Technology and emotion: A porcelain veneer case report

Case presentation

Diagnosis

A 24-year-old female patient in excellent medical and good dental health presented stating she had not been to the dentist in some time and wished to improve her oral health and the appearance of her teeth. The pa­tient was unhappy with the shape and shade of her teeth. She was particularly concerned with the im­proper proportions of the width-to-length ratios of her incisors and the diastema present between teeth #11 and 21 (Figs. 1 & 2).⁴ Several areas of gingival asymmetry were also noted. The patient stated that she had re­ceived orthodontic treatment in the past, and cos­metic bonding (which had already failed at the time of her presentation) to close the diastema between teeth #11 and 21. She expressed her desire to have a beautiful, brighter and natural-looking smile.

A full-mouth series of periapical radiographs was taken, and several failed composite restorations and a periapical abscess on tooth #16 were noted. Clinical examina­tion revealed a Class I dental relationship and sev­eral significant occlusal interferences. Evidence of moderate wear was found on the patient’s anterior teeth, and the patient presented with some muscular tension during a temporomandibular joint evaluation.⁵

Treatment plan

After discussion of aesthetic restorative options for her smile, the patient elected to pursue diagnos­tic occlusal analysis with an anterior deprogram­mer, occlusal equilibration as indicated, treatment of tooth #16 with endodontic therapy and a complete porcelain crown, and restoration of teeth #15–25 with full-prepara­tion porcelain veneers. The veneers were to be de­signed to aesthetically enhance the dentition while restoring the several failed composite restorations. The patient stressed that a natural, conser­vative, long-lasting result was her primary goal. Proper care of the future porcelain restorations was discussed, including nightly wearing of a hard protec­tive occlusal splint, and the importance of optimal maintenance, including regular cleaning and exam­inations, was stressed.⁶

A comprehensive set of records was taken of the patient’s preoperative condition, including a detailed laboratory prescription, to allow for proper communication between the dentist and the ceramist. Honigum Pro polyvi­nylsiloxane (DMG) impressions were taken of both arches, and two sets of study models were fabricated in die stone.^7–9 Centric occlusion was recorded with a Futar D poly­vinylsiloxane (Kettenbach) bite registration and a facebow trans­fer. Digital photographs documenting the preopera­tive shade, texture and shape of the surrounding teeth were taken.^{6, 7, 9, 10} All the records were sent to the laboratory, where one set of models was used to fabricate a Kois deprogrammer for oc­clusal evaluation. The second set of study models was mounted on a semi-adjust­able articulator after occlusal anal­ysis with the Kois deprogrammer, and teeth #16–25 were waxed to full contour. A Sil-Tech poly­vinylsiloxane (Ivoclar) stent was then formed to fabricate an incisal reduction matrix.

The patient’s teeth were cleaned with Consepsis chlorhexidine (Ultradent Products). A polyvinylsiloxane stent made from the diagnos­tic wax-up was filled with Luxatemp Ultra in the Bleach Light shade (DMG), placed over the prepared teeth and allowed to polymerise. After approximately 1 minute, the stent was gently removed, the provisional res­torations remaining inside. The preparations were cleaned again with chlorhexidine and covered to prevent desiccation. After final polymerisation, the provisional res­torations were removed from the stent, trimmed and then seated with TempoCem ID (DMG). The temporary cement was tack polymerised for 5 seconds on each tooth with the Bluephase LED curing light (Ivoclar). Excess material was removed with a #12 scalpel blade, an additional 15-second polymerising time per tooth was completed and the provisional res­torations were smoothed and finished with abrasive discs and a rubber cup pol­isher (all Cosmedent). The occlusion was verified, and the patient was appointed for a post­operative check 24 hours later.

The 24-hour post­operative check ap­pointment was particularly important because it allowed the patient to express feedback based on self-analysis of the proposed shapes and contours of her new smile. The patient reviewed and ap­proved the shape of her provisional res­torations and the shade tabs selected at the prior appointment. Proper phonetics, occlusion and anterior guidance were confirmed. A few minor adjustments to her occlusion on the lingual aspect of the provisional res­torations were required. Photographs of the approved provisional restorations and shade tabs were taken (Figs. 4–6). Other provisional records were taken, in­cluding a Futar D stick bite in centric occlu­sion and a Honigum Pro im­pression of the approved provisional restorations (Fig. 7). All the records were disinfected and sent to the ceramist, accompanied by a completed laboratory prescription, notes and all the photographs taken to that point. The ceramist was instructed to use the impression of the approved provisional res­torations as a guide for the final shape, size and contour of the porcelain restorations.

Laboratory phase

During the provisional phase, the pa­tient was able to further re-evaluate the provisional restorations. If she had re­quested any changes, they could have been communicated to the ceramist dur­ing this period; however, no changes were re­quested during this time.

