Clinical relevance

C areful case assessm ent, adjunctive treatm ent and precise

clinical and laboratory techniques are im portant aspects to
ensure optim al longevity and aesthetics of porcelain veneers.
D espite all precautions, post treatm ent com plications can
occur.
Objectives
The reader should understand the im portance of creating a
favourable environm ent for treatm ent w ith porcelain veneers
and the techniques involved in actual treatm ent. U sed w ith the
correct indications, porcelain veneers represent a relatively
conservative treatm ent m odality w ith the potential for an
excellent aesthetic outcom e and good longevity (Friedm an,
1998, D um fahrt and Schaffer, 2000, Peum ans et al, 2004).
M ost veneers are placed for cosm etic reasons and are therefore
elective. For this reason it is im perative to ensure m inim al tooth
destruction and attem pt to achieve m axim um restoration
longevity. This requires careful case selection, treatm ent
planning and precision in all clinical and laboratory stages. In
thin sections, porcelain is a fragile and unforgiving m aterial and
despite taking precautions, com plications m ay still occur during
treatm ent w ith porcelain veneers. The follow ing case details
the technique involved in restoring the m axillary incisor teeth
w ith porcelain veneers and illustrates a post treatm ent
com plication that m ay arise.
Case report
The patient presented com plaining about the incisors had been
restored num erous tim es w ith direct com posite resin to treat
interproxim al decay as w ell as to close the interdental spaces.
O n exam ination the follow ing findings w ere noted (Figures
1-4) :
W ear of the central incisor edges creating a flat
anterior occlusal plane
D iscolouration and m arginal staining of the existing
com posite restorations.
G ingival recession around the necks of lateral incisor,
canine and first prem olar teeth.
The com bination of the w orn incisal edges and increased
w idth of the upper incisors due to the com posite bonding,
detracted from the sm ile in tw o aspects.
1. The length to w idth ratio of the central incisors w as too
sm all, m aking the teeth appear too square. A ccording to
C hiche and others a pleasing proportion is 80% (C hiche and
Pinault, 1994, M agne et al, 2003).
2. The incisal edges of the central incisors w ere a sim ilar
length to those of the lateral incisors, creating a flat sm ile line.
A m ore attractive appearance is obtained w hen the incisal
edges of the central incisors are longer than those of the lateral
incisors and the sm ile line form s an arc in harm ony w ith the
curvature of the low er lip (Sarver, 2001, Fradeani, 2004).
It w as decided that porcelain veneers w ould be the optim al
solution to deal w ith the restorative and aesthetic concerns. A t
this early stage, it w as not possible to determ ine w hether four
or six veneers w ould be needed and this decision w as delayed
until a diagnostic w ax-up had been carried out.
A potential com plicating factor for porcelain veneers w as the
fact that the gingival recession m eant that the cervical m argin
of the veneers w ould be on dentine (Figure 4), since it has been
show n that veneers w ith their m argins in enam el are m ore
successful than those in dentine (Tjan et al, 1989, Lacy et al
1992, Ibaura et al 2007, D um fahrt 2000, Friedm an 1998).
PORCELAIN VENEERS: TECHNIQUES
AND PRECAUTIONS
BASIL M IZRAHI
Basil Mizrahi, BDS, MSc (Rand) MEd, Cert in Prosthodontics (USA)
Private Practice, London, UK
Abstract
This article describes the restoration of four upper anterior teeth w ith porcelain veneers. Because such
treatm ent is usually elective, all precautions should be taken to ensure treatm ent is as conservative as
possible. It m ay also be necessary to carry out non-restorative adjunctive procedures to create a
favourable environm ent and im prove the long-term prognosis of the veneers. Porcelain is extrem ely
fragile and com plications such as post bonding fracture m ay occur. If and w hen this does happen the
clinician should be aw are of the possible cause and how to deal w ith the situation.
6 INTERNATIONAL DENTISTRY SA VOL. 9, NO. 6
CLINICAL
Tw o options w ere available to address this issue:
Place the veneer m argins on enam el i.e. about 2-3m m
supragingival. This w ould have the potential to create an
aesthetic com prom ise at the m arginal interface due to a
potential colour m ism atch and the discolouration of the m argin
over tim e.
C arry out m ucogingival periodontal surgery to cover the
exposed root surface. This w ould allow the m argin of the
veneer to be placed on enam el at an equigingival level.
