In my enjoy, the cementation of glass-ceramic veneers is without doubt one of the maximum technique-sensitive procedures in restorative dentistry, owing to the minimum margin for error and the excessive aesthetic requirements required to succeed in a outcome that satisfies each clinician and affected person. Present protocols emphasise conservative preparation, preferably closing completely inside the tooth or, on the very least, minimising extension into the dentine. Preparation design and extent will have to now not be deliberate in isolation, however coordinated via shut collaboration between clinician and technician, making sure that the general result’s each biologically sound and aesthetically predictable.
Scientific presentation and remedy background
The case offered on this article is atypical in that it arose all of a sudden, with out standard pretreatment making plans steps corresponding to a diagnostic wax-up or mock-up. Those had been left out as a result of time and finances constraints at the affected person’s phase—a fact to which many clinicians can relate. Monetary issues frequently restrict acceptance of complete remedy plans; subsequently, phased making plans and efficient communique are very important in fostering affected person accept as true with and long-term dedication. The reason for this method within the provide case will transform clearer because the case unfolds.
The affected person was once a 70-year-old feminine retiree whom I were treating for a number of years. Remedy as much as that time had fascinated with stabilising and regularly making improvements to her posterior restorations, and the longer-term goal was once to deal with the anterior dentition to support each serve as and aesthetics. The affected person offered for an emergency appointment with a fractured porcelain veneer on teeth #21 (Fig. 1). Owing to the present phased strategy to her care, it was once conceivable to transition into aesthetic recovery with minimum resistance or hesitation via the affected person.
Fig. 2: Remedy making plans the use of virtual smile design, together with 4 porcelain veneers and 4 direct composite restorations.
Remedy making plans and targets
After cautious dialogue, it was once determined to take away and change the 4 current porcelain veneers and to switch 4 current Magnificence V stained composite restorations with new direct composite restorations. The proposed plan was once regarded as suitable for assembly the affected person’s aesthetic expectancies.
On the emergency appointment, time was once restricted, and simplest brief recovery of the fractured veneer with direct composite was once possible. Time remained the most important issue for the reason that affected person wanted to finish remedy once conceivable.
Teeth preparation, virtual workflow and provisional restorations
Guided via the virtual smile design plan (Fig. 2), the tooth had been constructed up with a flowable composite to create a coarse direct mock-up (Fig. 3). This mock-up equipped a visible and useful prototype, from which an impact was once taken to manufacture provisional restorations. Those provisional restorations had been positioned after teeth preparation and worn till supply of the definitive veneers.
Teeth preparation was once performed with an OptraGate latex-free lip and cheek retractor (Ivoclar) in position. The prevailing veneers had been got rid of the use of high-grit diamond burs at excessive velocity. As soon as the majority of the fabric were got rid of, gingival retraction was once accomplished with retraction twine to give a boost to visibility and get admission to. The arrangements had been then delicate with lower-grit diamond burs at lowered velocity to make sure precision and tissue protection. The main targets had been to hide the cervical defects glaring within the earlier restorations (Fig. 4) and to determine harmonious gingival zeniths after preparation (Fig. 5).
Fig. 3: Additive mock-up fabricated the use of a flowable composite to judge the proposed aesthetic result.
Fig. 4: Scientific state of affairs after substitute of the Magnificence V composite restorations on tooth #13, 23, 24 and 25.
Fig. 5: Scientific state of affairs after preparation of the maxillary incisors.
Subject matter variety and issues for veneer cementation
Glass-ceramic veneers have historically been cemented the use of a variety of resin cements. Just lately, using flowable or preheated paste resin composite for cementation has received consideration.
Fig. 6: PANAVIA V5 try-in paste Common (A2) for colour analysis.
A key good thing about this method is clinicians’ familiarity with composite colour methods, usually in response to the VITA classical A1–D4 information (VITA Zahnfabrik), which many clinicians to find extra intuitive than resin cement colour designations corresponding to “heat”, “mild” or “impartial”. To handle this limitation, some resin cement methods be offering try-in pastes comparable to cement sun shades, enabling correct analysis all the way through try-in. PANAVIA Veneer LC (Kuraray Noritake Dental) is one such machine, and PANAVIA V5 try-in pastes correspond to its sun shades (Fig. 6).
The usage of a cement colour that fits the supposed ultimate look is the most important when bonding glass-ceramic veneers as it decisively impacts each instant and long-term aesthetics, in particular owing to the sunshine diffusion houses of glass-ceramic fabrics corresponding to IPS e.max CAD and IPS e.max Press (each Ivoclar). In minimally invasive circumstances, restorations may also be as skinny as 0.3 mm. The thinner and extra translucent the recovery, the larger the affect of the cement colour at the ultimate result.
Fig. 7: Choice of IPS e.max translucency to fortify colour matching and covering of the underlying teeth construction.
The colour of the ready teeth additionally considerably impacts cement variety, as do choices relating to recovery thickness and ceramic translucency. IPS e.max is to be had in low translucency, medium translucency and excessive translucency (Fig. 7). When the ready tooth are darkish and a brighter result’s desired, deciding on a ceramic with decrease translucency is really helpful. Documenting the ready tooth photographically and sharing this knowledge with the ceramist is subsequently very important.
