingual inclination; it is effective in controlling upper molar bodily movements of about 1.5 mm; and it is not effective in controlling rotation of rounded teeth in particular. However, the results of this review should be interpreted with caution because of the number, quality, and heterogeneity of the studies.
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Various types of dental preparations for laminate veneers have been proposed,depending on factors such as the properties of the ceramic material, remaining dental structure color, need for altering the dental contour, laboratory fabrication technique, and occlusal relationships. Clinical observations of successes and failures associated with the development of techniques and materials have allowed some safe parameters to be delineated for effectively performing dental preparations for ceramic veneers or even placing veneers without any preparation. This article describes the use of an additive diagnostic wax-up that is transferred to the mouth by means of an intraoral mock-up (aesthetic pre-evaluative temporary) with associated mathematic parameters to guide dental preparations. This technique, called Do the Math and presented here in the form of a clinical case report, aims to avoid excessive or incorrect tooth preparation by indicating the exact amount and location of the tooth reduction necessary to attain the desired color and shape.
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When starting a case, having the end result in mind is the basis in any kind of treatment, even more so in those where the anterior teeth morphology, size and proportion will be changed. Here is where a good treatment plan based on a diagnostic wax-up that is tried in with a mock-up and approved by the patient becomes crucial. This case report exemplifies how transferring the information from the diagnostic wax up to the patient's mouth is of help not only to the restorative dentist and the laboratory technician, but also to the surgeon when performing the crown lengthening. This treatment plan cannot be seen as a sequence of isolated procedures but as a single workflow. The wax-up/mock-up binomial is a guide even for the periodontist in a novel approach to surgical crown lengthening.
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This article evaluates the long-term clinical performance of porcelain laminate veneers bonded to teeth prepared with the use of an additive mock-up and aesthetic pre-evaluative temporary (APT) technique over a 12-year period. Sixty-six patients were restored with 580 porcelain laminate veneers. The technique, used for diagnosis, esthetic design, tooth preparation, and provisional restoration fabrication, was based on the APT protocol. The influence of several factors on the durability of veneers was analyzed according to pre- and postoperative parameters. With utilization of the APT restoration, over 80% of tooth preparations were confined to the dental enamel. Over 12 years, 42 laminate veneers failed, but when the preparations were limited to the enamel, the failure rate resulting from debonding and microleakage decreased to 0%. Porcelain laminate veneers presented a successful clinical performance in terms of marginal adaptation, discoloration, gingival recession, secondary caries, postoperative sensitivity, and satisfaction with restoration shade at the end of 12 years. The APT technique facilitated diagnosis, communication, and preparation, providing predictability for the restorative treatment. Limiting the preparation depth to the enamel surface significantly increases the performance of porcelain laminate veneers.
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Thanks to sophisticated adhesive techniques in contemporary dentistry, and the development of composite and ceramic materials, it is possible to reproduce a biomimetic match between substitution materials and natural teeth substrates. Biomimetics or bio-emulation allows for the association of two fundamental parameters at the heart of current therapeutic treatments: tissue preservation and adhesion. This contemporary concept makes the retention of the integrity of the maximum amount of dental tissue possible, while offering exceptional clinical longevity, and maximum esthetic results. It permits the conservation of the biological, esthetic, biomechanical and functional properties of enamel and dentin. Today, it is clearly possible to develop preparations allowing for the conservation of the enamel and dentin in order to bond partial restorations in the anterior and posterior sectors therefore limiting, as Professor Urs Belser from Geneva indicates, "the replacement of previous deficient crowns and devitalized teeth whose conservation are justified but whose residual structural state are insufficient for reliable bonding."1 This article not only addresses ceramic adhesive restoration in the anterior area, the ambassadors of biomimetic dentistry, but also highlights the possibility of occasionally integrating one or two restorations at the heart of the smile as a complement to extensive rehabilitations that require more invasive treatment.
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A thorough understanding of the spatial distribution pertaining to the histo-anatomic coronal structures and dynamic light interaction of the natural dentition provides the dental team with the ultimate strategic advantage with regards to optical integration of the final restoration. The second part of this two-part article will attempt to provide insight on the illumination interactivity and the spatial arrangement of the coronal elements of natural teeth through the utilization of this knowledge in the clinical and technical restorative approach. The main goals for this article are to cognize histo-anatomic visualization by introducing: (1) Dynamic light interaction, (2) the 9 elements of visual synthesis, (3) dynamic infinite optical thickness, and (4) amplified visual perception effect of the hard dental tissues. Furthermore, a diversification of photographic illumination techniques will be illustrated in order to juxtapose optical associations between the enamel/dentinoenamel complex/dentin nexus.
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In a historical pendulum of porcelain veneer preparation concepts, an oversimplified version of the so-called "no prep" approaches has resurfaced. A case from the USC student clinics is presented, which could be easily considered by many as a "no prep" veneer case. Moderate tooth preparations guided by natural morphology were used instead with a great benefit on the final outcome. While it is widely accepted that minimally invasive restorative approaches should be favored, a certain controversy exists regarding strictly noninvasive approaches. The purpose of this article is to re-emphasize the concept of guided tooth preparations, based of natural tooth morphology (given by a wax-up and a mock-up), a customized and sensible approach to indirect ceramic veneer tooth preparations.
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The porcelain laminate veneer is an elective restoration, often placed in the absence of disease for purely esthetic reasons. As such, it would appear desirable that the success rate of the technique was 100%. It is therefore the purpose of this paper to review the literature on porcelain laminate veneer survival by searching dental databases containing clinical trials of porcelain veneer restorations. References of selected trials were also screened to identify relevant studies. Each paper that was included was examined to ascertain if preparation into dentin affected survival. A total of 24 papers were included in the review. It was concluded that survival rates of porcelain laminate veneers are rarely 100%, and there is reasonable evidence indicating that a veneer preparation into dentin adversely affects survival. A review of the literature has indicated that porcelain laminate veneer survival is rarely 100%. Accordingly, patients should be made aware of this before embarking on this elective restorative technique. Clinicians should also be aware that the ideal preparation for porcelain veneers remains within enamel. (J Esthet Restor Dent 24:257–265, 2012)