A fter discussing both options w ith the patient it w as decided
to carry out a root coverage procedures on the upper canine
and lateral incisors. Follow ing the m ucogingival surgery, the
gingivae w ere allow ed to m aturate for about four m onths
before the restorative phase of treatm ent w as begun (W ise
1985) (Figure 5).
Visualisation
In aesthetic treatm ent, it is im portant to start visualising the
final result as early as possible and to continue this visualisation
throughout treatm ent. This ensures that all parties involved in
the treatm ent have the sam e endpoint in m ind and allow s
changes to be m ade prior to the final restorations being
cem ented (M izrahi, 2005).
The first step in this visualisation process is the diagnostic
w ax-up (Figure 6). This w ax-up should be highly indicative of
the final result and it is im portant to verify that it corresponds
to the intended outcom e of both the dentist and the patient.
The key elem ent of porcelain veneers is the preservation of
existing enam el.
O ver the years, in the adult dentition, erosion and surface
w ear contribute to the thinning of the existing enam el. W hen
determ ining the final contour of the w ax-up, the technician
should seek to replace this lost enam el by bulking out the tooth
slightly w herever possible. This has a tw o-fold effect of
strengthening the rem aining tooth and allow ing for
preservation of existing enam el (M agne and D ouglas 1999).
From the w ax-up, it w as determ ined that only four veneers
w ould be required. The w axup w as used to fabricate a series of
Figure 2. Pre-op smile Figure 1. Pre-op smile
Figure 3. Pre-op smile
Figure 5: Post periodontal surgery with root coverage (Dr J onathan Lack)
Figure 4: Gingival recession with exposed dentine. Note the large
interproximal composite restorations on the four incisors
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INTERNATIONAL DENTISTRY SA VOL. 9, NO. 6 7
silicone m atrices w hich w ould later be used for m aking an
intra-oral diagnostic m ockup, a tooth preparation guide and
the tem porary veneers. A n intra-oral m ock up of the final
proposed result w as m ade using a Bis-acryl resin tem porary
resin m aterial (PreVISIO N C B, H ereaus Kulzer) in a silicone
m atrix (Figure 7). O nce the resin had polym erised, the m atrix
w as rem oved and an aesthetic and functional analysis w as
m ade of the result (G urel and Bichacho, 2006) (Figures 8-10).
Tooth preparation
Various techniques for accurate tooth reduction have been
proposed, including silicone m atrices, freehand preparation
and depth lim iting burs (C herukara et al, 2005). It is im portant
that w hatever tooth reduction guide m ethod is used, it is
based on the definitive w ax up and not the original tooth.
Failure to do this m ay result in excessive and unnecessary
rem oval of tooth enam el. In this case depth lim iting burs w ere
used to prepare directly through the bis-acryl m ockup, as
described by G urel (2003) (Figure 11). The teeth w ere prepared
w ith a m arginal cham fer labially and interproxim ally, and a butt
fit m argin palato-incisally w ith no w rap around onto the palatal
aspect (C astelnuovo et al, 2000, M agne and D ouglas, 1999)
(Figure 12).
C ontact points w ere not preserved as the teeth had natural
8 INTERNATIONAL DENTISTRY SA VOL. 9, NO. 6
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Figures 6a and b Original study casts compared to diagnostic wax-up
Figure 7: Bis-acryl resin in silicone matrix Figure 8: Bis-acryl mock up on teeth
Figure 9: Bis-acryl mock up on teeth Figure 10: Bis-acryl mock up on teeth
diastem a betw een them . This also allow ed for the changing of
the tooth w idths in the final restorations. Follow ing tooth
preparation, the final im pression w as m ade. Even though the
preparation m argins w ere at the level of the gingival m argins,
a retraction cord w as used to allow an im pression of the tooth
surface beyond the m argins to be captured (Figure 12). This
ensures accurate and com plete capture of the entire m argin
and aids the dental technician in obtaining the correct cervical
profile for the restorations. A n im pression w as taken using a
w ell-designed custom tray and a single stage im pression
technique. Polyvinyl siloxane im pression m aterial w as used,
w ith heavy body m aterial placed in the tray and light bodied
m aterial syringed around the teeth (Figure 13).