Within the provide case, the ready teeth construction seemed fairly darkish within the incisal 3rd. A medium-translucency IPS e.max CAD subject matter in Coloration A1 was once subsequently decided on to permit minimum thickness whilst attaining a herbal result.
Subject matter assessment: PANAVIA Veneer LC machine
In keeping with the issues for veneer cementation, PANAVIA Veneer LC was once decided on. This light-polymerising resin cement is indicated for ceramic and composite restorations of not up to 2 mm in thickness. It’s to be had in 4 sun shades—Transparent, Common (A2), White and Brown (A4; Fig. 8a)—and PANAVIA V5 try-in pastes are to be had in corresponding sun shades (Fig. 8b), enabling simulation of the general recovery look. The machine is composed of 4 parts: a 35% phosphoric acid etching gel (Okay-ETCHANT Syringe, Kuraray Noritake Dental), a teeth primer (PANAVIA V5 Teeth Primer), a ceramic primer (CLEARFIL CERAMIC PRIMER PLUS, Kuraray Noritake Dental) and PANAVIA Veneer LC paste (Figs. 9a–d).
Check out-in process and colour variety
After fabrication of the 4 lithium disilicate veneers within the decided on translucency and colour (Fig. 10), the resin cement colour was once evaluated. A vibrant outcome that might harmonise with the adjoining dentition was once desired; subsequently, the Common colour was once decided on. The affected person and scientific group had been glad with the simulated result (Fig. 11), and the veneers had been wiped clean and pretreated for definitive placement.
Adhesive cementation protocol
For adhesive cementation of the veneers, the tooth had been remoted the use of a latex-free dental dam (Isodam HD, heavy gauge, 4 D; Fig. 12). After placement of the dental dam, clamps had been positioned and the veneers attempted in once more to substantiate have compatibility (Figs. 13a & b).
Afterwards, teeth floor pretreatment started with the central incisors. Adjoining tooth had been safe with a steel strip, and air abrasion with a 35 μm aluminium oxide powder was once carried out (Fig. 14a). After roughening of the outside (Fig. 14b), the phosphoric acid etching gel was once carried out and left for 15–30 seconds (Fig. 15), adopted via thorough rinsing and drying. The lateral incisors had been then remoted with PTFE tape to facilitate removing of extra cement (Fig. 16).
The true cementation steps integrated priming of the teeth construction with PANAVIA V5 Teeth Primer (Fig. 17), left for 20 seconds and gently air-dried. The intaglio surfaces of the veneers had been handled with hydrofluoric acid for 20 seconds and, after thorough rinsing, primed with CLEARFIL CERAMIC PRIMER PLUS (Fig. 18) and dried.
PANAVIA Veneer LC was once then carried out to the pretreated ceramic surfaces, and the veneers had been seated sparsely (Figs. 19a & b). Mild, managed force the use of a smooth tool ensured correct seating. When light-polymerising resin cements are used, extra subject matter can frequently be got rid of previous to polymerisation, thereby decreasing extra and simplifying clean-up.
The resin cement supplies a continuing marginal transition between teeth and recovery, bettering each aesthetic and useful integration of the veneers. Glycerine gel was once carried out to the recovery margins ahead of mild polymerisation to stop formation of an oxygen inhibition layer (Fig. 19c).
The lateral incisor veneers had been cemented in the similar method; alternatively, floss was once used for gingival retraction as a substitute of clamps (Figs. 20a & b). Sequencing the process via first cementing the central incisors and due to this fact the lateral incisors is beneficial. This protocol offers the practitioner complete regulate over the location of the central incisor veneers, which is especially essential as a result of their place has a substantial affect at the total look of the smile. When the lateral incisor veneers are cemented first, the chance of positioning mistakes within the central incisor area and ensuing aesthetic problems is higher. Then again, any error with the location of the central incisor veneers too can result in issues such because the misfit of the lateral incisor veneers. Subsequently, the entire process must be performed with utmost care and precision.
A complete polymerisation protocol, together with palatal, incisal and facial mild publicity, is essential to make sure whole polymerisation. After placement of the veneers, extra cement was once got rid of the use of ultra-high molecular weight polyethylene floss (Gorilla Floss, Erskine Merchandise) to give protection to the margins (Figs. 21a–c). Ultimate sprucing of the ceramic–teeth interface was once carried out the use of sprucing rubbers. The dental dam remained solid during the process.
The instant result after cementation confirmed reasonably erythematous and smooth gingival tissue, reflecting a temporary reaction to the adhesive process (Fig. 22). This represents a brief tissue reaction and usually improves over the next days as therapeutic progresses. With a constant and suitable oral hygiene regimen, complete restoration of the smooth tissue may also be anticipated. This will have to be obviously communicated to the affected person after removing of the dental dam.
Scientific follow-up
On the follow-up appointment, soft-tissue therapeutic and affected person adaptation had been assessed. The gingival tissue had absolutely recovered after 3 weeks (Fig. 23). This seek advice from additionally equipped a possibility for ultimate photographic documentation (Figs. 24a–d). At this appointment, cautious analysis of the interproximal spaces is very important to hit upon any residual cement, which would possibly lead to continual irritation and compromise aesthetics. Inspection from the occlusal side is helping make sure that whole removing of extra subject matter and helps long-term gingival well being.
