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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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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 12 • NUMBER 4 • WINTER 2017
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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VENEZIANI
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 Classication 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
CLINICAL RESEARCH
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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 rening
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 (0.3to0.5 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 deective 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 5min; 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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