Temporisation
The tem porary veneers w ere m ade using a bisacryl tem porary
resin. Because teeth prepared for veneers are designed to have
m inim al to no m echanical retention, retaining tem porary
veneers is a problem . M any techniques advocate allow ing the
tem porary m aterial to cure on the teeth and lock into
undercut/retentive areas such as the interproxim al em brasures
and incisal overlaps. The excess flash is then carefully trim m ed
aw ay w ith a scalpel. The tem porary veneers are then broken off
at the tim e of cem entation.
It is the authors opinion that it is not possible to accurately
trim , verify and refine the m argin of the tem porary veneers
w hile they rem ain in place on the teeth. Failure to do this m ay
lead to gingival inflam m ation, w hich could com plicate and
com prom ise the final cem entation. In addition, the fact that
there is no layer of tem porary cem ent m ay allow ingress of
bacteria, w hich m ay stain the underlying teeth or cause tooth
sensitivity. This becom es a m ore significant problem w hen the
delay betw een taking the im pression and fitting the final
veneers is m ore than one to tw o w eeks. A nother potential
problem w ith this technique is that any m odification to the
shape of the tem porary veneers and final polishing m ust be
m ade intra-orally.
The author m odifies the technique slightly by rem oving the
tem porary veneers carefully after they have polym erised on the
teeth. This is carried out using a scalpel to rem ove excess
m aterial as described earlier. In addition, any m aterial that has
engaged retentive/undercut areas around the teeth is also
rem oved. O nce all the retentive areas of the tem porary m aterial
has been rem oved, the tem porary no longer has m echanical
retention and can be gently rem oved. W here necessary, the
m argins are relined/refined w ith a m ethylm ethacrylate acrylic
resin, w hich is m ore versatile for m arginal relining than bisacryl
resin (Figures 14-16).
The tem porary veneers are then cem ented in place w ith a
clear tem porary cem ent (Tem p Bond C lear, Kerr). The excess
cem ent is cleaned aw ay and then sm all am ounts of the acrylic
resin are applied to the palatal, interproxim al and incisal
aspects to once again lock the tem poraries into place
m echanically and augm ent the retention provided by the
tem porary cem ent (Figure 17).
In the laboratory, the veneers w ere fabricated from
feldspathic porcelain. This allow s incorporation of m ultiple
shades and characterisations into the porcelain w hile
m aintaining m inim al thickness (Figures 18 and 19).
A t the tim e of cem entation, the tem porary veneers w ere
rem oved from the teeth by rem oving the palatal/incisal acrylic
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Figure 11: Use of depth cutting burs through Bis-acryl mock up Figure 12: Final preparations with single retraction cord ready for final
impression
Figure 13: Polyvinyl siloxane impression
resin m echanical locks w ith a sharp instrum ent. The teeth w ere
cleaned w ith pum ice and the veneers w ere tried in. C ontact
points w ere adjusted and the m arginal precision and fit w ere
checked.
Veneer surface preparation
A fter the veneers had been tried in they w ere cleaned w ith
alcohol and then the follow ing regim e for preparing the fitting
surface of the veneers w as carried out as described by (M agne
et al, 2006).
The internal surface of the porcelain veneers w ere etched for
90 seconds w ith 9% H ydrofluoric A cid (Figure 20). H ydrofluoric
etching generates a significant am ount of crystalline debris that
contam inates the porcelain surface and m ay reduce bond
strength by 50% .
To rem ove this debris, the veneers w ere rinsed w ith w ater for
20 seconds, then cleaned w ith 37% Phosphoric acid (gentle
brushing w ith m icrobrush for a m inute), re-rinsed w ith w ater
for 20 seconds and then finally im m ersed in 95% alcohol in
ultrasonic bath for five m inutes. Follow ing this protocol the
veneer surface should appear clean and have a sim ilar
appearance to etched enam el (Figure 21). Silane coupling
agent is then applied and if possible, dried w ell w ith w arm
air(Filho, 2004, Barghi, 2000, Shen et al, 2004).
W henever possible, cem entation should be carried out under
rubber dam one tooth at a tim e. The advantages of im proved
visual and instrum ent assess and m oisture control far
outw eighs the disadvantage of the increased tim e needed. The
clam p used is a butterfly style clam p w ith care taken to ensure
the jaw s of the clam ps are stabilised on the tooth surface and
not the gingivae (Figure 22). W arm im pression com pound can
be used to stabilise the clam p on the adjacent teeth if
necessary.