On the ceramist’s receipt of the case, the records were reviewed, and the ma­terial choice on the prescription was confirmed during a telephone conver­sation. Shape, shade and characterisa­tion were discussed again and finalised in the planning stage. Producing the pa­tient’s desired shade choice dictated the use of the lith­ium disilicate Amber Press in the MO 3 shade (HASSBIO) to be pressed as a base shade. Cutback and layering of the pressed veneers were planned to create restorations with the requested moder­ate incisal character and natural gingival staining with a lightly textured, polished gloss finish.

The full-contour pressed veneers were then tried on the physical die mod­els to confirm marginal accuracy. Cut­back of each full-contour veneer was performed as needed to allow for hand layering of porcelain to develop real­istic translucency, depth and charac­ter. After layering and firing, each veneer was hand finished and polished.

The ceramist meticulously confirmed fit and aesthetics for the entire case. The intaglio of each veneer was lightly sand­blasted and then acid etched for 1 min­ute with 9.5% hydrochloric acid (Keystone Industries). The veneers were then steam-cleaned and carefully packaged for sending to the dentist ready for the seating appointment.

Cementation

On receipt from the ceramist, the porce­lain restorations were reinspected on the dies for marginal fit and on solid models for proper interproximal contacts. Pro­found anaesthesia was obtained through the use of Lignospan standard during the seating appointment. An OptraGate lip retractor was placed to assist in isolation. The pro­visional veneers were removed, and the preparations were cleaned to remove any residual temporary cementation material or de­bris. The veneers were then tried in the patient’s mouth and evaluated for fit and aesthetics (first individually, then col­lectively). The patient was then asked to view and approve the aesthetics of her smile in a hand mirror.

The approved veneers were removed from the patient’s mouth and carefully cleaned with IvoClean cleaning paste (Ivoclar) to re­move any possible contamination. They were rinsed and dried, and Monobond si­lane coupling agent (Ivoclar) was applied to the intaglio of the veneers.¹² After 1 minute, they were air-dried, and a thin coating of All-Bond Universal bonding agent (BISCO) was ap­plied to the intaglio of the veneers and air thinned. Vitique clear veneer cement (DMG) was then applied to the veneers, and they were immediately placed into a Resin­Keeper light-safe box (Cosmedent) to prevent polymerisation of the resin.^6, 7

The preparations were acid etched for 15 seconds with the Uni-Etch 32% phos­phoric acid gel etchant (BISCO), followed by rinsing with a copious air and water spray.^6, 7 All the prepa­rations were lightly dried but not dessi­cated.^6, 7 Two coats of All-Bond Univer­sal were applied to each preparation and agitated for 20 seconds prior to air thin­ning to evaporate the solvents. After air thinning, each tooth was polymerised for 20 seconds with a Bluephase LED curing light. The veneers were then removed from the light-safe box and seated on their respec­tive preparations. Excess cement was re­moved with a regular micro-brush (Mi­crobrush International), and the veneers were tacked into place for 5 sec­onds each with the curing light.¹³ Addi­tional excess was removed gently with a scaler, dental floss was passed through the con­tacts in the apical direction only and the veneers were then polymerised fully for an ad­ditional 30 seconds each.¹³ The margins were then inspected, and any excess polymerised cement was removed with a #12 scalpel blade.¹³ The interproximal areas were cleaned with Epitex finishing strips (GC). DeOx oxygen inhibit­ing gel (Ultradent) was expressed around all the margins, and the restorations were polymerised for an ad­ditional 10 seconds to finalise polymer­isation.^6, 7, 12 The lingual aspect was then polished with diamond paste and Flex­iBuff polishers (Cosmedent) in a slow-speed handpiece, and the isolation was removed.

The patient’s occlusion was checked, and smooth, proper contacts were verified with floss. Postoperative home care instructions were given, and the patient was scheduled for a follow-up appointment for radiographic and photographic documentation, as well as a follow-up check for function and aesthetic evaluation.

The patient returned the following day. Her functional oc­clusion was evaluated, and her teeth were inspected for any re­sidual cement. Postoperative radiographs were taken to con­firm positive seating of the margins and the absence of any residual interproximal cement. Maxillary and mandibular alginate im­pressions were taken along with a polyvinylsiloxane bite reg­istration for fabrication of a maxillary full-arch bite guard for night-time wear.⁶ Postoperative home care instructions were given, and the patient was scheduled for a follow-up appoint­ment for additional photographic documentation, a final check for function and aesthetic evaluation, and delivery of the bite guard (Figs. 8 & 9).⁶

Conclusion

Porcelain veneers can be employed to provide beautiful, nat­ural and long-lasting functional cosmetic results. While the procedure, materials and skill involved are highly technical and quite meticulous, the result achieved often evokes a very emotional response. It is difficult to look at a genuine smile and not feel the emotion in the picture. Scientifically, a Duch­enne smile can initiate facial mimicry, and emotionally, it cer­tainly can be a window to the soul (Figs. 10 & 11).