The veneers w ere cem ented in place w ith a light cured
veneer luting resin cem ent (Rely X veneer cem ent, 3M ESPE).
W ith rubber dam retraction of the gingivae, excess resin
cem ent can be easily rem oved prior to polym erisation. This
elim inates the need for dam aging rotary instrum ent
finishing/polishing of the tooth-veneer interface (Figures 23-
25).
Together w ith precision in m arginal fit, this technique w ill
ensure excellent m arginal integrity and a healthy tissue
response (Figures 26- 28). A t com pletion of cem entation, a
successful result w as obtained and both clinician and patient
w ere extrem ely satisfied (Figures 29-31).
Post operative crack
W hen the postoperative photos w ere view ed, it w as apparent
that a vertical crack w as present in the lateral incisor. This w as
not noticed by either patient or dentist at the tim e of
Figure 14: Silicone matrix in place for fabrication of temporary veneers
from Bisacryl resin
Figure 15: Bis-acryl temporaries with margins refined/relined with
methylmethacrulate acrylic resin.
Figure 16: Temporary veneers cemented into place. Figure 17: Temporary veneers mechanically locked in place after
cementation with methylmethacrulate acrylic resin
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INTERNATIONAL DENTISTRY SA VOL. 9, NO. 6 11
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cem entation and seem ed to be m ade apparent by the cam era
flash. The patient w as recalled and the crack w as pointed to
her on the photos. Even at this tim e, despite the know ledge of
the crack is w as not noticeable w ith direct vision and as such,
it w as decided to leave the veneer in place.
M agne et al (1999) have proposed that a possible cause of
this is a ceram ic to luting is w ell bonded onto the underlying
enam el a post bonding cracks does not jeopardise the longevity
of the veneer and if the crack is not an aesthetic concern, the
veneer should be left in place (Barghi and Berry, 1997). If the
crack is obvious and detracts from the appearance, it is then
necessary to rem ove and rem ake the veneer.
Discussion
Porcelain veneers have been show n to be a good conservative
and aesthetic treatm ent option. H ow ever they do have
lim itations and it has been show n that lack of enam el is one of
the m ain causes of failure. Before treating a patient w ith
porcelain veneers, the favourability of the environm ent should
assessed. If this is not favourable and m argins w ill be on
dentine or if excessive enam el w ill need to be rem oved, then
alternative/adjunctive treatm ent options should be considered
eg orthodontics and or periodontics.
It is im portant to follow correct treatm ent protocols and
strive for clinical and laboratory com posite thickness ratio of
Figure 18: Final veneers. Note detailed, natural morphology, texture and
characterisation
Figure 19: Final veneers. Note detailed morphology, texture and
characterisation
Figure 20: Hydroflouric acid (9%) etching internal
surface of veneer
Figure 21: Clean frosty appearance of well etched
porcelain
Figure 22: Phosphoric acid (36%) etching of
enamel
Figure 23: Clean frosty appearance of well etched
enamel
Figure 24: Bonded veneer in place. Note excellent
visibility of margin due to rubber dam retraction.
Figure 25: Palatal fit of porcelain veneers
12 INTERNATIONAL DENTISTRY SA VOL. 9, NO. 6
above 3:1. W hen this ratio is large, the forces created by the
polym erisation shrinkage of the luting cem ent m ay cause
fracture of the thin porcelain veneer. Post bonding cracks are
an acknow ledged, albeit rare, com plication of porcelain
veneers.
Based on literature it appears that if the veneer precision.
This ensures m inim al dam age to tooth and gingivae and enures
optim al longterm prognosis. D espite follow ing all precautions,
because of the delicate nature of porcelain veneers, a possible
post-operative com plication is cracking. If the veneer has been
w ell bonded to the underlying enam el and is not an aesthetic
concern, the patient should be inform ed and the veneer should
be left in place.
Acknowledgement
D r Jonathan Lack, Specialist Periodontist, London, England for
the periodontal surgery results show n in Figure 5.
M r Salvatore Sgro, LEccellenza O dontotecnica, Rom e, Italy,
for the excellent technical w ork.
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Figure 26: Final veneers bonded in place
Figure 28: Final veneers bonded in place
Figure 27: Final veneers bonded in place
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Figure 29: Post op appearance of smile
Figure 30: Post op appearance of smile
Figure 31: Post op appearance of smile
Figure 32: Post-bonding crack on left lateral incisor
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